rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
10344,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2009-07-16,371,F,0,1,KV9O11,"Based on an observation and staff interview, the facility did not ensure employees do not store food and beverages in the refrigerator used to store resident food. This has the potential to affect all residents. Facility census: 64. Findings include: a) On 07/13/09 at 4:10 p.m., observation revealed a plastic bottle with fluid was stored in the refrigerator used to store food for the residents. An interview with dietary staff revealed the bottle of juice belonged to one (1) of the dietary workers. The dietary staff member told the owner of the bottle of juice to remove the bottle and that they were not permitted to have their personal items in the resident refrigerator.",2015-05-01
10345,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2009-07-16,241,D,0,1,KV9O11,"Based on an observation and staff interview, the facility did not ensure one (1) resident of a sample of fifteen (15) was provided care in a manner that maintained or enhanced the resident's dignity. Resident #42 was observed out in the hallway with a facility night gown open, exposing the resident's entire back. Facility census: 64. Findings include: a) Resident #42 On 07/14/09 at 8:30 a.m., observation found Resident #42 self-propelling down the B hallway dressed in a facility night gown with the resident's back fully exposed. An interview with the administrator revealed the resident was to be dressed before staff removed the resident from his room to the hallway. .",2015-05-01
10346,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2009-07-16,225,D,0,1,KV9O11,"Based on record review and staff interview, the facility did not ensure all allegations of resident neglect received by the facility immediately reported to State agencies as required by law. One (1) of thirteen (13) complaint records reviewed contained an allegation of neglect, which the facility did not identify as such and report as required. Facility census: 64. Findings include: a) A review of the facility's internal complaint records revealed that, on 01/14/09, a family member reported the following: ""Daughter reports coming to feed her mother at 11:45 a.m. and found her with dried food / liquid all over her mouth, chin and neck."" This complaint was submitted to the facility's social worker on at 3:45 p.m. on 01/14/09. This allegation of neglect were not immediately reported to the appropriate State agencies. In an interview on 07/14/09 at 2:00 p.m., the administrator (Employee #4) agreed the allegation of neglect received on 01/14/09 should have been reported to the appropriate State agencies. .",2015-05-01
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
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
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
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
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
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
10274,FAIRHAVEN REST HOME INC,515021,"700 MADISON AVENUE, PO BOX 2806",HUNTINGTON,WV,25727,2009-08-06,279,D,0,1,7LLN11,"**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 for all issues identified on the comprehensive assessment including the triggered resident assessment protocols (RAPs). This was evident for one (1) of ten (10) sampled residents. The facility also failed to develop a care plan to address care for a diabetic resident. This was evident for one (1) random resident. Resident identifiers: #36 and #17. Facility census: 40. Findings include: a) Resident #36 Resident #36's comprehensive assessment, dated 06/24/09, identified the problem of falls, resulting in a decision to develop a care plan for that issue. The care plan mentioned the risk of falls as it related to [MEDICAL CONDITION] drug use, but it failed to identify appropriate interventions to address the fall risk. The director of nursing was made aware of this at 9:30 a.m. on 08/06/09. During interview with the consultant pharmacist on 08/05/09 at 9:30 a.m., she clarified that gradual dose reductions (GDRs) had been made in a timely manner since admission. The dosage of antidepressant [MEDICATION NAME] was decreased in December 2008 and will be due for another GDR before December 2009, since the resident had been on it for greater than one (1) year. The anti-anxiety medication [MEDICATION NAME] had a GDR on 02/13/09 and is due for another GDR again in August 2009. The antidepressant [MEDICATION NAME] had a second GDR in July 2009, decreasing the dosage from 100 mg daily at the time of admission down to 50 mg, then reduced again down to 37.5 mg. The GDRs were not mentioned in Resident #36's care plan, especially as they related to the need for staff to monitor the resident's responses to adjustments in the medication regimen with respect to the potential for falls. b) Resident #17 Resident #17's [DIAGNOSES REDACTED]. Medication pass observation, on 08/05/09 at 4:10 p.m., revealed she had an elevated blood sugar of 483 which required coverage of 12 units of [MEDICATION NAME]-R insulin in addition to her scheduled dose of [MEDICATION NAME] 70/30 insulin 11 units. The medication nurse (Employee #11) said this resident's blood sugars were always up and down. During reconciliation of the medication pass the following morning, Resident #17's medical record revealed her care plan did not identify diabetes nor interventions for diabetic care needs. The care plan revealed blood sugars were to be assessed by staff four (4) times per day as listed under the laboratory section. The diet was listed as no added salt / low concentrated sweets under the nutrition section of the care plan. Interview with the director of nursing, on 08/06/09 at 9:30 a.m., revealed she was updating Resident #17's care plan at this time and would include more thorough diabetic care issues than the current plan of care contained. .",2015-05-01
10275,FAIRHAVEN REST HOME INC,515021,"700 MADISON AVENUE, PO BOX 2806",HUNTINGTON,WV,25727,2009-08-06,323,E,0,1,7LLN11,"Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. This was evident for residents on the third floor and had the potential to affect all ambulatory or self-wheeled residents housed on that floor. Third floor resident census: 20. Facility census: 40. Findings include: a) The door alarms to the four (4) exit doors on the third floor were Radio Shack units which could be set to chime when opened, alarm loudly when opened, or lock. The units were visible and within easy reach of ambulatory residents or those sitting in wheelchairs. The mechanisms that set the parameters for the units were thin plastic bars that could be slid with the touch of a fingertip to set the unit to chime, alarm, lock, or turn the unit off in a similar manner one would find on an alarm clock. Two (2) of the doors at each end of the unit opened to stairwells leading to outside exits. One (1) door close to the nurse's desk opened to a stairwell leading to the second floor. This door was set to chime to alert staff that the door had been opened. This door immediately opened to the first step with no landing between the door and the stairwell. Hence, a resident would be able to open the door and either exit or fall down the stairs if staff were not in the immediate vicinity to prohibit it. The fourth door was beside the latter and led to the stairwell going up to the fourth floor. It, too, was set to chime when opened. All four (4) doors could be opened from inside the stairwells to enter the third floor. On 08/03/09 at 6:42 p.m., the exit door at the end of the room 300-305 hallway was found to be unlocked and with no alarms sounding when opened. Employees #13, #25, and #24 staffed the floor and came to inspect the door being opened with no alarms sounding nor lock to prevent its opening. They immediately summoned a maintenance worker. The maintenance employee demonstrated how the mechanism was set to alarm loudly when the door was opened, and no one was able to determine how it came to be unlocked and with no alarm. The two (2) exit doors in the middle of the hallway were set to chime when opened, and staff reported they would be able to hear the chimes whenever the doors were opened. The exit door at the other end of the hall at the room 312-318 end of the hallway was set to alarm loudly in an ear splitting alarm when the door was opened. At 7:30 p.m., these findings were reported to the administrator (Employee #2). On 08/04/09, the physical environment director (Employee #44) stated he would order magnetic locks for the four (4) exit doors on the third floor similar to the locks on the second floor. The locks on three (3) of four (4) second floor exit doors can only be activated by entering a numeric code to allow opening. The fourth exit door leads to the stairwell leading upstairs to the third floor and chimes when opened. In the meantime, Employee #44 stated he can utilize a temporary method to block the third floor door alarms from being able to be pushed to the ""off"" position until the new locks arrive. The State survey agency's program manager was notified of the door lock / alarm situation and directed notification of the life-safety code program manager. Subsequently, the life-safety code program manager spoke directly with the administrator and physical environment director to address corrective action.",2015-05-01
10363,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-08-06,279,D,0,1,FGH911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop care plan interventions for all assessed problems, by failing to establish appropriate interventions to promote bowel regularity for three (3) of twenty (20) sampled residents. Resident identifiers: #39, #54, and #57. Facility census: 112. Findings include: a) Resident #39 Review of Resident #39's medical record revealed a [AGE] year old female who had been determined to have the capacity to make her own medical decisions, with [DIAGNOSES REDACTED]. She received [MEDICATION NAME] 5/500 mg per enteral tube every twelve (12) hours for backache and also had a [MEDICATION NAME] pump for pain control. She had self-imposed immobility, refusing to get out of bed except for a rare shower or to travel via ambulance for maintenance of her [MEDICATION NAME] pump. She had standing orders as follows: ""If no bowel movement (BM) in three days, give milk of magnesia (MOM) 30 cc PO (by mouth) x one dose. If no bowel movement on day four, give [MEDICATION NAME] suppository PR (per rectum) x one. If no bowel movement on day five, give Fleet enema. If no results from Fleet enema, call physician for further orders."" The July 2009 Medication Administration Record [REDACTED]. The nurses' notes, on 07/12/09, stated the resident was complaining of nausea and had refused her tube feeding. At 7:00 a.m. on 07/16/09, the nurses' notes stated, ""Resident assisted with digital removal of lg (large) BM via this nurse."" Review of previous MARs indicated use of MOM on a continuing basis and, although the frequency of bowel movements was difficult to determine, it was recorded in the nurses' notes on 04/16/09 that she had no BM x 4 days and, on 04/26/09, ""No BM x several days."" On both of these occasions, she refused an enema, and there was no mention in the record of her receiving a [MEDICATION NAME] suppository. The care plan for Resident #39, initiated on 01/26/04 and revised on 07/09/09, addressed ""... complications related to immobility and [DIAGNOSES REDACTED]."" The only interventions were: ""Administer medications as ordered...."" and ""Observe abdomen for distention, bowel sounds and tenderness"". Both interventions were initiated on 01/26/04. No additional interventions had been added since 2004, although it was clear the goals had not been met. During an interview with the minimum data set assessment / care plan nurse (Employee #9) at 1:40 p.m. on 08/05/09, she agreed the resident had chronic constipation and required intervention on a continuing basis, although she refused enemas. She stated the resident was on a fiber supplement and was encouraged to take fluids. She also stated, after reviewing the notes, that digital removal of stool was required at times, but she acknowledged that none of these interventions were in the care plan. b) Resident #54 Resident #54's medical record, when reviewed on 08/04/09 at 9:00 a.m., disclosed a [AGE] year old male with a past history of a [MEDICAL CONDITION]. The annual minimum data set (MDS), dated [DATE], reported the resident was frequently incontinent of bowels. The facility form titled ""Bowel Retraining Assessment"", dated 04/07/09, reported the resident chose not to participate in a bowel retraining program. The care plan, with revision date of 07/01/09, did not address the resident's bowel incontinence. The care plan nurse (Employee #24), when interviewed on 08/04/09 at 9:40 a.m., confirmed the resident was incontinent of bowel and the current care plan, with a revision date of 07/01/09, did not address the resident's bowel incontinence. c) Resident #57 Medical record review, conducted on the morning of 08/04/09, revealed that, on 05/12/09, Resident #57 was started on [MEDICATION NAME] 5/500 mg 1 tablet by mouth very eight (8) hours as needed (PRN) for pain. Information found via the Internet, at http://www.drugs.com/[MEDICATION NAME], revealed the following recommendation: ""Drink 6 to 8 full glasses of water daily to help prevent constipation while you are taking [MEDICATION NAME]. Ask your doctor about ways to increase the fiber in your diet."" Review of the comprehensive plan of care, developed on 06/11/09, found on page 5: ""Resident exhibits or is at risk for dehydration as evidence by other UTI; and inadequate oral intake of food & fluids."" On page 13 was: ""Resident is at risk for alterations in comfort related to chronic pain."" The facility failed to develop a comprehensive plan of care for constipation for Resident #57, who had a decreased intake of oral fluids and who was on a pain medication which caused constipation. .",2015-04-01
10364,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-08-06,309,G,0,1,FGH911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on observation, medical record review, and staff interview, the facility failed to ensure one (1) of twenty (20) sampled residents was effectively pre-medicated prior to completion of painful dressing changes to her wounds. Resident identifier: #57. Facility census: 112. Findings include: a) Resident #57 Observation of a dressing change, on the morning of 08/05/09, found Resident #57 had an ulceration on her left outer aspect of her heal. This area was noted to have a necrotic center measuring approximately 6 cm, and the surrounding tissue was reddened. Prior to the dressing being changed, staff began to remove her air boots (pressure reducing device from her toes to knees), and she immediately raised her legs up in the air and began to cry. Staff consoled her and removed the air boots. The nurse then attempted to remove the old dressing by cutting it with scissors; Resident #57 responded by guarding, raising her feet into the air, and crying. Once the dressing was removed, the nurse assessed and measured the wound using a cotton-tipped swab. As the swab got close to the wound, the resident again guarded the wound and cried. The nurse cleansed the wound and applied Santyl ointment; the resident responded to her wound being touched with facial grimacing, guarding, and crying. When staff asked if she was having pain, she identified ""yes"". When asked where her pain was, she identified ""my heart"". According to a significant change in status minimum data set assessment (MDS) completed on 06/05/09, Resident #57's cognitive skills for daily decision-making were severely impaired. Further review of her record revealed she received [MEDICATION NAME] for behavioral disturbances and [MEDICATION NAME] for [MEDICAL CONDITION]. Following the completion of the first of two (2) dressing changes, the nurse decided to complete the second dressing change in the afternoon. The nurse identified that Resident #57 had received [MEDICATION NAME] at 7:50 a.m. and a dose of Tylenol could not be given until 12:30 p.m. On 08/04/09 at 5:30 p.m., the director of nursing (DON) was interviewed concerning Resident #57 having pain during the dressing change, as evidenced by non-verbal signs of guarding and facial grimacing, as well as crying out. On 08/04/09 at 6:00 p.m., a physician order [REDACTED]. The facility failed to identify and act upon the verbal and non-verbal signs of pain exhibited by Resident #57 during a dressing change and failed to identify the [MEDICATION NAME] given prior to the dressing change was ineffective in controlling the resident's pain. --- Part II -- Based on record review, review of the facility's standing orders for constipation, and staff interview, the facility failed the monitor residents for irregularities in bowel elimination and failed to implement standing orders to alleviate constipation for three (3) of twenty (20) sampled residents, one (1) of whom was not checked for possible fecal impaction until she exhibited non-verbal signs of pain. Resident identifiers: #65, #57, and #39. Facility census: 112. Findings include: a) Resident #65 Review, on 08/03/09, of Resident #65's ADL record for July 2009 found the resident had no bowel movement for five (5) consecutive days, from 07/04/09 through 07/08/09. Review of the July 2009 MAR for this time period found no evidence that any medication was given to alleviate this constipation. On 07/09/09 at 11:40 a.m., a nurse wrote, ""Digital rectal (check) revealed formed stool. Resident (arrow pointing down) bed & restless & moaning & moving about. Fleets enema x 1 Xlg (extra large) results & resident then pleasant & quietly."" Resident #65 was identified as having problems with constipation, which was originally addressed in her care plan on 10/15/03. The facility failed to adequately monitor her bowel elimination and implement standing orders when indicated to alleviate constipation. Subsequently, the resident experienced pain evidenced by the non-verbal signs of ""restless & moaning & moving about"". b) Resident #57 Medical record review, conducted on the morning of 08/04/09, revealed that, on 05/12/09, Resident #57 was started on [MEDICATION NAME] 5/500 mg 1 tablet by mouth very eight (8) hours as needed (PRN) for pain. Information found via the Internet, at http://www.drugs.com/[MEDICATION NAME], revealed the following recommendation: ""Drink 6 to 8 full glasses of water daily to help prevent constipation while you are taking [MEDICATION NAME]. Ask your doctor about ways to increase the fiber in your diet."" Review of the comprehensive plan of care, developed on 06/11/09, found on page 5: ""Resident exhibits or is at risk for dehydration as evidence by other UTI; and inadequate oral intake of food & fluids."" On page 13 was: ""Resident is at risk for alterations in comfort related to chronic pain."" The facility failed to develop a comprehensive plan of care for constipation for Resident #57, who had a decreased intake of oral fluids and who was on a pain medication which caused constipation. (See citation at F279.) Review of Resident #57's activities of daily living (ADL) record for July 2009 found five (5) consecutive full days when the resident did not have a bowel movement followed by no bowel movement on the next two (2) consecutive shifts on the sixth day (from 07/01/09 through 07/06/09). Review of the July 2009 MAR for this time period found no medication was given to alleviate this constipation. According to the facility's standing orders for constipation: If no bowel movement in three days, give milk of magnesia 30 cc by mouth times one dose. If no bowel movement on day four, give [MEDICATION NAME] suppository per rectally times one. If no bowel movement on day five, give fleets enema. If no results from fleets enema, call physician for further orders. On 08/04/09 at 5:00 p.m., the DON was asked if there was any medication given to help alleviate Resident #57's constipation between 07/01/09 and 07/06/09. On the following morning (08/05/09), the DON identified she did not have any additional information regarding treatment of [REDACTED]. c) Resident #39 Review of Resident #39's medical record revealed a [AGE] year old female who had been determined to have the capacity to make her own medical decisions, with [DIAGNOSES REDACTED]. She received [MEDICATION NAME] 5/500 mg per enteral tube every twelve (12) hours for backache and also had a [MEDICATION NAME] pump for pain control. She had self-imposed immobility, refusing to get out of bed except for a rare shower or to travel via ambulance for maintenance of her [MEDICATION NAME] pump. She had standing orders as follows: ""If no bowel movement (BM) in three days, give milk of magnesia (MOM) 30 cc PO (by mouth) x one dose. If no bowel movement on day four, give [MEDICATION NAME] suppository PR (per rectum) x one. If no bowel movement on day five, give Fleet enema. If no results from Fleet enema, call physician for further orders."" The July 2009 Medication Administration Record [REDACTED]. The nurses' notes, on 07/12/09, stated the resident was complaining of nausea and had refused her tube feeding. At 7:00 a.m. on 07/16/09, the nurses' notes stated, ""Resident assisted with digital removal of lg (large) BM via this nurse."" Review of previous MARs indicated use of MOM on a continuing basis and, although the frequency of bowel movements was difficult to determine, it was recorded in the nurses' notes on 04/16/09 that she had no BM x 4 days and, on 04/26/09, ""No BM x several days."" On both of these occasions, she refused an enema, and there was no mention in the record of her receiving a [MEDICATION NAME] suppository. There was no evidence in the record that staff had contacted the physician for further orders, although he was notified of her complaints of nausea and refusal of tube feedings. The care plan for Resident #39, initiated on 01/26/04 and revised on 07/09/09, addressed ""... complications related to immobility and [DIAGNOSES REDACTED]."" The only interventions were: ""Administer medications as ordered...."" and ""Observe abdomen for distention, bowel sounds and tenderness"". Both interventions were initiated on 01/26/04. No additional interventions had been added since 2004, although it was clear the goals had not been met. (See citation at F279.) During an interview with the minimum data set assessment / care plan nurse (Employee #9) at 1:40 p.m. on 08/05/09, she agreed the resident had chronic constipation and required intervention on a continuing basis, although she refused enemas. After reviewing the record, Employee #9 was unable to say why the suppository was not used or if the physician was notified. .",2015-04-01
10365,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-08-06,364,F,0,1,FGH911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, confidential resident group interview, observation, and staff interview, the facility failed to provide food that was palatable to ensure resident satisfaction by failing to season foods in a manner acceptable to the residents for two (2) of the twenty (20) sampled residents, two (2) random residents, and several of the residents at the anonymous group meeting. Resident identifiers: #54, #49, #90, and #91 (other identifiers were withheld due to confidentiality). Facility census: 112. Findings include: a) Residents #49 and #90 and residents attending the confidential group meeting The residents noted above complained, during interviews, that the food was not well seasoned and had no taste, especially cooked vegetables. A review of the diet orders found these residents were ordered either regular or ""no added salt"" diets, which would not limit the use of seasoning in the preparation of foods. The recipes for the foods on the menus for the days of survey, when reviewed, were found to include planned seasonings. b) At 4:50 p.m. on 08/04/09, this surveyor observed the final preparation of the evening meal. The cook was observed draining a very large amount of water from cooked carrots, by pouring it off into a sink, and then placing the carrots into a container on the steam table. She did not add any seasoning at this time, nor did she taste the carrots. When this surveyor tasted these carrots, they were very bland and tasteless. The spinach was also tasted and was also bland and tasteless. No seasonings could be detected. The potatoes were the only vegetable that detected seasoning. The dietary manager was present and acknowledged the foods were bland. She asked the cooks if they tasted the food, and both stated they had not. She stated she would do immediate education with the new cooks regarding the new menus and following the recipes. She also instructed the immediate addition of seasoning to the vegetables presently being served. She stated the facility was aware of food complaints and had formed a committee of residents to address the concerns which had met for the first time yesterday. c) Resident #54 Resident #54's medical record, when reviewed on 08/03/09 at 1:30 p.m., revealed a [AGE] year old male who was admitted to the facility on [DATE]. The resident had a history of [REDACTED]. The physician had ordered a no added salt, puree consistency diet. The resident had been determined by his physician to possess the capacity to to understand and make his own informed health care decisions. Resident #54, when interviewed on 08/04/09 at 10:30 a.m., stated the food was ""not seasoned and taste bland"". d) Resident #91 Resident #91, when interviewed on 08/03/09 at 1:45 p.m., reported she had lived at the facility for four (4) months. The resident was alert and able to express her needs and preferences. The resident stated, ""The meat is either raw or burnt."" The resident stated the beans were ""not seasoned and tasted terrible"". The resident displayed a hamburger wrapped in a napkin. The beef patty was visibly burnt with blackened edges. .",2015-04-01
10366,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-08-06,319,G,0,1,FGH911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, resident interview, and review of medication side effects, the facility failed to ensure one (1) resident of a sample of twenty (20), who was exhibiting psychosocial adjustment difficulties, received appropriate treatment and services. Resident #59 was a [AGE] year old female recently admitted to the facility from a hospital stay. The resident, upon admission, began to exhibit behaviors of yelling and cursing and was placed on psychoactive medications with sedative effects and which should be used with caution in persons with renal impairment (such as Resident #59), without first assessing the resident for psychosocial needs and offering non-pharmacologic interventions. An initial care plan focused on orientation to the facility but did not address the resident's need for psychosocial interventions related to her youthful age, severe physical problems, family needs, and behaviors that exhibited anger and the resident's withdrawing from interactions with staff. Facility census: 112. Findings include: a) Resident #59 Observations of the resident, on 08/04/09 at 9:00 a.m., revealed the resident was in a private room at the end of the hallway. When observed, the resident was sleeping. At 11:00 a.m., the resident was observed sleeping. At 1:30 p.m., the resident was very lethargic but began talking about her children and plans to go home. The resident was observed nodding off to sleep several times during the interview. review of the resident's medical record revealed [REDACTED]. The resident also had a [MEDICAL CONDITION] and gastric tube. A social history revealed the resident had three (3) children, lived with her spouse and was employed prior to the hospitalization . The resident was very weak and was admitted to the facility for physical and occupational therapy. The resident had capacity and scored 30 out of 30 on the facility's ""Mini Mental Examination."" An interview with the physical therapist (Employee #146), on 08/05/09 at 9:30 a.m., revealed the resident was very angry at first and currently was very withdrawn. The resident was aware that she needed to participate with the therapy, because the resident's goal was to go home either with her mother or her husband. (The resident had steps at her home, and her mother's home did not have steps.) She further stated that anyone of the age of Resident #59, and with the severe health problems she had, would be angry and withdrawn. An interview with the occupational therapist (Employee #148), on 08/05/09 at 10: 00 a.m., revealed the resident had anger issues. She further stated the resident usually came to therapy in the afternoon, because she slept most of the morning. The resident wanted to come to therapy in the afternoon, because it was quiet and other residents weren't around at that time. She stated the resident was angry and now was withdrawn. An interview with the social worker (Employee #144), on 08/04/09 at 11:15 a.m., revealed a care conference was not held, because the resident was admitted on [DATE] and a future care conference would determine the resident's psychosocial needs at that time. She had not communicated with the nursing staff to identify any psychosocial needs requiring immediate attention. The other social worker (Employee #145) stated they like to monitor the residents for a week or more to determine if a resident has any psychosocial needs. Employee #144, who was assigned to the resident, further stated she was aware of the resident's severe medical problems and that the resident had three (3) little children. She also stated that, when the husband came in with the resident on admission to the facility, he had cried. An interview with the nurse (Employee #31), on 08/05/09 at 11:40 a.m., revealed the resident was very weak and was taking therapy to gain strength and go home. She further stated the resident was angry most of the time and was very withdrawn. (This nurse routinely took care of the resident on day shift.) A facility's ""Psychoactive Medication Dosage Monitor"" indicated that, on 07/29/09, the resident received Klonopin 2 mg every twelve (12) hours, [MEDICATION NAME] 5 mg every day, and [MEDICATION NAME] 30 mg every day. On 07/31/09, the physician ordered the following: ""Add to Klonopin, [MEDICATION NAME] behavior as evidenced by resistive to care, yelling and cursing, multiple medical complaints."" According to Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th edition): - Klonopin, a benzodiazepine, should be used with caution in debilitated persons and persons with renal impairment. Klonopin also causes central nervious system depression resulting in sedation, drowsiness, confusion and/or ataxia. - [MEDICATION NAME], an antipsychotic, is highly sedating and should be used with caution in patients with severe [MEDICAL CONDITION]. - [MEDICATION NAME] is an antidepressant. Its sedative effects may be additive with other central nervious system depressants and/or [MEDICATION NAME]. The degree of sedation is moderate-high relative to other antidepressants. It should be used with caution in patients with renal dysfunction. (See citation at F329.) .",2015-04-01
10367,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-08-06,329,G,0,1,FGH911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, resident interview, and review of medication side effects, the facility failed to ensure the medication regimen of one (1) resident of a sample of twenty (20), who was exhibiting psychosocial adjustment difficulties, was free of unnecessary drugs without adequate indications for use and in the presence of adverse consequences. Resident #59 was a [AGE] year old female recently admitted to the facility from a hospital stay. The resident, upon admission, began to exhibit behaviors of yelling and cursing and was placed on psychoactive medications without first assessing the resident for psychosocial needs and offering non-pharmacologic interventions. She received antipsychotic drug therapy without having been diagnosed with [REDACTED]. In addition to the antipsychotic, she also received an antidepressant and a benzodiazepine, all of which had sedative effects and should be used with caution in persons with renal impairment (such as Resident #59). Multiple observations of the resident, on 08/04/09, found her to be sleeping throughout the morning. At 1:30 p.m., the resident was very lethargic but began talking about her children and plans to go home; she was observed nodding off to sleep several times during the interview. According to an interview with therapy staff, the resident received therapy services in the afternoon, because she slept most of the morning. Facility census: 112. Findings include: a) Resident #59 Observations of the resident, on 08/04/09 at 9:00 a.m., revealed the resident was in a private room at the end of the hallway. When observed, the resident was sleeping. At 11:00 a.m., the resident was observed sleeping. At 1:30 p.m., the resident was very lethargic but began talking about her children and plans to go home. The resident was observed nodding off to sleep several times during the interview. review of the resident's medical record revealed [REDACTED]. The resident also had a [MEDICAL CONDITION] and gastric tube. A social history revealed the resident had three (3) children, lived with her spouse and was employed prior to the hospitalization . The resident was very weak and was admitted to the facility for physical and occupational therapy. The resident had capacity and scored 30 out of 30 on the facility's ""Mini Mental Examination."" An interview with the physical therapist (Employee #146), on 08/05/09 at 9:30 a.m., revealed the resident was very angry at first and currently was very withdrawn. The resident was aware that she needed to participate with the therapy, because the resident's goal was to go home either with her mother or her husband. (The resident had steps at her home, and her mother's home did not have steps.) She further stated that anyone of the age of Resident #59, and with the severe health problems she had, would be angry and withdrawn. An interview with the occupational therapist (Employee #148), on 08/05/09 at 10: 00 a.m., revealed the resident had anger issues. She further stated the resident usually came to therapy in the afternoon, because she slept most of the morning. The resident wanted to come to therapy in the afternoon, because it was quiet and other residents weren't around at that time. She stated the resident was angry and now was withdrawn. An interview with the social worker (Employee #144), on 08/04/09 at 11:15 a.m., revealed a care conference was not held, because the resident was admitted on [DATE] and a future care conference would determine the resident's psychosocial needs at that time. She had not communicated with the nursing staff to identify any psychosocial needs requiring immediate attention. The other social worker (Employee #145) stated they like to monitor the residents for a week or more to determine if a resident has any psychosocial needs. Employee #144, who was assigned to the resident, further stated she was aware of the resident's severe medical problems and that the resident had three (3) little children. She also stated that, when the husband came in with the resident on admission to the facility, he had cried. (See citation at F319.) An interview with the nurse (Employee #31), on 08/05/09 at 11:40 a.m., revealed the resident was very weak and was taking therapy to gain strength and go home. She further stated the resident was angry most of the time and was very withdrawn. (This nurse routinely took care of the resident on day shift.) A facility's ""Psychoactive Medication Dosage Monitor"" indicated that, on 07/29/09, the resident received Klonopin 2 mg every twelve (12) hours, [MEDICATION NAME] 5 mg every day, and [MEDICATION NAME] 30 mg every day. On 07/31/09, the physician ordered the following: ""Add to Klonopin, [MEDICATION NAME] behavior as evidenced by resistive to care, yelling and cursing, multiple medical complaints."" According to Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th edition): - Klonopin, a benzodiazepine, should be used with caution in debilitated persons and persons with renal impairment. Klonopin also causes central nervious system depression resulting in sedation, drowsiness, confusion and/or ataxia. - [MEDICATION NAME], an antipsychotic, is highly sedating and should be used with caution in patients with severe [MEDICAL CONDITION]. - [MEDICATION NAME] is an antidepressant. Its sedative effects may be additive with other central nervious system depressants and/or [MEDICATION NAME]. The degree of sedation is moderate-high relative to other antidepressants. It should be used with caution in patients with renal dysfunction. .",2015-04-01
10368,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-08-06,159,D,0,1,FGH911,"Based on record review and staff interview, the facility failed to obtained written authorization from the court-appointed conservator for one (1) of twenty (20) residents prior to handling the resident's personal funds. Resident identifier: #49. Facility census: 112. Findings include: a) Resident #49 A review of financial records revealed, on 11/13/07, the court appointed both a guardian (WV DHHR) and a conservator (Community Response Foundation, Inc.) to act on Resident #112's behalf. The facility's records indicated that, on 08/04/09, Resident #112 had a total of $1563.53 in personal funds deposited with the facility. Further review revealed the authorization for the facility to handle these funds was signed with an ""X"" by the resident on 01/08/09, but the resident's mark was not witnessed. A quarterly statement was given to Resident #112 on 04/17/09, and his mark was witnessed by two (2) employees (#111 and #200). During an interview at 10:30 a.m. on 08/05/09 with Employees #200 and E#201 (who were responsible for handling resident funds), they acknowledged they had never contacted the resident's court-appointed conservator, because it was ""hard to get through to anyone"". They also stated they would try to reach someone before the amount in the account reached $2000. .",2015-04-01
10369,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-08-06,250,D,0,1,FGH911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to obtain a re-evaluation of a resident's determination of capacity to make decisions about health care, and whether or not they would like anyone else to be involved in those decisions, after the physician had previously determined, on 06/14/09, the resident's incapacity was of short-term duration for one (1) of twenty (20) sampled residents. Resident identifier: #100. Facility census: 112. Findings include: a) Resident #100 A review of the clinical record revealed Resident #100 was a [AGE] year old male with [DIAGNOSES REDACTED]. He was admitted to the facility on [DATE] and, on 06/14/08, was determined by his physician to lack capacity to make medical decisions (with the incapacity was projected to be of short-term duration due to mild dementia), although he was allowed to sign his own release of medical information form on 06/13/08. A significant change in status minimum data set assessment (MDS), with an assessment reference date of 07/27/09, indicated the resident had ""some difficulty in new situations only"" with modified independence in cognitive skills for daily decision-making. The resident assessment protocol stated this was due to mild dementia and decreased memory / decision skills. Further record review revealed no evidence the resident's capacity status had been re-evaluated since admission. In an interview at 11:00 a.m. on 08/05/09, the social worker stated that, usually, all short-term determinations of capacity were re-assessed after three (3) months, and Resident #100's had just been overlooked. .",2015-04-01
10370,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-08-06,281,D,0,1,FGH911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to ensure a nurse obtained an order from the physician prior to performing an invasive procedure (digital removal of a fecal impaction) on one (1) of twenty (20) sampled residents. Resident identifier: #43. Facility census: 112. Findings include: a) Resident #43 Resident #43's medical record, when reviewed on 08/03/09 at 2:00 p.m., disclosed a [AGE] year old female who was admitted to the facility on [DATE]. The quarterly minimum data set assessment (MDS), with an assessment reference date of 06/26/09, reported the resident had a fecal impaction. Further record review revealed the physician ordered Senna S two (2) tablets daily for constipation. A nursing note, dated 06/17/09 at 1:00 p.m., stated, ""Emesis x 1. Temp 101.5. Med given per order."" A subsequent nursing note, dated 06/18/09 at 4:25 a.m., stated, ""This nurse assisted resident with digital removal of large BM (bowel movement)."" There was no mention in either note that the nurse notified the physician of a change in the resident's change in condition on 06/17/09 or 06/18/09. Review of the nursing notes and physician's orders [REDACTED]. The care plan nurse (Employee #24), when interviewed on 08/04/09 at 10:00 a.m., stated the resident had a fecal impaction on 06/18/09. Employee #24 provided a copy of the facility's policy on fecal impaction. The policy titled ""Fecal Impaction: Removal of"" (revised 01/01/04) stated, ""Digital removal of stool will be performed by a licensed nurse per physician order."" Review of the facility's ""Standing Orders Template"" found no order for the digital removal of stool as an intervention to treat constipation. The director of nurses (DON - Employee #25), when interviewed on 08/05/09 at 10:00 a.m., confirmed the policy titled ""Fecal Impaction: Removal of "" (revision date 01/01/04) was the facility's current policy. The DON did not provide any additional evidence to reflect the physician had ordered the procedure and/or was notified of an acute change in the resident's health status. (See citation at F157.) .",2015-04-01
10371,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-08-06,246,E,0,1,FGH911,"Based on observation, staff interview, and confidential resident group interview, the facility failed to ensure staff responded timely to residents' activated call lights. Resident identifier: #28 (other identifiers withheld due to confidentiality). Facility census: 112. Findings include: a) Resident #28 Upon arrival on the 400 hall through closed fire doors at 8:30 a.m. on 08/04/09, observation found the call light above the door to Resident #28's room was on. Observation of Resident #28 found her sitting on her bed in no apparent distress. A nurse was on the hall with the medication cart, and two (2) nursing assistants were observed passing Resident #28's room while a third nursing assistant was observed further down the hall. At 8:35 a.m., the fire doors were secured in an open position. At 8:45 a.m., the administrator came on the hall, entered Resident #28's room, and asked the resident about her needs. When this was discussed with the administrator shortly thereafter, she agreed that one (1) of the staff members observed by this surveyor should have answered Resident #28's call light sooner. b) Confidential Resident Group Meeting During the confidential resident group meeting beginning at 3:30 p.m. on 08/04/09, five (5) of the thirteen (13) residents present reported staff did not respond promptly to their call lights. c) During an interview with the administrator at 9:00 a.m. on 08/05/09, she stated the facility was monitoring the amount of time taken by staff to answer call lights on different halls and on different shifts and that education had been done, but she did not have any evidence of progress in addressing this issue at this time. .",2015-04-01
10372,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-08-06,157,D,0,1,FGH911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to ensure the physician was notified when one (1) of twenty (20) sampled residents had an acute change in condition evidenced by vomiting, elevated temperature, and a fecal impaction. Resident identifier: #43. Facility census: 112. Findings include: a) Resident #43 Resident #43's medical record, when reviewed on 08/03/09 at 2:00 p.m., disclosed a [AGE] year old female who was admitted to the facility on [DATE]. The quarterly minimum data set assessment (MDS), with an assessment reference date of 06/26/09, reported the resident had a fecal impaction. Further record review revealed the physician ordered Senna S two (2) tablets daily for constipation. A nursing note, dated 06/17/09 at 1:00 p.m., stated, ""Emesis x 1. Temp 101.5. Med given per order."" A subsequent nursing note, dated 06/18/09 at 4:25 a.m., stated, ""This nurse assisted resident with digital removal of large BM (bowel movement)."" There was no mention in either note that the nurse notified the physician of a change in the resident's change in condition on 06/17/09 or 06/18/09. Review of the nursing notes and physician's orders [REDACTED]. The care plan nurse (Employee #24), when interviewed on 08/04/09 at 10:00 a.m., stated the resident had a fecal impaction on 06/18/09. Employee #24 provided a copy of the facility's policy on fecal impaction. The policy titled ""Fecal Impaction: Removal of"" (revised 01/01/04) stated, ""Digital removal of stool will be performed by a licensed nurse per physician order."" Review of the facility's ""Standing Orders Template"" found no order for the digital removal of stool as an intervention to treat constipation. The director of nurses (DON - Employee #25), when interviewed on 08/05/09 at 10:00 a.m., confirmed the policy titled ""Fecal Impaction: Removal of "" (revision date 01/01/04) was the facility's current policy. The DON did not provide any additional evidence to reflect the physician was notified of an acute change in the resident's health status and/or ordered the digital removal of a fecal impaction. (See citation at F281.) .",2015-04-01
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
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
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
10452,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2009-08-13,156,B,0,1,924C11,"Based on observation and staff interview, the facility failed to post contact information for all pertinent State client advocacy groups in a location accessible to all residents. This practice has the potential to affect more than an isolated number of residents who could benefit from this information. Facility census: 153. Findings include: a) Observation, on the morning of 08/13/09, found the names, addresses, and telephone numbers for State advocacy groups were posted on a bulletin board located between two (2) sets of double doors as one enters the facility. Many residents do not go near this location and would not easily access the information on these postings. When brought to the attention of the administrator on the early afternoon of 08/13/09, he verified the information would be more easily accessible at another location and stated he would move them to a new area which was frequented more often by residents. .",2015-03-01
10453,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2009-08-13,159,D,0,1,924C11,"Based on record review and staff interview, the facility failed to obtain written authorization for two (2) of five (5) sampled residents prior to managing their personal funds accounts. Resident identifiers: #48 and #56. Facility census: 153. Findings include: a) Resident #48 Review of the financial records for this resident found the facility allowed the resident's health care surrogate to make financial decisions on behalf of the resident. The WV Health Care Decisions Act only allows a health care surrogate to make medical decisions on behalf of a resident who lacks capacity, not financial decisions. b) Resident #56 Review of this resident's financial records found an individual signed the authorization form to give the facility the right to handle the resident's personal funds, but there was no document giving this individual the legal authority to do so. This was discussed with the person in charge of handling resident funds on the afternoon of 08/11/09. .",2015-03-01
10454,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2009-08-13,167,C,0,1,924C11,"Based on staff interview and observation, the facility failed to post the most recent survey results for examination. This practice has the potential to affect all residents, their legal representatives, and members of the general public wishing to review this information. Facility census: 153. Findings include: a) Review of a binder located in the lobby area of the facility and labeled ""Survey Result: found the binder only contained the results from a recent complaint survey. The binder did not contain the results of the facility's last annual standard survey and all complaint investigations conducted from the date of the last annual survey (05/08/08) to the present. This was brought to the attention of the administrator on the early afternoon of 08/13/09, at which time he verified the results of the last annual survey were missing from the binder. He related that someone must have removed the full set of survey results and he would replace the report. .",2015-03-01
10455,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2009-08-13,514,D,0,1,924C11,"Based on record review and staff interview, the facility failed to ensure the clinical records of two (2) of two (2) hospice residents had current physician orders to receive the hospice services in the nursing facility. Resident identifiers: #17 and #28. Facility census: 153. Findings include: a) Residents #17 and #28 Review of the medical records for Residents #17 and #28 revealed no physician orders on record to receive hospice services. A member of the medical records staff (Employee #83) was asked to retrieve any original orders for hospice services from the thinned records of these residents. She was able to locate the information in the thinned medical records. At that time, it was identified that the physician orders for hospice services had not been carried over onto the monthly recapitulation of physician orders. Resident #17's physician ordered hospice care on 01/10/09, and Resident #28's physician ordered hospice care on 03/03/09. This was brought to the attention of nursing and medical records staff on the morning of 08/13/09.",2015-03-01
10456,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2009-08-13,279,D,0,1,924C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, a review of the facility's policy and procedures, and staff interview, the facility failed to include interventions in the plan of care to improve urinary incontinence for one (1) of twenty-one (21) sampled residents. The care plan addressed the problem of a decline in continence due to a recent [MEDICAL CONDITION] and the potential for improved control in bladder continence, and a goal was established for improved urinary control. However, there were no interventions initiated to further assess or manage this resident's incontinence. Resident identifier: #42. Facility census: 153. Findings include: a) Resident #42 Review of the resident's most recent minimum data set assessment (MDS), with an assessment reference date (ARD) of 05/03/09, revealed this resident had experienced a significant change in status. She had sustained a [MEDICAL CONDITION] and, as a result, she required increased staff assistance with the performance of activities of daily living (ADLs). Also noted on this assessment was the assessor coded the resident as a ""2"" in bladder continence, indicating she was occasionally incontinent of bladder two (2) or more times a week but not daily. The ARD established a lookback period of fourteen (14) days with respect to continence, which included a four-day period prior to the resident's [MEDICAL CONDITION] during which the resident was continent of bladder. However, after the hospitalization (from 04/25/09 to 04/27/09), the resident's bladder continence status declined. According to the medical record, this resident became incontinent daily, although this decline was not captured on the significant change in status assessment. (See citation at F278.) Review of this resident's ADL flow sheets, completed daily the resident's care givers, during the months of May, June, July, and August 2009, this resident was incontinent of bladder multiple times daily. The current plan of care for this resident was initiated on 05/09/09. At that time, she was experiencing urinary incontinence multiple times daily. The plan of care identified the resident was ""incontinent with potential for improved control or management of urinary elimination due to recent [MEDICAL CONDITION]"". The goal established for this problem stated she would ""demonstrate improved urinary elimination control as evidenced by experiencing less than 2 episodes of urinary incontinence per day"". Review of the approaches established to assist the resident in attaining this goal found no directive to complete a continence management diary and/or to establish a toileting plan or schedule to assist the resident in improving her urinary continence. A review of the facility's policy and procedure titled ""5.10 Continence Management"" (last revised on 11/15/08) indicated a three-day continence management diary was to be completed if the patient were incontinent upon admission or re-admission and with a significant change in condition. During an interview on 08/12/09 at 2:45 p.m., the MDS nurse (Employee #181) confirmed there were no interventions in the plan of care for further evaluation of this resident's continence. She also confirmed the plan of care did not follow the facility's policy and procedure for addressing a decline in bladder function. .",2015-03-01
10457,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2009-08-13,278,D,0,1,924C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the minimum data set assessment (MDS) accurately reflected a change in the status of Resident #42's bladder functioning. The assessment did not accurately reflect the status for one (1) of twenty-one (21) sampled residents. Resident identifier: #42. Facility census: 153. Findings include: a) Resident #42 Review of an abbreviated quarterly MDS, with an assessment reference date (ARD) of 03/10/09, found, at Item H.1.b., this resident was usually continent of her bladder - coded ""1"" to indicate the resident was only incontinent of bladder once a week or less. On the next assessment, a comprehensive MDS for a significant change in status (with an ARD of 05/03/09), the assessor noted the resident was now incontinent occasionally of bladder - coded ""2"" to indicated the resident was incontinent of bladder two (2) or more times a week but not daily. Review of the nursing assistant flow sheets found the resident's bladder elimination was coded ""I "" (incontinent) on a daily basis since her readmission from the hospital on [DATE]. At Item H.4. of the 05/03/09 MDS, the assessor noted ""0"" to indicate this resident had not experienced a change in continence in the last ninety (90) days or since her last assessment. This information was incorrect and did not accurately reflect the resident's status; she had actually experienced a decline and, since that time, had been incontinent each shift. During an interview on 08/12/09 at 2:45 p.m., the MDS nurse (Employee #181) confirmed this resident had experienced a decline in her bladder functioning but this was not accurately reflected on the 05/03/09 MDS. .",2015-03-01
10458,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2009-08-13,309,D,0,1,924C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, manufacturer's instructions, and staff interview, the facility failed to assure an aerosol medication was administered properly to assure the resident received the full therapeutic benefits of the medication. The resident self-administered two (2) puffs of a hand-held inhaler without waiting the required amount of time between puffs. There were no instructions provided by the nurse to assure the resident understood how to use this medication properly, and the resident's physician orders [REDACTED]. Medications were not properly administered for one (1) of forty (40) opportunities observed. Resident identifier: #33. Facility census: 153. Findings include: a) Resident #33 Observation of a nurse (Employee #24) administering medications on 08/10/09 at 5:45 p.m., found Resident #33 was to receive a hand held inhaler as follows: ""[MEDICATION NAME] -UD (unit dose) - Inhalation q 6 hours (every six hours) 2 puffs."" The nurse handed the inhaler to the resident, and the resident immediately administered two (2) puffs and handed the inhaler back to the nurse. The nurse did not provide any verbal instructions to the resident prior to the use of this medication, nor did the nurse provide corrective teaching to ensure the resident knew she needed to wait between puffs. The resident was alert and oriented, and her physician's orders [REDACTED]. A review of the manufacturer's instructions for use of this aerosol medication revealed the following directive: ""If your doctor has prescribed more than one spray, wait 1 minute and shake the inhaler again. Then repeat steps of administration."" .",2015-03-01
10459,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2009-08-13,315,D,0,1,924C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, a review of the facility's policies and procedures on Continence Management, resident interview, and family interview, the facility failed to provide appropriate assessment, treatment, and services to restore as much normal bladder function as possible after Resident #42 experienced a significant decline in urinary continence upon her return from a hospitalization for a [MEDICAL CONDITION]. The facility did not appropriately intervene to attempt to restore prior bladder functioning for one (1) of twenty-one (21) sampled residents. Resident identifier: #42. Facility census: 153. Findings include: a) Resident #42 In an interview during the initial tour of the facility on 08/10/2009 at 2:30 p.m., Resident #42 identified a decline in her bladder functioning within the last few months. According to the resident, she did not turn her light on in time to ask for help, and it was ""often too late by the time they get there."" She also stated she now had to wear ""diapers"". A family member, who present during the resident interview on 08/10/09 at 2:30 p.m., identified the resident had had a decline in her bladder functioning since her [MEDICAL CONDITION] a few months ago. According to the family member, the resident was very seldom incontinent prior to going to the hospital. Since her return, the family member stated the resident was incontinent every day. She stated that, sometimes, she came in and found Resident #42 lying in the bed wet. She reported that a nurse told her they were going to put Resident #42 on a toileting program as part of a restorative program, but the nurse who was supposed to initiate this plan never came in. The family member reported she takes the resident to the bathroom when she is visiting almost every day, and the resident is never incontinent when the family member is here. She stated she had verbalized this concern to the nurses and had not heard anything further about a toileting program Review of Resident #42's medical record found she was continent on all three (3) shifts during the month of April 2009, prior to her hospitalization on [DATE]. She returned from the hospital on [DATE] after only two (2) days. Upon her return, she was incontinent at times for the next three (3) days. According to the medical record, she was then incontinent on a daily basis on all three (3) shifts in the month of May 2009. A comparison of minimum data set (MDS) assessments found this resident declined from once being usually continent to now being occasionally incontinent two (2) or more times a week but not daily. However, review of her activities of daily living (ADL flow records revealed she was actually incontinent daily on each shift. Resident #42's care plan, revised on 05/09/09, identified Resident #42 was ""incontinent of urine with potential for improved control or management of urinary elimination due to her recent [MEDICAL CONDITION]."" The goal was for the resident to demonstrate improved urinary elimination by experiencing less than two (2) episodes of urinary incontinence per day. There were no intervention to assist her in achieving the goal, there were no further evaluations of the cause of the incontinence, and no toileting plan was initiated. A review of the facility's policy and procedure titled ""5.10 Continence Management"" (last revised on 11/15/08) found a urinary incontinence assessment and a three-day continence management diary were to be completed if the patient were incontinent upon admission or readmission and with a significant change in condition. (There was no evidence such an assessment was completed for Resident #42.) The policy also stated staff was to use the assessment and the three-day continence management diary as the basis for developing a care plan to improve the resident's bladder function. In an interview on 08/13/09 at 2:00 p.m., the restorative nurse (Employee #20) confirmed the resident had not received an assessment after her bladder continence decline and there was no evidence that a three-day continence management diary record had been kept as per the facility's policy. The nurse then initiated a three-day continence diary. .",2015-03-01
10460,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2009-08-13,431,D,0,1,924C11,"Based on observation and staff interview, the facility failed to assure medications used in the facility were labeled with the residents' names to assure each medication was administered to the correct resident. An inhaler was removed from the drawer; it did not have a box or a label to identify the resident for whom the medication had been ordered. There was no label for one (1) of forty (40) medications observed. Resident identifier: #33. Facility census: 153. Findings include: a) Resident #33 During medication administration on 08/10/09 at 5:45 p.m., observation found the nurse (Employee #24) preparing medications for Resident #33. An inhaler was obtained from the drawer of the medication cart. This hand held inhaler was in the medication cart without a box, and the inhaler itself did not have a label or a name on it. The nurse prepared the medications for administration. The surveyor then asked the nurse, ""How do you know that is the correct inhaler and who it belongs to."" The nurse said, ""Well, I guess I do not."" She then threw it in the trash and obtained a new one with the proper label on the box. The proper medication was then administered. .",2015-03-01
10461,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2009-08-13,246,E,0,1,924C11,"Based on observation and staff interview, the facility failed to assure staff responds promptly to residents' activated call lights. A call light was observed ringing for twenty-seven (27) minutes before a staff member answered it. A nurse was observed walking past the call light four (4) different times without stopping to check on the resident, and four (4) nursing assistants on that floor, who were standing at the dining room door waiting on the dinner trays to arrive from the kitchen, also did not check on the resident. This practice affected one (1) resident of random opportunity (#71) with the potential to affect more than an isolated number of other residents. Facility census: 153. Findings include: a) Resident #71 A random observation, on 08/10/09, found a call light activated above the corridor door to Resident #71's room. At 5:45 p.m., observation found a nurse in the hall just outside of that room preparing to administer medications. The nurse walked past Resident #71's room four (4) times while the call light was on without acknowledging it. This surveyor entered Resident #71's room at 6:00 p.m., to see what the resident needed. The resident was non-verbal and could not make himself understood. He was laying in bed and was observed to be safe. The surveyor walked back out into the hall, upon looking down the hall, observed four (4) nursing assistants standing by the dining room door waiting for the dinner trays to arrive. At 6:12 p.m., a nurse (Employee #64) was observed to go into Resident #71's room. The resident's call light turned off, and the nurse came out of the room. When asked what the resident needed, the nurse said he just wanted a drink of water and to be covered up. The nurse was made aware the call light had been on for twenty-seven (27) minutes prior to her answering the light. .",2015-03-01
10462,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2009-08-13,492,D,0,1,924C11,"Based on personnel file review and staff interview, the facility failed to ensure one (1) of ten (10) sampled employees was informed of the central abuse registry. West Virginia State code 15-2C-8 requires nursing facilities to inform staff of central abuse registry through a uniform notice. Employee identifier: #26. Facility census: 153. Findings include: a) Employee #26 A review of sampled employees' personal files, on 08/12/09 at approximately 5:00 p.m., revealed one (1) employee (#26) did not have evidence of having received a notice of the central abuse registry, as set forth in West Virginia State Code 15-2C-8. On 08/12/09 at approximately 5:10 p.m., a member of the business office staff (Employee #52) confirmed the employee's file did not contain evidence to show this mandatory notice was provided. .",2015-03-01
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
10487,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2009-08-20,159,D,0,1,D1B011,"Based on record review and staff interview, the facility disclosed information regarding a resident's personal funds account to an individual who did not have the legal authority to receive this information. This was evident for one (1) of five (5) residents whose personal funds were reviewed. Resident identifier: #21. Facility census: 60. Findings include: a) Resident #21 Financial records for this resident were reviewed as part of the resident funds accounting portion of the survey process. The review revealed this resident's quarterly financial statements were going to the individual designated as the resident's health care surrogate. (Under the WV Health Care Decisions Act, a health care surrogate only has the legal authority to make health care decisions on behalf on a resident lacking the capacity to do so; a health care surrogate does not have the legal authority to access a resident's finances or make financial decisions on behalf of a resident.) There was no document showing the resident's health care surrogate had the legal right to access this information. This was verified with the administrator and business office manager (Employee #69) on the afternoon of 08/19/09. .",2015-03-01
10488,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2009-08-20,249,C,0,1,D1B011,"Based on personnel file review and staff interview, the facility failed to employ the services of a qualified activities director. This practice has the potential to affect all residents, as this individual coordinates all activities for all the residents in the facility. Facility census: 60. Findings include: a) Personnel record review revealed the individual currently employed in the capacity of activities director did not possess any of the credential that would qualify this person to serve in that capacity. When this was discussed with the administrator at different times on 08/18/09 and 08/19/09, the administrator related the individual currently employed as the activities director would be completing an on-line course but had not started any lessons. This was also confirmed with the activities director on the early afternoon of 08/19/09, when she brought the surveyors computer printouts of what on-line course she would be taking in the future.",2015-03-01
10489,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2009-08-20,514,D,0,1,D1B011,"**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 clinical record was maintained in accordance with professional standards and practices. Documentation of fluid intake and output for Resident #40 was incomplete, and the hospice orders for Resident #55 were not readily accessible, accurate, and/or complete. Facility census: 60. Findings include: a) Resident #40 Review of this resident's medical record revealed incomplete documentation regarding fluid intake and output. The physician had ordered staff to monitor Resident #40's fluid intake and output. Review of intake and output records found multiple omissions, including omissions on 06/18/09, 06/21/09, 06/22/09, 06/26/09, 06/29/09, 06/30/09, 07/01/09 through 07/05/09, 07/09/09, 07/13/09, and 07/14/09. This was discussed with nursing staff and the administrator on the morning of 08/20/09, and they verified the documentation in the resident's medical record was not complete. They thought the information might be on care tracker computer system, but after review, it was not found there either. b) Resident #55 The current August 2009 physician orders [REDACTED]. Staff was asked about this on the afternoon of 08/19/09, at which time the surveyor was given a copy of the hospice agency's standings orders dated 04/28/09, which were signed by the attending physician from the facility. There were no further clarifications or directions regarding which of these standing orders should be followed for the resident's current care. No items had been deleted or carried forward from these orders to the facility's current physician orders. This was verified with the administrator on the morning of 08/20/09.",2015-03-01
10490,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2009-08-20,225,E,0,1,D1B011,"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 effect more than an isolated number of residents. Employee identifiers: #43 and #85. Facility census: 60. Findings include: a) Employees #43 and #85 On 08/19/09, 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 neighboring states. Employee #43 listed her address as Catlettsburg, Kentucky, and Employee #85 noted she had been graduated from a nursing school across the river in the State of Ohio. 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 RB-05 titled ""Abuse, Neglect, and Misappropriation of Resident's Property: Protection of Residents / Reporting and Investigation"" (effective 01/09/09) found no written procedure to ensure pre-employment screening included checking for evidence of criminal convictions in bordering states when information provided on an individual's employment application indicates residences, work experiences, and/or educational experiences in other states. During an interview on 08/19/09 at 2:00 p.m., the administrator 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. .",2015-03-01
10491,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2009-08-20,315,D,0,1,D1B011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure an indwelling urinary catheter was utilized only when a resident's clinical condition demonstrated this was necessary. Resident #58 had an indwelling catheter inserted for [MEDICAL CONDITION]. There was no evidence the facility assessed the resident's retention or adequately monitored this condition. Without an adequate assessment of the resident's bladder function, there was no evidence this catheter was necessary. This was true for one (1) of thirteen (13) sampled residents. Resident identifier: #58. Facility census: 60. Findings include: a) Resident #58 Record review revealed Resident #58 had a history of [REDACTED]. There was no evidence he had any signs of [MEDICAL CONDITION] at that time. According to the record, the resident was incontinent of bladder multiple times daily from 04/04/09 to 07/05/09. A physician's telephone order was written on 07/05/09 for: ""#18 FR Foley d/t (due to) Retention. Cath (catheter) care q (every) shift, change q month."" Review of the resident's medical record for the time period leading up to the insertion of the catheter in July 2009 found no evidence this resident had [MEDICAL CONDITION]. His nursing notes did not assess the presence of [MEDICAL CONDITION], and there was no nursing notes reflecting the resident had complained of [MEDICAL CONDITION] or of an inability to void normally or that a catheter was inserted for retention. The nursing assistant flow sheets for July 2009 indicated Resident #58 was incontinent of urine and had urinary output. During an interview at 2:30 p.m. on 08/18/09, the nurse (Employee #61) confirmed there was no evidence in the medical record to indicate this resident was having urinary elimination problems prior to the indwelling catheter being inserted on 07/05/09. The nurse also confirmed there had been no monitoring of the resident's fluid intake and output to verify a problem existed with [MEDICAL CONDITION]. .",2015-03-01
10492,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2009-08-20,356,C,0,1,D1B011,"Based on observation and staff interview, the facility failed to ensure the daily posting of nursing staff was updated at the beginning of each shift. The posting was not completed for evening shift at 6:05 p.m. on 08/17/09. This posting is to allow the residents and visitors to know how many staff members are caring for the residents at any given time. Facility census: 60. Findings include: a) Review of the nurse staffing data at 6:05 p.m. on 08/17/09 found the evening shift (3:00 p.m. to 11:00 p.m.) staffing data had not been posted. The administrator, when made aware on 08/17/09 at 7:30 p.m. that this posting was blank for the evening shift, confirmed it should have been completed at the beginning of the shift. .",2015-03-01
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
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
10480,GLENVILLE CENTER,515103,111 FAIRGROUND ROAD,GLENVILLE,WV,26351,2009-08-26,252,E,0,1,O8DH11,"Bases on observations and staff interview, the facility failed to provide a common shower bathing area that was clean. This has the potential to affect all residents on the 200 hallway who use this shower room. Facility census: 57. Findings include: a) Observations, on 08/24/09 at 11:45 a.m. and again at 3:30 p.m., revealed the shower room on the 200 hallway was not clean. The toilet was observed to have rust, feces, and urine stains in the toilet bowl and on the toilet seat. The tub was noted to have visible dirt, debris, stains, and a plastic razor blade cover and a plastic can cover in the bottom of the tub. Observations, on 08/25/09 at 9:45 a.m., revealed the shower room on the 200 hallway was again not clean. The toilet was observed to have rust, feces, and urine stains in the toilet bowl and on the toilet seat. The tub was noted to have visible dirt, debris, stains and a plastic razor blade cover and a plastic can cover in the bottom of the tub. The housekeeper (Employee #48), when interviewed on 08/25/09 at 9:45 a.m., reported the tub was broken and not in use. The housekeeper, who acknowledged being responsible for cleaning the 200 shower room area, reported having cleaned the toilet in the 200 shower room between 1:30 p.m. and 3:00 p.m. on 08/24/09. The 200 shower room was subsequently at 12:40 p.m. on 08/25/09. At that time, the tub and toilet were cleaned and free from stains. .",2015-03-01
10481,GLENVILLE CENTER,515103,111 FAIRGROUND ROAD,GLENVILLE,WV,26351,2009-08-26,279,D,0,1,O8DH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to develop comprehensive care plans for three (3) of thirteen (13) sampled residents, and one (1) of two (2) residents whose closed records were reviewed. The facility did not developed care plans for two (2) residents where the physician had ordered comfort measures. The facility failed to address, in the care plan, mood state for one (1) resident and bed safety for another resident with a physician's orders [REDACTED]. Resident identifiers: #63, #47, #44, and #19. Facility census: 57. Findings include: a) Resident #63 Resident #63's medical record, when reviewed on 08/26/09, revealed a [AGE] year old female who was admitted to the facility on [DATE]. The physician had ordered comfort measures on 07/16/09. The current care plan, with a revision date of 06/26/09, did not include comfort measures and the specific interventions the facility staff was implementing for this resident. The director of nurses (DON - Employee #70), when interviewed on 08/26/09 at 11:30 a.m., provided a copy of pages 162 and 164 from Lippincott Manual of Nursing Practice (Eighth Edition), as the facility's current policy on comfort measures. The clinical case manager, a registered nurse (RN- Employee #30), when interviewed on 08/26/09 at 2:25 p.m., reviewed the resident's current care plan and confirmed comfort measures were not addressed in the resident's plan of care. The RN was unaware pages 162 and 164, from the Lippincott Manual of Nursing Practice (Eighth Edition) were the facility's current policy for comfort measures. b) Resident #47 Resident #47's medical record, when reviewed on 08/25/09 at 9:00 a.m., revealed a [AGE] year old female, who was admitted to the facility on [DATE]. The minimum data set assessment (MDS), with an assessment reference date (ARD) of 07/30/09, reported the resident had repetitive health complaints. Review of the resident assessment protocol (RAP) summary associated with this MDS revealed mood state was to be addressed in the resident's current care plan. Review of the resident's current care plan, with a revision date of 08/05/09, found no mention of any problems, goals, or approaches to address the resident's mood state. The clinical case manager (Employee #30), when interviewed on 08/26/09 at 2:30 p.m., reviewed the resident's current care plan and confirmed the resident's mood state was not addressed in the current care plan. c) Resident #44 The medical record of Resident #44, when reviewed on 08/27/09, disclosed this [AGE] year old male was admitted to the facility on [DATE]. The resident had declined physically in the previous months and, on 08/12/09, the resident's attending physician had wrote in a progress note, ""Comfort measures primarily, treat infection and encourage fluids. Meds as tolerated."" The resident's current plan of care, when reviewed, disclosed no mention of the plan for this resident to receive comfort measures only, nor any mention of special directives to staff as to what was to be included in ""comfort care"". d) Resident #19 Observation, during a random tour of the facility on 08/24/09 at 11:45 a.m., found this resident's bed consisted 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 08/24/09, the resident was observed to be lying on the mattress. The resident's current plan of care, when reviewed, noted the resident had experienced numerous falls and the physician had written an order for [REDACTED]. The DON, when interviewed on 08/26/09 at 9:00 a.m., stated the staff, in conjunction with the resident's family / responsible party, had determined this method would be the best for this resident in preventing further falls and injuries. The resident's care plan made no mention of how staff was to address the resident's special needs in association with having a mattress on the floor, such as how the resident should be moved out of the bed, how and if the resident should receive food / snacks in bed, etc. The DON confirmed, on 08/26/09 at 2:30 p.m., the resident's care plan did not address these special issues. .",2015-03-01
10482,GLENVILLE CENTER,515103,111 FAIRGROUND ROAD,GLENVILLE,WV,26351,2009-08-26,280,D,0,1,O8DH11,"**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 plan of care for one (1) of thirteen (13) residents reviewed following an assessed change in the resident's condition. A resident had choked on two (2) occasions, and no change was made to the resident's plan of care to prevent further choking episodes. Resident identifier: #20. Facility census: 57. Findings include: a) Resident #20 The facility's incident / accident reports, when reviewed on 08/25/09, disclosed Resident #20 had choked while eating on two (2) occasions (07/07/09 and 08/18/09). The second occasion of choking required the resident be suctioned to clear her airway. The resident was a [AGE] year old female with a [DIAGNOSES REDACTED]. The resident's plan of care was reviewed to ascertain what steps the facility had implemented in an attempt to alleviate further choking episodes. Although the care plan divulged the resident had been identified as having difficulties with swallowing and chewing, there had been no changes to the care plan following the second episode on 08/18/09. The facility's director of nurses (DON), when interviewed related to this issue on 08/26/09 at 1:30 p.m., described steps the facility staff had undertaken since the choking episode, but she confirmed these steps were not described in the resident's plan of care. .",2015-03-01
10210,SHENANDOAH CENTER,515167,50 MULBERRY TREE STREET,CHARLES TOWN,WV,25414,2009-08-27,371,F,0,1,YIQY11,"Based on observations and staff interview, the facility failed to maintain sanitary food conditions for the handling of a brownie food mix in the dry storage room, failed to maintain sanitary practices when the utensils used in food preparation were not properly air dried prior to storage, and failed to clean the convection oven to destroy potential disease-carrying organisms. The practice of the dietary department allowing for improper sanitary conditions has the potential for food contamination and compromised food safety to affect the seventy-one (71) resident receiving oral nourishment from the kitchen. Facility census: 73. Findings include: a) During the initial tour of the kitchen on 08/24/09 about 3:15 p.m., observations found the following: 1. The dry food storage room revealed an opened package of brownie mix on a storage shelf. The food service supervisor acknowledged the brownie mix had been opened, and she removed and disposed the open food package. 2. Observation of the large mixing bowls stacked and stored on a shelf below the steamer revealed the bowls were still wet and had not been completely air dried. Also, the stacked steam table pans had not been totally air dried, as there was water between the stored pans. Repeat observations, with the food service supervisor on the afternoon of 08/26/09, found the large mixing bowls again had not been totally air dried (the same as found on 08/24/09). 3. The convection oven's air vent at the back of the oven revealed a build-up of food accumulation that was brownish / black in color. In an interview on the afternoon on 08/26/09, the food service supervisor acknowledged the oven was not being effectively cleaned .",2015-06-01
10211,SHENANDOAH CENTER,515167,50 MULBERRY TREE STREET,CHARLES TOWN,WV,25414,2009-08-27,314,G,0,1,YIQY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, a review of the medical record, and staff interviews, the facility failed to ensure two (2) of a sample of nine (9) residents (#64 and #24) received care and services, to include prompt identification and treatment of [REDACTED]. Resident #64 developed a coccygeal pressure ulcer during a hospital stay which was being treated by the facility. Upon removal of the dressing to this wound on the morning of 08/25/09, observation revealed two (2) additional breaks in skin integrity of which the nurse was not previously aware and for which no treatment had been initiated. One (1) of these wounds was a Stage II and the other was a Stage IV. Resident #24 had a pre-existing pressure ulcer to her coccyx and received dressings to her right foot and ankle. Upon removal of the dressing to the coccygeal wound on the morning of 08/25/09, observation two (2) additional breaks in skin integrity of which the nurse was not previously aware and for which no treatment had been initiated, both of which were dime-size and open. Additionally, observation of the resident's right foot at that time found the area on her right ankle was not covered with a dressing. Facility census: 73. Findings include: a) Resident #64 On 08/25/09 at 9:40 a.m., observation revealed the resident was receiving a dressing change to a pressure area on her coccyx. A registered nurse (RN - Employee #5) removed the dressing on the pressure sore and, below the coccygeal pressure sore, two (2) new pressure sores had developed. Employee #5 was unaware these two (2) new pressure sores had developed. She identified one (1) pressure sore as a Stage II and the other as a Stage IV. An observation revealed one (1) area was dime-size and open. The other area was nickel-size and open with white tissue in the center. An interview with the director of nursing (DON - Employee #30), on 08/25/09 at 11:30 a.m., revealed dressings were changed every day for this resident. She further stated she was responsible for the weekly measurements of the pressure sores in the facility and that she monitored the treatments for these pressure sores. A review of the resident's medical record revealed [REDACTED]. Orders were then written to treat the two (2) new pressure areas of which staff at the facility was not aware existed. A subsequent interview with the DON, on 08/26/09 at 10:00 a.m., revealed the physician had arrived at the facility on the evening of 08/25/09, assessed the two (2) new pressure sores for Resident #64, and had written orders to treat the new pressure sores. b) Resident #24 On 08/25/09 at 11:10 a.m., observation revealed the resident was receiving a dressing change to the coccyx area. The licensed practical nurse (LPN - Employee #87) removed the dressing to the coccygeal area, and two (2) new pressure areas were observed below the coccyx area. Both areas were dime-size and were open. The LPN was unaware of the two (2) new pressure sores. She stated that daily dressing were ordered to the pressure ulcer on the resident's coccyx and to the resident's right foot and ankle. Observation of the resident's right foot revealed a nickel-size open area that was not covered with a dressing. The LPN indicated the open area needed to be dressed and when she did the dressing change to the resident's right foot, a dressing was applied to the ankle. An interview with the DON, on 08/25/09 at 11:30 a.m., revealed dressings were changed every day for this resident. She further stated she was responsible for the weekly measurements of the pressure sores in the facility and that she monitored the treatments for these pressure sores. A subsequent interview with the DON, on 08/26/09 at 10:00 a.m., revealed the physician arrived at the facility on the evening of 08/25/09, assessed the two (2) new pressure sores for Resident #24, and wrote orders to treat the new pressure sores. .",2015-06-01
10212,SHENANDOAH CENTER,515167,50 MULBERRY TREE STREET,CHARLES TOWN,WV,25414,2009-08-27,309,G,0,1,YIQY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, a review of the medical record, and staff interviews, the facility did not ensure one (1) resident of random opportunity received appropriate and timely care and services after indicating to a nurse that her mouth and throat were sore and that she could not eat because of the irritation. Resident identifier: #33. Facility census: 73. Findings include: a) Resident #33 Random observation, on 08/26/09 at 12:30 p.m., found Resident #33 sitting up in bed with a food tray on the overbed table in front of the resident. The resident was not eating. When interviewed, the resident stated she could not eat, because her mouth and throat were burning and very sore. When asked if she had reported this to a nurse, the resident stated she had told the nurse a little while ago. A registered nurse (RN - Employee #5) caring for Resident #33 was asked by this nurse surveyor to assess the resident's mouth and throat, because the resident could not eat and was complaining of a sore mouth and throat. The RN came into the room and asked the resident if her mouth and throat were sore, but she did not look inside the resident's mouth. The nurse surveyor asked the director of nursing (DON - Employee #30) to accompany the RN (Employee #5) to the room for an assessment of the resident's mouth and throat. The RN stated she had ordered ""swish and swallow"" for the resident. A review of the physician's orders did not indicate any new orders were received for the resident's mouth and throat. At 12:35 p.m., the DON and the RN entered the resident's room. The RN stated to the resident that she was sorry for bothering the resident during lunch. The resident stated, ""I can't eat my lunch, because my mouth and throat are so sore."" The DON brought a flash light and a tongue blade for the assessment of the resident's mouth. The DON stated that the resident's mouth was red and the resident's throat was also very red. An observation of the resident's mouth revealed the resident's upper gum was red and irritated, and the resident's throat was also red and irritated. An order, dated 08/26/09 at 12:45 p.m., was received from the physician for: ""Magic mouthwash swish around in mouth 3 x's daily until soreness resolves."" A review of the resident's medical record revealed [REDACTED]. Nursing notes or physician progress notes [REDACTED]. A lab report, dated 08/12/09, indicated, ""Culture throat - no Beta-[DIAGNOSES REDACTED] source - Streptococcus isolated."" An interview with the DON, on 08/26/09 at 1:30 p.m., revealed the physician was in the building the evening of 08/09/09 and ordered the culture of the resident's throat. She was unaware as to why the culture was ordered. .",2015-06-01
10213,SHENANDOAH CENTER,515167,50 MULBERRY TREE STREET,CHARLES TOWN,WV,25414,2009-08-27,225,D,0,1,YIQY11,"Based on a review of the facility's complaint log and staff interview, the facility did not ensure one (1) complaint containing an allegation of neglect was submitted to the appropriate State agencies as required by law. Complaint identifier: #1. Facility census: 73. Findings include: a) Complaint #1 A review of the facility's complaint log revealed that, on 08/11/09, a family member reported an allegation of neglect. The report noted, ""Spoke with social worker and stated that an RN (registered nurse) and a new aide were getting resident up and ready for dinner, daughter states that resident had dry feces on her bottom and also attend soiled with clothing on wheel chair and was not placed in bag or hamper."" A written statement from an aide indicated, ""I was giving care to the resident on 8-11-2009 when I rolled her over to change her bottom. She had dry BM on her. Her daughter was there and was upset because the day shift aide had left her like that. She said she was going to talk to someone about the matter. I washed the resident and got her out of bed for dinner."" An interview with the social worker, on 08/25/09 at 3:00 p.m., revealed the facility staff believed this was not something that needed to be submitted to the State. The aide had provided incontinence care to the resident and did not do a thorough cleaning of the resident's bottom. She further stated the facility staff did not believe this was an allegation of neglect and did not need to be submitted to the appropriate State agencies. .",2015-06-01
10386,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2009-08-27,278,D,0,1,EK7F11,"**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 information regarding the use of physical restraints on the minimum data set assessment (MDS) for two (2) of thirteen (13) sampled residents. Resident identifiers: #57 and #26. Facility census: 64. Findings include: a) Resident #57 Review of Resident #57's MDS, with an assessment reference date (ARD) of 05/20/09, found, in Section P4 (Devices and Restraints) the resident used a ""chair prevents rising"". Observations each day of the survey revealed Resident #57 sitting in his wheelchair with a blue restraint across his abdomen with no self-release mechanism. Review of Resident #57's care plan revealed a focus area for ""Physical restraint - safety belt utilized when in W/C (wheelchair) and not involved in supervised activities"", and listed numerous care plan interventions related to restraint use. Review of physical therapy's plan of treatment for [REDACTED]."" Numerous interventions were listed as attempts to decrease incidence of falls and maintain functional ability. Review of Resident #57's medical record revealed monthly assessments for restraint use and assessments for reduction / elimination. Interview with nursing staff (Employees #63 and #32), on 08/26/09 at 12:50 p.m., revealed their opinions that Resident #57 could not remove the restraint by himself while sitting in his wheelchair. Interview with additional nursing staff (Employees #13 and #1), on 08/26/09 at 1:30 p.m., revealed their opinions that Resident #57 could not remove the restraint while in the wheelchair. Employee #1, the MDS coordinator, agreed that Section P4 of the MDS should have been coded to indicate the use of a ""trunk restraint"" rather than a chair that prevents rising. b) Resident #26 Review of Resident #26's MDS, with an assessment reference date (ARD) of 07/01/09, found, in Section P4 (Devices and Restraints) the resident used a ""chair prevents rising"". Review of Resident #26's care plan revealed a focus for ""Physical restraint - safety belt utilized when in dynergo w/c (wheelchair) and not involved in supervised activities to improve seated posture."" Numerous interventions were listed related to restraint use for the goal of not experiencing any adverse effects from restraint use. Review of Resident #26's medical record revealed monthly assessments for restraint use and assessments for reduction / elimination. Review of Resident #26's current recapitulation of physician's orders [REDACTED]. Interview with nursing staff (Employees #63 and #32), on 08/26/09 at 12:50 p.m., revealed their opinions that Resident #26 could not remove the restraint while sitting in her Dynergo wheelchair. Interview with additional nursing staff (Employees #13 and #1), on 08/26/09 at 1:30 p.m., revealed their opinions that Resident #26 could not remove the restraint while in the wheelchair. Employee #1, the MDS coordinator, agreed that Section P4 of the MDS should have been coded to indicate the use of a ""trunk restraint"" rather than a chair that prevents rising. .",2015-04-01
10387,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2009-08-27,280,D,0,1,EK7F11,"Based on record review and staff interview, the facility failed to revise a care plan for one (1) of thirteen (13) sampled residents, when hospice services were discontinued. Resident identifier: #52. Facility census: 64. Findings include: a) Resident #52 Review of Resident #52's current care plan, dated 05/27/09, revealed an intervention to refer to a hospice program in accordance with resident / health care decision maker's wishes. Review of Resident #52's medical record revealed hospice services were discontinued on 06/02/09. Resident #52's current care plan was not updated regarding the discontinuation of hospice services. Interview with the facility's social worker, on 08/26/09 at 2:30 p.m., revealed that hospice services were desired, in part, for volunteers to help escort Resident #52 who wanders; however, hospice had only one (1) volunteer, and the volunteer allegedly was fearful of Resident #52. Subsequently, the resident's physician decided the facility could provide services instead of the hospice; the resident's legal guardian agreed, and hospice services were discontinued. During interview with the administrator on 08/26/09 at 4:00 p.m., the above findings were shared. Subsequently, on 08/27/09 at approximately 8:45 a.m., an updated care plan was produced by the facility dated 08/26/09, that documented palliative / comfort care measures provided by nursing and other facility staff rather than with the hospice. .",2015-04-01
10388,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2009-08-27,514,D,0,1,EK7F11,"Based on record review and staff interview, the facility failed to maintain accurate and complete clinical records for each resident, as evidenced by having health information for one (1) resident filed incorrectly in another resident's medical record. This was evident for one (1) of thirteen (13) sampled residents. Resident identifier: #59. Facility census: 64. Findings include: a) Resident #59 A comprehensive review of Resident #59's medical record revealed a pre-admission screening form PAS-2000 (with faxed date of 03/30/09) with another resident's last name but same first name. Interview with Employee #53, on 08/25/09 at 9:40 a.m., revealed the PAS-2000 filed on Resident #59's medical record did not belong to a current resident at the facility; she thought, perhaps, the hospital had faxed the PAS-2000 to the wrong facility. She returned a few minutes later, after speaking with the social worker (Employee #31) and stated the person named on the PAS-2000 was a former resident at this facility. Her PAS-2000 was inadvertently filed on Resident #59's chart in error. Subsequently, Employee #53 said she corrected the error after surveyor intervention. .",2015-04-01
10389,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2009-08-27,364,E,0,1,EK7F11,"Based on observation, individual and group resident interviews, and staff interview, the facility failed to ensure food served for evening meal on 08/24/09 was palatable and attractive. This had the potential to affect all residents who were served Beef Burgundy, noodles, and peas. Facility census: 64. Findings include: a) During the confidential resident group meeting on 08/24/09 at 1:30 p.m., the residents in attendance reported that some of the meals served did not have good flavor, the type of meat served was sometimes unidentifiable, and the vegetables did not have enough flavor and were not always done. b) Review of the resident council meeting minutes from June 2009 through August 2009 found numerous complaints had been reported by residents about the food. c) Observation of preparation of the evening meal, on 08/24/09, including a review of the planned menu for that meal, found Beef Burgundy, noodles, and peas were to be served. 1. While the cook was taking temperatures of the food items being held for service, this surveyor noted peas were absent from the steam table. The cook, when questioned about the peas, said she left them in the refrigerator. The cook then put the peas into the steamer, leaving them in for ten (10) minutes; although the recipe indicated the peas should have been cooked for fifteen (15) to eighteen (18) minutes. She put the margarine into the bottom of the pan in the steamer, put the peas in on top of melted margarine, and added salt and pepper by shaking them over the pan, rather than measuring the amount indicated in the recipe. 2. The Beef Burgundy appeared watery and, when tasted, the beef was tough and hard to chew. 3. The other food items were tasted. The noodles were overcooked and sticking together, the peas were underseasoned. d) Observations were continued in the dining rooms and resident rooms. Fifteen (15) residents, who were confidentially interviewed, indicated the peas were not seasoned enough, the noodles were overcooked, and the beef was hard to chew. Further observations found several residents left the meat on the plate. .",2015-04-01
10390,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2009-08-27,225,D,0,1,EK7F11,"Based on a record review, resident interview, and staff interview, the facility failed to ensure three (3) allegations of neglect - all of which involved a clack of timely assistance by staff to avoid episodes of incontinence and which were recorded in customer concern forms and/or the residents' medical records, were immediately reported and/or thoroughly investigated as required by State law. Resident identifiers: #1, #54, and #15. Facility census: 64. Findings include: a) Resident #1 Review of the facility's record of customer and family concerns revealed a form, dated 08/24/09, documenting that Resident #1 complained: ""She had to wait for the call which made her incontinent."" On 08/26/09, an entry the concern form stated, ""Resident reinterviewed and said she the name ____, but could not remember the date or how long she waited, but was awhile."" Review of Resident #1's medical record revealed a 08/24/09 social services note, which stated, ""The resident today commented she had to wait to go the bathroom over the week end. She said it made her incontinent due to the wait. When I spoke to the staff they were unaware of the situation. The director of nursing did state that the resident is incontinent at times and there have been times that she didn't tell staff."" Interview with social worker, on 08/26/09 at 12:40 p.m., found she had not started any investigation yet and had not reported this concern as an allegation of neglect. She indicated the resident did not always get details. b) Resident #54 Review of the facility's record of customer and family concerns revealed a form, dated 07/08/09, documenting Resident #54's complaint that a certified nursing assistant (CNA) who worked the 11:00 p.m. to 7:00 a.m. (11-7) shift came into her room after she put on her call light and said, ""What do you need. I am busy, you know."" Documentation on the concern form indicated Resident #54 reported this comment to the nurse. During an interview on 08/25/09 at 3:33 p.m., Resident #54 identified the CNA involved. She said she had to wait a long time for the 11-7 shift staff to answer her call light, and when they come in, they will often shut the light off without providing her the needed assistance. She reported she sometimes has to wait until day shift comes in before she can get put on the bed pan. c) Resident #15 During an interview on 08/26/09 at 1:00 p.m., Resident #15 indicated she had to wait for a CNA to answer her call light, and it took a long time before she was taken to the bathroom. She indicated she had an incontinence episode as a result. Record review revealed a 08/19/09 social services notes documenting the resident expressed a concern over length of time she had to wait to go to the bathroom on the 3:00 p.m. to 11:00 p.m. (3-11) shift. She did not say she had any incontinence issues. Due to incidents in the past with the resident falling, the 3-11 shift CNA who makes her wait has told her she had to wait for another CNA to help her, due to the resident's functional level. ""She said she had explained this to the resident before. It was emphasized to the CNA to not make the resident wait any longer then necessary to get up so the resident could maintain safety. She agreed. I checked back with the resident. She said everything went okay last night."" d) Review of the facility's record self-reported allegations of abuse / neglect failed to find the allegations made by Resident #1, #54, and #15 were immediately reported or thoroughly investigated. This was confirmed during an interview with the social worker at 12:40 p.m. on 08/26/09. .",2015-04-01
10391,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2009-08-27,166,E,0,1,EK7F11,"Based on confidential resident group interview, staff interview, and a review of the resident council meeting minutes, the facility failed to ensure residents' complaints, about wandering residents and timely response to call lights were, adequately addressed in order to resolve grievances, including those with respect to the behavior of other residents. Resident identifiers: Withheld due to request for anonymity. Facility census: 64. Findings include: a) Call lights During the confidential resident group meeting on 08/24/09 at 1:30 p.m., eight (8) of (15) fifteen residents in attendance indicated call lights were not responded to in a timely manner by staff. Four (4) residents reported having complained to various staff members about the problem. The residents indicated that, sometimes, they had to wait up to forty five (45) minutes before staff responded, or staff would come into the rooms and shut off the lights, telling them they would return later, and then did not do so. Two (2) of the residents indicated they had experienced incontinence episodes as a result of delays in receiving assistance from staff. Two (2) of the residents indicated their complaints were not included in the resident council meeting minutes, as they quit complaining because the issue had been a problem for a long time and was never adequately addressed. b) Wandering residents During the confidential resident group meeting on 08/24/09 at 1:30 p.m., eight (8) of (15) fifteen residents in attendance indicated there were several residents in the facility who wandered into other residents' rooms. They said the facility tried stop signs and barriers on their doors, but this did not work. They said staff responds slowly to call lights and, by the time staff came, the residents wandered out of their rooms. One (1) resident said the wandering residents would take items, climb into other residents' beds, and would not leave when asked. The residents indicated staff at the facility was told of the problem, but it did not seem like anything had changed. c) Review of the resident council meeting minutes, from June through August 2009, found complaints about wandering residents and the facility's plan to purchase ""gates"" to keep residents out of other residents' rooms. An interview with the director of nursing (DON, on the early afternoon of 08/27/09, found she had ordered one (1) gate, but it had not come in yet. She did not want to order any more until she could see if what she ordered would work. The DON also indicated that staff received training in July 2009 regarding wandering residents and behavior problems. She indicated that, currently, no formal method to address these problems was in place. Observation of the facility did not find any other types of barriers in use to keep residents from entering other residents' rooms. d) Review of the previous year's recertification citations (12/09/09) found the facility was cited for residents complaining about wandering residents, as well as a lack of promptness by staff in answering call lights. The facility's plan of correction to address these concerns included monitoring, on a monthly basis, staff's response times to call lights and redirecting wandering residents. .",2015-04-01
10392,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2009-08-27,315,D,0,1,EK7F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview, the facility failed to assess one (1) of thirteen (13) sampled residents who was experiencing stress incontinence, to rule out medical causes of the incontinence and develop / implement measures to restore normal bladder function. Resident identifier: #22. Facility census: 64. Findings include: a) Resident #22 During an interview on 08/26/09 at 12:40 p.m., Resident #22 indicated she had incontinence episodes and often had to wear up to three (3) briefs in order to avoid being soaked. She said she was embarrassed when this happened. The resident said she used up to six (6) briefs per day. A review of the resident's bladder assessment, dated 01/07/09 and reviewed on 04/08/09, found it indicated ""Stress"" as a clinical factor; symptoms included ""wet when coughs, sneezes, bends, laughs"" and ""wears briefs"". All of the other areas on the assessment (including prompts to identify transient / reversible factors, actions, nursing interventions and care planning, action, and evaluation of program) were left blank. A 06/23/09 physician's progress note stated, ""... She does complain of continued problems leaking urine when she sneezes, coughs which I feel is secondary to stress incontinence and OAB (over active bladder). However due to her multiple medications I do not feel that any [MEDICATION NAME] is indicated as side effects my be too great and greater than possible benefits."" A review of the activities of daily living (ADL) records for July 2009 indicated the resident was ""continent"". The minimum data set (MDS) quarterly review, dated 07/15/09, indicated the resident only required supervision for toileting without any assistance needed and that she was ""continent"". The 07/20/09 care plan did not address the resident's stress incontinence. On the early afternoon of 08/26/09, the resident's medical record was reviewed with the director of nursing and additional information was requested. In the late afternoon on 08/26/09, physical therapy records from 06/17/07 were presented and indicated: ""... Overall, incontinence has remained unchanged despite Tx (therapy or treatment) to (arrow pointing up) pelvic (illegible) strength. ..."" .",2015-04-01
10409,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2009-08-27,156,B,0,1,Y5MX11,"Based on observation and staff interview, the facility failed to prominently display written information on how to apply for and use Medicare and Medicaid benefits. The facility also failed to include information on how residents / families could receive refunds for previous payments covered by Medicare and Medicaid benefits. This practice has the potential to affect more than an isolated number of residents at the facility. Facility census: 76. Findings include: a) On 08/27/09 at approximately 11:00 a.m., a tour of the facility revealed no posting describing how residents and their families could make application for and use Medicaid or Medicare benefits. The facility had information posted regarding how to file complaints and also advocacy information such as the name / address of the ombudsman; however, Medicare / Medicaid information was not on display. At approximately 11:30 a.m., the administrator agreed this information was not posted. He then made arrangements to have it posted for public display in the facility's main hallway. .",2015-04-01
10410,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2009-08-27,465,E,0,1,Y5MX11,"Based on observations and staff interviews, the facility failed to provide a safe, sanitary, and comfortable environment for residents. Random observations found eight (8) residents were seated in wheelchairs with arm rests that were cracked and/or torn. Resident identifiers: #37, #40, #47, #48, #60, #61, #68, and #74. Facility census: 76. Findings include: a) Residents #37, #40, #47, #48, #60, #61, #68, and #74 Random observations, during the initial tour on 08/24/09, noted the armrests of wheelchairs used by Resident #68 and Resident #60 were in need of repair or replacement. On 08/26/09, additional observations of residents in wheelchairs identified the wheelchairs of Residents #37, #40, #47, #48, #60, #61, #68, and #74 all had armrests that were cracked and/or torn. This was brought to the attention of the administrator on 08/26/09, during the mid afternoon. .",2015-04-01
10411,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2009-08-27,310,D,0,1,Y5MX11,"Based on observations and resident interview, the facility failed to ensure one (1) of thirteen (13) residents on the sample was positioned to facilitate independence in eating. The resident's meal was served on a table that was too high relative to the resident's seating. Resident identifier: #61. Facility census: 76. Findings include: a) Resident #61 At lunch time on 08/26/09, Resident #61 was observed sitting in her wheelchair in her room eating her lunch. Her meal had been placed on an overbed table. Her food was sitting on a tray with a bowl of beans and a smaller bowl of greens positioned closest to the resident. She had to reach over these bowls to access her potatoes and other food items and beverages. When she did reach for one (1) of the items toward the back of the tray, she had to lean over to her left, dropping her left shoulder to the level of her waistline. This did not facilitate ease of eating. The resident said it would probably help if the table were a bit lower, but she managed. .",2015-04-01
10412,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2009-08-27,256,D,0,1,Y5MX11,"Based on observation and resident interview, the facility failed to provide adequate lighting during meal times for one (1) of thirteen (13) current residents on the sample. At lunch time, no lights had been turned on in the resident's room, nor had the window blinds been opened. Resident identifier: #61. Facility census: 76. Findings include: a) Resident #61 At lunch time on 08/26/09, observation found this seated in her wheelchair with her back toward the door to the room. The room was dimly lighted. No artificial lighting had been turned on, nor had the mini blinds over the window been opened. When asked whether she needed more light, she said, ""It would help."" She asked that the light switch on the wall be turned on. After that was done, she said it ""helped a little."" With her permission, the mini blinds were opened, and she said, ""That helped a lot."" .",2015-04-01
10413,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2009-08-27,514,D,0,1,Y5MX11,"Based on observations, medical record review, and staff interview, the facility failed to maintain accurate and complete records for each resident. One (1) resident's record contained a minimum data set assessment with an inaccurate height, and one (1) resident's medical record contained a copy of an e-mail print out regarding another resident. Resident identifiers: #58, #38, and #72. Facility census: 76. Findings include: a) Resident #58 Review of the resident's medical record found her admission minimum data set assessment (MDS), with an assessment reference date (ARD) of 06/29/09, listed the resident's height as 38 inches. Observation of the resident noted that, although she was short, she appeared taller than three (3) feet and two (2) inches. Additional review of the medical record found her dietary assessment identified her as being 48 inches tall. This was brought to the attention of the director of nursing in mid morning on 08/26/09. She later reported the resident was 48 inches tall and the assessment had been corrected. b) Residents #38 and #72 Review of the Resident #38's medical record, on 08/25/09, found an e-mail printout regarding Resident #72 had been attached to a document for Resident #38.",2015-04-01
10414,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2009-08-27,387,D,0,1,Y5MX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to ensure each resident was seen by a physician at least once every thirty (30) days for the first ninety (90) days after admission. One (1) of four (4) residents, for whom there was a question regarding physician visits, was found to have a missing visit. Resident identifier: #73. Facility census: 76. Findings include: a) Resident #73 Review of the resident's medical record, on 08/27/09, found he had been readmitted to the facility on [DATE]. Documentation of physician visits was found for 11/07/08 and 01/07/09, but none was found for December 2008. A visit was due around 12/23/08, plus or minus ten (10) days. The director of nursing was asked to see if she could find the missing documentation, but reported, on 08/27/09, at approximately 1:00 p.m., she could not find anything. .",2015-04-01
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
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
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
10422,PINE VIEW NURSING AND REHABILITATION CENTER,515184,400 MCKINLEY STREET,HARRISVILLE,WV,26362,2009-09-03,226,D,0,1,YHVS11,"Based on record review and staff interview, the facility failed to implement its abuse policy procedure regarding screening and verification of new employees. This was found for one (1) of five (5) newly hired employees whose personnel files were reviewed. Employee identifier: #51. Facility census: 52. Findings include: a) Employee #51 Review of sampled employees' personnel files revealed the facility failed to conduct a criminal background check and license verification for Employee #51, who lived in another state (Ohio), to ensure there were no findings to indicate this individual was unfit for service in a nursing facility. This was discussed with Employee #3 at 11:10 a.m. on 09/02/09, who verified a check of the individual's status in Ohio had not been completed. .",2015-04-01
10423,PINE VIEW NURSING AND REHABILITATION CENTER,515184,400 MCKINLEY STREET,HARRISVILLE,WV,26362,2009-09-03,463,D,0,1,YHVS11,"Based on observation and staff interview, the facility failed to maintain the nurse call system in good working order in the room of one (1) of twelve (12) sampled residents. Room number: D416. Facility census: 52. Findings include: a) Room D416 On the morning of 09/03/09, the surveyor conducted observations of the facility, including testing of the nurse call system for sampled residents. Observation and performance testing revealed the call light for Bed 1 in Room D416 did not illuminate the light above the door in the hallway when the call button was activated at bedside. A nurse aide, who was asked about the light, came into the room at the time and verified that Bed 1's nurse call cord did not work. She tried Bed 2's nurse call cord, which did activate the light in the hall. This was brought to the attention of the administrator later in the morning of 09/03/09, and she stated they had told her about the issue and maintenance was repairing it immediately.",2015-04-01
10424,PINE VIEW NURSING AND REHABILITATION CENTER,515184,400 MCKINLEY STREET,HARRISVILLE,WV,26362,2009-09-03,280,D,0,1,YHVS11,"**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 twelve (12) sampled residents, to revise the comprehensive care plan. A resident who had frequent falls did not have her plan of care updated and revised to include all interventions the facility staff were implementing to prevent future falls. Resident identifier: #42. Facility census: 52. Findings include: a) Resident #42 Resident #42's medical record, when reviewed on 09/02/09 at 10:00 a.m., disclosed a [AGE] year old female who was admitted to the facility on [DATE] after a recent hospitalization to repair a fractured right hip. The resident had dementia and a history of falls. Review of the nursing notes and the facility's incident / accident report forms, for 06/01/09 through 08/31/09, found the resident had numerous falls. The incident / accident reports stated the resident fell on [DATE], 07/06/09, 07/09/09, 07/18/09 (resulting in a hematoma to the head), 07/20/09 (two (2) falls), 07/24/09 (two (2) falls), 07/27/09, 08/01/09, 08/14/09, 08/15/09, and 08/31/09. Resident #42's care plan, dated 06/26/09, when reviewed on 09/02/09 at 10:15 a.m., reported the resident to be ""at risk for falls"". The care plan was not revised to include new interventions the facility staff was implementing to prevent the recurrence of falls. The care plan approaches included: ""Use Hoyer lift for transfers, side rails up when in bed."" and ""D/C [MEDICATION NAME], Prostat 101, MVI with minerals, [MEDICATION NAME] and increase [MEDICATION NAME] to BID."" Review of the current physician's orders [REDACTED]. The director of nurses (DON - Employee #31), when interviewed on 09/02/09 at 3:15 p.m., reported the resident did not use a Hoyer lift or side rails. The DON also confirmed the intervention related to medication changes was ""confusing"" and the care plan did not clearly state all current interventions being implemented to prevent the recurrence of falls. The DON reported interventions of the provision of therapeutic activities and monitoring the resident for restlessness and agitation were not included in the current care plan. The facility form titled ""Care Plan For Falls Occurrence"" (dated 08/14/09) was provided by the DON at 3:15 p.m. on 09/02/09. The revised care plan was stapled to the incident / accident report sheet for the resident's 08/14/09 fall. The fall care plan was not incorporated into the comprehensive care plan dated 06/26/09. This additional care plan was completed after the resident had twelve (12) previous falls. The care plan nurse (Employee #67), when interviewed on 09/02/09 at 3:45 p.m., confirmed the resident's current care plan was not accurate and had interventions listed for falls that were not being implemented for the resident. Employee #67 confirmed the plan of care inaccurately listed pain medications, nutritional supplements, multivitamins, and an increase of [MEDICATION NAME] as interventions to prevent falls. .",2015-04-01
10425,PINE VIEW NURSING AND REHABILITATION CENTER,515184,400 MCKINLEY STREET,HARRISVILLE,WV,26362,2009-09-03,314,G,0,1,YHVS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and resident interview, the facility failed to prevent the development of a clinically avoidable Stage II pressure ulcer. This was true for one (1) of twelve (12) sampled residents. Resident #42 was admitted to the facility on [DATE], with a Stage II pressure ulcer to the coccyx and ""mushy heels"". The ulcer to the coccyx was treated and later resolved on 08/05/09; however, no treatment was initiated at the time of admission for the ""mushy heels"". On 07/25/09, the resident complained of pain to the heel of the left foot, and assessment of the foot revealed a fluid filled blister (Stage II pressure ulcer). There was no evidence to reflect the facility implemented measures upon admission to prevent the development of this pressure ulcer, given that the resident's heels were assessed as being ""mushy"" at that time and the resident was at high risk for developing additional breaks in skin integrity related to the presence of the Stage II ulcer on the coccyx. Once interventions to the Stage II ulcer on the left heel were ordered by the physician, the facility failed to ensure these interventions were consistently implemented, and the ulcer to the left heel increased in size. Facility census: 52. Findings include: a) Resident #42 Resident #42's medical record, when reviewed on 09/01/09 at 2:45 p.m., disclosed a [AGE] year old female resident who was admitted to the facility on [DATE], for rehabilitative services after a fractured right hip. The resident had dementia and a history of falls. The facility form titled ""Nurses Admission and Assessment Record"", dated 06/25/09, recorded the resident as having a ""Stage II Decubitus coccyx"" and ""heels mushy"". The resident received treatment to the coccyx pressure ulcer, and this ulcer resolved on 08/05/09. The physician did not ordered a treatment to the heels at the time of admission. A nursing note, dated 07/25/09, recorded the resident's complaint of heel pain to the left foot. The resident was found to have ""a 2 cm long x 0.4 cm wide fluid filled blistered area noted to inner aspect of Lt. (left) heel"". The physician ordered, ""Skin repair cream to inner aspect of Lt. heel BID (twice daily) (10 a.m. and 10 p.m.) times two (2) weeks then review, apply heel protectors bilaterally when in bed q (every) shift, monitor skin condition of heels q shift."" The July and August 2009 treatment sheets, when reviewed on 09/02/09 at 8:30 a.m., disclosed treatments were not consistently completed as ordered. The skin repair cream was ordered twice a day. The July 2009 treatment sheet was not initialed, indicating the treatment was completed as ordered for the following dates: 07/25/09 at 10:00 p.m., 07/26/09 at 10:00 p.m., 07/28/09 at 10:00 a.m., 07/29/09 at 10:00 a.m., and 07/31/09 at 10:00 a.m. The physician ordered bilateral heel protectors every shift when in bed beginning on 07/25/09. The shifts at this facility run from 6:00 a.m. to 2:00 p.m. (6-2), 2:00 p.m. to 10:00 p.m. (2-10), and 10:00 p.m. to 6:00 a.m. (10-6). The treatment sheet was not initialed for this intervention for the following dates: 07/26/09 (10-6 shift), 07/27/09 (10-6 shift), 07/28/09 (6-2 shift), 07/29/09 (6-2 shift), 07/30/09 (10-6 shift), 07/31/09 (10-6 and 6-2 shifts). The physician's orders [REDACTED]. shifts), 08/14/09 (6-2 shift), 08/15/09 (6-2 shift), 08/16/09 (2-10 shift), 08/23/09 (2-10 shift), 08/27/09 (10-6 shift), and 08/28/09 (10-6 shift). On 08/05/09, the physician ordered, ""Topically apply Marathon to reddened area on left heel, air dry, and if necessary cover with bordered foam for added protection. Reapply Q week and prn (as needed) x four weeks and review."" Review of the treatment sheet for August 2009 disclosed the Marathon treatment was not completed 08/17/09 through 08/24/09, as required by the physician's orders [REDACTED]. On 09/01/09 at 4:00 p.m., Resident #42 was observed in her room. The licensed practical nurse (LPN - Employee #55) changed the dressing to the left heel. The resident was observed to have a 4 cm x 3 cm x 0.1 cm Stage II pressure ulcer to the left heel. The wound bed was pink without drainage. The surrounding tissue was not [MEDICAL CONDITION] or red. Resident #42, when interviewed on 09/01/09 at 4:15 p.m., reported it ""hurt a little"". The director of nurses (DON - Employee #31), when interviewed on 09/02/09 at 3:15 p.m., was asked for evidence of the implementation of measures to prevent skin breakdown to the heels at the time of admission to the facility, when the resident's heels were found to be ""mushy"" on the 06/25/09 admission assessment. The DON did not provide any additional evidence of preventative measures for the heels having been implemented prior to 07/25/09. The DON, when informed of the omissions noted on the resident's July and August 2009 treatment records, was also unable to provide evidence that these interventions were completed as ordered by the physician. .",2015-04-01
10165,MANSFIELD PLACE,515129,PO BOX 930,PHILIPPI,WV,26416,2009-09-10,241,D,0,1,N3OU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to assure the dignity of two (2) of fourteen (14) sampled residents during dining, by delayed meal service to one (1) resident after other residents at the table were eating and by failing to ensure a resident with cognitive and visual impairments received interventions to promote effective self-feeding without excessive spillage. Resident identifiers: #25 and #15. Facility census: 56. Findings include: a) Resident #25 A review of the clinical record revealed Resident #25 was a [AGE] year old female whose [DIAGNOSES REDACTED]. She self-propelled her wheelchair around the facility and resisted care on a daily basis per her minimum data set (MDS) assessments. She had a recent weight loss, and her physician's diet orders included: ""Diet: Regular""; ""Send finger foods for self-feeding""; ""Two Cal HN 4 oz with 4 oz of ice cream as a shake between meals 10 - 4. May add chocolate or other syrup flavor as needed.""; and ""Plate guard at all meals."" The care plan included the following nursing interventions: ""Regular diet. All finger foods.... Ice Cream at lunch and dinner. ... Super cereal two bowls at breakfast, two bowls at lunch, four bowls at dinner. ... Plate guard / raised edge plate at meals to prevent food from being pushed off tray. Food will be left on meal tray to create a boundary for the resident. Keep non food items out of reach. Cloth napkin will be used after tray set up. Do not leave paper / plastic items on tray. Resident will put non food items in her mouth. ... Set up tray open packs / cartons cut foods a resident needs / desires."" The resident was observed at 12:30 p.m. on 09/09/09. She was eating in the dining room alone at a table located among tables occupied by other residents. She was sitting in her wheelchair and rolling the chair back and forth continuously. Her food was not on a tray but had been placed on a paper placemat on the table. She had solid food items on a regular plate that could be picked up, a cup of coffee, carton of ice cream, and two (2) bowls of thin (soup-like) liquid which was identified as the ""super cereal"". She was wearing a dress and had a lap-robe on her lap, but there was no napkin. She was observed feeling around and into the containers to locate food, picking up the bowl, and scooping the thin cereal into her mouth, spilling at least half of it onto her lap and floor. She did manage her coffee cup reasonably well, only spilling small amounts, and she was noted to use a spoon at one (1) point. Her lap-robe became very wet, and the aide took it and left the room, bringing back a folded sheet which she draped over the resident's lap. While the aide was gone, the resident continued to eat, spill, and used her dress hem to wipe her mouth, exposing herself to the other diners. There was no screen or other method used to shield the resident for her own privacy. In an interview with the aide in the dining room (Employee #10) at 12:40 p.m. on 09/09/09, the aide stated the resident would not allow anyone to feed her and she recently had refused to eat anything except the super cereal. The aide, when asked if the resident's food was ever left on the tray so she could locate it easier, said no, but maybe she would try it. The resident was also observed at the evening meal on the same day, with bowls of liquid cereal again being spilled, although the resident did fairly well with cups with handles. During an interview with the director of nurses (DON) at 12:30 p.m. on 09/10/09, she stated the resident was very hard to direct and she knew that she was only eating liquids at present, spilling a lot. She also stated that, since all of the residents in the dining room needed assistance to eat, they had not considered the need to block any of them from view, although she did admit that some of the residents eating there were cognizant of their surroundings and that there were visitors occasionally present. b) Resident #15 During lunch in the activities dining area beginning at 12:20 p.m. on 09/09/09, observation revealed only one (1) employee passing trays to ten (10) residents. Several residents were observed to be eating at the table for greater than fifteen (15) minutes until the last resident was served. At 12:47 p.m., Resident #15 was the last resident to be served; prior to her tray being set up, she stated, ""Better hurry. My sugar is getting low."" On the morning of 09/10/09, the DON, when interviewed in her office, stated, ""Usually, two people are in the activities dining room, but the other one is on vacation. I told her this morning that she needs to get help if she is needing it when passing trays by herself."" .",2015-06-01
10166,MANSFIELD PLACE,515129,PO BOX 930,PHILIPPI,WV,26416,2009-09-10,279,D,0,1,N3OU11,"Based on medical record review and staff interview, the facility failed, for one (1) of fourteen (14) sampled residents, to develop a comprehensive plan of care to promote improved bladder function after a resident experienced a decline in continence. Resident identifiers: #22. Facility census: 56. Findings include: a) Resident #22 Medical record review, completed on 09/09/09, revealed Resident #22 had a decline in bladder continence. According to the quarterly minimum data set assessment (MDS) with an assessment reference date (ARD) of 04/24/09, the assessor encoded Item H1b as ""1"", indicating the resident was usually continent with incontinent episodes occurring once a week or less. In a subsequent MDS, with an ARD of 07/24/09, the assessor encoded Item H1b as ""2"", indicating the resident was occasionally incontinent of bladder two (2) or more times a week but not daily. Her medical record contained a ""Bladder Retraining Assessment"" form which recorded information in under the heading ""Current Resident Status"" and was signed by a registered nurse on 07/31/08 (date of admission). However, the sections for recording the results of a bladder assessment and whether the resident was able to participate in bladder retraining were blank. The only other documentation on this form were periodic narrative notes as follows: - 11/03/08 - ""Usually cont(inent) of bladder)"" - 02/04/09 - ""Continent of bladder."" - 04/07/09 - ""Usually continent of bladder."" - 07/26/09 - ""Occasional bladder incontinence."" Although this assessment was incomplete, the facility placed the resident on a toileting schedule in January 2009. Review of the resident's comprehensive plan of care for 08/05/09 through 11/05/09 found reference to the toileting schedule as follows - ""Toilet upon rising, before and after meals and out of room activities, before going to bed and offer toielting (sic) during each bed check at HS (hour of sleep)."" However, there was no mention of other interventions developed to promote improved bladder continence. (See also citation at F315.) .",2015-06-01
10167,MANSFIELD PLACE,515129,PO BOX 930,PHILIPPI,WV,26416,2009-09-10,280,E,0,1,N3OU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and family interview, the facility failed, for three (3) of fourteen (14) sampled residents and three (3) randomly observed residents, to revise the comprehensive plan of care for residents who were no longer candidates for speech therapy services and/or when dietary orders and needs changed. Resident identifiers: #43, #37, #8, #25, #24, and #10. Facility census: 56. Findings include: a) Resident #43 Medical record review, on 09/09/09, revealed a comprehensive plan of care dated 12/31/08 through 09/24/09, with the following problem statement: ""Alteration in nutrition status, poor dental status, 10/17/09 family does not want dental consult at this time, GERD, moderate oral dysphagia, moderate / severe pharyngeal dysphagia, eats / drinks fast at times, constipation, dementia, [MEDICAL CONDITION], GERD, ABN (abnormal) involun. (involuntary) movement occasionally will hold his cup is fed by staff. No feeding tube wants IV fluids for defined trial period per POST."" Interventions to address these identified problems included speech therapy as needed. At noon on 09/09/09, this resident was observed to be feeding himself. On the afternoon of 09/10/09, the speech language pathologist (SLP - Employee #89) identified she had been employed at the facility for one (1) year, Resident #43 was not a candidate for speech therapy dysphagia treatments, and, currently, she did not have any resident who was a candidate for this type of treatment. The facility failed to update the resident's care plan with respect to this intervention. b) Resident #37 Medical record review, on 09/09/09, revealed a comprehensive plan of care dated 05/13/09 through 11/12/09, with the following problem statement: ""Alteration in nutrition r/t (related to) dislikes many food, refuses to eat many foods, unable to feed herself, edentulous and refuses dentures, mild to moderate oropharyngeal dysphagia, will accept only chopped meat, refuses minced / ground meats and pureed foods, DX of [MEDICAL CONDITION], joint contractures, [MEDICAL CONDITION], kyphosis apyrexia, [MEDICAL CONDITION], mild mental [MEDICAL CONDITION], late ef-hemplga (effect [MEDICAL CONDITION]) nutritional deficiency, gerichair for comfort at meals. HX (history) of coughing at times during meals. Allergy to bananas. POST 03/29/07 IVF (intervenous fluids) defined trial period not tube feeding."" Interventions to address these identified problems included evaluation by the speech pathologist PRN. On the afternoon of 09/10/09, Employee #89 identified Resident #37 was not a candidate for speech therapy dysphagia treatments and, currently, she did not have any resident who was a candidate for this type of treatment. The facility failed to update the resident's care plan with respect to this intervention. c) Resident #8 Medical record review, on 09/09/09, revealed a comprehensive plan of care dated 08/19/09 through 11/19/09, with the following problem statement: ""Alteration in nutrition status r/t dx right [MEDICAL CONDITION] does not want adaptive feeding equipment, [MEDICAL CONDITIONS], with tendency for fluid retention, [MEDICAL CONDITION], DM (diabetes mellitus) CAD [MEDICAL CONDITIONS], gout, constipation, GERD, [MEDICAL CONDITION], Hx. of dysphagia, refuses therapuetic.mechanically altered diet AMA (against medical advice) signed for a regular diet, No tube feedings.IV fluids, provide other measures to assure comfort per post non compliant with therapeutic diet at times."" Interventions to address these identified problems included evaluation by speech therapy as ordered. On the afternoon of 09/10/09, Employee #89 identified Resident #8 was not a candidate for speech therapy dysphagia treatments and, currently, she did not have any resident who was a candidate for this type of treatment. The facility failed to update the resident's care plan with respect to this intervention. d) Resident #25 A review of the clinical record revealed Resident #25 was a [AGE] year old female whose [DIAGNOSES REDACTED]. She self-propelled her wheelchair around the facility and resisted care on a daily basis per her minimum data set (MDS) assessments. She had a recent weight loss, and her physician's diet orders included: ""Diet: Regular""; ""Send finger foods for self-feeding""; ""Two Cal HN 4 oz with 4 oz of ice cream as a shake between meals 10 - 4. May add chocolate or other syrup flavor as needed.""; and ""Plate guard at all meals."" A review of the current care plan, dated 07/22/09, revealed under the stated problem of ""alteration in nutritional status"" several interventions that were either incorrect, in conflict with each other, or were no longer in effect and should have been revised. The care plan stated the resident was to receive ""All finger foods"", but elsewhere it stated the resident was to receive ""Super Cereal two bowls at breakfast, two bowls at lunch, four bowls at dinner."" This Super Cereal was observed at three (3) meals to be a thin liquid, which was confirmed to be the correct consistency by reviewing the recipe provided by dietary. There was no intervention proposing a method for self-feeding of this food item. The resident, who was observed successfully drinking from a cup with a handle, was served bowls of thin Super Cereal, attempted to transfer to her mouth with her fingers, spilling much of it onto her lap. During an interview with a nursing assistant (Employee #12) at 12:30 p.m. on 09/09/09, she stated the resident had been refusing all finger foods and was only eating the Super Cereal. This was also observed by the surveyor at three (3) meals during the survey. Review of the current care plan also revealed an intervention previously entered for: ""Two cal HN 4 oz with 4 oz of ice cream as a shake between meals 10AM and 3PM. May add Choc Syrup (chocolate syrup)."" This intervention had been deleted by putting a line through all of it; but there was still an active physician's orders [REDACTED]. There is also an intervention stating, ""Food will be left on meal tray to create a boundary for the resident. ... Keep non food items out of reach. Cloth napkin will be used. After tray set up do not leave paper / plastic items on tray. Resident will put non food items in her mouth."" The resident was observed at lunch meals at 12:30 p.m. on 09/08/09 and at 12:30 p.m. on 09/09/09, and at the evening meal on 09/09/09. At each meal, her food was removed from the tray and placed on a paper placemat on the table. There were no napkins or clothing protectors observed in use. During an interview with Employee #12 at 12:30 p.m. on 09/09/09, when asked if she ever tried leaving the food on the tray, she stated she had not. A review of the aide instruction sheet located in the activities of daily living (ADL) book, at 3:00 p.m. on 09/09/09, found none of these instructions. During an interview with the director of nurses (DON) at 12:30 p.m. on 09/10/09, she stated she knew the resident was only eating the cereal and that her foods were not left on the tray. She said she would review the care plan. She also said she thought the resident still got her shake but would check. e) Resident #24 A review of the medical record revealed Resident #24 was evaluated by the SLP for ""oral dysphagia"" on 07/22/08, after his admission on 07/08/08, and was determined to have no problems with the pureed diet he was ordered at that time. A follow-up note, written by the SLP on 11/19/08 after being told by nursing that he was eating regular food obtained without permission, stated he could be ""at risk of aspiration (secondary) to impulsivity and increased rate of oral intake."" On 07/16/09, the SLP approved an increase to a mechanical soft consistency with ground meats, but the resident was changed back to pureed foods and thin liquids because of his poor chewing skills. The resident's care plan, which was reviewed on 07/15/09 and indicated a revision of the diet order on 07/22/09, included the following intervention: ""Observe for any chewing / swallowing problems (coughing, red face, wet voice) - report any problems to the nurse."" The annual comprehensive minimum data set assessment (MDS), completed on 07/03/09, indicated in Section Gh that the resident was independent with eating and needed no help or oversight. The resident, when observed at three (3) meals during the survey, was eating in the activity room, which was the dining location of residents whose ADL needs during mealtimes were minimal. During an interview with the DON at 12:30 p.m. on 09/10/09, she stated the resident had had no problems since he had been put on pureed foods and she would review the care plan. The speech therapist, interviewed shortly after, stated the resident had a problem chewing but that was solved with the pureed diet, and he had never had any problem with swallowing. f) Resident #10 A review of the care plan, dated as reviewed on 07/29/09, revealed interventions including: ""Puree diet baby food consistency..."" and ""sippy cup"". The physician's orders [REDACTED]. During an interview with the resident's daughter, who feeds her frequently, at 6:00 p.m. on 09/09/09, she stated they had used a sippy cup for awhile, but they stopped when it didn't work. During an interview with the care plan nurse (Employee #81) at 10:15 a.m. on 09/10/09, she acknowledged the diet stated in the care plan was in error and she would review the care plan. .",2015-06-01
10168,MANSFIELD PLACE,515129,PO BOX 930,PHILIPPI,WV,26416,2009-09-10,323,G,0,1,N3OU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and observation, the facility failed, for two (2) of fourteen (14) sampled residents and one (1) randomly observed resident, to provide adequate supervision and/or assistive devices to promote resident safety. Resident #22 was assessed as having a decline in urinary continence on her comprehensive assessment of July 2009. Resident #22's care plan was revised on 08/05/09 to address, among other concerns, late loss activities of daily living (ADLs) and falls. After Resident #22 had a fall with injury on 08/10/09, the care plan was not revised with interventions to promote increased safety, including safe toilet use. Resident #22 subsequently fell in her room related to an episode of urinary incontinence on 09/07/09 and sustained injuries. Additionally, review of documentation related to offerings of scheduled toileting reflect a lack of consistent provision of staff supervision with toileting at regular intervals on a daily basis. The nursing assistant in the activity / dining room by herself was not aware Residents #15 and #8 required additional supervision for swallowing problems. Resident identifiers: #22, #15, and #8. Facility census: 56. Findings include: a) Resident #22 Review of Resident #22's nursing notes, on 09/07/09 at 2:25 p.m., revealed the following entry: ""9/7/09 0130 (1:30 a.m.) Residents (sic) alarm sounding. Upon entering room resident was found laying (sic) on (R) (right) side. Resident stated she had wet herself and her feet slid. Resident was assessed & noted 0.2 cm cut to back of head scant amt (amount) bleeding. Resident c/o (complained of) (R) shoulder pain, (R) elbow pain and (R) arm pain. (Name) RN supervisor was called and notified ... Noted abnormality to R humerus. ..."" The resident was subsequently transferred to the emergency room for treatment. Review of the facility's patient safety events revealed Resident #22 had another fall less than a month earlier, which also required medical intervention. On 08/10/09 at 1735 (5:35 p.m.), ""Called to room (number) by housekeeping, resident lying on left side. C/O pain in Left shoulder, elbow, and hip, able to squeeze my hand, weak grip, screamed in pain with elbow. rolled (sic) onto back 9 (sic) logrolled) able to move l (left) leg on command but c/o pain from hip to back. 3 cm x 3 cm laceration with skin flap on l (left) elbow sic) steri stripped small 2cm open area below this area. Logrolled onto stretcher and trasferred (sic) to gurney. ..."" The resident was subsequently transferred to the emergency room for treatment. Record review revealed Resident #22 was a [AGE] year old female admitted to the facility on [DATE]. Her monthly recapitulation of physician's orders [REDACTED]. Treatment orders included: ""Bed pad alarm for safety. Personal alarm for safety. Resident is to ambulate with wheeled walker with supervision to and from functions and meals."" Her most recent minimum data set assessment (MDS), a comprehensive annual assessment with an assessment reference date (ARD) of 07/24/09, revealed, in Section B, she had both short-term and long-term memory problems, she was not able to recall the current season, location of her own room, the names and faces or staff members, or that she was in a nursing home, and her cognitive skills for daily decision-making were moderately impaired. The 07/24/09 MDS also recorded, in Section G, the resident required limited assistance by one (1) staff member with the following ADLs: bed mobility, transfer, walk in room, walk in corridor, and toilet use. In Section J4, the assessor noted the resident had a previous fall within the past thirty-one (31) to one hundred eighty (180) days. Review of the resident's two (2) most recent consecutive assessment found she had a decline in bladder continence. On the quarterly MDS, with an ARD of 04/24/09, the assessor encoded Item H1b as ""1"", indicating the resident was usually continent with incontinent episodes occurring once a week or less. On the 07/24/09 annual MDS, the assessor encoded Item H1b as ""2"", indicating the resident was now occasionally incontinent of bladder two (2) or more times a week but not daily. Review of the resident's comprehensive plan of care for 08/05/09 through 11/05/09 found reference to the toileting schedule as follows - ""Toilet upon rising, before and after meals and out of room activities, before going to bed and offer toielting (sic) during each bed check at HS (hour of sleep)."" However, there was no mention of other interventions developed to promote improved bladder continence, which was a factor in the resident's fall on 09/07/09. (See citations at F315 and F279.) Further review of the resident's care plan revealed the following problem statement with respect to ADLs and falls: ""Alteration in ADL / mobility status with potential for falls R/T (related to) osteoarthritis, Alzhiemers (sic), dememtia (sic) AEB (as evidence by) extensive assist with bathing, dressing, locomotion off unit; limited assist with bed mobility, transfers, ambulation, toilet use, hygiene; feeds self after tray set up."" The goals associated with this problem statement were: ""Will have no decline with late loss ADLs (eating, toilet use, bed mobility, transfers) thru next review. Will have no fall with injury thru next review."" In addition to interventions to promote the resident's cooperation with and/or participation in bathing, grooming / personal hygiene, and bed mobility, staff was to: ""... Cue / encourage resident to plant feet solidly on floor to assist with transfers and prevent falls QS (every shift). Ensure safe environment ie bed in low position with wheels locked, personal items within reach, call bell in reach, floor dry, clean and clutter free QS. Ensure resident is wearing appropriate foot wear (sic) ie non-skin (sic) shoes / slippers / socks QS. Remind resident frequently during each shift not to attempt to transfer / ambulate self independently and to ring call bell for assist. ... May have Merriwalker (sic) for independent ambulation PRN (as needed). Personal and bed alarm for safety QS. ... Resident to ambulate with front wheeled walker with supervision to and from functions and meals."" Interventions such as reminding the resident to not attempt to transfer / ambulate independently and to ring the call bell for assistance are of questionable value given the resident's memory and cognitive impairments. Additionally, while other ADLs were addressed in this care plan, interventions to promote safe toilet use were not. Also in this same care plan was the following problem statement: ""Cognitive Loss (sic) related to Alzheimer's dementia, impaired decision making and poor safety awareness."" None of the goals or interventions associated with this problem statement spoke to the resident's poor safety awareness. No revisions were made to the resident's care plan after the fall with injury on 08/10/09 (which occurred five (5) days after the resident's comprehensive care plan was reviewed and revised) to promote increased safety and prevent a subsequent fall with injury. Review of documentation of related to toileting (forms titled ""Toileting Schedule for Activity Room"" and ""Midnight Toileting Schedule"") found inconsistent / incomplete documentation to reflect Resident #22 was, on a daily basis, offered assistance with toileting at the intervals specified to reduce episodes of incontinence and promote safe toileting, given that Resident #22 was to be reminded to not transfer / ambulate independently. b) Residents #15 and #8 A lunch time observation, on 09/09/09, found Employee #1 to be the only staff member assisting ten (10) residents to eat in the activity / dining area. Among the residents present were Residents #15 and #8. The following morning, Employee #1, when asked which residents who ate in the activity / dining area had swallowing problems, identified all residents who received pureed foods were at a risk for swallowing problems. Employee #1 further related that none of the residents with regular diets had swallowing problems. Medical record review, on 09/10/09, revealed both Residents #15 and #8 received regular consistency diets and both had been identified in their comprehensive care plans as having swallowing problems. On page 3 of Resident #15's comprehensive care plan, under the problem of alteration in nutrition dated 07/08/09 through 10/01/09, found the following intervention: ""Periodically monitor for swallowing difficulty (coughing, red face, wet voice) report any problems to the nurse."" On page 8 of Resident #8's comprehensive care plan, under the problem of alteration in nutrition dated 08/19/09 through 11/19/09, found the following intervention: ""Periodically monitor for swallowing difficulty (coughing, red face, wet voice) report any problems to the nurse."" On the afternoon of 09/10/09, the director of nursing (DON - Employee #80), when questioned regarding any form of communication which identified for the nursing assistants which residents who received regular consistency diets also had swallowing problems, related there was no such communication. The DON further related Employee #1 had been with the facility for several years, and Resident #15 had previously choked in the activity / dining room during a meal. .",2015-06-01
10169,MANSFIELD PLACE,515129,PO BOX 930,PHILIPPI,WV,26416,2009-09-10,369,D,0,1,N3OU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed, for two (2) of fourteen (14) sampled residents and one (1) randomly observed resident, to ensure the correct adaptive eating equipment was supplied by the dietary department as ordered by the physician. Resident identifiers: #35, #27, and #25. Facility census: 56. Findings include: a) Residents #35, #27, and #25 On 09/09/09, a lunch meal observation was completed. During this time, the physician's diet orders / tray card orders were compared to the adaptive eating utensils sent on the meal trays by the dietary department. The following was found: 1. Resident #35 was observed to have her coffee in a sippy cup and her tomato juice and tea in a regular cup. Review of the physician's orders [REDACTED]. Review of the nursing assistant communication record also revealed a sippy cup was to be used with all liquids. 2. Resident #27 was observed to have a sippy cup with a spout. Review of the physician's orders [REDACTED]. The nursing assistant communication record indicated she used a sippy cup. 3. Resident #25 was observed to have a regular plate. The physician's orders [REDACTED]. At this time, the dietary manager was questioned concerning the lack of a plate guard; she went to the kitchen and returned with a plate with a one-half (1/2) inch raised lip. The facility dietary staff failed to ensure the correct adaptive eating utensils were provided to residents as ordered by the physician. .",2015-06-01
10170,MANSFIELD PLACE,515129,PO BOX 930,PHILIPPI,WV,26416,2009-09-10,520,E,0,1,N3OU11,"Based on record 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. The facility identified thirty-five (35) residents, including Resident #22, who were incontinent of bladder and for whom no bladder retraining program was available. This had the potential to affect more than an isolated number of residents. Facility census: 56. Findings include: a) Resident #22 Medical record review, completed on 09/09/09, revealed Resident #22 had a decline in bladder continence. According to the quarterly minimum data set assessment (MDS) with an assessment reference date (ARD) of 04/24/09, the assessor encoded Item H1b as ""1"", indicating the resident was usually continent with incontinent episodes occurring once a week or less. In a subsequent MDS, with an ARD of 07/24/09, the assessor encoded Item H1b as ""2"", indicating the resident was occasionally incontinent of bladder two (2) or more times a week but not daily. Resident #22's medical record contained a ""Bladder Retraining Assessment"" form which recorded information in under the heading ""Current Resident Status"" and was signed by a registered nurse on 07/31/08 (date of admission). However, the sections for recording the results of a bladder assessment and whether the resident was able to participate in bladder retraining were blank. The only other documentation on this form were periodic narrative notes as follows: - 11/03/08 - ""Usually cont(inent) of bladder)"" - 02/04/09 - ""Continent of bladder."" - 04/07/09 - ""Usually continent of bladder."" - 07/26/09 - ""Occasional bladder incontinence."" Although this assessment was incomplete, the facility placed the resident on a toileting schedule in January 2009. Review of the resident's comprehensive plan of care for 08/05/09 through 11/05/09 found reference to the toileting schedule as follows - ""Toilet upon rising, before and after meals and out of room activities, before going to bed and offer toielting (sic) during each bed check at HS (hour of sleep)."" However, there was no mention of other interventions developed to promote improved bladder continence. On the afternoon of 09/10/09, the MDS / care plan coordinator (Employee #81), when interviewed, stated she did identify a decline in Resident #22's continence and felt she was a candidate for a bladder retraining program, but the facility did not have a restorative bladder retraining program. According to the facility's policy titled ""Bowel and Bladder Training"" (revised 07/19/04): ""1) After assessing the resident's bowel bladder function, implement the training program initiating a bowel and bladder flow sheet. 2) The flow sheet should be marked with the resident's identification sticker. 3) During the first three (3) days of the training program, the resident should be assessed hourly and findings recorded in the appropriate boxes. This will establish the resident's current voiding and defecation pattern. 4) Toileting times for training are to be used on all shifts, noting if resident expresses the need for toileting. 5) After a pattern is established, staff will increase the time increments for toileting by 1/2 hour each week until a maximum schedule is maintained."" The facility failed to thoroughly assess for reversible causes and/or develop and implement interventions, in accordance with facility policy, to promote improved bladder function after Resident #22 experienced a decline in urinary continence. (See citations at F315 and F279.) On 09/10/09 at 3:00 p.m., the facility's infection control coordinator (Employee #90), when interviewed, identified the quality assessment and assurance committee evaluated each resident to determine whether they were attaining their goals to attain or maintain self-performance of activities of daily living, but the QAA committee had not identified that the facility did not have a restorative bladder retraining program. Review of the facility-generated resident census and condition of residents (Form CMS-672) found thirty-five (35) residents whom the facility assessed as incontinent of bladder and who were not participating in a bladder retraining program.",2015-06-01
10171,MANSFIELD PLACE,515129,PO BOX 930,PHILIPPI,WV,26416,2009-09-10,309,E,0,1,N3OU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and medical record review, the facility failed, for three (3) of fourteen (14) sampled records and three (3) randomly observed residents, to provide care and services necessary to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. [MEDICAL CONDITION] settings were not immediately available for nursing to refer to while Resident #6 was experiencing respiratory distress. Additionally, the facility failed to have effective communication between the dietary department, rehabilitative therapy services, and the direct care nursing assistants to ensure five (5) residents received the correct adaptive equipment to promote increased independence with activities of daily living (ADLs). Resident identifiers: #6, #35, #1, #43, #27, and #25. Facility census: 56. Findings include: a) Resident #6 During a medication administration observation with the nurse (Employee #60) on 09/08/09 at 2:20 p.m., a nursing assistant came out of Resident #6's room and notified Employee #60 that he was not feeling good and was dizzy. Employee #60 immediately went into the room and assessed this resident. Surveyor observation found the resident was exhibiting labored breathing with use of abdominal accessory muscles and shortness of breath during speech. Employee #60 had the nursing assistant obtain a set of vital signs. The nursing assistant reported the following vital signs: temperature 97.8; pulse 68; respirations 18; blood pressure 158/88; and oxygen saturation 87 percent. Employee #60 then explained to Resident #6 she needed to apply his [MEDICAL CONDITION] machine to increase his oxygen saturation. Resident #6 agreed, and Employee placed him on the [MEDICAL CONDITION]. At this time, Employee #60 related the [MEDICAL CONDITION] setting to be 12-6 spontaneous with an oxygen delivery rate of 4 liters per minute. Employee #60 then expressed to the surveyor, in the hallway, her concern that she was not sure if the oxygen was to be on 2 or 4 liters per minute. At this time, the nursing supervisor came down the hall and Employee #60 related her question about the oxygen delivery rate. The nursing supervisor left to check the order, returned shortly thereafter, and decreased the delivery rate of the oxygen from 4 liter to 2 liters. Approximately thirty (30) minutes following the administration of the [MEDICAL CONDITION], Resident #6's oxygen saturation increased to 92 percent. Later on that day, Employee #77 was questioned where the [MEDICAL CONDITION] settings were recorded. She related they were found in the treatment administration record, and she went to the treatment cart to show where the settings were contained. b) Residents #35, #1, #43, #27, and #25 On 09/09/09, a lunch meal observation was completed. During this time, the physician's diet orders / tray card orders were compared to the adaptive eating utensils sent on the meal trays by the dietary department. The following was found: 1. Resident #35 was observed to have her coffee in a sippy cup and her tomato juice and tea in a regular cup. Review of the physician's orders [REDACTED]. Review of the nursing assistant communication record also revealed a sippy cup was to be used with all liquids. 2. Resident #1 was observed to have no sippy cup in use. Review of the physician's orders [REDACTED]. A nursing assistant was randomly interviewed and revealed the resident had not been using the sippy cup for coffee, that she did not like it, and they used a coffee cup with a lid. Review of the nursing assistant communication record failed to indicate any special adaptive equipment to be used for this resident. 3. Resident #43 was observed to have no sippy cup in use and his coffee cup had a lid and a straw. Review of the physician's orders [REDACTED]. Review of the nursing assistant communication record indicated he needed a spout cup with two (2) handles and a scoop plate guard. 4. Resident #27 was observed to have a sippy cup with a spout. Review of the physician's orders [REDACTED]. The nursing assistant communication record indicated she used a sippy cup. 5. Resident #25 was observed to have a regular plate. The physician's orders [REDACTED]. At this time, the dietary manager was questioned concerning the lack of a plate guard; she went to the kitchen and returned with a plate with a one-half (1/2) inch raised lip. The facility dietary staff failed to ensure adaptive utensils were provided as ordered. According to Resident #25's plan of care, she was to receive finger foods, ice cream for lunch and dinner, super cereal at all meals, and a plate guard. Food was to be left on the tray to create boundary, and no paper or plastic items were to be on the tray. Additional observations made during this meal found thin liquids were served in a bowl, a paper placemat was on the table under the food, and all food was taken off the tray. On the afternoon of 09/10/09, the director of nursing employee (Employee #80), the dietary manager (Employee #43), and the speech language pathologist (Employee #89) were interviewed. Employee #80 identified it was the dietary department's responsibility to ensure all adaptive eating equipment was sent out on the trays as ordered. Employee #43 was not sure why the equipment was not being sent out correctly. All agreed there were inconsistencies between what adaptive equipment had been ordered, what was sent out by the dietary department, and what was actually in use. .",2015-06-01
10172,MANSFIELD PLACE,515129,PO BOX 930,PHILIPPI,WV,26416,2009-09-10,315,E,0,1,N3OU11,"Based on medical record review, staff interview and facility policy review, the facility failed, for one (1) of fourteen (14) sampled residents, to thoroughly assess for reversible causes and/or develop and implement interventions to promote improved bladder function after Resident #22 experienced a decline in urinary continence. Resident identifiers: #22. Facility census: 56. Findings include: a) Resident #22 Medical record review, completed on 09/09/09, revealed Resident #22 had a decline in bladder continence. According to the quarterly minimum data set assessment (MDS) with an assessment reference date (ARD) of 04/24/09, the assessor encoded Item H1b as ""1"", indicating the resident was usually continent with incontinent episodes occurring once a week or less. In a subsequent MDS, with an ARD of 07/24/09, the assessor encoded Item H1b as ""2"", indicating the resident was occasionally incontinent of bladder two (2) or more times a week but not daily. Her medical record contained a ""Bladder Retraining Assessment"" form which recorded information in under the heading ""Current Resident Status"" and was signed by a registered nurse on 07/31/08 (date of admission). However, the sections for recording the results of a bladder assessment and whether the resident was able to participate in bladder retraining were blank. The only other documentation on this form were periodic narrative notes as follows: - 11/03/08 - ""Usually cont(inent) of bladder)"" - 02/04/09 - ""Continent of bladder."" - 04/07/09 - ""Usually continent of bladder."" - 07/26/09 - ""Occasional bladder incontinence."" Although this assessment was incomplete, the faciltiy placed the resident on a toileting schedule in January 2009. Review of the resident's comprehensive plan of care for 08/05/09 through 11/05/09 found reference to the toileting schedule as follows - ""Toilet upon rising, before and after meals and out of room activities, before going to bed and offer toielting (sic) during each bed check at HS (hour of sleep)."" However, there was no mention of other interventions developed to promote improved bladder continence. (See also citation at F279.) On the afternoon of 09/10/09, the MDS / care plan coordinator (Employee #81), when interviewed, stated she did identify a decline in Resident #22's continence and felt she was a candidate for a bladder retraining program, but the facility did not have a restorative bladder retraining program. According to the facility's policy titled ""Bowel and Bladder Training"" (revised 07/19/04): ""1) After assessing the resident's bowel bladder function, implement the training program initiating a bowel and bladder flow sheet. 2) The flow sheet should be marked with the resident's identification sticker. 3) During the first three (3) days of the training program, the resident should be assessed hourly and findings recorded in the appropriate boxes. This will establish the resident's current voiding and defecation pattern. 4) Toileting times for training are to be used on all shifts, noting if resident expresses the need for toileting. 5) After a pattern is established, staff will increase the time increments for toileting by 1/2 hour each week until a maximum schedule is maintained."" The facility failed to thoroughly assess for reversible causes and/or develop and implement interventions, in accordance with facility policy, to promote improved bladder function after Resident #22 experienced a decline in urinary continence. .",2015-06-01
10173,MANSFIELD PLACE,515129,PO BOX 930,PHILIPPI,WV,26416,2009-09-10,159,D,0,1,N3OU11,"Based on record review and staff interview, the facility failed to obtain written authorization from the legally responsible person before handling the personal funds for one (1) random resident, and failed to ensure quarterly reports of financial activity were being provided to one (1) sampled resident with capacity and the legal representative of one (1) random resident. The financial records of five (5) residents were reviewed. Resident identifiers: #28 and #43. Facility census: 56. Findings include: a) Resident #28 A review of the clinical record of Resident #28 revealed an alert and oriented female who has been determined by her physician to have the capacity to make her own healthcare decisions. A review of her financial records revealed the quarterly statements of her personal fund account were sent to a family member, but not to the resident. This was confirmed by Employee #92 (the person responsible for handling resident funds) at 10:40 a.m. on 09/10/09. b) Resident #43 A review of the clinical record of Resident #43 revealed his physician determined he lacked the capacity to make healthcare decisions and appointed a health care surrogate to act on his behalf. The authorization for the facility to handle his personal funds was signed on 10/06/05 by a person who indicated he was the resident's ""conservator"", but there was no evidence of the conservatorship appointment in the files and no indication this person received quarterly statements of the resident's financial activity. During an interview with Employee #92 at 10:40 a.m. on 09/10/09, she stated that, to her knowledge, the person in question was no longer the conservator for the resident and did not want to be contacted, although she had no documentation to confirm this. She stated she signed the quarterly statements and filed them. She admitted that, at this time, there was no one legally responsible for Resident #43's finances and she knew of no actions in process to remedy the situation. This was confirmed by the social worker (Employee #83) at 11:30 a.m. on 09/10/09. This resident was a Medicaid recipient and also received benefits from the Veterans Administration, although his total personal account was not above the allowed amount at this time. In a follow-up interview with Employee #92 at 2:30 p.m. on 09/10/09, she stated made an inquiry at the bank and was told that a representative at the bank was the conservator and would be in touch with the facility. .",2015-06-01
10174,MANSFIELD PLACE,515129,PO BOX 930,PHILIPPI,WV,26416,2009-09-10,274,D,0,1,N3OU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to recognize a significant change in health status and complete a comprehensive assessment for one (1) of fourteen (14) sampled residents who exhibited a deterioration in both activities of daily living (ADL) self-performance and bladder continence and developed a stasis ulcer. Resident identifier: #28. Facility census: 56. Findings include: a) Resident #28 A comparison of consecutive assessments (an abbreviated quarterly minimum data set assessment ((MDS) dated [DATE] and an abbreviated quarterly MDS dated [DATE]) revealed Resident #28 declined in ADL self-performance and was newly coded as a ""3 or 4"" (extensive or total assistance) in six (6) areas and did not perform an ADL (coded an ""8"" - did not occur) in one (1) area. This comparison also revealed her bladder continence pattern changed from ""1"" (usually continent) to ""3"" (frequently incontinent); she developed a chewing problem, a Stage III stasis ulcer, and she declined in the average time involved in activities. Because these changes in health status were not recognized, a comprehensive assessment including completion of triggered resident assessment protocols for in-depth review were not completed. During an interview at 10:15 a.m. on 09/10/09, the MDS nurse (Employee #81) acknowledged the resident had experienced changes, and she stated she would review the MDS. .",2015-06-01
10175,MANSFIELD PLACE,515129,PO BOX 930,PHILIPPI,WV,26416,2009-09-10,371,F,0,1,N3OU11,"Based on observation and staff interview, the facility failed to assure the safe and proper foodhandling and storage for items in the refrigerator of the kitchen in the resident care area. Facility census: 56. Findings include: a) Observation of the kitchen located adjacent to the nurses' station, at 12:30 p.m. on 09/09/09, found two (2) cartons of milk labeled to be used prior to 09/07/09 and a partially used bottle of cranberry juice dated as having been opened on 07/13/09. An open 1/2 gallon cardboard container of ice cream was found in the freezer without any label to indicate when it was opened, and the freezer itself was dirty with debris on the inner storage surface. These items were shown to the director of nurses, who acknowledged they should have been discarded, and she proceeded to do so and to clean the freezer. .",2015-06-01
10176,MANSFIELD PLACE,515129,PO BOX 930,PHILIPPI,WV,26416,2009-09-10,281,D,0,1,N3OU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, observation, and staff interview, the facility failed to develop an interim plan of care for one (1) of fourteen (14) sampled residents, to address all known care needs present on admission. A newly admitted resident with a respiratory infection, sleep apnea, and a Stage II pressure ulcer, did not have an adequate interim plan of care to address his known clinical needs. Resident identifier: #6. Facility census: 56. Findings include: a) Resident #6 Resident #6's medical record, when reviewed on 09/08/09 at 1:30 p.m., disclosed a [AGE] year old male who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Resident #6 was observed on 09/08/09 at 2:00 p.m., in bed with oxygen via nasal cannula at two (2) liters per minute. A ""[MEDICAL CONDITION]"" device was noted at the bedside. The resident's right hand was noted to have a med lock. The resident reported he was admitted to the facility, on 08/27/09, for rehabilitation after a fall at home. The resident reported that, shortly after his admission, he had respiratory distress and was readmitted to the acute care hospital. The resident returned to the facility on [DATE]. The resident reported he used the [MEDICAL CONDITION] for sleep apnea. The resident stated he had a ""sore"" on his coccyx. Review of facility form title ""Mansfield Place Ulcer Flow Sheet"", dated 09/09/09, confirmed the resident had a Stage II pressure ulcer on his coccyx. The ""working care plan"", dated 09/03/09, did not address care and interventions relating to the resident's pressure ulcer. The resident's September 2009 Medication Administration Record [REDACTED]"". The ""working care plan"", dated 09/03/09, did not address the care and maintenance of the IV ""med lock"" for the resident. The director of nurses ( DON - Employee #80) provided a copy of the facility's policy titled ""IV Med Lock"" (revision date of January 2004). The policy, when reviewed on 09/10/09 at 10:30 a.m., stated, ""Assess insertion site of med lock every shift. Discontinue med lock if signs of infiltration, phlebitis, pain or tenderness at site, or purulence are detected."" The ""working care plan"" did not include assessment of the resident's intravenous line. The care plan nurse (Employee #81), when interviewed on 09/10/09 at 2:20 p.m., confirmed the use of the [MEDICAL CONDITION], the pressure ulcer, and the med lock, were not address in the ""working care plan"" and should have been included. .",2015-06-01
10177,MANSFIELD PLACE,515129,PO BOX 930,PHILIPPI,WV,26416,2009-09-10,514,D,0,1,N3OU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain complete clinical records for two (2) of fourteen (14) sampled residents. Two (2) resident's ""Resident Record: Meal & Snack(s) Percentages"" forms were not complete. Resident identifiers: #27 and #50. Facility census: 56. Findings include: a) Resident #27 Resident #27's medical record, when reviewed on 09/09/09 at 3:00 p.m., disclosed a [AGE] year old female who was admitted to the facility on [DATE]. The resident had [MEDICAL CONDITION] and was currently receiving hospice services. The quarterly minimum data set (MDS), dated [DATE], reported the resident required total assist with all meals. The care plan, dated 08/26/09, reported the resident had a weight loss. An intervention listed for the resident was: ""Record meal and HS (bedtime) snack percentages."" Review of the facility form titled ""Resident Record: Meal & Snack(s) Percentages"" found it was incomplete for August and September 2009. The ""8 PM Snack"" portion of the form was left blank for 09/04/09, 09/05/09, and 09/06/09. The August 2009 Meal & Snack Percentages sheet recorded ""NA"" for fifteen (15) of the thirty-one (31) days of the month. The director of nurses (DON - Employee #80), when interviewed on 09/09/09 at 3:45 p.m., reviewed the resident's ""Meal & Snack Percentages"" forms and confirmed the forms were incomplete. The DON stated ""NA"" was not acceptable documentation, and she acknowledged the resident was to have an evening snack offered each day at 8:00 p.m. b) Resident #50 Resident #50's medical record, when reviewed on 09/08/09 at 11:00 a.m., disclosed a [AGE] year old female who was admitted to the facility on [DATE]. The resident had senile dementia, [MEDICAL CONDITIONS] and hypertension. The care plan, dated 07/15/09, stated the resident was ""unable to feed self "". The care plan instructed staff to: ""Record meal and HS snack percentages."" Review of the facility form titled ""Resident Record: Meal & Snack(s) Percentages"" found it was incomplete for August and September 2009. The ""8 PM Snack"" portion of the form was left blank for 08/09/2009 and 09/05/09. The August 2009 ""Resident Record: Meal & Snack Percentages"" sheet recorded ""NA"" for 08/08/09, 08/10/09, 08/11/09, and 08/12/09. The DON, when interviewed on 09/09/09 at 3:45 p.m., reviewed the resident's ""Resident Record: Meal & Snack Percentages"" forms and confirmed the forms were incomplete. The DON stated ""NA"" was not acceptable documentation, and she acknowledged the resident was to have an evening snack offered each day at 8:00 p.m. .",2015-06-01
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
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
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
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
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
10419,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2009-09-23,242,D,0,1,JZ9F11,"Based on observation, record review, and staff interview, the facility failed to assure dietary personnel honored resident preferences in food choices during one (1) meal observed. Three (3) randomly observed residents were served food items that were noted on their dietary ""likes and dislikes"" lists as a dislike. Resident identifiers: #68, #35, and #30. Facility census: 65. Findings include: a) Residents #68, #35, and #30 Observation of the noon meal in the main dining room of the facility, at 12:00 p.m. on 09/22/09, found residents were being served spaghetti and garlic bread. Further observation of resident trays disclosed the tray cards of each of the above mentioned residents (#68, #35, and #30) noted they disliked spaghetti. All three (3) were served spaghetti. Each of the residents, when briefly questioned, confirmed they did not like spaghetti. A facility nurse (Employee #8) was present during the observations and brief questioning and confirmed the findings. .",2015-04-01
10420,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2009-09-23,514,D,0,1,JZ9F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure documentation in the medical records of two (2) of eleven (11) residents reviewed was accurate. There was a lack of internal consistency between documentation in two (2) areas of the medical record related to the specific behaviors of these residents. Resident identifiers: #54 and #36. Facility census: 65. Findings include: a) Resident #54 The medical record of Resident #54, when reviewed on 09/22/09, disclosed this [AGE] year old resident was receiving the medication [MEDICATION NAME] 0.25 mg mg every twelve (12) hours for ""hallucinations, stressful to resident; thinks people are hanging from trees"". Review of nurses' notes for this resident disclosed that, on two (2) occasions in July (07/16/09 and 07/17/09), nurses documented the resident was ""seeing things on the ceiling"" and ""picking in air"". The resident's behavior / intervention monthly flow record for the month of July was reviewed. This form, used to document the occurrence of behaviors on each shift, had no entries to suggest the resident had experienced any behaviors in the month of July. The facility's director of nurses (DON - Employee #69), when questioned on 09/23/09 at 10:25 a.m. related to these documents, confirmed the two (2) documents should contain the same information. b) Resident #43 The medical record of Resident #43, when reviewed on 09/23/09, disclosed this [AGE] year old resident was receiving the medication [MEDICATION NAME] 50 mg at bedtime and 25 mg two (2) times daily for ""combativeness, verbally abusive, and inappropriate touching of staff"". Review of nurses' notes for this resident disclosed that, on four (4) occasions in July (07/01/09, 07/08/09, and twice on 07/26/09), the resident exhibited behaviors of combativeness, verbal abuse, and inappropriate touching of staff. The resident's behavior / intervention monthly flow record for the month of July was reviewed. This form, used to document the occurrence of behaviors on each shift, had no entries to suggest the resident had experienced any behaviors in the month of July between the dates of 07/01/09 and 07/26/09. The DON, when questioned on 09/23/09 at 10:25 a.m. related to these documents, confirmed the two (2) documents should contain the same information.",2015-04-01
10421,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2009-09-23,364,B,0,1,JZ9F11,"Based on observation and staff interview, the facility failed to ensure residents who were ordered a pureed / mechanical soft diet were served attractive and colorful meals. Fifteen (15) residents received pureed or mechanically altered diets. Resident identifiers: #3 #4, #5, #7, #10, #11, #15, #18, #30, #35, #48, #51, #54, #61, and #64. Facility census: 65. Findings include: a) Residents #3 #4, #5, #7, #10, #11, #15, #18, #30, #35, #48, #51, #54, #61, and #64 On 09/22/09 at approximately 6:00 p.m., residents were observed eating their evening meal in both the dining room and their individual rooms. A nurse aide assisting Resident #15 indicated she could not identify the main entree on the resident's plate. Other residents also could not definitively identify the main entree. Staff members in the dining room indicated they thought the entree was fish but were not sure. The menu revealed the mechanical soft and puree diets received lemon baked fish, two (2) slices of white bread, mashed potatoes, and a mayonnaise packet. All of these food items were bland in color. The dietary manager said she realized the food lacked color but did not know what to do, because those were the items listed on the menu. .",2015-04-01
10474,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2009-09-23,315,E,0,1,60BJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed, for six (6) of fourteen (14) sampled residents, to assess residents with increased frequency of urinary incontinence and/or a decline in urinary continence and failed to develop and implement interventions to restore as much normal bladder function as possible. Resident identifiers: #24, #51, #16, #40, #62, and #17. Facility census: 62. Findings include: a) Resident #24 Medical record review, on 09/16/09, revealed Resident #24 was an alert and oriented [AGE] year old female who was admitted to the facility on [DATE]. In her comprehensive admission assessment with an assessment reference date (ARD) of 04/02/09, the assessor recorded in Section H (continence in last 14 days) Resident #24 as being occasionally incontinent of bowel (coded ""2"" to indicate incontinent episodes occurred two (2) or more times a week but not daily) and continent of bladder (coded ""0"" - no incontinent episodes). On 04/07/09, a staff member started to complete a form titled bowel / bladder continence evaluation, but the assessment tool was incomplete. In an abbreviated quarterly assessment with an ARD of 06/18/09, the assessor recorded Resident #24 as now being totally incontinent of both bowel and bladder (both coded ""4""). Following this decline, the facility's interdisciplinary care team failed to complete an in-depth assessment to identify possible reversible causes of this incontinence and failed to develop and implement interventions to help the resident restore as much normal bladder function as possible. On 09/17/09 at 10:00 a.m., interview with Resident #24 revealed she was aware of the need to void, but staff never assisted her to the toilet since she was able to walk with assistance and she, in the future, would like to return home. According to the expanded form CMS-672 (Resident Census and Conditions of Residents) generated by the facility on 09/17/09, the facility identified forty-two (42) of its sixty-two (62) residents as being occasionally or frequently incontinent of bladder with zero (0) residents on an individually written bladder training program. On the afternoon of 09/17/09, the director of nursing (DON - Employee #33) related the facility identified a problem with incontinence assessments but had not been able to complete new assessments everyone to determine their needs. The DON also acknowledged that no resident, at present, was on a urinary continence restoration program. b) Resident #51 Medical record review, on 09/21/09, revealed Resident #51, a [AGE] year old female who was alert, oriented to person, place, and circumstance, with short-term memory problems and modified independence with cognitive skills for daily decision making, was originally admitted to the facility on [DATE]. In a comprehensive admission assessment with an ARD of 06/18/09, the assessor noted in Section H the resident was continent of bowel (coded ""0"") and occasionally incontinent of bladder (coded ""2"" to indicate she was incontinent 2 or more times a week but not daily). There was no evidence of an in-depth assessment to the resident to rule out reversible causes for the urinary incontinence, nor were any interventions developed and implemented to assist Resident #51 in restoring as much normal bladder function as possible. c) Resident #16 Medical record review, on 09/16/09, revealed Resident #16, a [AGE] year old female who was alert, oriented to person, place, and circumstance, with short-term memory problems and modified independence with cognitive skills for daily decision making, was re-admitted to the facility on [DATE]. In a comprehensive annual assessment with an ARD of 04/20/09, the assessor noted in Section H the resident was usually continent of bowel (coded ""1"") and frequently incontinent of bladder (coded ""3""). On 05/02/09, a staff member started to complete a form titled bowel / bladder continence evaluation, but the assessment tool was incomplete. In an abbreviated quarterly assessment with an ARD of 07/16/09, the assessor noted in Section H the resident was usually continent of bowel (coded ""1"") and frequently incontinent of bladder (coded ""3""). In a significant change in status assessment with an ARD of 08/03/09, the assessor noted the resident was now totally incontinent of both bowel and bladder (both coded ""4""). Following this decline, the facility's interdisciplinary care team failed to complete an in-depth assessment to identify possible reversible causes of this incontinence and failed to develop and implement interventions to help the resident restore as much normal bladder function as possible. On 09/23/09 at 10:45 a.m., interview with Resident #16 revealed she does know when she needs to void, but no one ever takes her to the toilet. d) Resident #40 Medical record review, on 09/17/09, revealed Resident #40, a [AGE] year old female who was alert with short-term and long-term memory problems and moderately impaired cognitive skills for daily decision making, was admitted to the facility on [DATE]. In a comprehensive admission assessment with an ARD of 04/20/09, the assessor noted in Section H the resident was totally incontinent of bowel and bladder (both coded ""4""). Subsequent assessments revealed she continued to be totally incontinent of both bowel and bladder. On 04/22/09, a staff member started to complete a form titled bowel / bladder continence evaluation, but the assessment tool was incomplete. Further review of her medical record found no evidence of any interventions to improve the resident's continence status. In an interview on 09/17/09 at 10:45 a.m., Resident #40 reported she was able to sense the need to void but staff did not take her to the bathroom. e) Resident #62 Medical record review, on 09/16/09, revealed Resident #62, a [AGE] year old female who was alert with short-term and long-term memory problems and moderately impaired cognitive skills for daily decision making, was admitted to the facility on [DATE]. In her comprehensive admission assessment with an ARD of 08/20/09, the assessor noted the resident was occasionally incontinent of bowel (coded ""2"") and frequently incontinent of bladder (coded ""3""). In an abbreviated quarterly assessment with an ARD of 07/01/09, the assessor noted the resident was now frequently incontinent of bowel (coded ""3"") and totally incontinent of bladder (coded ""4""). Further review of her medical record found no evidence of any interventions to improve the resident's continence status. f) Resident #17 Record review revealed this [AGE] year old female, who was alert with short-term and long-term memory problems and moderately impaired cognitive skills for daily decision making, was admitted to the facility on [DATE]. Further record review revealed a bowel / bladder continence evaluation dated 08/27/09, which stated schedule toileting would be started for this resident. In her comprehensive admission assessment with an ARD of 09/07/09, the assessor noted the resident was totally incontinent of both bowel and bladder. On the resident assessment protocol (RAP) summary completed in conjunction with this assessment, the interdisciplinary care team indicated they were going to proceed in addressing the resident's incontinence on her care plan. Review of her current care plan found no goals or interventions regarding incontinence. Interview with the DON, on the mid-afternoon of 09/23/09, revealed the facility had identified Resident #17 needed a toileting program, but they were only doing so many residents at a time at the present. .",2015-03-01
10475,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2009-09-23,241,D,0,1,60BJ11,"Based on observation and staff interview, the facility failed, for one (1) of fourteen (14) sampled residents and one (1) random resident, to ensure care was provided in a manner and an environment that enhanced dignity and respect for each resident. Resident identifiers: #1 and #40. Facility census: 62. Findings include: a) Residents #1 and #40 During an initial tour completed of the facility on 09/16/09 at 6:50 a.m., observation found Resident #1 propelling himself in a wheelchair toward the nurses' station. Once he got to the nurses' station, he proceeded to the bathroom and asked staff to assist him. Further observation noted a registered nurse (RN - Employee #32) walked toward the hall where residents' rooms were and yelled down the hall to a nursing assistant, ""(Resident #1) has to go to the bathroom."" The RN then proceeded back toward the nurses' station. At 7:05 a.m. on 09/16/09, observation found Resident #40 sitting in the corridor half way down the hall motioning to staff the need for assistance. The RN yelled down the corridor, ""What's the matter, (Resident #40)? Come on down."" and motioned for the resident to come to the nurses' station. On the morning of 09/17/09, the ""person in charge"" (Employee #5) identified that, once she arrived at the facility, staff informed her of the above occurrences involving Residents #1 and #40. Employee #5 identified the need to conduct staff education and had begun with educating Employee #32. .",2015-03-01
10476,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2009-09-23,323,E,0,1,60BJ11,"Based on medical record review, staff interview and observation, the facility failed, for four (4) sampled residents and four (4) randomly sampled residents, to ensure the resident environment remained as free as possible of accident hazards. Residents #23, #48, #49, #52, #42, #11, and #51, who were not assessed for increased incontinence episodes, experienced falls while attempting to self-toilet and/or after experiencing episodes of incontinence. Additionally, Resident #54 was observed to be in bed and needing assistance and her call light was not in reach. Facility census: 62. Findings include: a) Residents #23, #48, #49, #52, #42, #11, and #51 Medical record review, during the course of this survey event, found the facility did not have in place a system to assess residents with increased frequency of urinary incontinence and/or a decline in urinary continence and to develop and implement interventions to restore as much normal bladder function as possible. (See citation at F315.) According to the expanded form CMS-672 (Resident Census and Conditions of Residents) generated by the facility on 09/17/09, the facility identified forty-two (42) of its sixty-two (62) residents as being occasionally or frequently incontinent of bladder with zero (0) residents on an individually written bladder training program. The facility also identified forty-one (41) of its sixty-two (62) residents as being occasionally or frequently incontinent of bowel with zero (0) residents on an individually written bowel training program. On the afternoon of 09/21/09, interview with the director of nursing (DON - Employee #3) revealed the facility's quality assessment and assurance committee had identified the need for an incontinence management program and they started an action plan to correct this quality deficiency, but there was no resident in the facility who had been fully assessed and placed on a bladder restoration program. Review of the facility's incident / accident reports, on 09/21/09, revealed seven (7) residents (#23, #48, #49, #52, #42, #11, and #51) had sustained falls without injury while attempting to ambulate unassisted to the bathroom or after being incontinent: 1. Resident #23 According to an incident / accident report on 09/06/09 at 6:45 a.m., a staff member ""entered the room to find resident (#23) sitting on the floor in puddle of stool."" According to the expanded form CMS-672 (Resident Census and Conditions of Residents) generated by the facility on 09/17/09, Resident #23 required staff assistance with toileting and transferring; she was not identified as having problems with incontinence and was not on a bladder training program. 2. Resident #48 According to an incident / accident report on 08/25/09 at 12:15 p.m., ""resident (#48) states that she was walking back from the bathroom unassisted and sat down on the floor..."" According to the expanded form CMS-672 (Resident Census and Conditions of Residents) generated by the facility on 09/17/09, Resident #48 required staff assistance with toileting and transferring; she was not identified as having problems with incontinence and was not on a bladder training program. 3. Resident #49 According to an incident / accident report on 08/22/09 at 10:35 p.m., a staff member ""found resident on mat on floor by bed states she was trying to get OOB (out of bed) to go to BR (bathroom)..."" According to the expanded form CMS-672 (Resident Census and Conditions of Residents) generated by the facility on 09/17/09, Resident #49 required staff assistance with toileting and transferring; she was identified as having problems with incontinence and was not on a bladder training program. 4. Resident #52 According to an incident / accident report on 08/07/09 at 4:00 a.m., ""CNA (certified nursing assistant) passing room saw resident (#52) sitting on the floor beside roommates bed & called me to room. Resident questioned about what happened, where she was going & what caused the fall. Resident was headed to toilet, voided incont. (incontinent) on floor & slipped & fell ..."" According to the expanded form CMS-672 (Resident Census and Conditions of Residents) generated by the facility on 09/17/09, Resident #52 required staff assistance with toileting and transferring; she was identified as having problems with incontinence and was not on a bladder training program. 5. Resident #42 According to an incident / accident report on 08/03/09 at 1:30 p.m., Resident #42 was found ""sitting on floor in front of recliner on L (left) side. Chair alarm turned off. When asked what happened, states 'I was trying to get up.' W/C (wheelchair) parked facing recliner. Incontinent bowel..."" According to the expanded form CMS-672 (Resident Census and Conditions of Residents) generated by the facility on 09/17/09, Resident #42 required staff assistance with toileting and transferring; she was identified as having bowel incontinence and was not on a bowel training program. 6. Resident #11 According to an incident / accident report on 08/02/09 at 1:30 p.m., ""res(ident) was ambulating up from toilet and fell down in bathroom..."" According to the expanded form CMS-672 (Resident Census and Conditions of Residents) generated by the facility on 09/17/09, Resident #11 required staff assistance with toileting and transferring; she was not identified as having problems with incontinence and was not on a bladder training program. 7. Resident #51 According to an incident / accident report on 07/17/09 at 5:15 p.m., ""CNA found resident sitting on floor in room. (Resident #51) stated I'm looking for the bathroom..."" According to the expanded form CMS-672 (Resident Census and Conditions of Residents) generated by the facility on 09/17/09, Resident #51 required staff assistance with toileting and transferring; she was identified as having problems with incontinence and was not on a bladder training program. b) Resident #54 On 09/17/09 at 10:45 a.m., observation found Resident #54 lying in bed, yelling out for assistance. This surveyor entered the room and observed the call light was behind the head of the bed on the floor and not in the resident's reach. At this time, the DON, upon being informed of the situation, entered the room, obtained the call light from the floor, and handed it to the resident. .",2015-03-01
10477,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2009-09-23,353,F,0,1,60BJ11,"Based on observations, staff interviews, resident interviews, family interview, review of the facility-generated form CMS-672 (Resident Census and Conditions of Residents), nursing assistant assignments, and shower schedules, the facility did not have sufficient staff to provide nursing and related services to assure each resident attained or maintained his or her highest practicable level of well-being. This deficient practice has the potential to affect all residents in the facility. Facility census: 62. Findings include: a) Review of the form CMS-672 (Resident Census and Conditions of Residents) generated by the facility on 09/17/09 revealed the following: - Zero (0) of the sixty-two (62) residents currently in the facility was independent in the performance of any of the five (5) following activities of daily living (ADLs) - bathing, dressing, transferring, toilet use, and eating. - Twenty-two (22) residents required the assistance of one (1) or two (2) staff members for bathing and forty (40) residents were totally dependent upon staff for this ADL. - Forty-seven (47) residents required the assistance of one (1) or two (2) staff members for dressing and fifteen (15) residents were totally dependent upon staff for this ADL. - Forty-four (44) residents required the assistance of one (1) or two (2) staff members for transferring and eighteen (18) residents were totally dependent upon staff for this ADL. - Forty-four (44) residents required the assistance of one (1) or two (2) staff members for toilet use and eighteen (18) residents were totally dependent upon staff for this ADL. - Fifty-two (52) residents required the assistance of one (1) or two (2) staff members for eating and ten (10) residents were totally dependent upon staff for this ADL. b) According to the facility's ""Bed List Report"", thirty-three (33) residents resided on the 200 hall. The following are estimations of staff time needed to meet the assessed care needs of these thirty-three (33) residents on day shift for a single day: 1. According to the facility's list, seven (7) residents were scheduled to receive showers on day shift on Thursdays and the remaining twenty-six (26) were to receive bed baths. It would take approximately twenty (20) minutes to bathe, dress, and groom each resident, which would equal a total of six hundred sixty (660) minutes of nursing care. 2. According to a list on the unit, five (5) residents were totally dependent upon staff for eating. The time required to serve each resident's tray, properly position the resident, feed the resident, remove the tray, and record the percentage of consumption was estimated at thirty (30) minutes, which would equal a total of one hundred fifty (150) minutes of nursing care per meal and three hundred (300) minutes of nursing care for two (2) meals per day on day shift. An additional twenty-seven (27) residents required some staff assistance with eating / meal service, to include tray set-up, prompting / cuing if indicated, tray removal, and recording of meal intake. It would take at least five (5) minutes per resident to accomplish these tasks, which would total one hundred thirty-five (135) minutes of nursing care per meal and two hundred seventy (270) minutes of nursing care for two (2) meals per day on day shift. 3. According to the expanded CMS 672, twenty-five (25) residents on this unit were listed as incontinent. For the residents to be checked every two (2) hours during an eight (8) hour shift, toileted if appropriate with incontinence care provided (estimated to require approximately twenty (20) minutes per resident), the facility must provide five hundred (500) minutes of nursing care. c) On 09/16/09 and 09/17/09, three (3) nursing assistants provided care to thirty-three (33) residents on the 200 hall during the day shift. Each nursing assistant worked for seven and one-half (7.5) hours during the day shift, totaling one thousand, three hundred, fifty (1350) minutes of nursing care. To meet the estimated needs of the thirty-three (33) residents on this unit as outline above, a total of one thousand, seven hundred, thirty (1730) minutes of nursing time was needed. This left a deficit of three hundred eighty (380) minutes of nursing care per day shift on this unit alone. Additional time would also be needed for turning and positioning residents, taking vital signs, changing bed linens, providing snacks, providing additional beverages, providing interventions identified on the individual resident's care plan, passing ice for water pitchers, restocking items such as disposable briefs, completing flow sheets, completing intakes and outputs on certain residents, etc. d) Observations, conducted on 09/16/09 through 09/23/09, revealed the licensed nurses were busy with other tasks and were not available to provide much assistance to the nursing assistants in carrying out the daily tasks required by the residents' individual needs. e) Confidential Family Interviews A confidential family interview revealed nursing staff was slow to answer call lights and did not always take resident into the bathroom; instead staff let the residents void and defecate in their incontinence briefs. e) Confidential Resident Interviews Confidential resident interview #1 identified staff was slow to answer his/her call light. Confidential resident interview #2 identified staff members took their time when called and did not always come when the call light was used. This resident reported having to wait up to one (1) hour for staff assistance after activating the call light and that staff will shut the call light off and not come return to render the needed assistance for extended periods of time. f) Confidential Resident Group Interview All five (5) residents in attendance agreed that staff takes up to thirty (30) minutes answer their call lights, and this delay occurs on all shifts, at different times of the day and on different days of the week. In the middle of the meeting, an additional resident joined the group. At this point, three (3) of the six (6) residents agreed the staff worked real hard but there were not enough of them, and they become ""sassy"", ""abrupt"", and ""rude"" when overworked. g) On the afternoon of 09/17/09, the director of nursing (DON - Employee #33), when interviewed, revealed the nursing assistant assignments were not based on resident acuity but on the physical layout of the building. She acknowledged they needed to make some changes with the distribution of the workload. She also reported she was not aware that, on some days, a single nursing assistant may be assigned to complete three (3) showers and care for three (3) to four (4) totally dependent residents and between seven (7) and nine (9) residents who were incontinent. .",2015-03-01
10478,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2009-09-23,441,E,0,1,60BJ11,"Based on infection control tracking review and staff interview, the facility failed, for three (3) of fourteen (14) sampled residents and two (2) randomly sampled residents, to maintain a infection control program that identifies clusters of infections within the facility and tracks all infectious organisms. Resident identifiers: #17, #57, #5, #50, and #16. Facility census: 62. Findings include: a) Residents #17, #57, #5, #50, and #16 1. Residents #17, #57, and #5 Review of the August 2009 infection control tracking log, on the morning of 09/17/09, revealed the facility had a cluster of three (3) residents (#17, #57 and #5) in the same nursing assistant assignment section on the A hall who, within one (1) week, all cultured positive for E. coli infections in the urine. - Resident #17's culture came back positive for E. coli in the urine on 08/27/09. - Resident #57's culture came back positive for E. coli in the urine on on 08/21/09. - Resident #5's culture came back positive for E. coli in the urine on 08/21/09. The facility failed to investigate and identify this cluster of infections and/or take spreads to prevent the spread of this infectious organism. 2. Residents #50 and #16 Review of the September 2009 infection control tracking log found not all organisms that had been identified via a culture were being tracked by the facility. - The results of a urine culture for Resident #50 were received on 09/05/09, but the infectious organism found in the specimen was not recorded on the tracking log. - The results of a urine culture for Resident #16 were received on 09/02/09, but the infectious organism found in the specimen was not recorded on the tracking log. b) In an interview on the afternoon of 09/17/09, the director of nursing (DON - Employee #33) agreed the infectious organisms for Residents #50 and #16 were not identified on the September tracking log and confirmed that the cluster of E. coli infections in the urine of three (3) residents on the same nursing assistant assignment was not identified. .",2015-03-01
10479,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2009-09-23,309,D,0,1,60BJ11,"Based on medical record review, resident interview, and staff interview, the facility failed, for two (2) of fourteen (14) sampled residents, ensure functionality checks were completed on their indwelling cardiac pacemakers as ordered by the physician. Resident identifiers: #24 and #43. Facility census: 62. Finding include: a) Resident #24 Medical record review, on 09/16/09, revealed that, prior to admission to the facility, Resident #24 received an implanted cardiac pacemaker, and the following order was written on 03/27/09: ""Pacemaker phone checks (company name) calling time is 10:20 a.m. Next scheduled check 05/26/09."" Further review of the medical record found no evidence this check was completed as scheduled. On 09/17/09 at 10:00 a.m., Resident #24, when interviewed, revealed it had been ""a while"" since the pacemaker was checked, and the resident could not remember last time it was checked while at the nursing home. On the afternoon of 09/17/09, the director of nursing (DON - Employee #33), when interviewed, related the pacemaker was not checked on 05/26/09, this information was not documented in the medical record, and the facility rescheduled the check to be completed within the next week. b) Resident #43 Medical record review, on 09/17/09, revealed Resident #43 had an implanted cardiac pacemaker. This review revealed the pacemaker was due to be checked on 07/24/09. The medical record failed to contain evidence to reflect this check was completed as scheduled. On the afternoon of 09/17/09, the DON acknowledged the pacemaker check needed to be rescheduled at a later date. She identified that the physician discontinued the pacemaker checks since it was no longer functioning properly, and the family and resident elected for hospice services. .",2015-03-01
10402,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,323,E,0,1,86JH11,"Based on record review and staff interview, the facility did not ensure fifty-five (55) residents with skin tears and forty-four (44) residents with bruises, out of one hundred-twenty (120) incident reports reviewed for a period of three and one-half (3.5) months were provided supervision to prevent accidents. Facility census: 89. Findings include: a) A review of the facility's incident reports for the months of June, July, August, and part of September 2009 revealed residents had received fifty-five (55) skin tears and forty-four (44) bruises. The bruises and skin tears were primarily found on the extremities (arms, hands, fingers, legs, and feet). An interview with the director of nursing (DON - Employee #1), on 09/23/09 at 3:00 p.m., revealed that a lack of adequate staffing was not the reason for so many bruises and skin tears at the facility. She related the staff may have been hurrying to get done, and she did not understand why the staff felt they needed to rush when providing care to the residents. She further related some of the bruises and skin tears were of an unknown origin and were submitted to the appropriate State agency. She identified that most of the residents at the facility required extensive or total assistance with transfers, and the facility had provided education for transfers to the nursing assistants, but she did not understand why there were so many bruises and skin tears. She stated the administrator, who was on sick leave, had started to track the incidents of bruises and skin tears and had began to put into place a prevention plan. However, no evidence was provided for the tracking, plan of action to prevent, or an evaluation of the plan of action. An interview with the acting administrator, on 09/23/09 at 3:00 p.m., revealed that when he arrived at the facility and reviewed the incidents of bruises and skin tears, he was concerned as to the number of incidents involving the residents.",2015-04-01
10403,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,309,E,0,1,86JH11,"Based on observation, review of operating / use instructions for BRODA Chairs (chairs used for safety reasons to prevent falls due to attempted unassisted ambulation), and staff interview, the facility failed to ensure two (2) of fifteen (15) sampled residents and three (3) randomly observed residents were provided the necessary care and services to maintain their highest practicable physical well-being. Residents #13, #9, #31, and #62 were seated in BRODA chairs with vinyl straps without padding to prevent injury and skin breakdown. Resident #23 was not positioned properly to prevent skin breakdown. Resident identifiers: #13, #9, #31, #62, and #23. Facility census: 89. Findings include: a) Resident #13 During meal service in the main dining room on 09/22/09 at 11:45 a.m., observation found this resident seated in a BRODA chair with vinyl straps in the back and seat and no padding. The resident's skin and clothing were pressed through the straps in the back due to unrelieved pressure. Further observations of this resident, on 09/23/09 at 3:40 p.m., found the resident seated in her room in the BRODA chair. The resident was wearing a hospital gown with the back open, and the resident's skin and curved spine were pressed against the vinyl straps of the chair due to the lack of protective padding. Review of incident / accident reports, on 09/22/09, found that, on 08/11/09, a report recorded the resident had a small abrasion on the mid-back due to the back rubbing against the strap of the BRODA chair. Review of operating instructions for the BRODA chairs, provided by the manufacturer of the chairs, found on page 5, item 1.10 titled ""Risk of Injury to Resident's Skin"", the following directions: ""We recommend that residents only be seated while they are fully dressed in clothing that meets the needs of their specific condition. If after being fully dressed, a resident's bare arms, legs, or body could still come into direct contact with the vinyl straps or vinyl pads, we recommend the use of a covering, such as the BRODA terry cloth covered seat and/or back pad or a folded cloth bed sheet to prevent contact. Direct contact of bare skin on the straps over a period of time could cause moisture on the resident, and/or cause the skin to stick to the straps."" In an interview on 09/23/09 at 4:15 p.m., the director of nursing (DON - Employee #1) confirmed this resident, while seated in the BRODA chair, was inappropriately dressed and no padding was present in the chair to protect her from injury. b) Resident #9 During meal service in the main dining room on 09/22/09 at 11:45 a.m., observation found this resident seated in a BRODA chair with vinyl straps in the back and seat and no padding. Further observation found the resident was wearing a hospital gown open in the back, and the resident's back was exposed through the straps in the back of the chair. During the meal service in the main dining room on 09/22/09 at 5:30 p.m., this resident was again seated in the BRODA chair while wearing a hospital gown. The back of the hospital gown was open, and the resident's back and adult incontinence brief were visible through the vinyl straps. During an interview in the dining room on 09/22/09 at 5:30 p.m., Employee #13 agreed the chair had no padding for the straps, and the resident's bare skin was against the vinyl straps. This practice had the potential to promote injury and/or skin breakdown. c) Residents #31 and #62 Observations in the facility, on 09/22/09 and 09/23/09, found Residents #31 and #62 seated in BRODA chairs with vinyl straps and no protective padding. During each of these observations, the resident's clothing and skin were pressed through the vinyl straps in the back and seat of the chairs due to the lack of padding. In an interview on 09/23/09 at 4:15 p.m., the DON confirmed these chairs lacked padding over the straps to prevent injury or skin breakdown to these residents. d) Resident #23 Observation, on 09/22/09 at 9:05 a.m., found this resident lying on her right side in a fetal position. A registered nurse (RN - Employee #9) uncovered the resident's legs to reveal the resident did not have a barrier between her knees, causing the knees to rub together. The resident was observed to be very emaciated. The RN stated the resident needed to have a pillow between her legs to prevent skin breakdown. .",2015-04-01
10404,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,250,D,0,1,86JH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the resident's medical record and staff interviews, the facility did not ensure one (1) of fifteen (15) sampled residents received medically-related social services to address his aggressive behaviors and verbals statements of a violent nature. Resident identifier: #80. Facility census: 89. Findings include: a) Resident #80 A nursing note, dated 06/16/09 at 2:00 p.m., recorded, ""Resident became upset and verbal with resident sitting next to him in dining room when another resident touched his coffee. Had to remove him from dining room. The resident calmed down."" On 07/31/09 at 6:45 p.m., a nurse recorded, ""Resident was sitting in middle of hallway after dinner blocking traffic when an aide moved him into his doorway. He reached up and slapped her across the left cheek. CNA (certified nursing assistant) had a red hand print across her cheek."" On 08/03/09 at 7:30 p.m., a nurse recorded, ""Resident called daughter to tell her he is dying of a broken heart and is going to die and is coming to haunt her, because she doesn't come to see him any more."" On 08/22/09 at 4:15 p.m., a nurse recorded, ""Resident was sitting in front of his room door. His roommate's daughter was trying to get into room and this resident did not want to move. CNA told resident that daughter was trying to get in room to visit and this resident stated I don't give a f*** about her. The CNA moved (Resident #80) out of doorway and he began cursing. Resident stated, I want to get the f*** out of this place."" On 08/29/09 at 4:00 p.m., a nurse recorded, ""(Resident #80) and another resident from 200 hall in hallway face to face having a verbal confrontation. (Resident #80) cursing and had fist drawn back threatening to hit 200 hall resident. (Resident #80) taken back to his room and told that he was to eat supper in his room. Continued to be agitated, stating he wasn't going to eat supper or take his pills. Also stated, he wanted his wheelchair which is motorized. Attempted to explain to resident that physical therapy would have to evaluate to determine if he can use his motorized wheelchair."" On 08/29/09 at 5:40 p.m., a nurse recorded, ""Resident sitting in hall outside of room. When told that his supper tray will be brought to his room. Resident stated you told me I couldn't eat. This nurse explained to him that he was told he would eat in his room at supper and that he was never told he couldn't eat. Continued to refuse supper stated, if his tray was brought to his room, he would throw it down the hall. Also stated, he would break the jaw of the resident from 200 hall."" On 08/29/09 at 6:00 p.m., a nurse recorded, ""Resident told station II nurse that he didn't want his nails cut anymore, because he wanted them to grow longer and sharp so he could rip 200 hall resident's throat out."" Further review of Resident #80's medical record revealed this [AGE] year old was admitted on [DATE], with [DIAGNOSES REDACTED]. He was evaluated by a psychiatrist on 03/24/09. with an assessment of anger and agitation. There was no evidence to reflect he was seen again by the psychiatrist. An interview with the director of nursing (DON), on 09/23/09 at 3:40 p.m., revealed she was unaware of the resident's behavior or the statement that he did not want his nails cut anymore, that he wanted them to grow long and sharp so he could rip the throat out of the resident on 200 hall. An interview with the social worker (Employee #86), on 09/23/09 at 3:45 p.m., revealed the social worker was not aware of the resident's escalating behaviors. She stated that nursing staff did not tell her the resident was making threats against another resident. She further stated she would immediately get the psychiatrist to see the resident for an evaluation A review of the resident's care plan, with a revision date of 08/05/09, revealed the following: - Problem - ""Potential for mood disturbance."" - Goal - ""Will remain free of signs and symptoms of distress, symptoms of depression, anxiety or sad mood."" - Intervention - ""Notify physician as soon as possible for any suicidal ideations or self-harming behaviors."" .",2015-04-01
10405,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,520,E,0,1,86JH11,"Based on record review and staff interview, the facility's quality assessment and assurance committee failed to implement corrective measures to address the facility's high prevalence of bruises and skin tears. The facility's incidents reports indicated that, over a three and one-half (3.5) month period, residents received fifty-five (55) skin tears and forty-four (44) bruises. Facility census: 89. Findings include: a) A review of the facility's incident reports for the months of June, July, August, and part of September 2009 revealed residents had received fifty-five (55) skin tears and forty-four (44) bruises. The bruises and skin tears were primarily found on the extremities (arms, hands, fingers, legs, and feet). An interview with the director of nursing (DON - Employee #1), on 09/23/09 at 3:00 p.m., revealed that a lack of adequate staffing was not the reason for so many bruises and skin tears at the facility. She related the staff may have been hurrying to get done, and she did not understand why the staff felt they needed to rush when providing care to the residents. She further related some of the bruises and skin tears were of an unknown origin and were submitted to the appropriate State agency. She identified that most of the residents at the facility required extensive or total assistance with transfers, and the facility had provided education for transfers to the nursing assistants, but she did not understand why there were so many bruises and skin tears. She stated the administrator, who was on sick leave, had started to track the incidents of bruises and skin tears and had began to put into place a prevention plan. However, no evidence was provided for the tracking, plan of action to prevent, or an evaluation of the plan of action. An interview with the acting administrator, on 09/23/09 at 3:00 p.m., revealed that when he arrived at the facility and reviewed the incidents of bruises and skin tears, he was concerned as to the number of incidents involving the residents. The facility's quality assessment and assurance committee failed to implement interventions to decrease the number of skin tears and bruises.",2015-04-01
10406,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,329,D,0,1,86JH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of OBRA's ""Unnecessary Drugs in the Elderly"", and staff interview, the facility failed to ensure the drug regimen of one (1) of fifteen (15) sampled residents was free from unnecessary drugs. Resident #55 was receiving the sedating drug [MEDICATION NAME] in a dosage higher than recommended for use in the elderly. The resident had a recent dose increase on 08/17/09, from 0.25 mg TID (three-times-a-day) to 0.5 mg TID for increased anxiety without adequate indications for this increase documented in the resident's record. Resident identifier: #55. Facility census: 89. Findings include: a) Resident #55 Medical record review, on 09/22/09, disclosed this [AGE] year old resident had a recent dose increase in the sedating drug [MEDICATION NAME]. On 08/17/09, the physician increased the [MEDICATION NAME] from 0.25 mg TID to 0.5 mg TID for increased anxiety. Review of physician's progress notes found no reference to the resident exhibiting an increase in anxiety and no mention of the clinical rationale for doubling the resident's daily dose of [MEDICATION NAME].. Review of nursing notes for the month of August 2009 found no contemporaneous documentation in the resident's medical record to reflect the resident was exhibiting an increase in anxiety. Review of a psychiatric consult, dated 08/17/09, revealed the following: ""Pt. (patient) alert, oriented to self only, pleasant & cooperative, restless, got out of w/c (wheelchair) a lot /c (with) shuffled gait, thought processes consistent /c dementia."" The psychiatrist recommended increasing the [MEDICATION NAME] to 0.5 mg TID. During the review of OBRA's ""Unnecessary Drugs in the Elderly"" revealed the recommended maximum daily dose for [MEDICATION NAME], a short acting Benzodiazapine sedating drug, was 0.75 mg for the elderly. With the dose increase, this resident was now receiving 0.5 mg TID for a total daily dose of 1.5 mg, twice the amount recommended. A comparison of the resident's most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 08/02/09, and a significant change in status MDS, with an ARD of 09/04/09, revealed the resident had experienced a decline in the self-performance of transfer and ambulation, a decline in continence, a decline in moods / behaviors, and the use of a physical restraint. The resident had been placed in the BRODA chair to prevent independent ambulation, the resident's [MEDICATION NAME] dosage was doubled on 08/17/09, and the decline in self-performance of ADLs began, resulting in the need to complete a significant change in status assessment. In an interview on 09/23/09 at 4:30 p.m., the director of nursing (Employee #1) confirmed the resident's [MEDICATION NAME] had been increased. .",2015-04-01
10407,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,363,D,0,1,86JH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record and planned menu reviews and staff interview, the facility failed to prepare menus for two (2) therapeutic diets as ordered by the physician (an 1800 ADA Vegetarian Diet and a Low Potassium Diet) for one (1) of fifteen (15) sampled residents and one (1) randomly selected resident. Resident identifiers: #68 and #85. Facility census: 89. Findings include: a) Resident #85 Review of Resident #85's medical record, on 09/22/09, revealed she was admitted to the facility on [DATE], with the order for an 1800 ADA Vegetarian Diet. Review of the care conference notes of 09/17/09 revealed the resident had requested that she have one (1) veggie burger a day. The resident and a family member, on 09/22/09, expressed concern to the surveyor as to whether she was receiving the daily recommended amount of protein in her diet. b) Resident #68 Review of Resident #68's medical record, on 09/23/09, revealed her current diet order was a Low Potassium (K) Diet (60 meq/day). Review of the tray card with the lunch meal on 09/23/09 revealed ""Mech Sft. Lo K"" and no plan for the food items she should receive for this diet, especially in view of the twenty-nine (29) food dislikes listed on the tray card. c) Planned Menus Review, on 09/22/09, of the Spring / Summer menus for Week 1 found no planned menus for the 1800 ADA Vegetarian or the Low K (60 meq/day) diets. Interview with the dietary manager, on the afternoon of 09/23/09, confirmed there were no planned menus for these two (2) therapeutic diets for any of the four (4) weeks of the Spring / Summer cycle. .",2015-04-01
10408,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,431,E,0,1,86JH11,"Based on observation, staff interview, and review of the facility policy on medication administration, the facility failed to document the dates multi-dose vials were opened. This was true for one (1) of two (2) medication rooms observed. Multi-dose vials of insulin and tuberculin derivative vials were not labeled with the date opened. This practice has the potential to affect more than an isolated number of residents. Facility census: 89. Findings include: a) On 09/22/09 at 5:45 p.m., observation of the medication room on the 100 hallway found four (4) opened vials of Lantus insulin and three (3) opened multi-dose vials of Tuberculin Purified Protein Derivative. The vials were not labeled with the date they were opened. A licensed practical nurse (LPN - Employee #18), when interviewed on 09/22/09 at 5:45 p.m., confirmed the multi-dose vials of medication were not labeled with the date each vial was opened. The LPN discarded the medications and ordered new insulin medication from the pharmacy. The LPN further stated it was the facility's policy to labeled all multi-dose vials with the date opened. The director of nursing (DON - Employee #1), when interviewed on 09/24/09 at 8:30 a.m., provided a copy of the facility's policy titled ""Administering Medications"". The policy stated, ""When opening a multi-dose container, place the date on the container."" .",2015-04-01
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
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
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
10156,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2009-10-08,312,D,0,1,SM0211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure two (2) female residents with long facial hair received assistance with removal of the hair. Resident identifiers: #41 and #55. Facility census: 66. Findings include: a) Resident #41 On 10/08/09 at approximately 9:30 a.m., observation of Resident #41 revealed this female had long facial hair. The resident said she had tweezers in her room and could remove them herself. An interview with Employee #47 (a licensed practical nurse - LPN) revealed this nurse had attempted to remove the resident's facial hair by shaving it off. According to the LPN, the resident refused this method of hair removal, because she thought it would make her facial hair grow back thicker. The LPN commented that this resident had a health care surrogate and, perhaps, this person would assist the resident in removing her facial hair. The nurse had a pair of scissors on her cart with [MEDICATION NAME] blades. It was suggested by the surveyor that, perhaps, the resident would allow her to use the scissors on the facial hair. At approximately 10:00 a.m., the LPN indicated the resident had allowed her to remove the facial hair using the scissors. The LPN and administrator both indicated staff had attempted several times to remove the hair in the past. b) Resident #55 Resident #55, a female resident, was also observed to have long facial hair throughout the survey. The facial hair was not removed during the four (4) days of observation. The resident would not be able to remove her facial hair independently. c) Neither resident's care plan contained information regarding their refusals to allow staff to remove their facial hair. The administrator indicated the residents would not allow the staff to groom them. However, this was not addressed in the care plans. The administrator agreed this issue should be included in the care plan. (See citation at F279.) .",2015-06-01
10157,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2009-10-08,279,B,0,1,SM0211,"Based on record review and staff interview, the facility failed to develop care plans for two (2) female residents to address refusal of staff assistance with grooming. Resident identifiers: #41 and #55. Facility census: 66. Findings include: a) Residents #41 and #55 On 10/08/09 at approximately 9:30 a.m., two (2) female residents (#41 and #55) were observed to have long facial hair. When the administrator was questioned about the residents, he indicated these two (2) residents would not allow staff to trim their facial hair. Record review revealed these two residents' current care plans did not reflect their refusal of this care. The administrator agreed this needed to have been included in their care plans. .",2015-06-01
10158,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2009-10-08,309,D,0,1,SM0211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and facility staff interview, the facility failed to assure one (1) of thirteen (13) sampled residents and one (1) randomly observed resident received care and services in accordance with physician orders [REDACTED]. The bowel protocol was not followed when Resident #41 experienced constipation, and the nurse administered medications to Resident #18 on days when they were ordered to be held due to [MEDICAL TREATMENT] treatments. Resident identifiers: #41 and #18. Facility census: 66. Findings include: a) Resident #41 A 10/08/09 review of the medical record fount the current care plan, with a target date of 12/01/09, identified Resident #41 was at risk for complications from constipation. One (1) of the interventions to prevent this occurrence was: ""Provide bowel regimen, utilize pharmacologic agents as appropriate..."". Review of the bowel regimen standing orders for Resident #41 found the following: 1) If no bowel movement in three days, give milk of magnesia 30 cc PO (by mouth) X 1. 2) If no bowel movement on day four, give [MEDICATION NAME] suppository PR (per rectum) X 1. 3) If no bowel movement on day five, give Fleets enema. 4) If no results from Fleets enema, call physician for further orders. Review of the September 2009 bowel movement record found no recorded bowel movements from 09/01/09 through 09/11/09, a period of eleven (11) days. Review of the Medication Administration Record [REDACTED]. Further review noted no recorded bowel movements from 09/13/09 through 09/22/09, a time period of ten (10) days. Review of the medical record noted that nursing staff members administered milk of magnesia 30 cc on 09/16/09. The medical record found no evidence that the bowel regimen was followed by administering a [MEDICATION NAME] suppository with no bowel movement on Day 4, nor was the Fleets enema administered on Day 5 when the bowel movement record continued to record no bowel movements. The facility failed to appropriately institute bowel regimen interventions and placed this resident at risk of potentially severe complications from constipation. b) Resident #18 During the medication administration pass on the morning of 10/07/09, it was noted that Resident #18 underwent [MEDICAL TREATMENT] treatment three-times-a-week. A physician's orders [REDACTED]. The MAR indicated [REDACTED]. Observation revealed the following anti-hypertensive medications were initialed as having been administered on 10/06/09: [MEDICATION NAME] 20 mg, Aidoment 500 mg, [MEDICATION NAME] 3.125 mg, and [MEDICATION NAME] 150 mg. An interview with the nurse (Employee #14), following the 10/07/09 observation at 10:15 a.m., revealed the nurse initialed the MAR, reflecting having administered those medications ordered to be held. .",2015-06-01
10159,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2009-10-08,441,F,0,1,SM0211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observation, review of the infection control records, facility staff interview, and facility policy review, the facility failed to establish and maintain an infection control program to prevent the potential development and transmission of disease and infection. The facility did not assure the direct care staff was properly educated concerning infection control protocols related to the use of protective equipment and handwashing. The facility did not assure environmental surfaces were properly sanitized in isolation rooms, did not assure residents with infectious diseases were appropriately cohorted, and failed to investigate and track infections present in the facility. These deficient practices had the potential to affect all sixty-six (65) residents currently residing in the facility. Facility census: 66. Findings include: a) During the initial tour of the facility on 10/05/09 at 2:10 p.m., a direct care staff member (Employee #35) was observed to enter the room of Residents #29 and #54 with cups of pudding and two (2) unwrapped plastic spoons. Observation found a sign posted on the door with instructions to report to the nursing station prior to entering the room. The employee was observed to touch the bedside table while serving pudding to Resident #29. She did not wash her hands prior to exiting the room with the second unwrapped spoon and cup of pudding. She, then, entered Resident #27's room and began feeding this resident a cup of pudding. This practice was reported to unit manager (Employee #66). She was asked why the sign was posted on the door to the room shared by Residents #29 and #54. Employee #66 stated that was for infection. When asked what infection and who had an infection, the employee stated she did not know and would have to look at the board. She directed this surveyor to a room behind the nursing station, which contained a large dry-erase board with each room and all residents listed. She referenced the board and reported Resident #54 had ""C-diff"" (Clostridium difficile). Observation found the dry-erase board contained the names of residents with an active, or history of, infection listed in red letters. Resident #29 was identified as being actively treated for [REDACTED].#54 had a history of [REDACTED]. Neither the dry-erase board, nor the signs posted at residents' door informed staff members what precautions to utilize in order to contain infectious organisms. An interview with the infection control nurse (Employee #60) following this observation revealed the dry-erase board was the sole reference utilized for cohorting residents with infections. Upon request, she provided facility policies related to differing levels of isolation for various organisms. Review of policy ""3.1 Contact Precautions"", under the section ""Process"" found the following, ""1.1 Patient may cohort with an individual who has the same organism."" Further review of the dry-erase board found two (2) female residents in-house (Residents #2 and 54) who had [DIAGNOSES REDACTED].#29 at unnecessary risk of contracting[DIAGNOSES REDACTED] infection. Following review of the dry-erase board, it was determined Employee #35 placed Resident #29 at risk of contracting[DIAGNOSES REDACTED] by the employee's failure to properly wash her hands prior to feeding the resident pudding from a contaminated spoon with contaminated hands. b) On 10/06/09 at 11:20 a.m., a housekeeping staff member was observed to clean an isolation room of a resident with[DIAGNOSES REDACTED]. The staff member was noted to don a protective gown and gloves prior to entering the room. The staff member sprayed and immediately wiped the sink with a sanitizing solution. She then returned to the cart, while still wearing the protective equipment, and touched the surface of the cart. This practice potentially contaminated the cart with[DIAGNOSES REDACTED] spores. The staff member then mopped the floor of the isolation room. It was noted that she did not sanitize the door knobs of the resident's room. The housekeeping staff member was also noted to remove the protective gown in the hallway and lay it on top of the housekeeping cart prior to placing it into a plastic bag for disposal. This practice also contaminated the cart and placed other residents at risk of their environment being contaminated with[DIAGNOSES REDACTED] spores. Two (2) housekeeping staff members were interviewed concerning the solution utilized to sanitize the floors of isolation rooms, particularly rooms with residents infected with[DIAGNOSES REDACTED]. Employees #22 and #85 both stated the floors were cleaned with a name brand wax floor cleaner. The administrator (Employee #24) was asked, on the afternoon of 10/08/09, to provide evidence that the cleaner utilized for the floors in isolation rooms killed[DIAGNOSES REDACTED] spores. He was unable to provide any evidence that the cleaner utilized would kill[DIAGNOSES REDACTED] spores. Additionally, review of the cleanser utilized to sanitize sinks and other environmental surfaces contained the following instructions: ""Killing Clostridium difficile spore: ... Apply 1:10 solution and let stand for 10 minutes. Rinse and air dry..."". The practice utilized by housekeeping personnel was not within the guidelines prescribed by the manufacturer, nor was a solution utilized to cleanse the floors of[DIAGNOSES REDACTED] isolation rooms shown to be effective in killing the spores. c) During random observations of the meal service, on 10/06/09 at 12:15 p.m., found a direct care staff (Employee #42) donning protective gown and gloves prior to delivering the meal tray into a[DIAGNOSES REDACTED] isolation room. She was noted to not wash her hands after removing the protective equipment. She exited the isolation room, utilized hand sanitizer, and served other residents. Another direct care staff member (Employee #55) was observed, at 12:20 p.m. on 10/06/09, to don protective equipment (gown and gloves) and serve a tray in a[DIAGNOSES REDACTED] isolation room. She was noted to touch items in the resident environment, including the water faucet. After disposing of the protective equipment, the staff member exited the room without washing her hands and walked up the hallway toward the dining room. When she returned a few minutes later, she was asked where she washed her hands. She stated that she washed her hands at the sink in the dining room. This practice potentially deposited[DIAGNOSES REDACTED] spores onto the faucet handle utilized by staff members who did not wear gloves while serving residents who chose to eat in the dining room. The infection control nurse (Employee #60) was informed of the above observations at 1:20 p.m. on 10/06/09. She stated that alcohol sanitizer was not effective in killing[DIAGNOSES REDACTED] spores and staff had been inserviced many times to wash their hands with soap and water prior to leaving isolation rooms. d) The infection control nurse (Employee #60) was asked on the afternoon of 10/08/09 to provide evidence that the facility tracked and investigated infections in the facility. Employee #60 provided a monthly line listing of different types of infections occurring within that month. She was unable to demonstrate that the facility tracked the incidence of infections on a month-to-month basis in order to determine potential sources of infections in order to prevent the spread of infections within the facility. .",2015-06-01
10160,RALEIGH CENTER,515088,PO BOX 741,DANIELS,WV,25832,2009-10-08,502,D,0,1,SM0211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure two (2) of thirteen (13) sampled residents received ordered laboratory services to meet the needs of Residents #23 and #16. Facility census: 66. Findings include: a) Resident #23 Review of the medical record found Resident #23's treating physician ordered intravenous [MEDICATION NAME] 1 Gm every twenty-four (24) hours for a perineal abscess with [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The physician also ordered a [MEDICATION NAME] peak and trough laboratory test every three (3) days. Review of the medical record found no evidence that the ordered testing was provided. An interview with the registered nurse unit manager (Employee #66), on 10/08/09 at 5:50 p.m., confirmed the laboratory test was not obtained on 09/20/09 or on 09/23/09. b) Resident #16 Review of the medical record found a nursing note, dated 08/10/09 at 9:00 p.m., which documented that the resident had several episodes of loose, foul smelling bowel movements. The note stated the physician was notified and ordered a [MEDICAL CONDITIONS] toxin screen. The medical record contained no laboratory results until 08/19/09. Review of the document found that the specimen was collected on 08/18/09. The laboratory test was positive for [MEDICAL CONDITION]. The physician ordered [MEDICATION NAME] 250 mg four-times-a-day for ten (10) days to treat the infection. Review of the bowel movement record for the nine (9) days the facility did not obtain the ordered laboratory test found the resident continued to have multiple loose stools on 09/14/09, 09/17/09, 09/18/09, and 09/19/09.",2015-06-01
10178,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2009-10-08,246,E,0,1,XHIH11,"Based on confidential resident interviews, review of facility's complaint log, and review of the resident council meeting minutes, the facility failed to ensure staff responded timely to requests for assistance. Staff was answering call lights when residents activated them for assistance, by turning the light off with a promise to return and not returning. This practice had the potential to more than an isolated number of residents. Resident identifiers: Withheld due to request for anonymity. Facility census: 59. Findings include: a) During the initial tour of the facility on 10/05/08 beginning at 11:30 a.m., a confidential interview with a dependent resident disclosed that his / her only complaint was when he / she turned on the call light for assistance, staff would frequently enter the room, turn off the light with a promise to return, and either not return or not return in a timely fashion. Review of the facility's log of complaints received from residents / families in the last year revealed a compliant submitted by the family of a previous resident, which alleged that, on different occasions, the resident would ask to go to the bathroom and the family would have to take him themselves, because the aide said she would ""be right back, and never returned."" The resident council meeting minutes for the previous three (3) months were reviewed during the course of the survey. The minutes from the September 2009 meeting stated the nurse aides were coming in and turning off the residents' call lights when they called for assistance and were not returning to help them. During a confidential group meeting on 10/06/09 at 10:30 a.m., three (3) residents in attendance reported the same complaint, that staff would come turn off their call lights and not return to assist them. .",2015-06-01
10179,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2009-10-08,329,D,0,1,XHIH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure the drug regimens, of three (3) of thirteen (13) sampled residents, were free from unnecessary drugs. Resident #27 received treatment for [REDACTED]. Resident #33 was receiving the antipsychotic drug [MEDICATION NAME] for behaviors since December 2007, in the presence of adverse consequences which indicated the dose should be reduced or discontinued. Resident #42 was receiving the antipsychotic drug [MEDICATION NAME] with no documented indication for its use. Resident identifiers: #27, #33, and #42. Facility census: 59. Findings include: a) Resident #27 Medical record review, on 10/05/09, disclosed this resident's medical [DIAGNOSES REDACTED]. Review of a quarterly minimum data set (MDS), dated [DATE], found the assessor recorded, in Section H2, the resident had diarrhea during the assessment reference period. A nursing note, dated 07/03/09, documented the resident's stool was light brownish, had some mucous in it, and was foul smelling. The note also indicated the physician, when notified, ordered a stool specimen which had been sent to the lab and [MEDICAL CONDITION] precautions were being taken. A nursing note, dated 07/04/09, indicated the physician's standing orders for [MEDICAL CONDITION] had also been started, which consisted of: Acidophilus 1 tab po (by mouth) BID (two times a day) for ten (10) days; Questran, one (1) pack in 8 oz of liquid every day for ten (10) days; [MEDICATION NAME] 500 mg 1 tab four (4) times a day for ten (10) days; Naturalogics two (2) capsules po BID while on [MEDICATION NAME]; send stool specimen for [MEDICAL CONDITION] toxin; and put resident on the acute list for the physician's assistant and call to notify her. A subsequent entry in the nursing notes, dated 07/04/09, found the lab results had been returned to the facility and the stool specimen was negative for [MEDICAL CONDITION]. This resident, whose normal bowel pattern was diarrhea, was started on an antibiotic for [MEDICAL CONDITION] before it had been diagnosed . During an interview on 10/07/09 at 3:30 p.m., the director of nursing (DON - Employee #69) confirmed the resident had been started on treatment for [REDACTED]. b) Resident #33 Medical record review, on 10/07/09, disclosed a physician's orders [REDACTED]. Further record review found no evidence to reflect any gradual dose reductions had been attempted as required by federal regulations, since the medication had been started. Nor was there documentation to state such a gradual dose reduction attempt was clinically contraindicated. Review of physician progress notes [REDACTED]. asleep in chair, hard to awaken. Nursing reports increased somnolence, lethargy, decreased appetite since med change."" Review of care plan notes, dated 06/12/09, revealed the resident had triggered a significant change in status assessment due to a decline in self-performance of activities of daily living (ADLs), and the resident now required extensive assistance with all ADLs. Review of the medication regimen review, dated 03/10/09, revealed the pharmacist requested a gradual dose reduction of [MEDICATION NAME], and the physician had responded by writing ""NO!"" No documentation was found to contain the clinical rationale for this decision or a benefit vs. risk statement. Observations of the resident, from 10/05/09 to 10/08/09, found the resident spent most of the days in his room or in the hallway, sleeping in a wheelchair. During an observation on 10/07/09 at 4:50 p.m., the resident was being ambulated with a walker. The resident was moving slow and required encouragement by staff to take each step. During an interview on 10/07/09 at 3:30 p.m., the DON confirmed a gradual dosage reduction of the [MEDICATION NAME] had not been attempted as required, even though the resident had experienced a subsequent decline in ADL self-performance with increased lethargy and somnolence. c) Resident #42 The medical record of Resident #42, when reviewed on 10/07/09, disclosed this [AGE] year old resident was admitted to the facility on [DATE]. Since the time of admission, the resident had, on occasion, exhibited behaviors that were dangerous to himself or to his wife (who lived in the room with him). The physician ordered [MEDICATION NAME] 25 mg three (3) times daily on 01/30/09 for ""dementia with increasing behavior - elopement"". At the time of review for this medication on 10/01/09, the resident's physician recorded that his reason for not attempting to decrease the dose was the same as described on 07/02/09 - ""still aggressive @ (at) x (times)."" The DON was asked, on 10/07/09, to provide documented evidence of the behaviors that were harmful / distressful to Resident #42 or others that would justify the continued use of an antipsychotic medication for this resident with no antipsychotic diagnosis. The documentation produced by the DON was as follows: - A nursing note dated 06/10/09, stating the resident ""refused personal hygiene"". - A nursing note dated 08/26/09, stating the resident ""does pace in the hallway at times if wife leaves the room"". - A nursing note dated 09/03/09, stating, ""Resident has to be reminded at times not to be mean to wife."" - A nursing note dated 09/09/09, stating the resident ""does get agitated at times"". At the time of exit conference on 10/08/09, the DON could provide no further evidence of behaviors that would necessitate the continued use of this antipsychotic medication. The documentation provided described very infrequent non-aggressive behavior did not justify the administration of an antipsychotic medication three (3) times daily. .",2015-06-01
10180,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2009-10-08,387,E,0,1,XHIH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's admission packet, and staff interview, the facility failed to assure two (2) of thirteen (13) sampled residents were seen by their physician each month for the first three (3) months following admission and every sixty (60) days thereafter. The facility failed, as well, to assure the resident's chosen physician visited every sixty (60) days for three (3) additional sampled residents. Resident identifiers: #19, #39, #32, #42, and #15. Facility census: 59. Findings include: a) Resident #19 The medical record of Resident #19, when reviewed on 10/06/09, disclosed the resident was admitted to the facility on [DATE] following hospitalization . The resident was seen by his attending physician at the facility on 07/29/09. The resident was then seen by a physician's assistant (PA) on 08/04/09. A PA student saw the resident on 08/13/09, along with his attending physician. A visit on 09/01/09 was completed by a PA, as well as an additional visit on 09/03/09. The resident's attending physician had co-signed all entries by the others. However, the visits completed by these physician extenders did not meet the regulation, which states a physician must see the resident every thirty (30) days for the first ninety (90) days. The facility's director of nurses (DON), when interviewed related to this discovery on 10/07/09 at 3:30 p.m., stated the physician was present when a visit is done by a PA student; however, all other co-signing was done at a later date. b) Resident #39 The medical record of Resident #39, when reviewed on 10/07/09, disclosed the resident had resided at the facility since 10/19/2001. Review of recent physician visits disclosed the resident's chosen physician had visited her on 12/04/08. A PA had visited her on 01/14/09. A different physician had made a visit on 01/31/09, with subsequent visits by a PA on 02/03/09, a PA on 03/31/09, a PA on 05/05/09, and a PA on 06/09/09. The resident's chosen physician had visited along with a PA student on 07/02/09. On 08/21/09, a different physician visited. It was noted that the resident's attending physician had co-signed all entries by others. The resident's chosen physician had visited her in December 2009 and July 2009; all other visits had been provided by a PA or a physician not of the resident's choosing. The facility's admission packet was requested and reviewed. In Section I entitled ""Physician Services"", the document states, ""Your physician is required to visit you at least once every 30 days for the first 90 days after admission and at least every 60 days thereafter. If you become ill between your regularly scheduled visits, the nursing staff will contact a physician for you when needed. You will be informed if your attending physician utilizes the services of any physician extender such as a physician's assistant or nurse practitioner."" The document then provided an area for the resident to designate a chosen physician. The DON, when interviewed related to this discovery on 10/07/09 at 3:30 p.m., stated the physician was present when the visit was done by a PA student; however, all other co-signing was done at a later date. c) Resident #32 The medical record of Resident #32, when reviewed on 10/07/09, disclosed the resident had resided at the facility since 03/13/08. Review of recent physician visits disclosed the resident had been seen by her chosen physician in December 2008 and again on 09/03/09. All other visits in 2009 had been provided by either a PA or a physician other than the one (1) chosen by the resident at the time of admission. It was noted that the resident's attending physician had co-signed all entries by others. The facility's admission packet was requested and reviewed. In Section I entitled ""Physician Services"", the document states, ""Your physician is required to visit you at least once every 30 days for the first 90 days after admission and at least every 60 days thereafter. If you become ill between your regularly scheduled visits, the nursing staff will contact a physician for you when needed. You will be informed if your attending physician utilizes the services of any physician extender such as a physician's assistant or nurse practitioner."" The document then provided an area for the resident to designate a chosen physician. The DON, when interviewed related to this discovery on 10/07/09 at 3:30 p.m., stated the physician was present when the visit was done by a PA student; however, all other co-signing was done at a later date. d) Resident #42 The medical record of Resident #42, when reviewed on 10/06/09, disclosed the resident had resided at the facility since 06/11/07. Review of the resident's most recent physician visits disclosed the resident had been seen by his chosen physician in March 2009. All other visits in the year 2000 to the present (October 2000) had been provided by either a PA or a physician other than one (1) of the resident's choosing at the time of admission. It was noted that the resident's attending physician had co-signed all entries by others. The facility's admission packet was requested and reviewed. In Section I entitled ""Physician Services"", the document states, ""Your physician is required to visit you at least once every 30 days for the first 90 days after admission and at least every 60 days thereafter. If you become ill between your regularly scheduled visits, the nursing staff will contact a physician for you when needed. You will be informed if your attending physician utilizes the services of any physician extender such as a physician's assistant or nurse practitioner."" The document then provided an area for the resident to designate a chosen physician. The DON, when interviewed related to this discovery on 10/07/09 at 3:30 p.m., stated the physician was present when the visit was done by a PA student; however, all other co-signing was done at a later date. e) Resident #15 Medical record review, on 10/07/09, disclosed this resident was admitted to the facility on [DATE]. Review of physician progress notes [REDACTED]. The resident was not seen again by a physician until 04/09/09. During an interview on 10/07/09 at 3:30 p.m., the DON agreed the resident was not seen at least every thirty (30) days for the first ninety (90) days after admission.",2015-06-01
10181,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2009-10-08,281,F,0,1,XHIH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, 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"" published by the West Virginia Board of Examiners for Registered Professional Nurses and The West Virginia State Board of Examiners for Licensed Practical Nurses (dated 06/17/09), and staff interview, the facility failed to assure services provided to the residents met professional standards of quality. The facility allowed a licensed practical nurse (LPN) to act outside her scope of practice, by allowing her to complete in-depth resident assessments and make decisions related to the development of residents' care plans. This practice requires the evaluation of assessment data, which falls outside the scope of practice for an LPN. The facility also created the potential for all nurses (LPNs and registered professional nurses (RNs)) to act outside their scopes of practice, by implementing standing orders that required them to diagnose an infection and implement treatment based on this diagnosis. These practices had the potential to affect all residents of the facility. Facility census: 59. Findings include: a) During the course of the survey event, record review revealed a licensed practical nurse (LPN) was consistently completing and summarizing the individual in-depth resident assessment protocols for each resident and making the decision to proceed with care planning based on her summaries. 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"" published by the West Virginia Board of Examiners for Register Professional Nurses and The West Virginia State Board of Examiners for Licensed Practical Nurses (dated 06/17/09), revealed following: On page 6 under the heading ""Review (sic) Existing Laws, Policies, and Standards of Nursing Practice"": ""Both the RN and LPN are responsible for implementing the nursing process in the delivery of nursing care. 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 director of the RN and reporting and documenting the information collected. ... Based on the definitions of practice in the Code, the RN can independently engage in activities that include assessing the health status of an individual, teaching, delegating, supervising and evaluating nursing practice. The LPN has a dependent role and provides care only at the direction of the RN, physician or dentist."" On page 13 under the heading ""Activities that may be delegated to the LPN"": ""Activities appropriate for delegation to the LPN should be those that, after careful evaluation by the supervising RN, are expected to contain only one option. That is, the LPN is expected to be able to proceed through the established steps or an activity without encountering an unexpected response or reaction and competence in performance of the activity has been demonstrated."" On page 13 under the heading ""Activities that should NOT be delegated to the LPN"": ""Activities that are NOT appropriate for delegation to an LPN are those 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."" b) Review of the facility document entitled ""Meadowview Manor Health Care Center Physicians Standing Orders"" disclosed standing order #19 for ""Upper Respiratory Infection"". The steps to be followed by the facility's staff nurses (who were mostly LPNs), once they had determined a resident did indeed have an upper respiratory infection, were as follows: ""* If not allergic - [MEDICATION NAME] 1 Gm IM (intramuscularly) daily for 3 days. ""* If not allergic - [MEDICATION NAME] 400 mg by mouth daily for 5 days. ""* If allergic to [MEDICATION NAME] - give Z pack as directed. ""[MEDICATION NAME] 100 mg po (by mouth) bid (twice daily) for 3 days if not allergic."" There were additional steps to be taken, and medications to be administered, during flu season. The facility's director of nurses (DON), when interviewed on 10/07/09 at 3:30 p.m., was asked how she would expect the facility's nurses to determine the presence of an ""upper respiratory infection"" as opposed to a simple cold, allergy, or other condition. The DON agreed that, although symptoms would be considered, the nurses (LPNs and RNs) did not have authority to diagnose an infection and implement medical interventions related to that diagnosis. .",2015-06-01
10182,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2009-10-08,152,D,0,1,XHIH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure determinations of incapacity were documented in accordance with State law for two (2) of thirteen (13) sampled residents. One (1) resident's determination of incapacity did not indicate the expected duration of incapacity, nor was there evidence the physician informed this alert resident that a surrogate decision-maker would be acting on her behalf. Another resident's determination of incapacity also did not note the expected duration of incapacity. Resident identifiers: Resident identifiers: #18 and #36. Facility census: 59. Findings include: a) Resident #18 The medical record of Resident #18, when reviewed on 10/05/09, disclosed the resident's physician had, on 02/05/09, determined she lacked the capacity to understand and make her own informed medical decisions. The resident had been admitted to the facility on [DATE] and had posessed capacity until this time. The physician's documentation did not indicate this alert resident had been informed that her medical power of attorney representative (MPOA) would be making medical decisions of her behalf, as required by State law. The documentation also did not include the length of time the physician expected the resident to lack this capacity. b) Resident #36 The medical record of Resident #36, when reviewed on 10/05/09, disclosed the resident's physician had determined she lacked the capacity to understand and make her own informed medical decisions. The physician's documentation did not indicate this alert resident had been informed that her MPOA would be making medical decisions of her behalf, as required by State law. In an interview on 10/07/09 at 3:30 p.m., the director of nursing (Employee #69) agreed the was no evidence to reflect physician had informed the resident that her MPOA would be making her medical decisions, as required by State law. c) According to W.V.C. 16-30-7. Determination of incapacity.: ""(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. ""(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ""(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. .",2015-06-01
10183,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2009-10-08,279,D,0,1,XHIH11,"**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 three (3) of thirteen (13) residents that described the services to be furnished and how the services would be provided. Resident # 30's pain control program was not described specifically in the care plan. Residents #42 and #19 were receiving services at a wound care clinic that was not described in their care plans. Resident identifiers: #30, #42, and #19. Facility census: 59. Findings include: a) Resident #30 Medical record review, on 10/06/09, disclosed this resident sustained [REDACTED]. Among the other numerous medical [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. There were also orders for [MEDICATION NAME] 5/325 every six (6) hours as needed (PRN) for moderate to severe pain and [MEDICATION NAME] 50 mg every four (4) hours PRN for moderate pain. Interview with the medication nurse, on 10/06/09 at 3:00 p.m., revealed the resident's pain was assessed, and he was initially given [MEDICATION NAME] alternated with Tylenol; the [MEDICATION NAME] was not given unless the resident's pain was not relieved. The nurse related the resident's parents did not want the [MEDICATION NAME] given unless absolutely necessary, due to a decrease in respirations and an increase in lethargy. Review of the resident's comprehensive care plan, dated 11/25/09, found the resident's pain control plan did not contain the information described by the medication nurse. During an interview on 10/07/09 at 3:30 p.m., the director of nursing (DON - Employee #69) agreed this information should have been included in the care plan to ensure consistent care was provided by all staff. b) Resident #42 The medical record of Resident #42, when reviewed on 10/07/09, disclosed the resident was admitted to the facility on [DATE]. The record contained recent documents describing care and providing orders for wound care from an outside Wound Clinic. When interviewed on 10/07/09 at approximately 3:00 p.m., the DON stated the resident was being seen at the Wound Clinic for [MEDICAL CONDITIONS] that had been present for some time but were worsening. The resident's care plan, when reviewed, contained no mention of the resident's care at the outside Wound Clinic, e.g., when he went, how he got there, etc. The DON had no further information related to the resident's care plan at the time of the survey exit at 1:00 p.m. on 10/08/09. c) Resident #19 The medical record of Resident #19, when reviewed on 10/06/09, disclosed the resident was admitted to the facility on [DATE] with numerous skin ulcers. The record contained recent documents describing care and providing orders for wound care from an outside Wound Clinic. When interviewed on 10/07/09 at approximately 3:00 p.m., the DON stated the resident was being seen at the Clinic and had been referred at the time of his discharge from the hospital. Each time the resident visited the clinic, he would return with treatment orders as well as an appointment for the return visit. The resident's care plan, when reviewed, contained no mention of the resident's care at the outside Wound Clinic, e.g., when he went, how he got there, etc. The DON had no further information related to the resident's care plan at the time of the survey exit at 1:00 p.m. on 10/08/09. .",2015-06-01
10347,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-10-08,164,D,0,1,5TIO11,"Based on observation and staff interview, the facility failed to protect the privacy of one (1) of thirteen (13) sampled residents by leaving confidential resident information observable in a hallway unattended. Resident identifier: #30. Facility census: 58. Findings include: a) Resident #30 When entering the room of Resident #30 for an observation of wound care at 11:10 a.m. on 10/06/09, the surveyor observed the treatment administration record lying open on top of the treatment cart located in the hallway outside the room. The resident's name, wound status, and treatment information were accessible to anyone who stopped in the hallway. Both of the treatment nurses (Employees #74 and #34) had already entered the room. The door was left open throughout the treatment, and the record was still open when the room was exited approximately fifteen (15) minutes later. During an interview with the assistant director of nursing (Employee #74) and the wound care nurse (Employee #62) at 10:30 a.m. on 10/07/09, they were informed of the observation. .",2015-05-01
10348,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-10-08,241,D,0,1,5TIO11,"Based on observation, record review, and staff interview, the facility failed to provide care with dignity by discussing care issues in the presence of an alert resident and in an area that did not assure auditory privacy for one (1) of thirteen (13) sampled residents. Resident identifier: #30. Facility census: 58. Findings include: a) Resident #30 During the provision of wound care by two (2) nurses (Employees #34 and #74) for Resident #30 in the resident's room at 11:10 a.m. on 10/06/09, Employee #74 stood by the resident's head at the top of the bed during the procedure. The resident was on the window bed farthest from the door, and the privacy curtain was pulled between the beds, but the door was not closed. The room was located on the main hallway from the front entrance, and several staff members and others were seen passing in the hall. While the resident could not be seen from the open door, the overbed table and its supplies were visible, making it obvious that wound care was being done. This surveyor stood against the wall across from the foot of the bed. At the start of the wound care, the resident was turned to face the inside of the room. At that time she said, on three (3) separate occasions and in a voice audible to this surveyor, that she needed to use the bathroom. Neither nurse acknowledged this request the first two (2) times; on her third try, when she said she had to ""go bad"" and apologized by saying, ""I'm sorry"", Employee #74 told her, ""It's OK. This won't take long."" At one point, Employee #74 asked the resident if she was having pain, and the resident replied that she was, but the nurse said nothing, and they continued with the procedure. During the procedure, Employee #34 related to this surveyor information which included the status of the wounds present, the care being given, and traits that the resident had that impeded the healing process. She stated the resident was refusing to eat, would not let them turn her off of the affected side often enough, and that she would not heal as long as she did this. The resident was alert and aware of her surroundings. She spoke clearly and made requests during the dressing change, but Employee #34 never spoke to her throughout the procedure, and none of her observations were directed to the resident. The surveyor could easily hear the nurse, and when the surveyor, at one point, walked to the doorway, Employee #34 could still be heard. During an interview with Employee #74 and the facility's wound care nurse (Employee #62) at 10:30 a.m. on 10/07/09, they both acknowledged Resident #30 was alert and aware of those around her. This resident was identified by the facility as being interviewable. Employee #74 acknowledged the resident had made the requests repeated above but did not comment about her failure to address them. .",2015-05-01
10349,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-10-08,272,E,0,1,5TIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the accuracy of the minimum data set (MDS) assessments for four (4) of the thirteen (13) sampled residents. Resident identifiers: #49, #21, #42, and #10. Facility census: 58. Findings include: a) Resident #49 Medical record review revealed Resident #49 was an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her admission MDS revealed, in Section M.1., the presence of two (2) Stage I, one (1) Stage II, and one (1) Stage IV pressure ulcers. A review of the significant change in status MDS, dated [DATE], indicated in Section M.1. the presence of one (1) Stage II and one (1) Stage IV pressure ulcers, but there was no entry in Section M.3. to indicated there were any resolved ulcers. This made the status of the resident unclear. During an interview with the MDS nurse (Employee #47) at 3:45 p.m. on 10/10/07/09, she acknowledged there should have been an entry in Section M.3., as she was sure two (2) of the ulcers had healed. b) Resident #21 Medical record review revealed Resident #21 had been receiving a diuretic ([MEDICATION NAME]) daily since at least November 2008, but the significant change in status MDS, dated [DATE], failed to indicate this in Section O.4. The MDS nurse, when questioned at 3:45 p.m. on 10/07/09, stated this was an oversight. c) Resident #42 Medical record review revealed Resident #42 was an [AGE] year old female with [DIAGNOSES REDACTED]. The resident's care plan contained a problem initiated on 05/10/09, stating: ""Resident at times sits up all night not allowing staff to put her to bed."" She was ordered [MEDICATION NAME] 25 mg each night for sleep, and this medication was increased to 50 mg on 08/15/09, after a psychiatric consult on 08/13/09, when the physician noted she was ""somnolent"" during the examination. A review of the annual MDS, dated [DATE], and the quarterly MDS, dated [DATE], found not mention, in Section E.1., of any ""sleep-cycle issues"", although the care plan dated 07/27/09 stated: ""Resident continues to sit up at night at times, refusing to go to bed, falling asleep in wheelchair."" During an interview with the MDS nurse at 3:45 p.m. on 10/07/09, she acknowledged there should have been an entry in Section E, because she and other nurses were aware the resident did have sleeping issues and would stay up at night and then be sleepy during the day. d) The MDS nurse reported to this surveyor, on 10/08/09, that she had corrected the inaccuracies noted above. e) Resident #10 Review of Resident's #10 medical record, on 10/06/09, revealed the MDS was completed on 09/16/09, with Section N. (Activity Pursuit Patterns) identifying the resident as not awake any time during the last seven (7) days. Observations at the time of this survey, and interview on 10/07/09 with the MDS nurse, revealed the resident stayed in bed most of the time watching TV and reading. The MDS nurse acknowledged this was an inaccurate assessment. .",2015-05-01
10350,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-10-08,274,D,0,1,5TIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete a comprehensive assessment minimum data set (MDS) for one (1) of thirteen (13) sampled residents who exhibited a significant change in health status. Resident identifier: #42. Facility census: 58. Findings include: a) Resident #42 Medical record review revealed Resident #42 was an [AGE] year old female with [DIAGNOSES REDACTED]. The facility completed an annual MDS on 05/04/09 and a quarterly MDS on 07/26/09. A comparison of these assessments revealed following changes: Section E1 (indicators of depression, anxiety, sad mood) - repetitive verbalizations and repetitive anxious complaints / concerns increased from less than six (6) times a week to daily or almost daily, and repetitive movements increased from non to less than six (6) times a week. Section E2 (mood persistence) - changed from present and easily altered to present and not easily altered. Section 4 (behavioral symptoms) - the frequency of resisting care increased from occurring one (1) to three (3) days in the last seven (7) days to occurring four (4) to six (6) days in the last seven (7) days. Section O4b - the resident was now receiving a medication for antianxiety. During an interview with the MDS nurse (Employee #47) at 3:45 p.m. on 10/07/09, she acknowledged, after reviewing the record, that the 07/26/09 MDS should have been a comprehensive significant change in status assessment instead of an abbreviated quarterly assessment. .",2015-05-01
10351,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-10-08,279,E,0,1,5TIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to initiate a care plan and/or adequately address all problems identified through the comprehensive resident assessment for nine (9) of fifteen (15) sampled residents, by either not establishing measurable goals and/or by the lack of nursing interventions designed to meet the goals. Resident identifiers: #3, #4, #13, #42, #59, #36, #24, #48, and #57. Facility census: 58. Findings include: a) Residents #3, #13, #42, #59, #36, #24, and #48 Each of these seven (7) residents was receiving one (1) or more psychoactive medications on a continuing basis including [MEDICATION NAME], [MEDICATION NAME], and/or [MEDICATION NAME]. These medications were identified in their comprehensive minimum data set (MDS) assessments, which triggered the resident assessment protocol (RAP) for [MEDICAL CONDITION] drug use. In each case, the interdisciplinary care team identified on the resident's RAP summary that the team would proceed with care planning the medication use to observe for the effectiveness of medication, potential medication side effects, and potential dosage reductions. However, none of residents' care plans contained a problem, under the column headed ""Focus"", for [MEDICAL CONDITION] drug use and there were no measurable goals established for this. The only entries found were the following statement under ""Interventions"": ""Administer antipsychotic and antidepressant per MD orders. Observe for effectiveness and side effects."" This intervention was usually addressing a behavioral or cognitive problem. In none of these residents' care plans were any of the side effects listed, although, in the documentation of the care plan meeting, at times, mentioned potential safety issues. During a meeting with the MDS nurse (Employee #47), the assistant director of nursing (Employee #74), and the administrator at 4:00 p.m. on 10/07/09, the MDS nurse acknowledged she did not address the use of a [MEDICAL CONDITION] drug as a problem and admitted that the wording in the RAP summaries did indicate this would be addressed for these residents. She said that they would have to discuss this. b) Resident #36 Review of Resident #36's medical record, on 10/06/09, revealed she had a [DIAGNOSES REDACTED]. The admission MDS, dated [DATE], identified in Section O (Medications) that the resident was receiving a daily diuretic. The RAP summary, completed on 08/06/09, was triggered for dehydration / fluid maintenance, and the care planning decision was checked to indicate this would be addressed on the resident's care plan. Review of the current care plan found it did not address the potential problem / risk of dehydration. In an interview on the afternoon of 10/07/09, the MDS nurse there was no care plan to address this risk. c) Resident #57 Review of Resident #57's medical record, on 10/06/09, revealed a [DIAGNOSES REDACTED]. d) Resident #4 Review of Resident #4's medical record, 10/07/09, revealed she had a current physician order [REDACTED]. In an interview at about 10:00 a.m. on 10/08/09, the MDS nurse acknowledged there had been no care plan developed for dehydration. .",2015-05-01
10352,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-10-08,280,D,0,1,5TIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to review and/or revise the care plan to include changes in health care needs including a significant weight loss due to poor intake for one (1) of thirteen (13) sampled residents. Resident identifier: #21. Facility census: 58. Findings include: a) Resident #21 A review of the significant change in status minimum data set (MDS), dated [DATE], revealed Resident #21 had a weight loss of 5% or more in the last thirty (30) days or 10% or more in the last one hundred eighty (180) days (Section K3a), and that she left twenty-five percent (25%) or more of food uneaten at most meals (Section K4c). The care plan meeting notes for 08/19/09 stated: ""MDS and Careplan reviewed for significant change in status on 8/12/09. Significant change due to weight loss, ..."" and ""Resident has exhibited a weight loss over past months. She is taking a regular no added salt diet with sugar substitute. Resident is able to feed self but needs much encouragement."" These changes in the MDS triggered the resident assessment protocol (RAP) for nutritional status, which included the above assessment information, and the interdisciplinary care team indicated that care planning would be done to address this. A review of the care plan, with a print date of 08/17/09, revealed the following entry on page 6 as an addition under the problem of dehydration: ""8/17/09 Res (resident) has exhibited significant weight loss over past review. At risk for additional weight loss due to poor intakes. Continue with POC (plan of care)."" There was no goal associated with this entry and no nursing interventions as suggested in the care plan meeting. During an interview with the MDS nurse (Employee #47) at 3:45 p.m. on 10/07/09, she reviewed the care plan and agreed it contained no interventions, possibly due to an oversight. .",2015-05-01
10353,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-10-08,285,B,0,1,5TIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the mental health status of a new resident had been evaluated under the Pre-Admission Screening and Resident Review (PASRR) program prior to the resident being admitted into the facility for three (3) of fifteen (15) sampled residents. Resident identifiers: #60, #36, and #49. Facility census: 58. Findings include: a) Resident #60 Review of Resident #60's medical record, on 10/07/09, revealed he was admitted to the facility on [DATE]. The PASRR determination was not made, as indicated by the dated signature in Section V, until 06/19/09. In an interview on 10/08/09, the social service director acknowledged the resident was admitted prior to the determination of the PASRR.. b) Resident #36 Review of Resident #36's medical record, on 10/06/09, revealed she was admitted to the facility on [DATE]. The PASRR determination was not made, as indicated by the dated signature in Section V, until 07/27/09. In an interview on 10/08/09, the social service director acknowledged the resident was admitted prior to the determination of the PASRR.. c) Resident #49 A review of the clinical record revealed Resident #49 was admitted to the facility on [DATE]. However, the Level II determination was not made, as indicated by the dated signature in Section V of the PASRR, until 07/15/09. During an interview with the administrator and the social worker at 10:15 on 10/08/09, they acknowledged the dates noted above were correct. .",2015-05-01
10354,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-10-08,329,D,0,1,5TIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the medication regimen of one (1) of thirteen (13) sampled residents was free of unnecessary drugs. There was a lack of monitoring for sleeplessness to ascertain the effectiveness of [MEDICATION NAME] in treating [MEDICAL CONDITION], and there was a lack of monitoring for the presence of adverse side effects associated with the use of the [MEDICATION NAME]. Resident identifier: #42. Facility census: 58. Findings include: a) Resident #42 Medical record review revealed Resident #42 was an [AGE] year old female with [DIAGNOSES REDACTED]. The resident's care plan contained a problem initiated on 05/10/09, stating: ""Resident at times sits up all night not allowing staff to put her to bed."" Her physician ordered [MEDICATION NAME] 25 mg each night to promote sleep. The dosage of this medication was increased on 08/15/09 to 50 mg after a psychiatric consult on 08/13/09, during which the physician noted, ""She's still having problems with decreased sleep at night"" and that she was ""somnolent during the examination"". Review of the resident's annual comprehensive assessment, dated 05/04/09, and the most recent abbreviated quarterly assessment, dated 07/26/09, found no entries in Section E1 to indicate the resident exhibited signs of ""sleep-cycle issues"". The resident assessment protocol (RAP) for [MEDICAL CONDITION] drug use stated: ""Will proceed with care plan to observe effectiveness of medication, potential medication side effects and for potential dosage reductions."" However, the only entry in the care plan was: ""Administer antipsychotic and antidepressant per MD orders. Observe for effectiveness and side effects."" A review of seventeen (17) interdisciplinary team progress notes, written between 07/27/09 and 08/10/09, only revealed one (1) entry (on 07/27/09) which addressed her problem of not sleeping, stating, ""Resident continues to sit up at night at times, refusing to go to bed, falling asleep in wheelchair."" A review of August and September 2009 nursing notes failed to reveal any monitoring of her sleeplessness or its decline or improvement after the addition of [MEDICATION NAME] medication therapy. Her monthly behavior monitoring flowsheets did not include sleeplessness as a behavior to be monitored daily. The care plan identified the problem of the resident sitting up all night with several nursing interventions, but there was no mention of the need to conduct any behavioral monitoring, and there was no evidence that such monitoring occurred. There was no evidence in the record of any behavioral monitoring or monitoring for the onset of adverse side effects. During a meeting with the MDS nurse (Employee #47), the assistant director of nursing (Employee #74), and the administrator at 4:00 p.m. on 10/07/09, they were asked where the information about the resident's not sleeping, as mentioned in the care plan meeting notes of 08/05/09, was recorded. They all stated they were aware the resident stayed up at night, and they stated they thought her sleeplessness may contribute to her behaviors and refusal of baths, but they could produce any documentation to support this. At the time of exit, there had been no additional monitoring documentation presented. .",2015-05-01
10355,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-10-08,386,D,0,1,5TIO11,"Based on record review and staff interview, the facility failed to assure a physician signed and dates all orders received for the care of one (1) of thirteen (13) sampled residents in a timely manner. Resident identifier: #49. Facility census: 58. Findings include: a) Resident #49 A review of the clinical record for Resident #49 revealed the attending physician's last required visit was on 09/16/09, with progress notes entered by him into the record and signed and dated. But there were five (5) verbally received treatment orders from August and eight (8) from September (prior to his visit date) that were not signed or dated to reflect his review. The monthly recapitulation of physician orders for September was on the record on 08/31/09, and these were also not signed or dated. During an interview with the administrator at 10:20 a.m. on 10/08/09, when informed of the physician's failure to sign the orders, she stated all orders should have been signed and she would review the chart. At the time of exit, no additional information had been received regarding this concern.",2015-05-01
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
10532,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-10-08,323,E,0,1,4DOJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of the facility's smoking policy, and resident and staff interviews, the facility failed to ensure three (3) of ten (10) residents who smoked, and who were assessed as requiring supervision for safe smoking, did not have access to lighters while unsupervised. Additionally, the facility failed to ensure one (1) of twenty (20) sampled residents, who was identified as being at risk for falls, had mats beside her bed as ordered. Resident identifiers: #12, #45, #82, and #103. Facility census: 112. Findings include: a) Residents #103, #45, and #82 1. Resident #103 Observation of Resident #103 on 10/6/09 at 4:00 p.m., found the resident sitting on the side of his bed while rolling his own cigarettes. At 8:50 a.m., on 10/07/09, the social worker was interviewed about residents who were allowed to smoke at the facility. She indicated that the residents who smoked were allowed to keep their own cigarettes, but could not have any lighters or matches, and these were given to the residents during scheduled smoking times. She indicated that the smoking schedule was a recent change at the facility in order to ensure that residents who smoked were safe and supervised. At 9:00 a.m. the social worker was accompanied by the surveyor the Resident #103 was observed in the hallway. He indicated that he was on his way to smoke outside. Whenever questioned as to if he had a lighter, he said, ""Yes."" The social worker then asked the resident to give her the lighter, and the resident complied. Whenever asked who gave him the lighter, he indicated it was as staff member from the day before, but could not name the person. Review of the Safe Smoking assessment dated [DATE] and reviewed on 06/17/09, found the resident required supervision to smoke. A review of the resident's care plan dated 09/16/09 and did not include a care plan to ensure safe smoking for the resident. 2. Resident #45 During an interview on 10/07/09 at 9:10 a.m., the social worker was asked to find out if any residents had lighters in their possession. In the early afternoon, the social worker was interviewed again regarding residents who were found with lighters on 10/07/09, and Resident #45 was identified as having a lighter on his possession. A review of the resident's most recent smoking assessment dated [DATE] indicating the resident required an apron and suspicion in order to smoke. A review of the resident's most recent care plan dated 07/29/09, but did not include any care plan regarding smoking until 10/07/09, which was signed by the social worker. 3. Resident #82 During an interview on 10/07/09 at 9:10 a.m., the social worker was asked to find out if any residents had lighters in their possession. In the early afternoon, the social worker was interviewed again regarding residents who were found with lighters on 10/07/09, and Resident #82 was identified as having a lighter on her possession. On 10/07/09 at 3:00 p.m., during an interview with the director of nursing (DON) in the East Wing dining room, Resident #82 was observed on the porch outside the dining room. The resident took another cigarette lighter from her cigarette case, and lit her cigarette. She then proceeded to light two (2) other residents' cigarettes. An unidentified housekeeper was out on the porch while this took place, and the DON observed this with the surveyor. She went out onto the porch and asked the resident to giver her the lighter. Another lighter was observed in the side of the resident's cigarette case at this time, and the DON was informed. A review of the resident's smoking assessments, dated 08/21/08, 04/08/09, 07/01/09, and 09/30/09, all indicated the resident required a smoking apron and staff supervision for safe smoking. A review of the resident's 09/30/09 care plan did not include any care plan regarding smoking until 10/07/09, which was signed by the social worker. 4. Review of the facility's smoking policy found residents were to be assessed on admission, quarterly, and with any changes for those residents who choose to smoke. The policy also indicated that smoking privileges would be addressed in the care plan. The policy further stated no resident could carry a cigarette lighter or matches, but these items shall be made available as needed. b) Resident #12 On 10/05/09, Resident #12 was observed in the late afternoon through 6:45 p.m. and was in a low bed. The physician's orders [REDACTED]."" There were no mats located beside of the resident's bed during any of the above observations. .",2015-02-01
10533,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-10-08,441,E,0,1,4DOJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and a review of facility policies and procedures, the facility failed to maintain an effective infection control program. This had the potential to affect residents residing on two (2) of four (4) hallways in the facility. Resident #12 was fed from an overbed table brought into her room from another resident's room without first being cleaned. Employee #61 was observed wiping off the sink with paper towels, recontaminating his hands after washing them. Employee #32 was observed using a stethoscope for Resident #62 who was in contact isolation for VRE; she then put the stethoscope around her neck and took the stethoscope out of the room without cleaning it first. Employee #36 was observed contaminating her gloves during medication administration and then touching items (including drinking cups) on her medication cart. Facility census: 112. Findings include: a) Resident #12 During the evening meal on 10/05/09, observation found a nursing assistant (NA - Employee #61) pushed an overbed table from the room adjacent to Resident #12's room into the resident's room without cleansing it first. The NA then put the resident's dinner tray on the table and proceeded to feed the resident. b) Employee #61 Employee #61 was observed during the evening meal on 10/05/09. After washing his hands, the NA took paper towels from the dispenser and wiped off water that accumulated around the sink basin on the counter, recontaminating his hands. This occurred two (2) times during this observation. c) Resident #62 and Employee #32 Observation, on 10/06/09 in the mid-morning, found a licensed practical nurse (LPN - Employee #32) using a stethoscope to check Resident #62's [DEVICE] placement during medication administration. Resident #62 was in contact isolation for [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE ). The nurse took the stethoscope with her when she exited the room and put it around her neck without cleansing the stethoscope. A review of the facility's policies and procedures for contact isolation found that equipment used for residents in isolation was to be dedicated to that resident and left in the room. d) Resident #56 At 1:50 p.m. on 10/07/09, the LPN (Employee #36) was observed administering medications to the resident via gastrostomy tube. The nurse donned her gloves, cut open the packets containing [MEDICATION NAME] and [MEDICATION NAME], crushed the [MEDICATION NAME], and opened the capsules of [MEDICATION NAME]. While wearing the same gloves, she obtained water from the sink in the resident's room without protecting her gloves from contamination. She then put her hands in her pockets to retrieve the keys to the medication cart. She unlocked the cart and got another cup from the bottom drawer. During this action, her contaminated gloved hand came in contact with the rims of other cups in the drawer. She then removed her gloves, washed her hands, and donned a fresh pair of gloves. However, she again got keys out of her pocket and obtained an alcohol pad from the cart. She proceeded to administer medications while wearing the contaminated gloves. .",2015-02-01
10534,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-10-08,492,E,0,1,4DOJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility failed to ensure services were provided in accordance with State laws. Residents with ""Physician order [REDACTED]. Additionally, a POST form for one (1) resident was marked for the resident not to have a feeding tube. The form was not revised after a feeding tube was inserted during a hospitalization , in keeping with [DATE] of the West Virginia Code. Resident identifiers: #24, #25, #99, #90, #113, #83, and #103. Facility census: 112. Findings include: a) Resident #24 1. Review of the resident's medical record found a POST form signed by the resident's health care surrogate (HCS) on [DATE]. The physician also signed the form on [DATE]. The form indicated the resident was NOT to have a feeding tube. However, the resident had a feeding tube inserted while in the hospital [DATE] to [DATE]. In Section G of the form, it was noted the form had been reviewed on [DATE]. An ""X"" had been placed in the box by ""No Change"" and the physician had signed the form. There was no indication the HCS had been involved in reviewing the form and it determined whether she wanted the feeding tube to be continued, nor had the form been voided and a new one completed to allow for the feeding tube. West Virginia State Code, [DATE], includes, ""After admission, the physician orders [REDACTED]. ""(1) The physician orders [REDACTED]. ""(2) The physician orders [REDACTED]. ""(3) The physician orders [REDACTED]."" 2. Additionally, the form had been marked for the resident to be ""Comfort Measures"". There was no evidence the HCS had been provided information stating the resident had the option of receiving hospice palliative care. West Virginia State Code, ,[DATE]C-20 includes, ""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."" 3. The requirement for offering hospice palliative care was brought to the attention of the admissions coordinator (Employee #2) in late morning on [DATE]. She was unaware of this requirement. It was further discussed with Employee #2 and the facility's pastor, at approximately 4:00 p.m., on [DATE]. The issue of the need to revise the resident's POST related to the gastrostomy tube was also discussed. b) Resident #25 This resident's POST form was signed by the physician on [DATE]. The form was marked for the resident to be ""comfort measures"". Review of the physician's progress notes, social services notes, nurses' notes, and interdisciplinary progress notes found nothing about information about hospice palliative care having been offered to the resident. It was confirmed by Employee #2 on [DATE], that information regarding hospice palliative services had not been offered to the resident. (See finding a.) c) Resident #99 Review of the resident's medical record found the POST form had been marked for comfort measures by her responsible party on [DATE]. No evidence was found regarding information about hospice palliative care having been offered. It was confirmed by Employee #2 on [DATE], that information about hospice palliative services had not been offered to the resident. (See finding a.) d) Resident #90 This resident's POST form had been marked for her to be comfort measures and signed by the resident's responsible party. No evidence was found to indicate the resident or responsible party had been provided information about hospice palliative care. On [DATE] at 1:45 p.m., the social services director (Employee #4) was asked what residents / responsible parties were told about the designation of comfort measures. She said it depended on who assisted with completion of the form. She did, however, acknowledge that information about hospice palliative care had not been offered to residents whose POST forms were marked comfort measures. e) Resident #113 A review of the resident's POST, dated [DATE], indicated the resident did not want CPR (cardiopulmonary resuscitation) and was to have comfort measures provided. A review of the social services and nursing notes failed to find evidence that information about hospice palliative care was offered to the resident. f) Resident #83 A review of the resident's POST, dated [DATE], indicated the resident did not want CPR and was to have comfort measures provided. A review of the social services and nursing notes failed to find evidence that information about hospice palliative care was offered to the resident. g) Resident #103 A review of the resident's POST, dated [DATE], indicated the resident did not want CPR and was to have comfort measures provided. A review of the social services and nursing notes failed to find evidence that information about hospice palliative care was offered to the resident. .",2015-02-01
10535,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-10-08,225,D,0,1,4DOJ11,"Based on medical record review and staff interview, the facility failed to adequately screen applicants to ensure it did not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law. One (1) of five (5) new employees whose personnel files were reviewed worked in another state, and the facility did not check that state for possible criminal convictions that would indicate the applicant was unfit for service in a nursing facility. Employee identifier: #18. Facility census: 112. Findings include: a) Employee #18 Review of the employment application for Employee #18 found this individual had worked in Texas in 2009. Review of the criminal background check, which included several other states, found it did not include Texas. This finding was reviewed with the certified nursing assistant supervisor (Employee #11) at 11:00 a.m. on 10/06/09. Employee #11 was unable to produce evidence to reflect the facility made reasonable efforts to screen Employee #18 for past criminal convictions in other states in which the individual had previous employment prior to hire. .",2015-02-01
10536,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-10-08,279,E,0,1,4DOJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policies and procedures, and staff interviews, the facility failed to develop care plans for three (3) of ten (10) residents who smoked at the facility, seven (7) of twenty-three (23) sampled residents who had a physician's orders [REDACTED]. Residents #45, #83, and #103 smoked, and care plans were not developed to ensure resident safety. Residents #113, #83, #103, #4, #23, #99, and #25 had physician's orders [REDACTED]. Resident #99 exhibited problem behaviors, and the care plan did not include measurable goals or provide guidance to direct the care giver on redirection. Facility census: 112. Findings include: a) Residents #45, #83, and #103 (residents who smoked) 1. Residents #103 Observation of Resident #103, on 10/6/09 at 4:00 p.m., found the resident sitting on the side of his bed rolling his own cigarettes. At 8:50 a.m. on 10/07/09, the social worker, when interviewed about residents who were allowed to smoke at the facility, related the residents who smoked were allowed to keep their own cigarettes but could not have any lighters or matches; these were given to the residents during scheduled smoking times. She related the smoking schedule was a recent change at the facility in order to ensure residents who smoked were safe and supervised. At 9:00 a.m., the social worker accompanied the surveyor to see Resident #103, who was observed in the hallway. Resident #103 stated he was on his way to smoke outside. When questioned as to if he had a lighter, he said, ""Yes."" The social worker then asked the resident to give her the lighter, and the resident complied. When asked who gave him the lighter, he related it was a staff member from the day before, but he could not name the person. Review of the Safe Smoking Assessment, dated 03/25/09 and reviewed on 06/17/09, found Resident #103 required supervision to smoke. A review of the resident's current care plan, dated 09/16/09, found it did not include a care plan to ensure safe smoking for the resident. 2. Resident #45 During an interview on 10/07/09 at 9:10 a.m., the social worker was asked to find out if any residents had lighters in their possession. Later in the early afternoon, the social worker, when interviewed again regarding residents who were found with lighters, identified Resident #45 as having had a lighter on his possession. A review of the resident's most recent smoking assessment, dated 07/29/09, revealed the resident required a smoking apron and staff supervision when smoking. A review of the resident's most recent care plan, dated 07/29/09, found it did not include any care plan regarding smoking until 10/07/09, which was signed by the social worker. 3. Resident #82 When interviewed on the early afternoon of 10/07/09, the social worker also identified Resident #82 as also having had a lighter on her possession. On 10/07/09 at 3:00 p.m., during an interview with the director of nursing (DON) in the East wing dining room, Resident #82 was observed on the porch outside the dining room. The resident took cigarette lighter from her cigarette case and lit her cigarette. She then proceeded to light two (2) other residents' cigarettes. An unidentified housekeeper was out on the porch while this took place, and the DON observed this with the surveyor. She went out onto the porch and asked the resident to give her the lighter. Another lighter was observed in the side of the resident's cigarette case at this time, and the DON was informed of this. A review of the resident's smoking assessments, dated 08/21/08, 04/08/09, 07/01/09 and 09/30/09, found they all indicated the resident required a smoking apron and staff supervision when smoking. A review of the resident's 09/30/09 care plan found it did not include any care plan regarding smoking until 10/07/09, which was signed by the social worker. --- b) Residents #113, #83, #103, #4, #23, #99, and #25 (comfort measures) 1. Resident #113 A review of the physician's orders [REDACTED].#113 had a physician's orders [REDACTED]. 2. Resident #83 A Review of the POS [REDACTED]. A review of the 08/19/09 care plan for the resident found it did not include a care plan to ensure comfort measures were to be provided to the resident. 3. Resident #103 A Review of the POS [REDACTED]. A review of the 09/16/09 care plan for the resident found it did not include a care plan to ensure comfort measures were to be provided to the resident. 4. Resident #90 The resident's POST form, signed by the physician on 05/06/09, was marked for the resident to be ""comfort measures"". The resident's care plan, established 05/13/09, did not address what ""comfort measures"" entailed for this resident. 5. Resident #24 A POST form had been signed by the physician on 04/02/09. The resident was hospitalized and returned to the facility on [DATE]. On the back of the form, in Section G, it was noted the form had been reviewed on 04/27/09 and there were no changes. The form was marked for the resident to be ""comfort measures"" and also was check for the resident not to have a feeding tube. While the resident had been in the hospital, a feeding tube had been inserted. The resident's care plan, established on 05/06/09, did not address comfort measures, nor did it address the presence of the feeding tube that was contrary to the POST form. 6. Resident #25 A POST form was completed on the day of the resident's admission, 09/08/09. The form was marked for the resident to be ""comfort measures"". The resident's care plan, established on 09/23/09, did not address comfort measures for this resident. 7. Resident #99 The POST form for this resident had been signed by the responsible party on 11/16/07. The resident was to be ""comfort measures"". The form indicated it had been reviewed 11/29/07, 02/15/08, and 07/28/09. The resident's care plan, established on 08/05/09, did not address what comfort measures for this resident would entail. --- c) Resident #99 (problem behaviors) This resident's [DIAGNOSES REDACTED]. The goal related to her behavioral problems was: ""Will have decrease episodes of mood and negative behaviors ...."" This goal was not stated in measurable terms so the effectiveness of the interventions might be ascertained. The interventions included instructions to redirect the resident, but they did not provide guidance to direct care givers regarding how to attempt to redirect the resident. .",2015-02-01
10537,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-10-08,281,D,0,1,4DOJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review, and staff interview, the facility failed to ensure residents received medications as ordered for one (1) of forty (40) opportunities for error observed. Resident #98 received regular Aspirin 325 mg, although Aspirin 325 mg EC ([MEDICATION NAME] coated) was ordered. Resident identifier: #98. Facility census: 112. Findings include: a) Resident #98 During the medication pass on 10/06/09 at 9:05 a.m., the nurse (Employee #41) administered to Resident #98 regular Aspirin 325 mg, instead of Aspirin 325 EC as ordered by the physician. This information was reviewed with the director of nursing on 10/08/09 at 3:00 p.m., who verified the wrong medication had been given. Review of the facility's ""Guidelines for Administering Medications"", in Section E ""General rules for giving Medications"" found, under Item #4, ""Check the MAR (medication administration record) with the label on the medication three times, reading the name on the medication, the route of the administration, and the strength dose..."" .",2015-02-01
10538,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-10-08,272,D,0,1,4DOJ11,"Based on review of medical records and staff interviews, the facility failed to ensure the minimum data set (MDS) assessment for one (1) of twenty (20) current residents on the sample was accurately coded with regard to her skin condition. The assessment was coded to indicate the resident had a pressure ulcer, although the physician had documented the area was a diabetic ulcer. Resident identifier: #90. Facility census: 112. Findings include: a) Resident #90 The ""Resident Level Quality Measure / Indicator Report: Chronic Care Sample"" (run date 09/30/09) indicated this resident had a pressure ulcer. On 10/05/09 at approximately 4:00 p.m., the treatment nurse (Employee #26), when asked about the ulcers of three (3) residents on the unit, said all three (3) had ""diabetic pressure ulcers"". Subsequent review of Resident #90's medical record found the physician had diagnosed the area as a diabetic ulcer. The resident's MDS, with an assessment reference date (ARD) of 08/08/09, was coded as ""2"" in Section M - item 2a, to indicate the resident had a pressure ulcer. The diabetic ulcer should have been coded in M1, but not in M2. .",2015-02-01
10539,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-10-08,309,E,0,1,4DOJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, resident interview, and staff interviews, the facility failed to ensure each resident received the necessary care and services to promote his or her highest level of well-being and in accordance with the plan of care. Physicians' orders were not carried out for two (2) of twenty (20) sampled residents. Resident identifiers: #25 and #24. Facility census: 112. Findings include: a) Resident #25 1. This resident was admitted on [DATE]. Her admission orders [REDACTED]."" Review of the resident's medical record did not find any record of intakes and outputs. The book in which current intake and output records was reviewed, but no records were found for this resident. On 10/07/09 at approximately 2:45 p.m., a registered nurse (Employee #16) was asked to find the record of the resident's intakes and outputs. She checked the resident's chart and the intake and output book, but was unable to locate any records. She said the order must have been missed. 2. On 09/16/09, telephone orders had been written for the resident, to include an order for [REDACTED]. The Accu-Checks were completed as ordered and documented on Medication Administration Record [REDACTED]. At the end of the five (5) day period, ""REEVAL"" had been written, but there was no evidence the data were evaluated. The Accu-Checks were documented for four (4) days at 6:00 a.m. - no insulin coverage was required. The checks for 11:00 a.m. were completed all five (5) days. For the first three (3) days, no insulin coverage was required. On the last two (2) days, two (2) units of regular insulin were given. The results for the 4:00 p.m. tests indicated insulin coverage was required on 09/16/09, 09/17/09, and 09/20/09. Eight (8) units of insulin were given on 09/17/09, and two (2) units were given the other two (2) days. The 9:00 p.m. tests indicated insulin coverage was required on 09/17/09, 09/18/09, and 09/20/09. Four (4) units were required on 09/17/09, and two (2) units were required on the other two (2) days. This was discussed with Employee #16 at approximately 2:40 p.m., on 10/07/09. She was unable to find any evidence the results of the Accu-Checks had been evaluated. 3. On 09/13/09, the physician gave an order for [REDACTED]."" Review of the nurses' notes found an entry, on 09/13/09 at 7:30 a.m., of: ""Resident C/O pain in neck & shoulder. Dr. ____ aware. New orders received to receive x-rays AP and ...."" There was no evidence of any evaluation of the pain, i.e., intensity, nature, when it occurred, etc. There was no evidence the resident had received any medication for pain found in the nursing entries or on the medication administration record. There was no evidence of any further evaluation of the resident's neck and shoulder pain. The ""Pain Monitor"" sheet for 09/13/09 was checked ""No"" for all three (3) shifts. The pain monitoring sheet was checked to indicate the resident had not had pain on any shift 09/08/09 through 09/30/09. In an interview with the resident at 2:15 p.m. on 10/07/09, she said she had pain in her stomach a lot. She lifted her gown and pointed to a bulging area saying she had ""ruptures"". When asked, she said the pain was not like heartburn or indigestion. She said she still had pain in her shoulders, especially when she laid down, and sometimes had pain in her back. According to the resident, she was receiving therapy, and it had helped some. She also said the nurses gave her a pain pill sometimes. (The resident had an order for [REDACTED]. --- b) Resident #24 The resident's admission orders [REDACTED]. Review of the ""Vital Sign Sheet"" for 09/17/09 through 10/06/09 found the resident's vital signs had not been recorded for one (1) or more shifts for twelve (12) of twenty-four (24) days. .",2015-02-01
10540,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-10-08,310,D,0,1,4DOJ11,"Based on random observations, the facility failed to ensure a resident's ability to eat did not diminish. Resident #36 was not positioned to facilitate ease in feeding herself. Facility census: 112. Findings include: a) Resident #36 On 10/05/09, the resident was observed eating the evening meal in the small dining room on the West wing. She was seated in a geri-chair, and her meal tray was on an overbed table. The back of the recliner was at 45 degrees, and her food was at the height of her mouth. She could not well visualize the foods on her plate. She would extend her arm and attempt to scoop food onto the spoon, but at times she would get little or no food. Because of the height and positioning of the chair relative to the table, not only could she not see what was on the plate too well, she had to extend her arm and hand above shoulder height to obtain the foods and beverages she had been served. Observation of the resident at lunch time, on 10/06/09 and 10/07/09, found similar positioning. On 10/07/09, the resident's positioning was discussed with the dietary manager and a registered nurse (Employee #16). .",2015-02-01
10541,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-10-08,325,D,0,1,4DOJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, resident interview, and staff interviews, the facility failed to ensure each resident maintained acceptable parameters of nutrition. There was no evidence the facility had recognized and evaluated a resident's 15 pound weight loss. One (1) of twenty (20) current residents on the sample was affected. Resident identifier: #25. Facility census: 112. Findings include: a) Resident #25 This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her admission comprehensive minimum data set (MDS) assessment, with an assessment reference date of 09/18/09, indicated she had [MEDICAL CONDITION] present during the seven (7) day look-back period. Her weight was listed as 268 pounds. She was not coded as being on a weight loss program. A form entitled ""Restorative"" had an instruction for weekly weights four (4) times. The first weight was listed for 09/07/09 (actually the day before she was admitted ) at 265 pounds. On 09/11/09, she again weighed 265 pounds. On 09/16/09, her weight had dropped to 252 pounds; on 09/23/09, she weighed 254 pounds; and by 09/30/09, she weighed 250 pounds. That was 15 pounds less than her initial weigh listed on the restorative document and eighteen 18 pounds less than the weight listed on her admission assessment. Further review of her medical record, i.e., dietary progress notes, nursing notes, and physician progress notes [REDACTED]. A registered nurse (Employee #16), when interviewed at approximately 2:45 p.m. on 10/07/09, acknowledged the resident's weight loss and said she had not been made aware. During an interview with the resident at 2:15 p.m. on 10/07/09, she stated she knew she had lost weight. She recounted she had eaten at a certain fast food restaurant prior to admission and now she had a healthier diet. The resident's weight loss was further discussed with medical records staff (Employee #8) and Employee #16 during the morning hours on 10/08/09. That she had been assessed as having [MEDICAL CONDITION], was known to have [MEDICAL CONDITION], was receiving a diuretic, and so on, made it important to assess the resident's rapid weight loss, even though the weight loss might be desirable. .",2015-02-01
10542,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-10-08,386,D,0,1,4DOJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to ensure the physician recorded a progress note at the time of each visit reflecting an evaluation of the resident's condition and decisions about the continued program of the resident's current regimen. An open area on the resident's right heel was noted in July 2009, but it was not reflected in the physician's progress notes. One (1) of twenty (20) current residents on the sample was affected. Resident identifier: #24. Facility census: 112. Findings include: a) Resident #24 The resident's monthly recapitulation of physician's orders for July 2009 did not include any orders for treatment to the resident's right heel. On 07/10/09, a physician's order was written for: ""Cleanse (R) (right) heel /c (with) NSS (normal saline solution), dry well, pad /c Collagen & secure /c hypofix QD (every day) & PRN (as needed) d/t (due to) breakdown."" This order was continued on the orders for August, September, and October 2009. On 10/06/09 at approximately 2:00 p.m., a licensed practical nurse (LPN - Employee #26) was asked what kind of area the resident had on her right heel. She said it was a diabetic ulcer. The nursing documentation in the resident's medical record referred to ""Decub(itus) update"" and ""diabetic pressure ulcer."" The physician progress notes [REDACTED]. Both progress notes, under ""Extremities"", noted: ""No [MEDICAL CONDITION], no cyanosis, no clubbing."" The ulcer was not referenced in the ""Assessment"" portion of the physician's note, nor was it mentioned elsewhere. A letter from the West Virginia Board of Medicine, dated 05/18/07, in response to a query by the West Virginia Health Care Association, included, ""It was the determination of the members that there must be a formal [DIAGNOSES REDACTED]. This constitutes the practice of medicine. If a registered professional nurse makes the determination, it must be reviewed by a licensed physician."" The LPN who provided treatments (Employee #26) also reviewed the record at approximately 3:00 p.m. on 10/07/09. She was unable to locate where the physician had documented a determination of the origin of the alteration of skin integrity. .",2015-02-01
10543,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-10-08,246,D,0,1,4DOJ11,"Based on observations and staff comments, the facility failed to provide reasonable accommodations to meet the needs of residents. One (1) of twenty (20) sampled residents was not positioned for comfort in a geri chair. Additionally, the facility failed to adapt the physical environment to enable residents to maintain unassisted functioning, in that a large clock, located in the dining room on the West wing, did not accurately reflect the time. All residents dining in the small dining room on the unit had the potential to be affected. Facility census: 112. Findings include: a) Resident #12 Observations, throughout the day on 10/06/09 and 10/07/09, found Resident #12 seated in a geri-chair with the foot rest elevated. The resident's feet were positioned on a metal bar with extensions located in the space between the geri-chair and the foot rest. The geri chair had a fitted sheet under the resident, which was not pulled over the bottom part of the chair, nor were there any pillows in the geri chair to cushion the resident's feet from the metal bars or extensions. b) Observations on the West wing, on 10/05/09 at approximately 3:30 p.m., found the large clock in the small dining area did not accurately reflect the time. The hands of the clock displayed at several minutes after 12:00. During the evening meal at 5:40 p.m., the hands of the clock had not moved since the initial observation. Additional observations found the hands of the clock remained in the same position throughout the survey. During the exit conference on 10/08/09, the administrator commented he had noticed the clock was not working on 10/05/09. He said he had instructed a staff member to change the batteries, but apparently it had not been done. The clock provided a measure to orient / reorient residents to the time of day without staff assistance. .",2015-02-01
10544,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-10-08,285,D,0,1,4DOJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility failed to ensure an independent mental evaluation, as required by a Level I pre-admission screening, was performed prior to admitting a resident. An applicant for admission was admitted to the facility approximately one (1) month prior to the survey, but the results of her Level II examination, to identify whether specialized rehabilitative services were required, were not available. One (1) of twenty (20) current residents on the sample was affected. Resident identifier: #25. Facility census: 112. Findings include: a) Resident #25 The pre-admission screening instrument (PAS-2000), specified by the State Medicaid agency, was signed by a nurse reviewer on 09/03/09. This was prior to the resident's admission to the nursing home. The Level I screening required a Level II examination be completed prior to the resident's admission. According to Chapter 514 - Covered Services, Limitations, and Exclusions for Nursing Facility Services: ""514.9.2 PRE-ADMISSION SCREENING (LEVEL II) - If the Level I evaluation found the possible presence of MI (mental illness) and/or MR/DD (mental [MEDICAL CONDITION] / developmental disability), further evaluation of the individual must be completed to obtain a definitive [DIAGNOSES REDACTED]. ... It is the responsibility of the referring entity to arrange for an evaluation (Level II). This evaluation must be completed, including a report of the mental health status and whether specialized services are needed, within 7-9 days following the referral and prior to the individual ' s admission into a nursing facility."" Review of the resident's medical record did not find the report of the Level II examination. On 10/07/09 at approximately 2:50 p.m., a registered nurse (Employee #16) was asked to locate the Level II examination results. She was unable to locate the results of the examination. The Level II report had not been provided as of exit conference mid-day on 10/08/09. .",2015-02-01
10545,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2009-10-08,241,D,0,1,4DOJ11,"Based on observation, staff interview, and medical record review, the facility failed to promote care in a manner and in an environment that maintained or enhanced dignity and respect in full recognition of each resident's individuality. One (1) of twenty (20) sampled residents (Resident #12), who was dependent upon staff for all activities of daily living, was observed in a low bed that would not raise to a higher level to facilitate the provision of care in a dignified manner. Facility census: 112. Findings include: a) Resident #12 1. Observations of meal service, from 5:30 p.m. through 6:45 p.m. on the evening of 10/05/09, found the second cart for residents on the East wing contained Resident #12's meal tray. From 6:00 p.m. through 6:30 p.m., several members of the nursing staff went to the food cart that held Resident #12's tray and those of two (2) other residents; each of the staff members pulled out Resident #12's tray, looked at it, and then put it back in the food cart. The staff members then went to other residents who were finished with their meals and picked their trays, ignoring Resident #12's dinner tray. At 6:35 p.m., Employee #61 (a nursing assistant) picked up the resident's tray and took it into the resident's room. Further observations Resident #12 in a low bed in her room. Employee #61 attempted to pull the resident up in the bed, but the bed was unable to be raised. Employee #61 then pulled the resident into a sitting position and had to hold the resident in a sitting position while attempting to manually adjust the head of the bed. Employee #61 then brought an overbed table into the resident's room from an adjacent room and put the resident's meal tray on the overbed table. The nursing assistant then fed the resident by standing over top of her and lowering the food to the resident's mouth. 2. During observations on the mid-afternoon of 10/07/09, with the director of nursing (DON) and an occupational therapist, two (2) nursing assistants (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 NAs appeared to have a difficult time putting the gait belt around the resident in order to appropriately help her to transfer. The resident was able to put her feet down but was not able to fully extend her legs in order to stand up and 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 in between the chair and the elevated foot rest. The occupational therapist related she was there to observe the resident for possible screening. On 10/08/09 at 9:00 a.m., the resident was observed in the therapy room in the geri chair. The physical therapist was attempting to evaluate the resident, but the resident did not cooperate and the evaluation was not able to be completed. .",2015-02-01
10018,WILLOWS CENTER,515085,723 SUMMERS STREET,PARKERSBURG,WV,26101,2009-10-15,323,E,0,1,5DR211,"Based on medical record review, staff interview, and facility policy review, the facility failed, for fifteen (15) of eighty-three (83) incident / accident reports, to ensure all incidents were thoroughly investigated to determine possible causes in order to develop interventions to prevent recurrences. This practice affected twelve (12) residents. Resident identifiers: #7, #11, #12, #15, #17, #30, #54, #66, #88, #96, #97, and #98. Facility census: 92. Findings include: a) Residents #7, #11, #12, #15, #17, #30, #54, #66, #88, #96, #97, and #98 Review of the facility's incident / accident reports, conducted on the afternoon of 10/14/09, revealed the reports failed to contain any information concerning factors contributing to each event, possible causes, preventive measures already in place, and/or immediate actions taken to prevent further occurrences. In an interview on the afternoon of 10/14/09, the facility's administrator (Employee #54) related an additional form on which staff records an investigation into the event and interventions implemented to prevent further occurrences. Upon request by the survey team, the administrator produced these completed forms. Review of these forms revealed that only the incidents involving resident falls were investigated. A total of eighty-three (83) incident / accident reports was completed between 07/07/09 and 09/30/09. Of these, fifteen (15) did not involve resident falls. These fifteen (15) events were not investigated, and there was no record of interventions implemented to prevent recurrences. On the afternoon of 10/15/09, a follow-up interview with the administrator revealed the facility did have a policy and form which they had not been using, although they were starting some staff education of them. Review of the policy titled ""1.1 Accidents / Incidents"" (effective 03/01/02) identified the following on page 2 under ""Documentation and Investigative Action"": ""4.1 The staff member must document the incident on the Investigation of Incident form and conduct an immediate investigation of the accident or incident."" The events that were not investigated were as follows: 1. Resident #7 - 08/18/09 at 3:45 p.m. - ""Pt (patient) tipped over w/c (wheelchair)"" 2. Resident #11 - 08/28/09 at 5:45 a.m. - ""Called to res(ident) room by CNA (certified nursing assistant). Res(ident) has skin tear to rt (right) (arrow up) upper forearm. CNA stated they were transferring res(ident) to w/c from bed. They are not sure exactly how it happened."" 3. Resident #12 - 08/03/09 at 7:00 a.m. - ""Skin tear to rt forearm."" - ""CNA stated she was transferring res(ident) from bed to chair and hit her arm with fingernail causing a skin tear."" 4. Resident #15 - 08/14/09 at 9:30 p.m. - ""Abrasion noted to upper (R) (right) side."" 5. Resident #17 - 08/21/09 at 9:45 a.m. - ""After receiving shower and transferred from shower bed to cardiac chair Hoyer tipped over while pulling it away from chair. Hook on bar that holds lift pad came in contact with her nose and forehead above the left eye."" 6. Resident #30 - 07/29/09 at 10:25 a.m. - ""Called to room per CNA skin tear noted to right elbow area."" - 09/11/09 at 11:00 a.m. - ""Old bruise to (L) (left) shoulder."" 7. Resident #54 - 07/07/09 at 10:00 a.m. - ""Resident was using bed controls to lower bed and upset bedside table on the bed slight redness noted to L (left) ABD (abdomen)"" - 07/13/09 at 7:00 p.m. - ""While being turned bed caught arm on call light small skin tear L (left) forearm."" 8. Resident #66 - 09/26/09 at 9:00 p.m. - ""Res(ident) in shower room on shower bed -when res(ident) tried to assist CNA by turning with hand on railing got caught between wall and shower small discolored area to middle knuckle on rt (right) hand."" - 09/27/09 at 10:30 p.m. - ""Res(ident) states L (left) arm was in side rail and CNA tried to reposition causing ST (skin tear)."" 9. Resident #88 - 09/30/09 at 10:00 a.m. - ""Small skin tear to lower L (left) leg while in PT (physical therapy)."" 10. Resident #96 - 08/14/09 at 7:00 p.m. - ""Resident stated the bed was raising up the table got bumped it fell over bumped my arm skin tear to LFA (left forearm)"" 11. Resident #97 - 08/31/09 at 1:20 p.m. - ""CNA's assisted resid(ent to bed and changing his clothes, noticed dried blood on arm protector to right arm, when removed there was skin tear and started to bleed."" 12. Resident #98 - 09/11/09 at 3:45 p.m. - ""CNA repositioned residents head and scratched him on top of his head with her fingernail."" .",2015-07-01
10019,WILLOWS CENTER,515085,723 SUMMERS STREET,PARKERSBURG,WV,26101,2009-10-15,520,E,0,1,5DR211,"Based upon record review, staff interview, and policy review, the facility's quality assessment and assurance (QAA) process failed to recognize that resident incidents / accidents were not being properly investigated to assure appropriate follow-up, in accordance with facility policy. This was determined for seventeen (17) of eighty-three (83) incident / accident reports reviewed. Resident identifiers: #7, #11, #12, #15, #17, #30 (two (2) occurrences), #54 (two (2) occurrences), #66 (two (2) occurrences), #78, #82, #88, #96, #97, and #98. Facility census: 92. Findings include: a) A review of the facility ""Resident / Patient Incident Report"" forms, on 10/15/09 at 11:00 a.m., revealed the reports for Residents #7, #11, #12, #15, #17, #30 (two (2) occurrences), #54 (two (2) occurrences), #66 (two (2) occurrences), #78, #82, #88, #96, #97, and #98 did not have ""Incident / Accident Investigation"" forms completed as instructed on that form, which stated: ""Complete this form in conjunction with the 'Resident / Patient Incident Report' for injuries of known or unknown origin, allegations of abuse or neglect, resident-to-resident incidents, elopements, or any other incident determined to need investigation."" Further instruction was found within the facility policy ""1.1 Accidents / Incidents"" under Section 4, ""Documentation and Investigative Action: 4.1 The staff member must document the incident on the Investigation of Incident form and conduct an immediate investigation of the accident or incident."" All of these incident reports were signed by the facility's director of nursing and the administrator, indicating their review of the incidents. b) During an interview on 10/15/09 at 11:30 a.m., the administrator (Employee #54), who was a member of the facility's QAA committee, indicated that all incident reports were discussed routinely at every monthly quality assurance meeting as part of ""Core Data"" that was always on the agenda. The purpose of this quality assurance review was to assure appropriate follow-up, to identify trends, and to maintain a safe environment within the facility. c) During an interview on 10/15/09 at 12:30 p.m., the director of nursing (DON - Employee #49), who was a member of the facility QAA committee, indicated that all incident reports were discussed routinely at every monthly quality assurance meeting, the purpose being to assure the facility responds to all occurrences appropriately d) During an interview on 10/15/09 at 12:45 p.m., the activities director (Employee #14), who was a member of the facility quality assurance committee, indicated that all incident reports were discussed routinely at every quality assurance meeting. e) During a follow-up interview on 10/15/09 at 1:30 p.m., with the administrator and the DON acknowledged the ""Incident / Accident Investigation"" forms were only being completed on incidents of unknown origin, contrary to facility policy which requires an investigation of all incidents.",2015-07-01
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
10051,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2009-10-16,371,F,0,1,EVU911,"Based on observation and staff interview, the facility store and prepare milk and food under sanitary conditions. The temperature of milk was measured at 45 degrees Fahrenheit (F), and a dietary employee closed the lid to the trash can and then went back to food preparation without washing her hands. This had the potential to affect all residents. Facility census: 89. Findings include: a) Observation, with the certified dietary manager on 10/13/09 at 4:55 p.m., found the temperature of the milk carton, stored on ice in a bin in the food preparation area, to be 45 degrees F. This was just prior to the evening meal service. The temperature of another carton of milk taken from the milk cooler was found it to be 40 to 42 degrees F. The temperature on the milk cooler registered at 40 degrees F. The dietary manager indicated the temperature of the milk cooler should have been about 38 degrees F and that a repair person would be called. b) During preparation of the evening meal on 10/13/09 at 4:45 p.m., a dietary staff person (Employee #45) washed and dried her hands with a paper towel. After using a second paper towel to turn off the faucet, the employee threw the paper towel into the trash can. The lid on the trash can did not close, and the employee used her hand to close the trash can lid. She then went back to the food prep area and began touching food items. .",2015-07-01
10052,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2009-10-16,166,D,0,1,EVU911,"Based on resident group interview, staff interview, and review of reports of lost / missing items, the facility failed to ensure one (1) random resident had received information from staff, keeping her informed of the status of and progress toward finding / replacing her missing items. Resident identifier: #55. Facility census: 89. Findings include: a) Resident #55 During the resident group interview on 10/14/09 at 3:00 p.m., one (1) resident explained she was missing a couple of personal items. She explained she had moved to a different room in the facility and, after the move, she was not able to locate a calling card and a jar of ""cold cream"". She related the facility had not replaced these items and had not informed her if they had located the items. The two (2) social workers (Employees #89 and #90) were interviewed on 10/14/09 at approximately 5:00 p.m. and again on 10/15/09 at approximately 9:00 a.m., regarding this issue. The social workers provided a copy of the lost / missing item form that documented Resident #55's missing items. The form, dated 03/24/09, indicated the facility would replace the Ponds cold cream, a calling card, one (1) blue flat sheet, and two (2) gowns. The social workers indicated they thought all the items were replaced, but they were not positive. They agreed the documentation of the resolution on the lost / missing item form was unclear and could be more organized. The form contained several hand written notes and no complete / accurate conclusion summarizing what occurred. The administrator reviewed the lost / missing item form, on 10/14/09 at approximately 9:30 a.m., and agreed the form needed improvement. She said she had signed the form and, after signing, the social workers had continued to work on the issue. She said she would prefer the investigation be complete and a resolution reached prior to her signature. Employee #55 (maintenance / housekeeping / laundry) indicated she had no knowledge of the missing calling card or Ponds cold cream. She did talk about the replacement of the resident's gowns. On 10/15/09 at approximately 3:00 p.m., Resident #55 expressed great satisfaction that her cold cream and calling card had been replaced. The activity director purchased the items for the resident on 10/15/09. It took seven (7) months for the facility to replace these items. No one at the facility knew why it had taken so long to replace these items. On 10/16/09 at approximately 10:00 a.m., the administrator provided copies of new missing / lost item forms which she felt would improve the documentation and make the resolution of missing property more accurate and complete. .",2015-07-01
10053,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2009-10-16,224,D,0,1,EVU911,"Based on group interview, resident interview, and staff interview, the facility failed to ensure one (1) resident's personal care item was not removed from her room without her permission or without an explanation of the reason for the removal. Resident identifier: #55. Facility census: 89. Findings include: a) Resident #55 On 10/14/09 at approximately 3:00 p.m., a group interview was conducted with the residents at the facility. At this interview, Resident #55 related she was missing a can of hairspray. She indicated Employee #57 (a maintenance worker) came into her room and removed a can of hairspray given to her by the beautician as a Mother's Day gift. According to the resident, Employee #57 told her she could not have the hairspray because of the aerosol can and took it from her room. On 10/15/09 at approximately 3:00 p.m., Resident #55 was in the hallway of the facility, talking about the items the facility had replaced for her. She she commented that they still had not replaced her hairspray. She also recounted the story of how the beautician had given her the hairspray as a gift. The resident displayed emotions associated with being upset. On 10/15/09 at approximately 2:00 p.m., the administrator related she had no knowledge of the resident's missing hairspray. She said Employee #55 had not told her anything about the incident. The administrator also said her insurance policy recommended the facility not allow any aerosol cans in the building. She presented a page from the admissions contract that listed aerosol cans among items that could not be brought into the facility. On 10/16/09, the administrator called Employee #57 on the telephone, and he told her he did take the hairspray, because the resident could not have an aerosol can in her room. He also said he kept the hairspray locked up and that the resident could contact him when she needed to use it and he would bring it to her. Employee #57 had failed to tell his supervisor or the administrator that he had confiscated Resident #55's hairspray. He simply removed the item without the resident's permission. There was no indication that Employee #57 gave the resident an opportunity to give the hairspray to her husband or another family member to take home. The hairspray was simply removed from the resident's room without her consent. On 10/16/09, several months after the hairspray was taken from Resident #55 by Employee #57, the facility did replace the hairspray with two (2) bottles with pumps, not an aerosol can. .",2015-07-01
10054,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2009-10-16,157,D,0,1,EVU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to notify the physician of a resident's repeated refusal to take the medication [MEDICATION NAME]. Additionally, this resident's nursing notes identified attempts to inform the resident's physician when her heart rate was 44 beats per minute, but it was not noted whether the physician was ever made aware, nor was the physician notified of the results of a positive urine culture or the recommendation that the urine culture be repeated. One (1) of fourteen (14) current residents on the sample was affected. Resident identifier: #42. Facility census: 89. Findings include: a) Resident #42 1. review of the resident's medical record revealed [REDACTED].e., the resident refused the medication, it was not available, etc. The MAR for October 2009 was also reviewed and, again, all documented doses had been circled. There was no evidence the physician had been informed of the resident's repeated refusal to take the stool softener. 2. This resident's [DIAGNOSES REDACTED]. (name) to advise of Resident's [MEDICAL CONDITION]. Apical heart rate remains @ 44 beats per minute. No other S/Sx (signs or symptoms) noted R/T (related to) heart rate."" It was noted at 10:10 p.m., ""Gave report to oncoming LPN (licensed practical nurse) - monitor closely - pg (paged) Dr. again to give report on Resident's Sx."" The next entry was: ""Pulse 45 @ 12 A (a.m.) Paged Dr. (name). Dr. (name) has not called back. No s/s (signs/symptoms) of distress or discomfort. . . . Will continue to monitor."" Although the resident had a [DIAGNOSES REDACTED]. The resident was receiving [MEDICATION NAME] for hypertension, and a side effect of this medication is slow heart rate. There was no evidence the physician had ever been made aware of the resident's low heart rate. 3. Review of the resident's medical record noted she had been treated for [REDACTED]. coli at the emergency roiagnom on [DATE]. A physician's orders [REDACTED]. The specimen was not collected until 10/05/09. On 10/07/09 at 10:11 a.m., the lab had faxed the culture report to the facility. Under the comments section, it was noted, ""This is a mixed culture of 3 or more species. The probability of contamination is high. Suggest a repeat specimen. . . . "" The physician had not signed the report. Further review of the medical record did not find evidence the physician had been informed of the report or that another specimen had been submitted for culture. On 10/16/09 at 8:45 a.m., Employee #11 was asked why the culture had not been done until 10/05/09, although it had been ordered on [DATE], which was a Wednesday. She also was asked whether the culture had been repeated. She did not know why the specimen collection had been delayed and was unable to locate any record of a repeat culture. On 10/16/09, in mid-morning, Employees #40 and #41 were asked to see whether they could find whether the culture had been repeated and/or if the physician had been notified. At approximately 10:30 a.m., Employee #41 reported the culture had apparently not been repeated. Neither Employee #40 or #41 could find evidence the physician had been notified. Review of the nursing entries did not find any evidence the physician had been informed of the results. .",2015-07-01
10055,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2009-10-16,309,D,0,1,EVU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, staff interview, and observations, the facility failed to ensure each resident received the necessary care and services to attain or maintain his or her highest practicable level of well being in accordance with the plan of care. One (1) resident, who was observed at random, had support stockings on both legs while up in her wheelchair. The hose had wrinkled on the legs above the ankles. Another resident, who was on the sample of fourteen (14) current residents, had a physician's orders [REDACTED]. Resident identifiers: #82 and #42. Facility census: 89. Findings include: a) Resident #82 On 10/15/09 from 3:30 p.m. to 4:00 p.m., Resident #82 was observed sitting in the hall way in her wheelchair. She wore flesh colored support stockings that had wrinkled around her lower legs, causing significant indentations in her legs. At 4:00 p.m., Employee #41 was shown the condition of the stockings. She pulled the resident's stockings up, so they were wrinkle free. Indentations were apparent where the stockings had been wrinkled. These indentations persisted for at least one-half hour, when observations were ended for the day. Review of the resident's medical record found an order for [REDACTED]."" The order had been received on 07/22/08. Her [DIAGNOSES REDACTED]."" On 10/16/09 at 8:55 a.m., the resident was observed seated in her wheelchair in her room with her feet resting on the floor. The stockings were again wrinkled around the resident's lower legs. The resident was observed intermittently from 8:55 a.m. until 10:35 a.m., and the stockings remained wrinkled. At 10:35 a.m., Employee #41 was again informed of the wrinkled stockings. She said someone had [MEDICATION NAME] them earlier that morning, but the stockings would not stay [MEDICATION NAME]. b) Resident #42 Review of medical records found an order for [REDACTED]. Review of the resident's medical record found some vital signs had been recorded on the medication administration record (MAR), but many were missing. On 10/16/09 at 8:40 a.m., Employee #8 was asked where the vital signs should be documented. She said they should be on the MAR or the Skilled Nurse's Note pages. Review of the skilled nurses' notes found only one (1) set of vital signs recorded on a daily basis. These were recorded at the top of the page and were thought to be the vital signs for day shift. However, they did not always correlate with the vital signs recorded on the MAR. Review of the MAR for 10/01/09 through 10/15/09, found the vital signs had been recorded only fourteen (14) of the forty-five (45) times they should have been documented. The 6:00 a.m. vital signs were documented three (3) of fifteen (15) times; the 2:00 p.m. vital signs were documented four (4) times, plus one (1) blood pressure and respiration, of of fifteen (15) times; and 10:00 p.m. vital signs six (6) of of fifteen (15) times. .",2015-07-01
10056,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2009-10-16,441,D,0,1,EVU911,"Based on observations and review of posted hand washing signs, the facility's infection control program failed to ensure staff practiced appropriate hand washing to prevent the spread of infection. Additionally, staff had not labeled a bottle of saline when opened to ensure it was not used more than forty-eight (48) hours after it was opened. Three (3) residents observed at random were affected. Facility census: 89. Findings include: a) Residents #89 and #14 1. Resident #89 On 10/14/09 at approximately 8:30 a.m., a nurse (Employee #8) washed her hands after administering the resident's medications. She washed her hands for approximately three (3) seconds and turned the water off with her bare hands, recontaminating them on the faucet handles. 2. Resident #14 On 10/14/09 at approximately 8:40 a.m., Employee #8 was observed administering medications to Resident #14. The nurse only washed her hands for approximately three (3) seconds, then turned the water off with her bare hands, thus recontaminating her hands. 3. Signage posted in the staff and public restrooms indicated the hands should be washed for at least ten (10) seconds and directed staff to use a dry paper towel to turn off the water. -- b) Resident #6 After lunch on 10/14/09, a nurse (Employee #88) was observed providing a treatment to the resident. Observation found a bottle saline for irrigation sitting on a cabinet in the resident's room. The bottle was open, but it had not been dated to indicate when it should be discarded. .",2015-07-01
10057,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2009-10-16,514,D,0,1,EVU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, the facility failed to ensure medical records were accurate and complete. One (1) resident had expired, but there were no nursing entries regarding the resident's final hours or that there had been a cessation of vital signs. There was no documentation regarding the reason one (1) resident did not take her [MEDICATION NAME], nor was the effectiveness of her pain medication noted. Two (2) of seventeen (17) residents on the sample were affected. Resident identifiers: #91 and #42. Facility census: 89. Findings include: a) Resident #91 1. This resident was selected for closed record review as she had expired in the facility. Review of her medical record found a form entitled ""Nursing Transfer / Discharge Note"". The form noted the resident had died at 8:35 a.m. on [DATE]. There was information regarding the release of the body to the mortuary, but other sections were blank or marked as ""N/A"" (not applicable). Review of the nursing entries found an entry for [DATE] at 6:00 a.m., noting the resident had required suctioning three (3) times. The next entry was [DATE] at 1:00 p.m., which noted the physician had been in to see the resident and there were no new orders. From [DATE] at 1:00 p.m. through the time of death on [DATE] at 8:35 a.m., there were no further notes. The findings at the time of death (i.e., there was no heart beat, respirations were absent, etc.) were not identified. It was not noted whether the resident's family had been notified or whether the physician had been made aware of the resident's death. 2. During review of the resident's close medical record, a copy of a CMS-802 with the names of seven (7) other residents was found in Resident #91's file. This document included confidential information such as continence status, whether the individual was cognitively impaired, whether the resident had a [DIAGNOSES REDACTED]. Another document, including the names of thirty-one (31) other residents along with confidential information was also found in Resident #91's closed record. b) Resident #42 1. Review of the resident's medical record noted almost every dose of [MEDICATION NAME] had been circled on the Medication Administration Record [REDACTED]. The reason the [MEDICATION NAME] had been circled was not noted on the designated space on the back of the MAR, nor was it noted in the nurses' notes. According to Employee #11, the resident said she did not need the stool softener. 2. The September ""PRN (as needed) Pain Medication Flow Sheet"" indicated the resident had been given Tylenol 650 mg five (5) times for generalized pain. The form prompted the nurse to note the effectiveness of the pain medication at intervals of 30 minutes, 1 hour, and 2 hours. Only one (1) of the five (5) had any further entries, and this may have been the nurse's initials. One (1) notation indicated the pain had been an ""8"" on the pain scale when the medication was given. The nurse had written ""9"" in the blank for the effectiveness at 30 minutes and the remainder was blank. The ""9"" would have indicated the pain was worse after 30 minutes and further monitoring / action would have been indicated. .",2015-07-01
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
10395,ST. MARY'S HOSPITAL,515113,2900 FIRST STREET,HUNTINGTON,WV,25702,2009-10-21,225,D,0,1,K1CL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, a review of the facility's abuse / neglect and concern files, policy review, and staff interview the facility failed to assure all allegations of neglect were thoroughly investigated and immediately reported to the appropriate State agencies in accordance with State law. An allegation of neglect involving Resident #13 was not investigated and immediately reported to State agencies when the physician made the facility aware of a family member calling him with concerns about the nurses not giving this resident medications as needed. The facility also failed to conduct a thorough investigation into allegations made by a family member of neglect involving Resident #16, by failing to interview this alert and oriented resident. The facility did not thoroughly investigate and/or immediately report incidents of neglect for two (2) of eight (8) sampled residents. Resident identifiers: #13 and #16. Facility census: 15. Findings include: a) Resident #13 Review of the medical record found a nursing note, on 10/14/09 at 1430 (2:30 p.m.), stating the physician called to say Resident #13's daughter-in-law called him and left a message about the skilled nursing unit's nursing care. According to the the message, the nurses were not giving the resident her pain medications and were not giving her [MEDICATION NAME] when she returned from physical therapy. The nurse told the doctor she did not know the daughter-in-law was upset with the skilled nursing unit. According to the nurse's progress note, ""Will pass to offer pain meds."" During an interview on 10/20/09 at 2:00 p.m., Employee #34 confirmed this had not been written up as a complaint and investigated according to the facility's policy. There was no evidence this allegation was investigated thoroughly with proper follow-up to ensure neglect did not occur. Employee #34 stated she knew this allegation was not true and did not report it. b) Resident #16 Review of the facility's records revealed an allegation of neglect involving Resident #16. This resident's daughter alleged that her skin breakdown had worsened since her admission to the facility due to her incontinence care. This allegation was reported timely to the State survey and certification agency on 08/24/09, as required. A five-day follow-up report was completed and submitted to the State survey and certification agency on 08/28/09, containing the results of the facility's investigation. The facility determined the allegation of neglect was not substantiated, as the resident's area of skin breakdown was smaller and was healing upon her discharge from the skilled nursing unit. However, there was no evidence that the facility interviewed this alert and oriented resident (who possessed the capacity to make her own health decisions) regarding this incident, to see if she had further input into the allegation. A review of the facility's policy titled ""Abuse, Mistreatment, Neglect, and Misappropriation of Property"" (last revised 03/02/2009) revealed, in the section regarding the investigation, that staff was to ""document all information provided by the victim and/or witnesses."" It also directed staff to ""interview all individuals who may have information concerning the incident, including the patient..."".",2015-04-01
10396,ST. MARY'S HOSPITAL,515113,2900 FIRST STREET,HUNTINGTON,WV,25702,2009-10-21,371,F,0,1,K1CL11,"Based on observation and staff interview, the facility failed to assure the walk-in freezer was functioning properly. There was no thermometer on the inside of the freezer. Ice had formed all over the ceiling, around the fan units, and around all of the metal tubing inside the freezer. There were boxes of food observed to have ice frozen completely around the outside of the entire box. This deficient practice had the potential to affect all residents in the facility. Facility census: 15. Findings include: a) Observation of the facility's walk-in freezer, at 10:30 a.m. on 10/20/2009, found a sign on the freezer door that read: ""Do not leave this door open."" The thermometer on the outside of the freezer was jumping from one (1) temperature to another, and the facility's chef reported the freezer was defrosting. The inside of the freezer was observed at that time. There was no thermometer found inside the unit, and there was thick, white ice frozen all over the ceiling and covering boxes. The fans in the freezer were covered with ice, and the metal tubing was all covered with ice. Staff identified this unit to be the facility's newest freezer. The facility's chef asked another kitchen employee about the freezer and the ice inside it, and he stated that it had been that way since they bought it.",2015-04-01
10550,CAREHAVEN OF PLEASANTS,515191,PO BOX 625,BELMONT,WV,26134,2009-10-22,225,D,0,1,938011,"Based upon record review, staff interview, and policy review, the facility failed to follow its policy and procedure to ensure allegations of abuse / neglect and/or injuries of unknown source were being properly investigated. This was noted for one (1) of thirteen (13) residents reviewed. Resident identifier: #36. Facility census: 65. Findings include: a) Resident #36 1. A review of the facility's incident reports, conducted on 10/21/09 at 10:40 a.m., revealed an incident report for Resident #36 dated 10/13/09, in which the section of the form headed ""Describe exactly what happened ..."" contained the following descriptive narrative: ""During resident care CNA (certified nursing assistant) observed dark purple bruise to right thigh 3 cm x 2 cm."" There was no documentation of how the bruising occurred. Under the section of the form headed ""Additional comments and/or steps taken to prevent recurrence"" was: ""Reapproach resident when she is resistent to care."" The report was signed by the facility's administrator (Employee #77) on 10/19/09, and director of nursing (DON - Employee #1) on 10/13/09. 2. A review of the facility's policy and procedure entitled ""Abuse Prohibition Policy"", conducted on 10/21/09 at 11:00 a.m., found included under the heading ""Process"": ""6. Staff will identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse, and determine the direction of the investigation."" ""7. Upon receiving information concerning a report of abuse, the Administrator or designee will: ""7.1 Report it to appropriate agencies as per state requirement and conduct an immediate and thorough investigation. ""7.1.1. The investigation will be documented on any state required form, and on CareHaven of Pleasants' investigation form and log. ""7.1.2. The form and log will be kept confidential in a file in the Administrator's office. ""7.1.3. The investigation will include signed statements from perpetrator, witnesses, and all concerned."" 3. A review of facility-provided cases of reporting and investigations of allegations of abuse and neglect, conducted on 10/20/09 at 8:30 a.m., did not find any documentation of either reporting or investigation of a bruise of unknown origin on Resident #36. The administrator stated, on 10/22/09 at 11:00 a.m., that he was aware of a report but did not know where it was. When interviewed on 10/21/09 at 11:30 a.m., the facility's social worker (Employee #54) was asked if all reports and investigations had been furnished to the survey team. She indicated the team was given all reports and investigations. When interviewed on 10/21/09 at 3:20 p.m., the administrator stated the facility's management team meets daily to review all allegations of abuse, neglect, and injuries of unknown origin. He related that the administrator, director of nursing, and social worker investigate and report all allegations of abuse, neglect, and injuries of unknown origin. After reviewing the incident report of 10/13/09 concerning Resident #36, the administrator stated the incident report was unclear and the event was reportable as an injury of unknown origin. He was informed that the survey team had been given no documentation to reflect the incident had been reported or investigated by the facility. 4. At approximately 5:30 p.m. on 10/21/09, a report regarding Resident #36 was provided by the facility consisting of: - An ""Immediate FAX Reporting of Allegations"" to the Nursing Home Program which, under the section ""Allegation Information"", documented the following: ""Date of Incident: 10/13/09. Time of Incident: 5:30 a.m. Location of Incident: unknown. Brief description of the incident: CNA reported a 3cm by 2cm purple bruise noted to right (""R"" enclosed by a circle) upper thigh."", and - A ""Five Day Follow-up"" form to the Nursing Home Program dated 10/15/09 which, under the section, ""Outcome / Results of Investigation"", documented: ""Unable to determine a timeline for when the incident occurred. The surrounding tissue is un-remarkable. Resident is resistive to care daily. No evidence to confirm mistreatment."" The administrator related the form had been located in the DON's office. The incident was not logged, investigated, recorded, and filed as stated in facility policy and procedure. The social worker and administrator were unaware that all reports and investigations were not in the master file provided to the survey agency. 5. A review of the medical record for Resident #36, on 10/21/09 at 4:00 p.m., revealed that, on the ADL Flow Record for October 2009 (a form designated by the facility for CNAs to document resident behaviors), there were no behaviors documented during the month to date. On the Monthly Flow Record for October 2009 (a form designated by the facility for licensed nurses to document resident behaviors), there were no behaviors documented during the month to date. There was no indication, based on this information, that the bruising of unknown origin was self-inflicted. .",2015-02-01
10551,CAREHAVEN OF PLEASANTS,515191,PO BOX 625,BELMONT,WV,26134,2009-10-22,356,C,0,1,938011,"Based upon observation and staff interview, the facility failed to ensure the daily nurse staffing posting was posted in a clear and readable format. This has the potential to affect all residents and visitors. Facility census: 65 Findings include: a) Daily observations, throughout the survey, found the facility nurse staffing data posting lying on its side in a single pocket wall file which contained many old posting sheets behind the current copy. There was no signage to indicate what the paper was. During an interview with the facility's administrator (Employee #77) on 10/21/09 at 11:30 a.m., there was discussion about concerns expressed during resident interviews, family interviews, and the resident group meeting regarding staffing levels in the facility. It was explained that the posting should be clear, readable, and prominently located in order to make accurate staffing information accessible to residents and visitors. Subsequent observations, following the interview with the administrator and up until exit, revealed no changes were made in the manner of the nursing staffing data posting. .",2015-02-01
10552,CAREHAVEN OF PLEASANTS,515191,PO BOX 625,BELMONT,WV,26134,2009-10-22,323,D,0,1,938011,"Based upon observation, staff interview, record review, and policy review, the facility failed to ensure the resident environment remained free of accident hazards, and failed to ensure each resident received adequate supervision and/or assistive devices to prevent accidents. This was found for one (1) of thirteen (13) residents reviewed and one (1) resident of random observation. Resident identifiers: #63 and #34. Facility census: 65. Findings include: a) Resident #63 On 10/21/09 at 5:45 p.m., as the survey team was at the facility nurses' station, observation found Resident #63 approaching the soiled utility room, ambulating independently with a walker. Using his right index finger, he entered the security code on the door lock, opened the door, and partially entered the room. He was prevented from fully entering the room by the presence of four (4) biohazard receptacles on the floor impeding the forward progress of his walker. He was observed to drop a roll of plastic trash bags on the counter in the room. He, then, backed his way out of the soiled utility room and walked up the corridor toward the front of the facility. b) Resident #34 Medical record review, on the morning of 10/20/09, revealed Resident #34 had sustained two (2) falls from her bed within three (3) days. Review of an incident report, dated 10/04/09 at 2:05 a.m., found: ""Responded to bed alarm sounding, found resident on the floor. Laceration 0.6 cm x 0.2 cm to forehead, skin tear to RFA (right forearm) 3.5 cm x 10.2 cm, skin tear to Rt (right) elbow 1.1 cm x 0.6 cm. Bruising observed to forehead and Rt side of face. Neuros (neurological checks) initiated."" The person completing the form also noted that bed rails were ordered, were present, and were up when the fall occurred. In response to this fall, staff recorded on the incident report, as additional comments and/or steps taken to prevent reoccurrence: ""Bed alarm & mat to floor to continue. Eval(uate) need for paremeter (sic) mattress. Bilat(eral) 1/4 SR (side rails) to aid in positioning."" The incident report did not identify from which side of the bed the resident fell or on which side of the bed the resident was found. Review of the medical record revealed the use of a bed alarm had previously been initiated on 04/22/09, and the use of a floor mat to the left side of the bed had previously been initiated on 07/03/09. There was no evidence to reflect the facility evaluated and/or initiated the use of a perimeter mattress after this fall occurred. Review of an incident report, dated 10/07/09 at 2:00 a.m., found: ""Resident was observed to be sitting with her knees on the floor mat facing the bed with upper body on the bed. No injuries noted."" The incident report did not identify from which side of the bed the resident fell or on which side of the bed the resident was found. In response to this fall, staff recorded on the incident report, as additional comments and/or steps taken to prevent reoccurrence: ""Room change. Cont(inue) interventions, parameter (sic) mattress 10/12/09."" Review of the facility's policy titled ""Fall Risk Assessment with Post Fall Intervention"" (dated ""7/14/9"") revealed the following policy statement: ""It is the Policy of Carehaven of Pleasants to identify resident's (sic) fall risk through the Fall Risk Assessment Tool and to implement interventions to prevent further falls with injury."" Under the heading ""Procedure"" was found: ""... The Fall Risk Assessment form along with the Falls Investigation / Root cause (sic) Analysis form will be completed post fall. ..."" Under the heading ""Post-Fall Intervention"" was found: ""... 3) Complete the Resident Fall Risk and Root Cause Analysis (sic) review the current treatment plan and change / modify or add new interventions based on the post-fall assessment. ..."" Review of the information documented related to these two (2) falls found no evidence the facility explored why the resident was falling from bed in the early morning hours (e.g., 2:00 a.m.) and whether the resident was falling from the left or right side of the bed (given that a floor mat was only placed on the left side of the bed). And while the facility also the need to evaluate the use of a perimeter mattress after the fall on 10/04/09, the use of a perimeter mattress was not implemented until 10/12/09, five (5) days after the second fall on 10/07/09. .",2015-02-01
10553,CAREHAVEN OF PLEASANTS,515191,PO BOX 625,BELMONT,WV,26134,2009-10-22,329,D,0,1,938011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility failed to ensure each resident's medication regimen was free from unnecessary drugs. Resident #36 received the antipsychotic medication [MEDICATION NAME] without adequate indications for its use. This practice affected one (1) of fifteen (15) sampled residents. Facility census: 65. Finding include: a) Resident #36 Review of Resident #36's medical record, on 10/21/09 at 9:00 a.m., found a nurse's dated 10/14/09 at 6:55 p.m., which stated, ""Due to increase in behaviors received V.O. (verbal order) from Dr. (name) to restart [MEDICATION NAME] 0.5 mg po (by mouth) daily. (Initials), MPOA (medical power of attorney) notified of new order."" The drug was started on 10/14/09. A review of the monthly behavior flow record for October 2009, a form designated by the facility for licensed nurses to document resident behaviors, revealed there were no behaviors documented for any day or any shift during the month to date leading up to the date the [MEDICATION NAME] was started. .",2015-02-01
10554,CAREHAVEN OF PLEASANTS,515191,PO BOX 625,BELMONT,WV,26134,2009-10-22,241,E,0,1,938011,"Based on observation and staff interview, the facility failed to provide, for all resident in the main dining room, pre-meal activities to enhance the dining environment. This practice affected approximately twenty (20) residents who eat in the main dining room. Facility census: 65. Findings include: a) Observation of the main dining area, on 10/21/09 at 4:45 p.m., revealed approximately twenty (20) resident were in the dining room awaiting meal service. Three (3) random nursing assistants were observed to be sitting in front of the fire place and talking among themselves. When the survey team entered the dining room, the three (3) nursing assistants stood up and begun to pass fluids of choice and engage in conversation with the residents in the dining room. In an interview on 10/21/09 at 6:00 p.m., the facility's administrator revealed he had seen, in the past, staff in conversation with each other, without engaging the residents, and had immediately corrected the situation, but he was not aware this was still occurring. .",2015-02-01
10555,CAREHAVEN OF PLEASANTS,515191,PO BOX 625,BELMONT,WV,26134,2009-10-22,281,E,0,1,938011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure services provided by the nursing staff met professional standards of quality. Staff inserted an the incorrect size indwelling Foley urinary catheter into Resident #33 on two (2) different occasions and failed to administered medications as ordered by the physician. Residents #30 and #17 also did not receive medications as ordered the physician. Resident identifiers: #33, #30, and #17. Facility census: 65. Findings include: a) Resident #33 Medical record review, conducted on the morning of 10/21/09, revealed nursing staff, on two (2) separate occasions, inserted a Foley urinary catheter into Resident #33 that was a different size than was ordered by the physician. According to the physician's orders [REDACTED]. Change catheter, tubing and drain bag monthly and PRN (as needed.)"" According to nursing treatment notes dated 09/04/09 at 11:00 p.m., ""Foley Cath(eter) (symbol indicating changed) r/t (related to) unable to irrigate, old 20/30 Fr (20 French with 30 cc balloon) removed intact, new 20/30 Fr inserted /s (without) difficulty, tolerated well, immediate urine return."" Another entry in the nursing treatment notes, on 09/21/09 at 8:45 p.m., stated, ""Foley cath re-inserted @ this time (20 F) procedure tolerated well by pt (patient)."" On 09/24/09, Resident #33 started to experience bladder spasms. The physician was notified and ordered ""[MEDICATION NAME] 1 mg po (by mouth) BID (two times a day) bladder spasms."" On 09/2509, the physician ordered ""[MEDICATION NAME] 7.5 mg po qd (every day) r/t bladder spasms d/c (discontinue) [MEDICATION NAME]."" The nursing staff failed to follow the physician's orders [REDACTED]. The nursing staff also failed to assess the resident to determine whether the bladder spasms may have been related to the use of the incorrect size Foley catheter. b) Residents #33, #30, and #17 An audit was completed of the medications on hand in the medication cart on two (2) different occasions. The first observation was completed at 3:50 p.m. on 10/20/09, and the second was completed at 8:30 a.m. on 10/21/09. These audits revealed three (3) residents (#33, #30, and #17) had more medications on hand than they should have if all doses of medications had been administered as ordered. 1. Resident #33 On 10/20/09 at 3:50 p.m., a medication cart audit, completed with Employee #10, revealed Resident #33 had sixty-five (65) doses of [MEDICATION NAME] on hand. According to the pharmacy control card, a thirty (30) day supply of [MEDICATION NAME] was sent on 08/21/09, and the last dose should have been administered on 09/21/09. According to the consultant pharmacist, when interviewed on the morning of 10/22/09, stated that, based on the pharmacy fill date record, he could possibility account for thirty (30) of these pills but not sixty-five (65). 2. Resident #30 On 10/20/09 at 3:50 p.m., a medication cart audit, completed with Employee #10, revealed Resident #30 had eighteen (18) doses of [MEDICATION NAME] on hand. According to the pharmacy control card, a thirty (30) day supply of [MEDICATION NAME] was sent on 09/22/09, and the last dose should have been administered on 10/21/09. Review of the Medication Administration Record [REDACTED]. 3. Resident #17 On 10/21/09 at 8:30 a.m., a medication cart audit, completed with Employee #14, revealed excess doses of three (3) medications for Resident #17. The prescription for Isorbide was refilled on 09/23/09, with fourteen (14) excess doses left. The prescription for [MEDICATION NAME] was refilled on 09/18/09, with seven (7) excess doses left. The prescription for [MEDICATION NAME] was refilled on 09/28/09, with eighteen (18) excess doses left. 4. The director of nursing (DON - Employee #1), the administrator (Employee #77), and the consultant pharmacist (Employee #79) were interviewed on both 10/21/09 and 10/22/09 and informed of this situation. None of the three (3) employees was able to explain why excess doses of the above medications were on hand. They did note that no system was in place to identify and track problems with residents not receiving their medications. 5. According to http://dynamicnursingeducation.com/class.php?class_id=38&pid=15, the facility's nursing staff failed to assure the seven (7) rights of medication administration were followed and that each resident received his/her medication as ordered by the physician: RIGHT drug; RIGHT client; RIGHT dose; RIGHT time; RIGHT route; RIGHT reason; and RIGHT documentation. .",2015-02-01
10556,CAREHAVEN OF PLEASANTS,515191,PO BOX 625,BELMONT,WV,26134,2009-10-22,285,D,0,1,938011,"**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 thirteen (13) sampled residents, to ensure another pre-admission screening was completed when the original physician certification, of a nursing home stay of less than three (3) months, expired. Resident identifier: #34. Facility census: 65. Findings include: a) Resident #34 Medical record review, on the afternoon of [DATE], revealed a preadmission screening form (PAS-2000) was completed on [DATE]. Documentation on page 5 of the form revealed the physician anticipated the resident's need for nursing home placement would be for less than three (3) months. Once this three (3) month period had lapsed, the facility failed to complete another screening to determine if she was still appropriate for nursing home care. On the afternoon of [DATE], the facility's social worker (Employee #54), when interviewed, acknowledged she had not completed another pre-admission screening after the certification period of the initial one (1) duration had lapsed. .",2015-02-01
10557,CAREHAVEN OF PLEASANTS,515191,PO BOX 625,BELMONT,WV,26134,2009-10-22,309,G,0,1,938011,"Based on observation, resident interview, medical record review, and staff interview, the facility failed, for one (1) of thirteen (13) sampled residents, to ensure care and services were provided to ensure the highest practical well being possible. Resident #29 exhibited verbal and non-verbal indicators of pain on multiple occasions during the survey event, and staff did not intervene to reduce her pain and discomfort until after surveyor intervention. Facility census: 65. Findings include: a) Resident #29 Multiple observations, from 10/20/09 through 10/22/09, revealed that every time Resident #29 was up in the chair for over twenty (20) minutes, she began to both exhibit verbal and non-verbal signs of pain. On 10/20/09 at 10:15 a.m., she was yelling. In response to her yelling, the survey team observed this resident, who was noted to be guarding, crying, and moving her left hip outward, lifting her buttocks from the chair seat. When asked if her hip hurt, she replied, ""Yes."" Staff, when immediately informed of the situation, laid her down in the bed. At 11:35 a.m., she was observed to be resting in bed, with no guarding, crying, or movement of her hip. On 10/21/09 at 4:30 p.m., again she was up in the chair and heard yelling out in pain. The survey team entered the room and observed the resident was exhibiting guarding and moving her hip and leg. Both lower extremities were observed to be not supported on the foot rests (they were dangling in front), and her hips were noted to have slid out from the chair. Staff was immediately informed of the situation and repositioned her in the chair. Following repositioning, the resident no longer yelled out and, when asked, indicated she was more comfortable. On 10/22/09 at 9:00 a.m., observation again found her up in the chair and yelling. Upon entering the room, she related, ""I am wore out."" Staff was immediately informed and assisted her to lay down. Shortly thereafter, she was observed to be resting comfortably. Interview with Employee #6, on 10/21/09 at 10:00 a.m., revealed she thought physical therapy had evaluated her for a new chair and one (1) had been ordered last week to aid in her comfort. At this time, copy of the purchase order / invoice was requested. Staff took several hours to produce the requested information. In the meantime, the administrator (Employee #77), when interviewed, related he was not aware of a new chair being ordered for Resident #29, as staff had not obtained any billing information from him; he did, however, relate that in a meeting, they had talked about ordering a new chair. Review of Resident #29's medical record found no physical therapy notes or other evidence the resident had been evaluated for a new chair. On the afternoon of 10/22/09, staff produced a purchase order / invoice for a new chair for Resident #29; the document was dated 10/22/09. The facility failed to provide prompt interventions to promote comfort and/or alleviate Resident #29's pain. .",2015-02-01
10558,CAREHAVEN OF PLEASANTS,515191,PO BOX 625,BELMONT,WV,26134,2009-10-22,425,F,0,1,938011,"Based on observation, staff interview, and review of Title 15 Legislative Rule West Virginia Board of Pharmacy Series 1 (Rules and Regulations of the Board of Pharmacy), the facility failed to have a system in place to ensure medications received by the facility were administered properly and correctly. An audit completed of the medication cart revealed three (3) of thirteen (13) residents had excess doses of medications on hand, indicating they did not receive their medications as ordered by the physician. Resident identifiers: #17, #30 and #33. Facility census: 65. Findings include: a) Residents #33, #30, and #17 An audit was completed of the medications on hand in the medication cart on two (2) different occasions. The first observation was completed at 3:50 p.m. on 10/20/09, and the second was completed at 8:30 a.m. on 10/21/09. These audits revealed three (3) residents (#33, #30, and #17) had more medications on hand than they should have if all doses of medications had been administered as ordered. 1. Resident #33 On 10/20/09 at 3:50 p.m., a medication cart audit, completed with Employee #10, revealed Resident #33 had sixty-five (65) doses of Depakote on hand. According to the pharmacy control card, a thirty (30) day supply of Depakote was sent on 08/21/09, and the last dose should have been administered on 09/21/09. According to the consultant pharmacist, when interviewed on the morning of 10/22/09, stated that, based on the pharmacy fill date record, he could possibility account for thirty (30) of these pills but not sixty-five (65). 2. Resident #30 On 10/20/09 at 3:50 p.m., a medication cart audit, completed with Employee #10, revealed Resident #30 had eighteen (18) doses of Depakote on hand. According to the pharmacy control card, a thirty (30) day supply of Depakote was sent on 09/22/09, and the last dose should have been administered on 10/21/09. Review of the Medication Administration Record [REDACTED]. 3. Resident #17 On 10/21/09 at 8:30 a.m., a medication cart audit, completed with Employee #14, revealed excess doses of three (3) medications for Resident #17. The prescription for Isorbide was refilled on 09/23/09, with fourteen (14) excess doses left. The prescription for Lasix was refilled on 09/18/09, with seven (7) excess doses left. The prescription for Protonix was refilled on 09/28/09, with eighteen (18) excess doses left. 4. The director of nursing (DON - Employee #1), the administrator (Employee #77), and the consultant pharmacist (Employee #79) were interviewed on both 10/21/09 and 10/22/09 and informed of this situation. None of the three (3) employees was able to explain why excess doses of the above medications were on hand. They did note that no system was in place to identify and track problems with residents not receiving their medications. 5. According to http://dynamicnursingeducation.com/class.php?class_id=38&pid=15, the facility's nursing staff failed to assure the seven (7) rights of medication administration were followed and that each resident received his/her medication as ordered by the physician: RIGHT drug; RIGHT client; RIGHT dose; RIGHT time; RIGHT route; RIGHT reason; and RIGHT documentation. b) According to Title 15 Legislative Rule West Virginia Board of Pharmacy Series 1 (Rules and Regulations of the Board of Pharmacy): 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: a. Prescriptions; b. Floor stock; c. Emergency boxes or kits; d. Investigational drugs; e. Samples; and f. Outdated or discontinued drugs. ..."" .",2015-02-01
10559,CAREHAVEN OF PLEASANTS,515191,PO BOX 625,BELMONT,WV,26134,2009-10-22,441,F,0,1,938011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, facility policy review, and staff interview, the facility failed to ensure a resident who had an active infection with a resistant organism was properly isolated and infection control measures were completed to prevent the spread of infection. This was found for one (1) of thirteen (13) sampled residents. Facility census: 65. Findings include: a) Resident #34 According to the medical record, reviewed on the morning of 10/20/09, the resident had a [MEDICATION NAME] resistant [MEDICATION NAME] infection in a wound and was actively being treated with antibiotics. Observation of staff to resident interactions, on 10/20/09, revealed staff had not donned any personal protective equipment (gowns) while providing care and services. Also, the room did not have receptacles to properly dispose of used personal protective equipment. During an interview, on 10/20/09 at 10:35 a.m., Employee #40 identified that no resident had contact infection control measures. If a resident had been identified, a barrel would be in the room to dispose of used equipment. She identified that personal protective equipment was located in and retrieved from the biohazard room. On 10/20/09 at 10:40 a.m., this room was inspected. Each bag contained one piece of equipment, and the gown was cloth. During an interview, on 10/20/09 at 10:45 a.m., the director of housekeeping (Employee #74) stated they currently do not have any residents on infection control measures, but if there were, a barrel would be in the room for used personal protective equipment. Later on that morning at 11:00 p.m., she identified they would wear paper gowns which were located in the supply room. The supply room was observed and contained a case and a half of the paper personal protective gowns. Employee #77 was requested to provide a invoice as to when these gowns were purchased. This invoice indicated that one (1) case with a total of fifty (50) gowns was purchased on 09/16/09. This would have been the unopened case in the supply room. The infection control log, reviewed on 10/20/09 at 11:00 a.m., revealed five (5) residents (#34, #23, #50, #10 and #19) were on contact isolation precautions since 09/16/09. The infection control policy and procedure, on page 31, entitled ""infection control policy and procedure manual revised 2007"", indicated that with contact insolation precautions the following measures would be used: gloves, handwashing, and gowns when any interaction may involve contact with the resident or potentially contaminated items in the resident's environment. Also, it indicated to remove the gown and perform hand hygiene before leaving the resident's room. On 10/21/09 at 10:00 a.m. the director of nursing (Employee #1) stated a gown was optional, and the provided policy concerned visitors not direct care staff. . b) During daily observations of both the morning and the afternoon ice pass on 10/19/09, 10/20/09, and 10/21/09, two (2) plastic ice scoops, being used to scoop ice from the container, were observed to be lying together in the open and uncovered, in a small shelf at one end of the ice cart. On the final day of the survey, 10/22/09, during the morning ice pass, the scoops were observed to be encased in small plastic bags to protect them from contamination. .",2015-02-01
10065,"WYOMING NURSING AND REHABILITATION CENTER, LLC",515164,P.O. BOX 149,NEW RICHMOND,WV,24867,2009-10-23,502,D,0,1,0RO511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure that three (3) of thirteen (13) sampled residents received ordered laboratory testing in a timely manner. Resident identifiers: #26, #23, and #12. Facility census: 59. Findings include: a) Resident #26 Review of the medical record found a late entry nursing note at 1:00 p.m. on 10/15/09. The nurse documented that staff reported the resident had a loose stool with blood present. An order was obtained, at 1:45 p.m., to collect stool for [MEDICAL CONDITIONS] a stool culture and test for ova and parasites. Further review found a nursing note, dated on 10/16/09 at 4:30 a.m., which documented the stool specimen was obtained for testing related to [MEDICAL CONDITION] and parasite infestation. A thorough review found no evidence the facility had obtained the laboratory report. A registered nurse (Employee #84) was notified that the resident had this test ordered and the laboratory report could not be located Employee #84 and the director of nursing (DON, Employee #82), when interviewed about the missing laboratory results at 12:15 p.m. on 10/21/09, relayed the stool culture had been stored in a cabinet (for five (5) days) and had not been sent to the laboratory as ordered. Further interview elicited that the resident had been experiencing liquid stools on a daily basis from 10/1/09 through 10/21/09. The staff members obtained a stat stool culture, which was negative for [MEDICAL CONDITION], but had no results for possible parasitic involvement. b) Resident #23 Review of the medical record found a nursing note written on 10/17/09 at (unable to decipher handwritten time) to obtain a [MEDICAL CONDITION] stool culture due to two (2) reported bowel movements containing mucus, orange color, and odor. Further review found that the facility did not obtain the ordered stool sample until at 6:00 a.m. on 10/20/09. An interview with Employee #82, on 10/22/09 at 4:10 p.m., elicited that she considered a 24-hour turn around for laboratory testing to be in a timely manner. c) Resident #12 The medical record review for Resident #12, conducted on 10/21/09 at approximately 12:00 p.m., revealed a nurses note dated 08/13/09 at 1:20 a.m., indicating that a stool specimen was collected for a [MEDICAL CONDITION] culture. The laboratory results report showed the stool was collected by the lab on 08/18/09. The clinical care manager agreed the laboratory test results indicated the stool specimen was collected five (5) days after the facility indicated they gathered the specimen. She confirmed this was not timely. She went on to say that the facility did not have a way to track the actual date and time the laboratory picked up specimens, but she did agree the results reported the specimen was collected on 08/18/09.",2015-07-01
10066,"WYOMING NURSING AND REHABILITATION CENTER, LLC",515164,P.O. BOX 149,NEW RICHMOND,WV,24867,2009-10-23,371,F,0,1,0RO511,"Based on observation and staff interview, the facility failed to assure beverage glasses and bowls were free from moisture (wet nesting) and failed to assure garbage was properly secured during food service. These deficient practices had the potential to affect all resident receiving on oral diet. Facility census: 59. Findings include: a) Random observations of the dietary department, on 10/20/09 at 5:30 p.m., found racks containing bowls and beverage glasses stored in the dishwasher room. An inspection of the glasses and bowls noted drops of water present on the inside of randomly selected glasses and bowls. The dietary manager agreed that moisture was present and the glasses and bowls had not been properly air dried. b) On 10/19/09 at approximately 5:30 p.m., observation during meal service in the kitchen revealed an open trash can in the dishroom that did not have a lid on it. The dietary manager indicated the lid was probably left off by an employee who was preparing coffee. However, she agreed the employee needed to put the lid on the can after she it was used to discard trash. .",2015-07-01
10067,"WYOMING NURSING AND REHABILITATION CENTER, LLC",515164,P.O. BOX 149,NEW RICHMOND,WV,24867,2009-10-23,279,D,0,1,0RO511,"**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 which contained measurable objectives, timetables, and relevant services to be provided to achieve the highest practicable physical, mental, and psychosocial well-being for two (2) of thirteen (13) residents currently residing in the facility. Resident identifiers: #5 and #36. Facility census: 59. Findings include: a) Resident #5 1. Review of the current care plan (with a resolution date of 11/20/09) found the facility identified the resident as demonstrating decreased cognitive ability related to dementia and confusion. The resident was refusing most invitations to group activity with some activity in room. The objectives (goals) developed by the facility were for the resident to participate in one-on-one activities two (2) times a seek and continue to do individual activities in the room. A review of the services to be provided in order to achieve the above goal included: ""Do not correct resident try to redirect;"" ""Invite resident to go out of room for short periods of time just for a stroll;"" and ""When husband is visiting invite and encourage them to come and sing for peers and staff."" None of the services to be provided were consistent with the goal of participating in one-on-one or in- room activities. 2. Further review of the care plan found the facility had identified the resident was at risk for falls. The objective was for the resident to have no falls requiring hospitalization through the next review. The services provided to obtain the stated objective included: ""Administer Ambilify (sic) 20 mg po (by mouth) daily"" and ""Administer [MEDICATION NAME] 60 mg po daily"". The care plan nurse could not state how the administration of antipsychotic and antidepressant drugs would assist the resident in not experiencing falls, during an interview on the afternoon of 10/21/09. b) Resident #36 1. The record review for Resident #36, conducted on 10/22/09 at approximately 2:00 p.m., revealed the resident had a [DIAGNOSES REDACTED]. The resident's care plan (effective 09/17/09 through 12/17/09) still contained [MEDICATION NAME] 2.5 mg by mouth twice daily for sixty (60) days as an intervention for the resident's anorexia. The resident nursing assessment coordinator (RNAC) confirmed this intervention was no longer in place and should not be part of the current care plan. 2. The facility also care planned the resident's resistance to care and lack of understanding for what was taking place around her. However, the facility had included [MEDICATION NAME] (an appetite stimulant) as an intervention to this problem. This medication was being given for the resident's anorexia not for her resistance to care or lack of understanding. .",2015-07-01
10068,"WYOMING NURSING AND REHABILITATION CENTER, LLC",515164,P.O. BOX 149,NEW RICHMOND,WV,24867,2009-10-23,281,D,0,1,0RO511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of standing orders, facility staff interview, and review of West Virginia Nursing Code and Legislative Rules, Including Criteria for Determining Scope of Practice of Licensed Practical Nurses and Guidelines for Determining Acts That May Be Delegated or Assigned by Licensed Nurses (2009 Edition), the facility failed to assure licensed nurses acted within their respective scopes of practice while delivering care to two (2) of thirteen (13) sampled residents. Licensed practical nurses (LPNs) failed to notify the registered professional nurse (RN) or physician when Resident #26 had a change in condition, failed to act under the direction of the physician when ordering and administering medications for Resident #26, and failed to accurately document when Resident #23 refused medications. Resident identifiers: #26 and #23. Facility census: 59. Findings include: a) Resident #26 1. Review of the medical record found a nursing transfer / discharge summary with nursing notes written by a licensed practical nurse (LPN) on the night shift of 10/08/09. The LPN documented that the resident was nauseated and vomited a small amount at 3:30 a.m. At 4:30 a.m., the resident vomited a moderate amount. At 5:30 a.m., the resident vomited a large amount, his respirations were 30, and his oxygen saturation was 84%. Review of the facility's standing orders found the following: ""IX. Acute Shortness of breath ...2. Check oxygen saturation via pulse oximeter PRN (as needed). If O2 (oxygen) SAT (saturation) less than 90, call physician."" The nursing note written at 6:30 a.m. found the resident's oxygen saturation was only 87% with the use of oxygen. The documentation contained no evidence the LPN collected data related to the resident's breath sounds, bowel sounds, skin color, etc., nor was there evidence to reflect the LPN attempted to contact the physician or the RN for direction in providing care. The nursing transfer / discharge summary also contained no evidence the LPN attempted to notify the RN or the physician concerning the resident's change in condition. At 7:00 a.m. on 10/08/09, the director of nursing (DON) provided a thorough assessment of the resident, contacted the physician and the resident was sent to an acute care facility for treatment of [REDACTED]. Review of the West Virginia Nursing Code and Legislative Rules, et al (2009 Edition, page 13), under the section entitled, ""ACTIVITIES THAT SHOULD NOT BE DELEGATED TO THE LPN"" found the following: ""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 as the provider proceeds through the steps of the activity."" Further review of the West Virginia Nursing Code and Legislative Rules, et al (page 45), under 10 CSR 3-3. Standards Related to the Licensed Practical Nurses' Contribution to, and Responsibility for, the Nursing Process, found the following: ""3.3. Provide nursing care under the direction of a registered professional nurse by: 3.3.1 caring for clients whose conditions are stabilized or predictable; 3.3.2 assisting with clients whose conditions are critical and/or fluctuating under the direct supervision of the registered professional nurse; ..."". An interview on 10/21/09 at 12:25 p.m., the DON verified the LPN should have notified the physician or registered nurse on call. 2. Review of the medical record found a late entry nursing note dated 10/15/09 at 1:00 p.m., documenting that staff had informed the LPN that the resident had loose stools with blood in the stool. The nurse documented that [MEDICATION NAME] was administered to the resident. Review of the physician's telephone order sheet found a standing order written to administer [MEDICATION NAME] 2 mg give two (2) tablets after the first loose stool. Review of the Medication Administration Record [REDACTED]. The LPN documented that she utilized a standing order to justify the use of this medications. Review of the standing orders found the physician ordered Pepto-Bismol 30 cc for loose stool, not [MEDICATION NAME]. Review of West Virginia Nursing Code and Legislative Rules, et al (page 46), 10 CSR 3-4.5, which states the licensed practical nurse shall ""(f)unction under the direction of a registered professional nurse, licensed physician, or licensed dentist; ..."". This LPN acted outside her scope of practice by ordering and administering a medication which had not been approved by the physician. b) Resident #23 Review of the medical record found a nursing note, written at 9:00 p.m. on 10/18/09, which documented the resident refused her 9:00 p.m. medications. Review of the Medication Administration Record [REDACTED]. During an interview with Employee #31 on 10/22/09 at 3:25 p.m., she stated she remembered holding the medication and just forgot to circle it or write the reason it was not given on the back of the MAR. An interview with the DON, on the afternoon of 10/22/09, verified the LPN should have circled her initials (to indicate the medication was not given) and documented on the back that the medication was refused.",2015-07-01
10069,"WYOMING NURSING AND REHABILITATION CENTER, LLC",515164,P.O. BOX 149,NEW RICHMOND,WV,24867,2009-10-23,309,D,0,1,0RO511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure two (2) of thirteen (13) sampled residents received the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the plan of care. Facility nurses continued to administer laxatives to Resident #26 in the presence of multiple liquid stools. Additionally, the facility failed to assure Resident #57 received ordered antibiotics for treatment of [REDACTED]. Resident identifiers: #26 and #57. Facility census: 59. Findings include: a) Resident #26 Review of the medical record found a late entry nursing note on 10/15/09 at 1:00 p.m., documenting that staff reported the resident had a loose stool with blood present. The LPN wrote an order for [REDACTED].) Review of the Medication Administration Record [REDACTED]. Further review found licensed nurses administered both laxatives on 10/16/09, 10/17/09, 10/18/09, 10/19/09, and 10/20/09, and administered the [MEDICATION NAME] 8.6 mg/50 mg on the morning of 10/21/09. The facility utilizes a computer system to track resident bowel movements. The director of nursing (DON, Employee #82) accessed the information concerning Resident #26's bowel movements during an interview conducted at 12:15 p.m. on 10/21/09. Upon reviewing the electronic records, Employee #82 relayed the resident had large-to-extra-large liquid stools at the following times: 10/16/09 at 2:47 p.m., 10/17/09 at 2:50 p.m. and 9:50 p.m., 10/18/09 at 5:04 a.m., 10/19/09 at 2:14 a.m., 10/20/09 at 9:41 p.m., and 10/21/09 at 6:44 a.m. Following the above interview, the facility obtained an order to discontinue all the resident's laxatives due to loose stools. The nursing staff continued to administer laxatives to Resident #26 in the presence of liquid stools for a period of six (6) days. b) Resident #57 Review of the medical record found Resident #57 was prescribed the antibiotic [MEDICATION NAME] 875 mg every twelve (12) hours on 08/03/09 for treatment of [REDACTED]. .",2015-07-01
10070,"WYOMING NURSING AND REHABILITATION CENTER, LLC",515164,P.O. BOX 149,NEW RICHMOND,WV,24867,2009-10-23,364,E,0,1,0RO511,"Based on random observation, testing of food temperatures, and staff interview, the facility failed to assure each resident received food at the proper temperature for palatability. This deficient practice had the potential to affect more than an isolated number of residents receiving an oral diet. Facility census: 59. Findings include: a) During the evening meal service on the resident hallway on 10/20/09 at 5:50 p.m., random observations noted that undistributed resident trays were sitting on racks on an open cart. After the last resident on the hall was served their tray and began to eat, the dietary manager was asked to assist in obtaining food temperatures on the remaining tray. She obtained a thermometer and determined that the beans were 108.1 degrees Fahrenheit (F) and the hot dog chili was 109.9 degrees F. She agreed that both food items should have been at least 120 degrees at the point of service. .",2015-07-01
10071,"WYOMING NURSING AND REHABILITATION CENTER, LLC",515164,P.O. BOX 149,NEW RICHMOND,WV,24867,2009-10-23,328,D,0,1,0RO511,"Based on observation, policy review, and staff interview, the facility failed to assure a licensed nurse appropriately positioned one (1) of two (2) residents receiving medications via gastrostomy tube to avoid choking and potential aspiration. Resident identifier: #2. Facility census: 59. Findings include: a) Resident #2 During observation of the medication administration pass on 10/21/09 at 7:40 a.m., the nurse (Employee #13) was noted to prepare Resident #2's medications for administration via her gastrostomy tube. Observation found that, while the head of the resident's bed was raised approximately 30 degrees, the resident had slid down the bed until her chest and stomach were lying in a flat position. Employee #13 prepared the resident's medications individually. She checked for proper placement of the gastrostomy tube prior to flushing the tube with approximately 30 cc of water. The nurse then placed diluted medication into the tube followed by a 5 cc to 30 cc flush, administered another medication followed by a flush, administered another medication followed by a flush. After this, the resident began to make gurgling sounds. The nurse then administered a 350 cc flush, and the resident started to gurgle and cough. The nurse surveyor pointed out to Employee #13 that the resident's chest and stomach were flat in the bed and suggested the resident be pulled up in the bed, so she was in an elevated position. The resident continued to gurgle and cough until the nurse obtained assistance in pulling her up in the bed. The director of nursing (DON) was informed of the above observation. She provided the facility's policy, which stated the resident was to be assisted to a semi or high-Fowler's position (30 degrees to 45 degrees) if tolerated (policy titled Administering Medications through a Gastrostomy Tube, revised July 1, 2006). The DON agreed the resident should not have been administered medications when she was lying flat in the bed. .",2015-07-01
10072,"WYOMING NURSING AND REHABILITATION CENTER, LLC",515164,P.O. BOX 149,NEW RICHMOND,WV,24867,2009-10-23,441,D,0,1,0RO511,"Based on observation and review of facility policy, the facility failed to ensure licensed nursing staff sanitized or washed their hands prior to instilling medications via gastrostomy tubes for two (2) of two (2) randomly observed residents. Resident identifiers: #2 and #42. Facility census: 59. Findings include: a) Resident #2 During the medication administration pass on 10/21/09 at 7:40 a.m., observations found the nurse (Employee #13) preparing Resident #2's medications for administration via her gastrostomy tube. She was noted to touch her keys, the medication cart, the medication administration book, and the sink faucet handle prior to donning gloves without first washing or sanitizing her hands. b) Resident #42 During the medication administration pass on 10/21/09 at 8:20 a.m., the nurse (Employee #6) was observed to prepare Resident #2's medications for administration via her gastrostomy tube. She was noted to touch the medication cart, the medication administration book, and the sink faucet handle prior to donning gloves without first washing or sanitizing her hands. c) Review of the facility's policy related to ""Administering Medications through a Gastrostomy Tube"" (revised July 1, 2006), under the section entitled ""Infection Control Protocol and Safety"", found the following language: ""1. Wash your hands thoroughly with soap and water at the following intervals: a. before the procedure;..."". .",2015-07-01
10106,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,253,E,0,1,9ELI11,"Based on observation, review of facility complaint log, confidential resident interviews and staff interview, the facility's housekeeping staff failed to assure an interior that was clean and sanitary. Floors in resident rooms were dirty. Residents complained of their windows being dirty. A wheelchair was noted to be dirty. And there were five (5) resident complaints in the facility complaint log between May 2009 and August 2009 related to an unclean environment. This practice had the potential to affect more than an isolated number of residents of the facility. Facility census: 99. Findings include: a) During the course of the survey, from 10/19/09 through 12:00 noon on 10/23/09, observations were made of dirty floors. The floors were especially dirty around the baseboard area, and some appeared to have not even been swept. The rooms most observed were rooms #125, #140, #228, #231, and #263. At 10:00 a.m. on 10/22/09, the floor in room #125 was bought to the attention of the administrator (Employee #84). This room had been observed for the preceding twenty-four (24) hour period and was noted by two (2) surveyors to have something spilled at the foot of the first bed which had not been mopped in the observation period. The administrator confirmed, at that time, the floor was in need of mopping and the floor should have been mopped at some point within the twenty-four (24) hours that it was observed. b) During a confidential resident group meeting on 10/21/09 at 2:00 p.m., the residents were asked about the cleanliness of the facility and their rooms. Four (4) residents were noted to be sleeping throughout most of the meeting, but out of ten (10) residents present and participating in the conversation, three (3) had concerns with housekeeping issues. One (1) resident stated her windows were dirty and that she had been here for six (6) years and did not recall the windows every being washed both inside and out. One (1) resident stated reported her room had been left for three (3) to four (4) days without the trash being removed or the floor being mopped. One (1) resident stated she had been here for eight (8) months and her window had not been washed. She further added that housekeeping staff ""swipe, not mop"" her room. c) Resident #19 On 10/21/09 at 8:20 a.m., Employee #39 was observed giving medications to this resident. The resident was sitting up in a chair equipped with a device to prevent her from leaning to the side. The device was soiled with dried liquid spills, as was the right armrest and side of chair. d) Review of the facility's complaint forms disclosed five (5) complaints reported to the facility complaining about residents' rooms being dirty and untidy. Further review of the complaints revealed four (4) were made by family members and one (1) by a resident. The complaints were reported between the months of May 2009 and August 2009. The complaints detailed concerns about dirty, sticky floors, trash under beds, stockpiling dirty / used bedpans in resident bathrooms, dust on furniture, dirty overbed tables, and untidy appearance of rooms. .",2015-06-01
10107,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,309,D,0,1,9ELI11,"**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 the necessary care and services for two (2) of eighteen (18) sampled residents to maintain their highest practicable physical well-being. Resident #47 was admitted to the facility from a hospital on [DATE] (where she had been treated for [REDACTED]. Resident #71 had an elevated temperature, and there was no evidence of continued assessment of his condition. Resident identifiers: #47 and #71. Facility census: 99. Findings include: a) Resident #47 Medical record review, on 10/20/09, disclosed this resident had been admitted to the facility from a hospital on [DATE]. Review of hospital discharge information disclosed the resident had been admitted to the hospital for toxic drug levels of [MEDICATION NAME] and high levels of [MEDICATION NAME], an anticoagulant. Further review of hospital discharge information found the resident's dosage of [MEDICATION NAME] had been changed at the hospital, and a blood level had been done prior to discharge. Review of current physician's orders [REDACTED]. Further review of physician's orders [REDACTED]. Review of the lab section of the medical record found no evidence of monitoring the resident's [MEDICATION NAME] blood levels since admission to the facility on [DATE]. Review of the facility's policy for residents on anticoagulant therapy disclosed the blood levels were to be monitored at least monthly. During an interview on 10/22/09 at 4:00 p.m., the director of nursing (DON - Employee #35) confirmed no [MEDICATION NAME] levels had been done on Resident #47 according to the facility policy. b) Resident #71 The medical record of Resident #71, when reviewed on 10/22/09, disclosed the resident, according to nurse's notes on 09/09/09, was ""febrile with 99.4 (degrees Fahrenheit) ax (axillary). Medicated with APAP (Tylenol) 650 mg PO @ (at) 4:50 (p.m.). Temp 99.1 at 10:00 p.m."" Continued review disclosed no additional nurses's notes for this resident until 09/28/09, when a student practical nurse administered the resident's annual TB ([MEDICATION NAME]) skin test. On 09/29/09, the resident was documented by nurses to be coughing with non-productive cough. Respirations were labored and wheezing. The resident's physician was contacted and ordered an intravenous (IV) dose of Solu-[MEDICATION NAME] (a medication that prevents the release of substances in the body that cause inflammation, used for breathing problems and other [MEDICAL CONDITION] conditions) along with the antibiotic [MEDICATION NAME] 400 mg for seven (7) days. The DON was made aware of this lapse in documentation for a resident who was febrile and later developed a respiratory infection. Nurse aide documentation was provided that disclosed vital signs had been taken on this resident on 09/15/09 and 09/22/09 and were within normal range. The DON further confirmed the nursing staff had not continued to document on this resident's status, who was medicated for an elevated body temperature when last addressed in nurse's notes. .",2015-06-01
10108,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,387,E,0,1,9ELI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure four (4) of twenty-one (21) sampled residents were seen by a physician at least once every thirty (30) days for the first ninety (90) days after admission and at least once every sixty (60) days thereafter. Resident identifiers: #36, #41, #65, and #83. Facility census: 99. Findings include: a) Resident #36 Medical record review revealed this resident was admitted to the facility on [DATE]. A history and physical examination [REDACTED]. The first thirty (30) day visit should have occurred between 06/04/09 and 06/14/09. The resident went out to the hospital on [DATE], and a new H & P was completed on 06/03/09. This H & P was counted as the first thirty (30) day visit. The next physician's visit was 06/23/09, and there was not another physician's visit until 08/21/09. The resident was not seen in July for the second thirty (30) day visit for the first ninety (90) days after admission. This was confirmed by the director of nursing (DON) during the afternoon of 10/22/09. b) Resident #41 Medical record review revealed this resident was not seen at least every sixty (60) days by a physician. The resident was seen on 01/27/09. The next physician's visit was not until 04/29/09. A visit should have occurred between 03/27/09 and 04/06/09. This was confirmed by the DON during the afternoon of 10/22/09. c) Resident #83 Medical record review, including a review of physician progress notes [REDACTED]. Further review of the progress notes revealed the physician's next visit (progress note) did not occur until 09/02/09. During an interview on 10/22/09 at 4:00 p.m., the DON agreed the time between the physician visits exceeded the required sixty (60) days as required. d) Resident #65 The medical record of Resident #65, when reviewed on 10/21/09, disclosed the resident was a [AGE] year old male who had been admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Documentation of physician visits for this resident, when reviewed, revealed the resident was seen by a physician's assistant on 01/27/09, and the resident's attending physician did not see him again until 04/24/09. The DON, when interviewed related to this finding on 10/22/09, confirmed the attending physician had failed to meet the requirement of seeing the resident every sixty (60) days, which may be alternated with a physician's assistant. The resident was not seen in the month of March.",2015-06-01
10109,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,441,E,0,1,9ELI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and review of facility policies and procedures, the facility's infection control program failed to ensure staff practiced infection control techniques to prevent the development and transmission of disease and infection. Handwashing was not performed after contact with residents and environmental objects as indicated. Gloves that had been placed in uniform pockets were used to perform treatments and administer eye drops. Treatment supplies were not placed on a clean field, and contaminated supplies were returned to the treatment cart. Resident identifiers: #79, #22, #7, #42, and #5. Facility census: 99. Findings include: a) Resident #79 On 10/21/09 10:00 a.m., a nurse (Employee #85) was observed changing the dressing to the resident's right heel. The nurse cut the old dressing off with a pair of scissors, then placed the scissors directly on the resident's overbed table. This created a potential for transfer of microorganisms from the old dressing to the table. The facility's procedure for dressings instructed a clean field be established upon which the supplies were to be arranged. No clean field was established. The nurse did not change her gloves after removing the old dressing and before cleaning the wound. The facility's procedure for clean dressings instructed that after the old dressing was removed, ""Pull glove over dressing and discard into plastic or biohazard bag."" The procedure further directed that after removing the contaminated gloves, the nurse wash her hands. The nurse cleaned the wound with a back and forth motion. The facility's procedure instructed, ""Clean from the least contaminated area to the most contaminated area (usually, from the center outward)."" After the wound was cleaned, the nurse used the same scissors used to cut off the soiled dressing, to cut the calcium alginate that was to be placed directly against the wound. After completing the dressing change, the nurse exited the room with the plastic bag with the soiled dressing and other discarded items. She had removed her isolation garb, but did not wash her hands prior to leaving the room. b) Resident #22 On 10/21/09 at 2:35 p.m., a nurse (Employee #39) was observed changing the dressing to Resident #22's right lower leg. During the procedure, the nurse tore tape from a roll while wearing the same gloves she had worn to dress the resident's wounds. This tape was later placed back in the treatment cart, creating a potential for transfer of microorganisms from Resident #22 to others. Also during this procedure, the nurse used gloves she had placed in her uniform pocket. The pockets of her uniform would not be clean, as she had placed her hands in and out of her pockets throughout the course of the day. Additionally, the nurse had placed the dressing supplies on the resident's bed without benefit of a clean field. The unused supplies were then returned to the treatment cart. c) Resident #7 On 10/22/09 at 11:28 a.m., Employee #39 took gloves out of her uniform pocket, donned the gloves, then retrieved a lancet and an alcohol pad from her pocket. She then did a finger stick blood sugar on a finger of the resident's right hand. The gloves had been contaminated by contact with the nurse's pocket. After completing the procedure, the nurse removed her gloves and exited the room without washing her hands. d) Resident #42 On 10/22/09 at 11:32 a.m., Employee #39 performed a finger stick blood sugar on this resident without having washed her hands after checking the blood sugar on Resident #7. e) Resident #5 On 10/21/09 at 8:40 a.m., Employee #39 was observed administering eye drops to the resident. She removed gloves from her pocket and donned them. She then removed the eye drop bottle from the box in which it had been packaged. This created a potential for introduction of microorganisms from the nurse's pocket, and from the box in which the eye drops had been placed into the resident's eyes. f) Resident #65 The medical record of Resident #65, when reviewed on 10/21/09, disclosed the resident had received his annual PPD ([MEDICATION NAME] skin test) on 09/28/09 by a student practical nurse (SPN). The record contained no evidence that the results of the test site had been observed for outcome. The director of nursing (DON), when asked to provide evidence that the test had been observed for outcome following its administration, confirmed, on 10/22/09 at 2:00 p.m., that the test had not been read as necessary to determine results. g) Resident #71 During a random tour of the facility on 10/20/09 at 10:00 a.m., a small volume nebulizer (SVN) with tubing and face mask attached was observed, by two (2) surveyors to be in the room of Resident #71, sitting in the floor which was soiled with debris and dust. The room was observed on several occasions during that day and the next. The resident's medical record was reviewed to confirm he was not currently receiving treatments via this nebulizer. On 10/21/09 at 3:00 p.m., the unit assistant director of nurses (ADON - Employee #100), when made aware of this observation, confirmed the equipment should not be stored in the floor and also confirmed the unclean floor. She then removed the SVN from the room. .",2015-06-01
10110,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,329,D,0,1,9ELI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, review of facility's drug reference handbook, and staff interview, the facility failed to ensure the drug regimens of three (3) of eighteen (18) sampled residents was free of unnecessary drugs. Resident #85 received Tylenol with [MEDICATION NAME] (a drug not recommended for long term use in the elderly) at bedtime since 05/20/09 for pain, with no monitoring for the presence of adverse side effects, and [MEDICATION NAME] (an antipsychotic drug) since 11/07/08 with no attempted dose reductions. Resident #36 received [MEDICATION NAME] (an antipsychotic drug) without documented evidence of need and no non-pharmacological interventions attempted. Resident #5 received [MEDICATION NAME] since 08/18/08 with no gradual dose reduction attempts. Resident identifiers: #85, #36, and #5. Facility census: 99. Findings include: a) Resident #85 Medical record review, on 10/22/09, including a review of physician's orders [REDACTED]. Further medical record review found no evidence that a gradual dose reduction had been attempted for [MEDICATION NAME] as required every six (6) months, nor were the benefits vs. risks / needs of its use documented by the physician. Observations of this resident, on 10/22/09, found the resident was thin, frail, nonambulatory and nonverbal. Documentation in the current care plan indicated the resident was dependent on staff for total care for all activities of daily living (ADLs), was nutritionally compromised, and had a recorded weight of 75 pounds. The resident was observed seated in a reclining gerichair in her room and did not respond to verbal stimulation. Review of the resident's current care plan, dated 10/30/09, found the resident exhibited behaviors of resisting care with verbal and physical abuse of staff. In an interview with nursing staff on 10/22/09 at 11:00 a.m., Employee #143 (who provided care for this resident daily) revealed this resident would be in a bad mood in the morning, but if staff talked to her or approached her later, she would be better. Review of the physician's orders [REDACTED]. Review of the facility's nursing drug handbook found Tylenol with [MEDICATION NAME] should be used cautiously in the elderly due to its [MEDICATION NAME] effects and when taking other drugs such as antipsychotics and antianxiety agents. According to the literature review, [MEDICATION NAME] had the potential side effects of constipation, sedation, lethargy, confusion, physical and psychological dependency, hallucinations, and respiratory depression and should be used cautiously in individuals with compromised [MEDICAL CONDITION] function. Medical record review disclosed this resident had a history of [REDACTED]. Further medical record review disclosed no documentation to reflect the physician had evaluated the risks vs. benefits of daily use of Tylenol with [MEDICATION NAME] for pain for this elderly debilitated resident who was also receiving antipsychotic and antianxiety medications. During an interview on 10/23/09 at 10:15 a.m., the director of nursing (DON - Employee #35) agreed there was no documentation of monitoring for adverse side effects of [MEDICATION NAME]. b) Resident #36 Medical record review, on 10/20/09, revealed this resident was admitted to the facility on [DATE]. On 10/09/09, a telephone order was obtained for [MEDICATION NAME] 1 mg twice daily for ""agitation"". review of the resident's medical record revealed [REDACTED]. There was no evidence the facility attempted to determine causal factors for the agitation and behaviors or attempted non-pharmacological interventions prior to requesting a medication to address the resident's behaviors. The DON was interviewed the afternoon of 10/22/09, regarding additional evidence that causal factors and non-pharmacological interventions had been explored. At that time, it was confirmed there was no evidence to suggest either of these interventions had been attempted. c) Resident #5 Medical record review, on 10/21/09, revealed this resident had been receiving [MEDICATION NAME] 0.5 mg twice daily since at least 08/18/08. There was no evidence the facility had attempted a dose reduction since that time, a period of fourteen (14) months, or that a dose reduction was contraindicated. In an interview on the afternoon of 10/22/09, the DON confirmed there had been no attempts at a dose reduction since 08/18/08. .",2015-06-01
10111,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,428,E,0,1,9ELI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure drug irregularities were identified and reported to the physician and the director of nursing (DON) and the reports acted upon for four (4) of eighteen (18) sampled residents. Resident #85 was receiving a scheduled dose of Tylenol with Codeine (not recommended for long term use in the elderly) and was also receiving the antipsychotic drug Seroquel with no attempted dose reduction, and these irregularities had not been identified by the pharmacist. Resident #32 was receiving Vitamin B12 injections monthly; the pharmacist requested the physician to order a B12 level and CBC on the next lab draw and every six (6) months thereafter, and the physician denied the request with no clinical rationale documented. Resident #47 had been receiving Coumadin (an anticoagulant) since admission to the facility on [DATE] and had no blood levels monitored; this irregularity had not been identified by the pharmacist. Resident identifiers: #85, #32, #47, and #5. Facility census: 99. Findings include: a) Resident #85 Medical record review, on 10/22/09, including a review of physician's orders [REDACTED]. Further medical record review found no evidence that a gradual dose reduction had been attempted for Seroquel as required every six (6) months, nor were the benefits vs. risks / needs of its use documented by the physician. Review of the physician's orders [REDACTED]. Review of the facility's nursing drug handbook found Tylenol with Codeine should be used cautiously in the elderly due to its anticholinergic effects and when taking other drugs such as antipsychotics and antianxiety agents. According to the literature review, Codeine had the potential side effects of constipation, sedation, lethargy, confusion, physical and psychological dependency, hallucinations, and respiratory depression and should be used cautiously in individuals with compromised pulmonary function. Medical record review disclosed this resident had a history of [REDACTED]. Further medical record review disclosed no documentation to reflect the physician had evaluated the risks vs. benefits of daily use of Tylenol with Codeine for pain for this elderly debilitated resident who was also receiving antipsychotic and antianxiety medications. During an interview on 10/23/09 at 11:00 a.m., the director of nursing (DON - Employee #35) confirmed these drug irregularities had not been identified and reported. b) Resident #32 Medical record review disclosed this resident was receiving Vitamin B12 injections monthly for a [DIAGNOSES REDACTED]. The pharmacist's drug regimen review contained a recommendation to the physician for a B12 blood level and a CBC (complete blood count) on the next lab draw and every six (6) months thereafter. Further review revealed the physician had responded to this recommendation that he did not wish to draw the labs, with no rationale provided for that decision. c) Resident #47 Medical record review, on 10/20/09, disclosed this resident had been admitted to the facility from a hospital on [DATE]. Review of hospital discharge information disclosed the resident had been admitted to the hospital for toxic drug levels of Phenobarbital, Dilantin and high levels of Coumadin, an anticoagulant. Further review of hospital discharge information found the resident's dosage of Coumadin had been changed at the hospital, and a blood level had been done prior to discharge. Review of current physician's orders [REDACTED]. Further review of physician's orders [REDACTED]. Review of the lab section of the medical record found no evidence of monitoring the resident's Coumadin blood levels since admission to the facility on [DATE]. Review of the facility's policy for residents on anticoagulant therapy disclosed the blood levels were to be monitored at least monthly. During an interview on 10/22/09 at 4:00 p.m., the DON confirmed no Coumadin levels had been done on Resident #47 according to the facility policy and this irregularity had not been reported by the pharmacist. d) Resident #5 Medical record review, on 10/21/09, revealed this resident had been receiving Risperdal 0.5 mg twice daily since at least 08/18/08. There had not been a dose reduction since that time, a period of fourteen (14) months. There was no evidence the consultant pharmacist had reported this as an irregularity and/or recommended a gradual dose reduction. During the afternoon of 10/22/09, the DON, when interviewed, confirmed the consultant pharmacist had not identified this as an irregularity or made a recommendation for a dose reduction. .",2015-06-01
10112,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,332,D,0,1,9ELI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations of medication administration pass and reconciliation with current physician's orders, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater. Of the forty-eight (48) observed opportunities for error, three (3) errors were made for an error rate of 6.25%. Two (2) of eight (8) residents observed during medication pass were affected. Resident identifiers: #46 and #5. Facility census: 99. Findings include: a) Resident #46 1. At 7:50 a.m. on 10/20/09, a nurse (Employee #143) was observed preparing to administer medications to this resident. Each medication was recorded on the CMS-677 as it was poured. The medications were [MEDICATION NAME], low dose aspirin, [MEDICATION NAME] liquid, and potassium. Reconciliation of the documented observations found an order for [REDACTED]. At 8:10 a.m., the Medication Administration Record [REDACTED]. The medication should have been given at this time. The nurse stated he was sure he had poured the medication. The medication wrappers had been discarded into a plastic container after the medication was removed. These were examined, as were other wrappers that had been discarded in the cart's trash receptacle, but no packaging was found for [MEDICATION NAME]. 2. After Employee #143 had poured the medications, he crushed all of the medications with the exception of the [MEDICATION NAME], as it was a liquid. The K-Dur was double checked against remaining doses to ascertain it had indeed been a caplet, not a capsule. During the reconciliation of the observed medication administration and the physician's orders, it was noted a clarification order had been written on 10/01/09. The order included, ""Clarification - K-Dur 10 mEq QD (every day) (May Dissolve in Liquid - Do Not Crush)."" The MAR indicated [REDACTED]. The nurse said he had not been aware of the order to dissolve the medication in liquid. b) Resident #5 On 10/21/09 at 8:40 a.m., a nurse (Employee #39) was observed administering medications to this resident. She poured Centram-Care Liquid with minerals. Review of the resident's current orders found [MEDICATION NAME] was ordered, not [MEDICATION NAME] with minerals. .",2015-06-01
10113,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,281,E,0,1,9ELI11,"Based on observations and review of facility policies and procedures, the facility failed to ensure a staff member checked placement of a gastrostomy tube in accordance with current standards. Additionally, the nurse charted medications on the medication administration records as she poured them and prior to administering them to the resident. Resident identifiers: #63, #60, #19, and #5. Facility census: 99. Findings include: a) Resident #63 1. On 10/21/09, at approximately 8:28 a.m., a nurse (Employee #39) was observed preparing the resident's medication. After the medications were prepared, the nurse entered the resident's room to administer them via the resident's gastrostomy tube. She drew up water in to a piston syringe, attached it to the gastrostomy tube, and auscultated as she pushed the water into the resident's stomach. Although it appeared the tube had migrated inward, she did not check placement prior to instilling the water. The facility's policy and procedure regarding administration of medications via gastrostomy tube did not address assessing placement. According to Kimberly-Clark, ""Before feeding, check the tube to be sure it is not clogged or displaced outside the stomach. You may do this by drawing 5-10 mls of air into a syringe. Place a stethoscope on the left side of the abdomen just above the waist. Inject the air into the extension set feeding port and listen for the stomach to 'growl....' "" b) Residents #60, #19, #63, and #5 During the observation of medication pass the morning of 10/21/09, Employee #39 was observed to initial some medications after each medication was poured and some after several had been poured. All were initialed before they were given. In one (1) instance, the nurse poured the medications and initialed the Medication Administration Record [REDACTED]. The resident was not in her room. The nurse returned to the medication cart and destroyed the prepared medications. She said the resident was probably still in the dining room. She said would re-pour them when the resident returned to her room. However, the Medication Administration Record [REDACTED]. The nurse did not circle the medications to indicate they had not been administered. In the event the nurse did not remember to go back to administer the medications, or was unable to for some reason, it would still appear that medications had been given. 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.""",2015-06-01
10114,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,323,E,0,1,9ELI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, the facility failed to ensure the resident environment was as free of accident hazards as possible. A nurse left a medication on the top of a medication cart when the cart was out of her line of sight. Another nurse left a medication cart unlocked and unsupervised. Medications were observed in a resident's room sitting on an open shelf and accessible to anyone entering the room. Resident identifiers: #22 and #60 and any mobile resident in the vicinity of the unlocked cart. Facility census: 99. Findings include: a) Resident #60 On [DATE] at 8:10 a.m., a nurse (Employee #39) poured this resident's medications. She went to a room at the far end of another hall, leaving the medication cart in alcove on another hall. The nurse left a packet of Digoxin 0.125 mg that had not been opened on top of the unattended cart. b) Resident #22 On [DATE] at 10:30 a.m., during observations of this resident's room, a small container of Silver Sulfadiazine (expired ,[DATE]), Nystatin Topical Powder 15 grams labeled Rx (prescription) only, two (2) Asmanex Twisthalers (a prescription medication), and Fluticasone Propionate (also a prescription medication) were noted sitting on a shelf on the wall across from the foot of the resident's bed. The shelf was open and accessible to anyone entering the resident's room. c) At 10:35 a.m. on [DATE], a licensed practical nurse (LPN - Employee #143) was observed passing medications to residents on the 100 Hall. A door alarm sounded, and Employee #143 immediately ran down the hall to determine the cause. At that time, the medication cart was left unlocked, unattended, and out of Employee #143's sight during the time the LPN was checking on the alarm. .",2015-06-01
10115,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,152,D,0,1,9ELI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility failed to ensure the individual acting on behalf of an incapacitated resident had the legal authority to make health care decisions. The facility had not obtained documentation to validate the appointment of a health care surrogate for the resident. One (1) of eighteen (18) residents on the sample was affected. Resident identifier: #40. Facility census: 99. Findings include: a) Resident #40 The resident was admitted to the facility on [DATE]. According to documentation in the resident's medical record, a health care surrogate had been appointed for the resident. An individual, other than the resident, had signed documents regarding health care decisions. However, there was no evidence the health care surrogate appointment had been validated. On 10/21/09 at 4:00 p.m., the social worker (Employee #23), when asked whether a copy of the health care surrogate appointment had been obtained, said she had asked the appointed individual to bring in a copy, but he had yet to do so. It was suggested a copy might have been received with the documents provided by the hospital at the time of transfer. Employee #23 checked, but was unable to locate a copy of the surrogate appointment. On 10/22/09 at 8:10 a.m., Employee #23 provided a copy of the health care surrogate appointment that had been faxed to the facility at 8:09 a.m. that morning. The facility had not obtained verification of the health care surrogate appointment for nearly a month after the resident was admitted . .",2015-06-01
10116,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,164,D,0,1,9ELI11,"Based on random observations, the facility failed to ensure privacy was provided during care and treatment. A dressing change to a resident's leg wound was being provided without the door to the room or the cubicle curtains being drawn. Another resident was given an insulin injection in the abdomen without privacy being provided. Resident identifiers: #22 and #42. Facility census: 99. Findings include: a) Resident #22 On 10/21/09 at 2:35 p.m., while passing by Resident #22's room, observation found a nurse (Employee #39) performing a dressing change to the resident's right lower leg. The resident was sitting up in a chair near the foot of her bed. The door to the hall was open, the resident's roommate was also sitting up in a chair and could view the dressing change, the cubicle curtains had not been drawn, and the window blinds had not been closed. A nursing assistant came into assist the nurse as she prepared to change the dressing on the resident's left leg. The nursing assistant closed the door, pulled the cubicle curtain, and closed the blind on the window. b) Resident #42 On 10/22/09 at 11:32 a.m., Employee #39 was observed checking residents' blood sugars. Resident #42's blood sugar reading was 202. This required insulin coverage. The nurse drew up the insulin and gave the injection in the resident's abdomen. The resident was sitting in a chair near the door to the hall. Her roommate was also present. The door open was open, and the nurse did not draw the cubicle curtain to provide privacy for the resident. .",2015-06-01
10117,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,246,D,0,1,9ELI11,"Based on observations and resident interview, the facility failed to provide a reasonable adaptation of the resident's physical environment to ensure her ability to reach items on her overbed table. One (1) of eighteen (18) residents on the sample was affected. Resident identifier: #22. Facility census: 99. Findings include: a) Resident #22 On 10/22/09 at approximately 10:30 a.m., several beverages and an open container of Dannon Nutriday were observed on the overbed table positioned by the resident's bed. The resident's bed was in the low position (close to the floor). The overbed table top was at approximately the level of the resident's head. When asked whether she could reach anything on the table, she reached up as though to get a glass of water, commenting it was hard. She was only able to reach the glass that was near the end of the table. The resident then asked for a bowl of soup. The resident was not aware of the other items on the table as she could not visualize them. The resident was noted to refuse to eat or drink at times, but according to the director of nursing, the resident was having a good day that day. It would be important to make food and beverages easily available to the resident to capitalize of times when she was inclined to eat or drink. .",2015-06-01
10118,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,360,E,0,1,9ELI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's diet manual, and staff interview, the facility failed to implement measures to assure residents' special dietary needs were met according to current standards and according to the facility's approved diet manual. The physicians' diet orders did not correlate with the approved diet manual. The diet manual indicated strict calorie controlled diabetic diets were no longer recommended, yet seventeen (17) residents were ordered this type of diet. Resident identifiers: #6, #16, #18, #24, #15, #43, #46, #50, #51, #56, #62,#67, #69, #70, #76, #87, and #100. Facility census: 99. Findings include: a) Residents #6, #16, #18, #24, #15, #43, #46, #50, #51, #56, #62,#67, #69, #70, #76, #87, and #100 Medical record review revealed each of these residents had a physician's orders [REDACTED]. On 10/22/09 at 2:30 p.m., an interview was conducted with the dietary manager (DM)regarding the facility's approved diet manual. The DM produced the facility's diet manual, which had been approved in April 2008 by the facility's chairman of the board of directors, the chief executive officer, the registered dietitian, the administrator, the medical director, and the director of dietary services. The manual was a 2007 edition of the Liberalized Diet Manual. Review of the directives for diabetic diets revealed the following statement on page 65: ""The strict diabetic calories controlled diets of the past are no longer recommended. These diets do not reflect the current nutrition recommendations for diabetes management...."" Current standards for nursing home residents' diets are espoused in the following abstract from the Journal of the American Dietetic Association 2002; 102:1316-1323: ""It is the position of the American Dietetic Association (ADA) that the quality of life and nutritional status of older residents in long term care facilities be enhanced by a liberalized diet ... "" Nutrition care for older adults in long-term care settings must meet two goals: maintenance of health through medical care and maintenance of quality of life ... ""For frail older adults, overall health goals may not warrant the use of a therapeutic diet because of its possible negative effect on quality of life..."" .",2015-06-01
10119,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,159,D,0,1,9ELI11,"Based on review of residents' funds and staff interview, the facility failed to notify two (2) of two (2) residents who received Medicaid benefits when the amounts in their accounts reached $200 less than the SSI resource limit, as specified in section 1611(a)(3)(B) of the Act. Each of these residents were within less than $20 of the SSI limit before they were notified. Resident identifiers: #49 and #79. Facility census: 99. Findings include: a) Resident #49 On 10/21/09 at 2:00 p.m., this resident's funds were reviewed with the facility's accounting office manager (Employee #58). At that time, this resident had a balance of $1993.21. According to Employee #58, when a resident's funds reach $200 within the SSI limit, this information is provided to the social worker (SW), so the resident and/or family can be contacted. At 8:15 a.m. on 10/22/09, an interview was conducted with the SW (Employee #23). The SW stated she had received an e-mail from Employee #52 regarding the resident's funds. The SW produced the e-mail, which was dated 10/16/09. At that time, the resident was already within $6.79 of the SSI limit. Upon inquiry, the SW confirmed this was the first and only notice she had been provided regarding this resident's funds. b) Resident #79 On 10/21/09 at 2:00 p.m., this resident's funds were also reviewed with the facility's accounting office manager (Employee #58). At that time, this resident had a balance of $1982.36. At 8:15 a.m. on 10/22/09, during the interview with the SW, the SW confirmed the information regarding this resident's funds was provided in the same e-mail as Resident #49's, on 10/16/09. At that time, the resident was already within $17.64 of the SSI limit. Upon inquiry, the SW confirmed this was the first and only notice she had been provided regarding this resident's funds. .",2015-06-01
10120,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,364,F,0,1,9ELI11,"Based on the confidential group interview, an individual confidential resident interview, taste testing, menu review, and staff interview, the facility failed to assure foods were well seasoned. This practice has the potential to affect all residents who receive nourishment from the dietary department. Facility census: 99. Findings include: a) On 10/21/09 at 11:15 a.m., foods were taste tested in the kitchen. The cauliflower did not taste as though it contained any seasoning. An inquiry regarding seasoning was made of the cook who had prepared the cauliflower. The cook stated she had added salt but nothing else. When asked if the cook had followed the recipe for how much salt to add, the cook stated, ""No. I just guessed."" Review of the cauliflower recipe revealed it called for a specific amount of salt and a specific amount of margarine. The cook had not followed the recipe to assure a well-seasoned product. b) During the confidential resident group interview at 2:00 p.m. on 10/21/09, the residents were asked, ""Is the flavor and appearance of your food satisfactory?"" (This is a routine question on the CMS group interview form.) The residents were unanimous in their response that the foods, as prepared in the kitchen, were not well-seasoned. One (1) resident even stated she had received cauliflower which was not seasoned that day. c) During the afternoon of 10/22/09, an individual confidential interview was conducted with a resident. When asked about the food, the resident stated, ""It tastes horrible. They don't season it very good. It's never salted."" .",2015-06-01
10121,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,243,C,0,1,9ELI11,"Based on review of the facility's resident council meeting minutes, the confidential resident group interview, and staff interview, the facility failed to assure a designated staff person responded to the requests and concerns from the residents' group meetings. There was no evidence the facility seriously considered the group's recommendations, attempted to accommodate those recommendations to the extent possible, and/or communicated the decisions to the resident group. This practice had the potential to affect all facility residents. Facility census: 99. Findings include: a) Review of the facility's resident council meeting minutes, on 10/21/09, revealed no evidence the facility responded to resident concerns and/or requests. b) During the confidential resident group interview at 2:00 p.m. on 10/21/09, the residents stated they did not receive responses to their concerns and recommendations. c) At 9:05 a.m. on 10/23/09, an interview with the facility's administrator revealed the facility had no written and/or formal method of documenting and responding to concerns and suggestions from the facility's resident council. .",2015-06-01
10126,GRANT MEMORIAL HOSPITAL,515045,P.O. BOX 1019,PETERSBURG,WV,26847,2009-10-27,279,D,0,1,SUPS11,"**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 and/or adequately address all problems identified through the assessment process for three (3) of six (6) sampled residents. Resident identifiers: #2, #5, and #4. Facility census: 6. Findings include: a) Resident #2 A review of Resident #2's clinical record revealed an [AGE] year old female with [DIAGNOSES REDACTED]. Her history revealed long-term [MEDICATION NAME] therapy which was thought to be the source of the diabetes insipidus. She had an indwelling urinary catheter which was placed due to the extensive diuresis caused by the diabetes insipidus, and she also received diuretics per order of her attending physician. Because of the diuresis, the [MEDICATION NAME] was stopped, and the resident had been receiving ""[MEDICATION NAME] 0.25 mg twice daily and 0.5 mg at bedtime"" and ""[MEDICATION NAME] 25 mg at bedtime"" since 10/16/09. Her interim care plan, which was last revised on 10/17/09, did not at all address the problem of dehydration secondary to the diabetes insipidus and diuretic use. The care plan also failed to address the use of psychoactive medications. No goal was set or any nursing interventions established to assure the resident would be properly maintained on these medications without adverse side effects. The only mention of the medications was under Problem #8: ""Risk of alteration in psychosocial well-being and change in daily routine related to admission to facility and use of [MEDICATION NAME], and [MEDICATION NAME]"", which included as an intervention: ""Medicate per order."" During an interview with the MDS nurse (Employee #27) and a staff nurse (Employee #28) at 11:00 a.m. on 10/27/09, they reviewed the chart and agreed these two (2) problems had been overlooked on the resident's care plan. b) Resident #5 A review of Resident #5's clinical record revealed a [AGE] year old male admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He was started on [MEDICATION NAME] 20 mg daily for the depression on 10/15/09. The Medicare 5-Day minimum data set assessment (MDS) revealed the use of the psychoactive medication, and the resident assessment protocol documentation identified the [MEDICATION NAME] and stated that its use would be care planned. Review of the resident's current care plan found no evidence of the establishment of a goal or nursing interventions necessary to ensure the safe use of this medication. During an interview with the MDS nurse and a staff nurse at 11:00 a.m. on 10/27/09, they reviewed the chart and acknowledged that the care plan did not include use of the [MEDICATION NAME]. c) Resident #4 A review of Resident #4's clinical record revealed a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. She also [MEDICATION NAME] mg daily for ""[MEDICAL CONDITION]"". The admission MDS, completed on 10/13/09, noted the administration of psychoactive medications and triggered the resident assessment protocol (RAP). The RAP summary indicated a care plan would be completed addressing these medications. Review of the current care plan found no evidence of this problem, a goal being set, or of any interventions planned to assure the safe use of these medications. This was verified during an interview with the MDS nurse and a staff nurse at 11:00 a.m. on 10/27/09. .",2015-06-01
10127,GRANT MEMORIAL HOSPITAL,515045,P.O. BOX 1019,PETERSBURG,WV,26847,2009-10-27,272,D,0,1,SUPS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the accuracy of the minimum data set (MDS) for one (1) of six (6) sampled residents. Resident #4's admission MDS, completed on 10/13/09, did not reflect the resident was receiving an antianxiety medication (Ambien) daily. Facility census: 6. Findings include: a) Resident #4 A review of Resident #4's clinical record revealed orders for [MEDICATION NAME] (an antidepressant) 40 mg daily since 09/30/09 [MEDICATION NAME](an antianxiety medication) 5 mg daily since 10/09/09. The comprehensive admission MDS noted, in Section O4, the resident received the antidepressant but not the antianxiety medication. During an interview with the MDS nurse (Employee #27) and a staff nurse (Employee #28) at 11:00 a.m. on 10/27/09, after reviewing the resident's chart, physician's orders [REDACTED]. .",2015-06-01
10128,GRANT MEMORIAL HOSPITAL,515045,P.O. BOX 1019,PETERSBURG,WV,26847,2009-10-27,329,D,0,1,SUPS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the medication regimen of one (1) of six (6) sampled residents was free of unnecessary drugs, by administering a daily dose [MEDICATION NAME] for [MEDICAL CONDITION] without any evidence of [MEDICAL CONDITION] in the medical record. Resident identifier: #4. Facility census: 6. Findings include: a) Resident #4 A review of Resident #4's clinical record revealed a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. She also [MEDICATION NAME] mg daily for ""[MEDICAL CONDITION]"" which was ordered on [DATE], although there was no indication in the history and physical or physician's progress notes of this problem and no listing of this [DIAGNOSES REDACTED]. The admission minimum data set (MDS), completed on [DATE], contained no mention of difficulty with sleeping and, in fact, indicated no concerns with either behaviors or moods. The only entry in the nurses' notes referring to [MEDICATION NAME] on the day it was ordered ([DATE]), when the nurse recorded the resident's brother had died earlier that day and the physician was in and ordered the medication as needed ""to help with rest"". (The order was later clarified to be administered daily.) There was no indication in the care plan of any problem with [MEDICAL CONDITION] During an interview with the MDS nurse (Employee #27) and a staff nurse (Employee #28) at 11:00 a.m. on [DATE], they reviewed the record and acknowledged there was no documentation in the resident's record of problems with sleep, nor was there evidence of monitoring for adverse side effects related to the use of the Ambien.",2015-06-01
10099,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2009-10-29,356,C,0,1,8O9311,"Based upon observations and staff interview, the facility failed to ensure the daily nurse staffing posting contained all required information. This had the potential to affect all residents and visitors. Facility census: 179. Findings include: a) During daily observations throughout the survey, the facility's daily nurse staffing posting was observed to contain the current date and the total number of registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs), but it did not the actual hours worked by RNs, LPNs, and CNAs. When interviewed on 10/29/09 at 8:15 a.m., the administrator confirmed the total hours worked by RNs, LPNs, and CNAs were not included on the staffing posting at the facility's entrance. .",2015-06-01
10100,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2009-10-29,279,D,0,1,8O9311,"**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 care plans to address problems identified through the resident assessment process. There was no care plan to address Resident #43's implanted cardiac pacemaker, Resident #78's constipation, or Resident #141's incontinence. The care plans did not describe the services to be furnished to meet the assessed needs of three (3) of twenty-five (25) sampled residents. Resident identifiers: #43, #78, and #141. Facility census: 179. Finding include: a) Resident #43 Review of Resident #43's medical record disclosed on a hospital record in the section describing past medical / surgical history that this ""patient also has a permanent pacemaker put in place previously."" Review of the nursing admission assessment, dated 09/25/09, revealed (in the cardiovascular section) the nurse checked ""Yes"" to indicate the presence of a pacemaker. The section to assess the pacemaker instructed the assessor to describe the type of pacemaker; this section was left blank. The instructions then stated, ""If Yes, complete Care Plan."" A review of Resident #43's care plan revealed no plan had been developed related to the ongoing care of the pacemaker, including any directives to periodically test it for functionality. During an interview on 10/28/09 at 2:00 p.m., Employee #57 verified the facility had not developed a plan to assure the proper care of and/or to prevent complications associated with presence of this implanted cardiac device. b) Resident #78 Review of the resident's bowel and bladder detail report found the resident had no bowel movements from 10/02/09 through 10/05/09. Review of the ""Routine Protocol"" (revised August 1, 2007) found Section 5 addressed constipation. The protocol noted that, if a resident did not have a bowel movement for two (2) days, the bowel protocol was to be initiated. Review of the Medication Administration Record [REDACTED]. Further record review revealed the current care plan did not address the resident's constipation. c) Resident #141 Medical record review, on 10/27/09, disclosed the resident was admitted to the facility on [DATE]. Review of the Medicare 14-Day minimum data set assessment (MDS), with an assessment reference date (ARD) of 02/20/09, and the most recent quarterly MDS, with an ARD of 08/15/09, disclosed the resident was occasionally to frequently incontinent of bowel and bladder. Review of the resident's current comprehensive care plan found the problem of incontinence had not been identified and had no plan had been developed to address this problem. Interview with the MDS coordinator (Employee #151), on 10/28/09 at 4:00 p.m., confirmed a care plan for the problem of incontinence had not been developed. Interview with the nurse manager (Employee #178), on 10/28/09 at 4:00 p.m., also revealed a bowel / bladder continence assessment had not been done for this resident. .",2015-06-01
10101,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2009-10-29,315,D,0,1,8O9311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide care and services for one (1) of twenty-five (25) sampled residents to restore as much normal bladder function as possible. Resident #141, who was identified as being occasionally to frequently continent of bladder after being admitted to the facility, had no bladder assessment completed and no care plan developed to include interventions to assist the resident in regaining as much normal bladder function as possible. Resident identifier: #141. Facility census: 179. Findings include: a) Resident #141 Medical record review, on 10/27/09, disclosed the resident was admitted to the facility on [DATE]. Observations, on 10/27/09, found the resident was ambulatory without assistance, answered simple questions appropriately, and was oriented to name and sociable with staff and other residents. The resident also fed herself and performed some activities of daily living. Review of the Medicare 14-Day minimum data set assessment (MDS), with an assessment reference date (ARD) of 02/20/09, and the most recent quarterly MDS, with an ARD of 08/15/09, disclosed the resident was occasionally to frequently incontinent of bladder. Review of the resident's current comprehensive care plan found the problem of incontinence had not been identified and had no plan had been developed to address this problem. Interview with the MDS coordinator (Employee #151), on 10/28/09 at 4:00 p.m., confirmed a care plan for the problem of incontinence had not been developed. Interview with the nurse manager (Employee #178), on 10/28/09 at 4:00 p.m., also revealed a bladder continence assessment had not been done for this resident. .",2015-06-01
10102,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2009-10-29,364,E,0,1,8O9311,"Based on confidential resident interviews, the confidential resident group meeting, observations and temperature measurements, and staff interview, the facility failed to ensure foods were served at the proper temperature. This practice had the potential to affect flavor and palatability of food items received by all residents who consume an oral diet. Facility census: 179. Findings include: a) During individual confidential resident interviews conducted during the survey, complaints of cold food were voiced. During the confidential resident group meeting held on 10/27/09 at 11:00 a.m., residents complained of cold food in the old building (OB) and in other areas of the facility. Residents at the group meeting indicated the breakfast and evening meals were most often affected. Observations in the main first floor dining room, on 10/28/09 at 8:45 a.m., found residents being served oatmeal, eggs, and biscuits and gravy. Measurements of food temperatures of the last tray being served, at 8:45 a.m., found the oatmeal was 98 degrees Fahrenheit (F), eggs were 99 degrees F, and pureed biscuit and gravy was 100 degrees F. Interview with the dietary manager (Employee #126), on 10/28/09 at 8:45 a.m., confirmed the temperatures of these breakfast foods at the point of service were too cold for palatability. .",2015-06-01
10103,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2009-10-29,490,C,0,1,8O9311,"Based on observations and staff interview, the facility failed to provide services in compliance with applicable Federal and State regulations regarding accepted professional standards and principles that apply to professionals providing services in this facility, by not ensuring the Roster / Sample Matrix (form CMS-802) was provided within one (1) hour after surveyors entered the facility, as required by the CMS Survey Protocol for Long Term Care Facilities. This practice impeded the survey process. Findings include: a) Surveyors entered this facility at 1:30 p.m. on 10/26/09. During the entrance conference, the administrator indicated the facility had been expecting the survey team. The survey team leader provided to the administrator the entrance information prior to conducting the tour and informed the administrator that a completed form CMS-802 was needed as soon as possible (but no later than one (1) hour after entrance), in order for the survey team to select the Phase I sample and begin the survey process. The survey team completed the tour of the facility, and the team leader was not provided with the CMS 802 until 5:00 p.m. During an interview with the administrator at 9:30 a.m. on 10/29/09, it was agreed the completed form CMS-802 was not provided to the survey team in a timely manner.",2015-06-01
10104,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2009-10-29,309,E,0,1,8O9311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's routine protocol, and staff interview, the facility failed to initiate interventions for treatment of [REDACTED]. Additionally, there was no plan developed or implemented to periodically assess the functionality of one (1) sampled resident's implanted cardiac device (pacemaker). Resident identifiers: #78, #102, #93, #127, and #43. Facility census: 179. Findings include: a) Resident #78 Review of the resident's bowel and bladder detail report found the resident had no bowel movements from 2:15 a.m. on 10/02/09 through 5:32 p.m. on 10/05/09. Review of the ""Routine Protocol"" (revised August 1, 2007) found Section 5 addressed constipation. The protocol noted that, if a resident did not have a bowel movement for two (2) days, the bowel protocol was to be initiated. The resident was to be checked for the presence and removal of hard / soft stool in the rectum, to be followed up with a Fleets enema per rectum and a call physician within twenty-four (24) hours. If no stool was found in the rectum, two (2) tablets of Senakot S were to be administered and the physician called within twenty-four (24) hours. Resident #78's medical record contained no evidence to reflect the bowel protocol was initiated when the resident had no bowel movements for two (2) days. An interview with the director of nursing (DON), on the evening of 10/27/09, confirmed staff should have instituted the bowel protocol on the evening of 10/04/09. b) Resident #102 Review of the resident's bowel and bladder detail report, on the morning of 10/28/09, noted the resident was recorded as having no bowel movements from 2:51 a.m. on 10/04/09 through 2:37 p.m. on 10/08/09. The facility provided no evidence to reflect the bowel protocol was initiated for this resident's constipation. c) Resident #93 Review of this resident's bowel and bladder detail report, on the evening of 10/27/09 at 6:20 p.m., noted the resident was documented as having no bowel movements from 2:48 a.m. on 10/04/09 through 10:44 p.m. on 10/11/09. The facility provided no evidence to reflect the bowel protocol was initiated for this resident's constipation. d) Resident #127 Review of the resident's bowel and bladder detail report found the facility documented the resident had no bowel movements from 12:54 a.m. on 10/13/09 through 3:53 p.m. on 10/18/09. The facility provided no evidence to reflect the bowel protocol was initiated for this resident's constipation. e) Resident #43 Review of Resident #43's medical record disclosed on a hospital record in the section describing past medical / surgical history that this ""patient also has a permanent pacemaker put in place previously."" Review of the nursing admission assessment, dated 09/25/09, revealed (in the cardiovascular section) the nurse checked ""Yes"" to indicate the presence of a pacemaker. The section to assess the pacemaker instructed the assessor to describe the type of pacemaker; this section was left blank. The instructions then stated, ""If Yes, complete Care Plan."" A review of Resident #43's care plan revealed no plan had been developed related to the ongoing care of the pacemaker, including any directives to periodically test it for functionality. During an interview on 10/28/09 at 2:00 p.m., Employee #57 verified the facility had not developed a plan to assure the proper care of and/or to prevent complications associated with presence of this implanted cardiac device. There was no evidence the facility was aware of what type of pacemaker the resident had, when the pacemaker needed to be checked, or how long the resident had the pacemaker. Employee #68, when interviewed on 10/28/09 at 1:00 p.m., was made aware of the concerns with this resident. She verified there had been no follow-up regarding the pacemaker. She talked with the resident and phoned his family to further assess the resident's history and needs associated with the pacemaker. A plan was established then with the resident's physician to follow-up to have the pacemaker checked .",2015-06-01
10105,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2009-10-29,441,E,0,1,8O9311,"Based on observation, facility staff interview, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) Guidelines for Hand Hygiene in Health-Care Settings, the facility failed to assure the wound care nurse (Employee #23) followed CDC guidelines and facility policy to refrain from wearing artificial nails while caring for open wounds. Additionally, Employee #23 contaminated an open wound during a dressing change. This deficient practice affected one (1) of twenty-three (23) sampled residents and had the potential to affect more than an isolated number of residents with open wounds or other treatments with the potential for introduction of infection. Resident identifier: #158. Facility census: 179. Findings include: a) Resident #158 Employee #23 was identified as being the wound care nurse by facility staff. This nurse was asked to allow this surveyor to observe a wound treatment as part of the survey process. At 10:15 a.m. on 10/27/09, Employee #23 retrieved the treatment cart from the third floor of the facility, entered the elevator, and exited on the fourth floor. While in the elevator, observation found Employee #23 was clicking her fingernails on the treatment cart. She was noted to have approximately 1/4 inch square-tipped nails with whitened ends. Employee #23 was asked if those were her natural nails. She stated they were not natural nails. Further interview elicited that Employee #23 was the full-time wound nurse and provided all wound treatments in the building when working. When the nurse arrived outside of Resident #158's room with the cart, she removed a clean field drape and a plastic bag of supplies from the treatment care. She removed several pairs of gloves and enfolded them into her hand. (This contaminated the gloves with any bacteria present on the treatment cart and any other items touched prior to touching the gloves.) The nurse placed the plastic bag containing supples, the clean field drape, and the gloves which had been enfolded into her hand on top of the resident's bedside table. She then washed her hands at the resident's sink, donned a pair of contaminated gloves from the top of the pile of supplies on the bedside table, and set-up her clean field. The nurse was noted to utilize her gloved finger to touch the resident's bedside control in order to raise the bed. After cleaning the wound with the assistance of Employee #115, Employee #23 gathered Santyl ointment onto this contaminated gloved finger and rubbed it directly into the resident's open wound. The unsanitary practices observed during this dressing change placed this resident at risk of infection of his open wound. The administrator was informed of the above practice and was asked to provide the facility's policy concerning the use of artificial nails. She provided a document entitled ""Personal Hygiene"" which referenced CDC guidelines for Hand Hygiene in Health-Care Settings, MMWR, October 25, 2002. Review of the document found under, Section VI. Nail Care, the following language: ""B. Employees providing resident care with high risk residents should refrain from use of artificial nails, wraps, etc., which may allow for carriage of microorganisms and yeast to susceptible residents."" Review of CDC guidelines for Hand Hygiene in Health-Care Settings, MMWR, October 25, 2002 (located at www.cdc.gov) found the following language: ""Healthcare workers who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than are those who have natural nails, both before and after handwashing... Personnel wearing artificial nails also have been epidemiologically implicated in several other outbreaks of infection caused by gram-negative bacilli and yeast."" The facility failed to assure the licensed nurse providing care to open wounds utilized techniques to avoid contamination of those wounds, and failed to assure that artificial nails were not worn to avoid the potential for infection referenced in the facility's policy and CDC guidelines. .",2015-06-01
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
10034,PENDLETON MANOR INC,515124,68 GOOD SAMARITAN DRIVE,FRANKLIN,WV,26807,2009-11-04,278,D,0,1,FWJG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, facility staff failed to ensure a resident received an accurate assessment concerning behaviors. This was found for one (1) of fourteen (14) residents. Resident identifier: #83. Facility census: 84. Findings include: a) Resident #83 When reviewed on 11/04/09 at 8:00 a.m., the minimum data set assessment ((MDS) dated [DATE] revealed Resident #83 had been identified as having exhibited with a deterioration in behavioral symptoms in Section E5 of the MDS. (The alleged presence of behavioral symptoms was a factor in the selection of residents for the survey sample.) Further review of the MDS revealed that, although Resident #83 was assessed to have had a deterioration in behavioral symptoms, she was coded as not having exhibited any behavioral symptoms in Section E4 of the same assessment of 08/27/09. When interviewed on 11/04/09 at 9:40 a.m., the facility's social worker (Employee #117) confirmed the coding on the MDS indicating Resident #83 had experienced a deterioration in behavioral symptoms was an error. .",2015-07-01
10035,PENDLETON MANOR INC,515124,68 GOOD SAMARITAN DRIVE,FRANKLIN,WV,26807,2009-11-04,274,D,0,1,FWJG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to recognize a significant change in status of one (1) of fourteen (14) sampled residents. Resident #58 exhibited an increase in indicators of depression, anxiety, and/or moods, a decline in bowel continence, an increase in the frequency of her pain, and she developed two (2) Stage II pressure ulcers. As a result, a comprehensive assessment was not completed, applicable resident assessment protocols (RAPs) were not triggered for further review, and the care plan was not revised accordingly. Resident identifier: #58. Facility census: 84. Findings include: a) Resident #58 A review of Resident #58's clinical record revealed an abbreviated quarterly minimum data set (MDS), dated [DATE]. When compared to her previous MDS (a comprehensive annual assessment dated [DATE]), the resident demonstrated a decline in mood, as evidenced by being newly coded as a ""1"" in seven (7) areas, including sadness and crying, a ""2"" in four (4) new areas, and a decline from ""1"" to ""2"" in one (1) area. Also noted on her abbreviated 08/12/09 MDS, she developed two (2) Stage II pressure ulcers, declined in bowel continence, and increased the frequency of her pain. During an interview with the MDS nurse (Employee #56) at 11:15 a.m. on 11/04/09, she acknowledged these changes should have triggered a comprehensive assessment (for a significant change in status) and the resulting RAPs, and she stated she would complete one (1) as soon as possible. .",2015-07-01
10036,PENDLETON MANOR INC,515124,68 GOOD SAMARITAN DRIVE,FRANKLIN,WV,26807,2009-11-04,280,D,0,1,FWJG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on record review and staff interview, the facility failed to evaluate and revise the care plan when the resident's mood and/or behavior status changed after a change in medication for Resident #70. The facility also failed to ensure that swallowing strategy techniques - as identified by the speech language pathologist - were incorporated into the comprehensive care plan for all staff to follow for Resident #62. This practice affected two (2) of fourteen (14) sampled residents. Facility census: 84. Findings include: a) Resident #70 A review of Resident #70's clinical record revealed an [AGE] year old male admitted on [DATE], with [DIAGNOSES REDACTED]. Since his admission, the resident had been determined to lack the capacity to form health care decisions, but he was alert and oriented and able to take part in his day-to-day care and move about the facility in a wheelchair. He had been receiving [MEDICATION NAME] ([MEDICATION NAME]) to treat depression for a long period of time and, on 09/22/09, his attending physician increased the dosage to 100 mg bid (twice daily) after the resident told him he was ""often anxious"" and after being told by the nursing staff (i.e., nurses' notes dated 09/22/09) that ""resident was upset by his roommate's yelling - yelled at him to 'shut-up'."" A review of the physician's progress notes, dated 09/29/09, revealed that, because the resident's daughter had stated concern about the resident having ""night-sweats"", he conferred with the pharmacist and ordered a tapered reduction of the [MEDICATION NAME] and the introduction of [MEDICATION NAME] over the next few weeks. On 10/05/09, the resident became very anxious and tearful while speaking to his visiting chaplain and told him that he just wanted to die and didn't know why the Lord hadn't taken him when he took his wife. The chaplain repeated this information to the nurse (Employee #95), who recorded in her notes (on 10/05/09) that she informed the unit supervisor, director of nurses, and social worker, and placed a note on calendar for the physician. The resident's daughter, when contacted, stated he had never expressed these thoughts before. On 10/09/09, the resident became very confused and called his daughter, telling her he was very sick and no one had been in to see him all day. This happened again on 10/14/09, with episodes of the resident yelling and calling for his dead wife. During this time, he was also refusing to come out of his room, refusing care, and refusing to eat at times. During an interview with the resident in his room at 11:30 a.m. on 11/04/09, he stated to this surveyor that his wife and mother and most of his family was dead and he wished he were dead, too. A review of the resident's care plan revealed it was reviewed and revised on 08/26/09. A problem stated: ""Potential for adverse consequences R/T (related to) medication regime (sic)."" The associated goal was"" ""Will not have any adverse effects R/T medication regime (sic) through this quarter."" This was to be accomplished by the plan to: ""Monitor for adverse consequences of all medications Q (every) shift."" There had been no revisions or additional interventions in this plan since the medication changes on 09/29/09 or the expression of symptoms of increased agitation, [MEDICAL CONDITION], suicidal tendencies, depression, and/or apathy, which have been documented and are all listed as adverse side effects of [MEDICATION NAME]. The care plan does not address the [MEDICAL CONDITION] at all. During an interview with the nurse manager (Employee #56) at 1:45 p.m. on 11/04/09, she stated she was aware of his statements and she was concerned with the changes in mental status with the changes in his medications, including his suicidal thoughts. She acknowledged, after reviewing the care plan, that it had not been updated, and she agreed, when asked, that there was no acute plan to address these issues. At 3:25 p.m. on 11/04/09, the social worker (Employee #116) presented the draft of a plan she had formulated, after talking to the surveyor earlier and receiving a phone call from the resident's daughter, to get him to come out of his room. b) Resident #62 Medical record review, on 11/03/09 at 8:30 a.m., revealed that, on 09/02/09, the speech language pathologist (SLP) assessed Resident #62 for problems with oral intake and identified swallowing techniques to be used for safe consumption. The medical record contained a one-page form that had been signed by five (5) staff members. The swallowing techniques identified on the form included: - Level I texture - Thin liquids in Provale 5 cc cup - Total assist with partial assist for drinks - Utensil placement with one (1) to two (2) word cues. - Allow resident to close mouth on utensil before removing; do not rake utensil up to remove food with upper teeth. - Cue drink with verbal cue ""drink"" and hand cup to resident - Avoid asking questions, use simple directions one (1) to two (2) words Review of the resident's comprehensive care plan, developed on 08/16/09, found it had not been revised to include any of the above-identified swallowing techniques. On 11/04/09 at 11:00 a.m., the registered nurse (RN) supervisor (Employee #55), when interviewed, revealed the swallowing interventions were available to direct care staff in a green book in the dining room, and she was not sure why the comprehensive care plan did not have any of the swallowing interventions. .",2015-07-01
10037,PENDLETON MANOR INC,515124,68 GOOD SAMARITAN DRIVE,FRANKLIN,WV,26807,2009-11-04,329,D,0,1,FWJG11,"**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 fourteen (14) sampled residents, to ensure [MEDICATION NAME] was given with adequate indications for use and in absence of adverse reactions. Resident identifier: #48. Facility census: 86. Findings include: a) Resident #48 Medical record review, on the morning of 11/04/09, revealed Resident #48 was ordered, on 09/21/09, [MEDICATION NAME] 25 mg one (1) caplet every eight (8) hours as needed for anxiety attacks. According to the facility's medication handbook titled ""Nursing 2010 Drug Handbook"", on pages 827 and 828, there was no evidence to reflect [MEDICATION NAME] was approved for use in treating anxiety. Additionally, the handbook noted [MEDICATION NAME]'s adverse side effects include dry mouth, nausea, epigastric distress, vomiting, diarrhea, and constipation. Review of the Medication Administration Record [REDACTED]. On 10/13/09, nursing progress notes indicated [MEDICATION NAME] given for complaints of feeling nauseated. On 10/13/09, milk of magnesia was given for constipation. On 10/27/09, [MEDICATION NAME] was ordered for complaints of constipation. On 10/31/09, [MEDICATION NAME] was given for nausea, and around 11:00 a.m., she was noted to be vomiting. At 12:30 p.m., [MEDICATION NAME] was again given for vomiting. On 11/01/09, she complained of nausea and was given [MEDICATION NAME]; she was also found to have a large amount of hard stool in the colon, for which milk of magnesia was given. Later on that morning at 8:30 a.m., she complained her stomach hurt and she was nauseated; bowel sounds were noted to be very sluggish in her lower quadrants. At 9:10 a.m., the physician was notified of her complaints of nausea and constipation and ordered the Senakot be changed to Senakot S and to give a [MEDICATION NAME] rectal suppository if there was no result from the milk of magnesia to be given at 2:00 p.m. Following administration of the [MEDICATION NAME] suppository, she had a large, hard bowel movement, and further assessment identified there was still more stool in her bowel. On the afternoon of 11/04/09, the director of nursing (DON - Employee #132), when interviewed, and identified Resident #48 was having some constipation and nausea, and this could have been related to adverse side effects of the [MEDICATION NAME]. .",2015-07-01
10038,PENDLETON MANOR INC,515124,68 GOOD SAMARITAN DRIVE,FRANKLIN,WV,26807,2009-11-04,309,G,0,1,FWJG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, staff interview, and facility policy review, the facility failed, for one (1) of seventeen (17) sampled residents, to thoroughly assess a resident who experienced an acute change in condition (increased confusion and yelling out, in addition to elevated temperature), to rule out underlying medical causes and to ensure prompt treatment. Resident #87 exhibited acute behavioral changes on [DATE]. There was no evidence of a thorough nursing assessment of the resident until 5:00 p.m. on [DATE], after he experienced several episodes of foul-smelling diarrhea; at that time, he was treated for [REDACTED]. Resident #87 was transported to the hospital on the evening of [DATE], and expired on the morning of [DATE]; the cause of death was noted to be [MEDICAL CONDITION] secondary to urosepsis. Facility census: 86. Findings include: a) Resident #87 Closed record review, on [DATE], revealed Resident #87 had a history of [REDACTED]. According to the comprehensive admission assessment completed on [DATE], he was able to make himself understood and usually understands others. He required two-person physical assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He was frequently incontinent of urine, and he left twenty-five percent (25%) or more of his food on the tray at meals. On [DATE], a nurse recorded that his lungs were clear per auscultation, he was receiving oxygen at a rate of 2 liters per minute, his mucous membranes were moist, and his mood was pleasant. On [DATE], a nurse noted he was exhibiting behavioral changes, becoming really confused and yelling at staff to get out of his room. There was no evidence of a thorough nursing assessment of the resident's overall status (e.g., neurological, respiratory, cardiac, urinary output, etc.) after these behavioral changes were exhibited. On [DATE] at 5:00 p.m., a nurse recorded he had foul-smelling diarrhea times three (3) in two (2) hours, his temperature was elevated at 102.7 degrees Fahrenheit (F), his pulse rate was elevated at 105, respirations were elevated at 24, lungs sounds were clear to auscultation, respiration were shallow and unlabored, bowel sounds were audible times all four (4) quadrants. He was medicated with Tylenol and [MEDICATION NAME] for the elevated temperature and, at 7:30 p.m., and the physician was notified that the medication was effective for treating the elevated temperature. Later that night at 8:30 p.m., a nurse recorded his temperature remained elevated at 101 degrees F; at 10:00 p.m., it was 101.6 degrees F; and at midnight, it remained elevated at 101 degrees F. At 2:00 a.m., 3:15 a.m., and 4:10 a.m. on [DATE], his temperature was slightly elevated at 99.8 degrees F, and at 5:50 a.m., it was 98.7 degrees F. On [DATE] at 7:30 a.m., his blood pressure was noted to be low at ,[DATE]. The next nursing note was not completed until [DATE] at 8:00 p.m.; it recorded an oral temperature of 98.6 degrees F, pulse 90, blood pressure ,[DATE], respirations 22, and oxygen saturation was ninety-four percent (94%) on 2 liters of oxygen. Beyond checking and recording his vital signs, there was no evidence of a thorough nursing assessment of the resident. On [DATE] at 12:20 a.m., his temperature elevated again to 100.4 degrees F. On [DATE] (time not noted in the nursing note), his blood pressure was again low at ,[DATE], and he was noted to report, ""I do not feel well."" On [DATE] at 2:45 p.m., the physician was notified and ordered staff to check the resident's blood pressure every shift for her to review on Friday. At 6:30 p.m., his blood pressure decreased to ,[DATE], and his prescribed hypertensive medication was held after notifying the physician. Again, beyond checking and recording his vital signs, there was no evidence of a thorough nursing assessment of the resident. At 8:45 p.m. on [DATE], the physician was again notified and requested the family be contacted for approval to transport him to the hospital to determine the cause of the intermittent fever. At 9:00 p.m., the family agreed, and the ambulance service transported him to the hospital at 9:18 p.m. On [DATE] at 1:30 a.m., the facility called the hospital and was notified that they were in the process of giving him a bolus of fluids and were not sure if he would be admitted . At 4:00 a.m., the hospital was again contacted, and he was admitted to the hospital with [REDACTED]. According to the hospital history and physical and discharge / death summary, dated [DATE], Resident #87 was admitted from the nursing home. Over the past two (2) days, he was noted to have episodes of fever, decreased level of consciousness, and decreased urinary output. He was found to have significant urosepsis in the emergency room , for which he was given 1 liter of saline and an antibiotic ([MEDICATION NAME]). On [DATE], he became unresponsive, had a small amount of vomitus, and went into [MEDICAL CONDITION]. A full code was initiated and, at 0701, death was pronounced. Discharge [DIAGNOSES REDACTED]. During an interview on [DATE], the nurse manager (Employee #55) was asked about the facility's policies and procedures for notification of the physician when there is a change in a resident's condition. She identified that a purple book was used, and the surveyor requested a copy of the book to review. The book was titled ""Protocols for Physician Notification - Assessing and Collecting Data on Nursing Facility Patients"". Review of the contents found a table on page 1 which contained the following under the column heading ""Condition"": ""Agitation and behavioral disturbances (may be the first sign of acute physical change, e.g. bacterial or [MEDICAL CONDITION] infection, blood sugar change, recent neurological change, or heart related conditions including impending MI ([MEDICAL CONDITION] infarct) or arterial fibrillation)"". Under the column heading ""Physical Data"" in association with agitation and behavioral disturbances found the following were to be assessed: 1. Vital signs 2. Neurological, cardiac, [MEDICAL CONDITION], and abdominal assessment 3. Blood sugar if patient is diabetic 4. Any signs or symptoms of infection / acute illness including dehydration 5. Description of current bowel and bladder function (assess urine for S&S (signs and symptoms) of UTI (urinary tract infection) 6. Assess for bruising or any other signs of an unreported / unwitnessed fall 7. Pain assessment (location, character, and severity) 8. Assess patient for change in mood, behavior, orientation or alertness. The facility failed to follow their own policy and procedures for conducting a thorough nursing assessment of Resident #87 when he experienced increased agitation and a behavioral change, to rule out underlying medical causes and to ensure prompt treatment. .",2015-07-01
10039,PENDLETON MANOR INC,515124,68 GOOD SAMARITAN DRIVE,FRANKLIN,WV,26807,2009-11-04,371,F,0,1,FWJG11,"Based on observation and staff interview, the facility failed to ensure the high temperature dishwasher was functioning properly to effectively sanitized the dishes between uses. Facility census: 86 Findings include: a) Observations of the dietary department, with the dietary manager (Employee #69) on 11/03/09, including observations of the dishwasher. Employee #69 and this surveyor observed the water temperature of the rinse cycle only reached 180 degrees Fahrenheit (F) for approximately four (4) seconds and then the red light would turn off. The dishwasher was sent through ten (10) cycles, and each time, rinse water did not reach the proper temperature and the red light would turn off prematurely during the rinse cycle. Employee #69 acknowledged the rinse cycle temperature should be higher and she would need to make a service call; until then, the facility would complete a bleach dip in the 3-compartment sink in order to ensure the dishes were effectively sanitized between uses. On the afternoon of 11/01/09, Employee #69 reported that the service technician had come to the facility and determined there was a problem with the water pressure to the dishwasher, and he was not able to get the temperature of the rinse water to achieve and maintain 180 degrees F for length of time needed to effectively sanitize. He installed a chemical sanitization unit on the dishwasher and lowered the water temperature to correct the problem. .",2015-07-01
10040,PENDLETON MANOR INC,515124,68 GOOD SAMARITAN DRIVE,FRANKLIN,WV,26807,2009-11-04,428,D,0,1,FWJG11,"Based on medical record review and staff interview, the facility failed, for two (2) of fourteen (14) sampled residents, to ensure the pharmacist's recommendations were acted upon by the attending physician. Resident identifiers: #29 and #44. Facility census: 86. Findings include: a) Resident #29 Medical record review, completed on 11/02/09 at 3:20 p.m., revealed a consultant pharmacy recommendation dated 06/08/09. Further review found no evidence to reflect the physician had seen or acted upon the recommendation. On the afternoon of 11/03/09, the director of nursing (DON - Employee #132), when interviewed, related she was not sure why the recommendation was placed back on the chart without any doctor notification. She further stated the physician was in the building, and she would ensure that the physician saw the recommendation. b) Resident #44 Medical record review, completed on 11/03/09 at 10:00 a.m., revealed a consultant pharmacy recommendation dated 08/13/09. Further review found no evidence to reflect the physician had seen or acted upon the recommendation. On the afternoon of 11/03/09, the DON, when interviewed, related she was not sure why the recommendation was placed back on the chart without any doctor notification. She further stated the physician was in the building, and she would ensure that the physician saw the recommendation. .",2015-07-01
10041,PENDLETON MANOR INC,515124,68 GOOD SAMARITAN DRIVE,FRANKLIN,WV,26807,2009-11-04,441,E,0,1,FWJG11,"Based on medical record review and staff interview, the facility failed, for fourteen (14) residents, to obtain informed consent in a timely manner to ensure that residents who wanted the influenza vaccine received it prior to an outbreak of flu-like symptoms in the facility. Resident identifiers: #3, #4, #12, #32, #37, #43, #46, #51, #59, #60, # 65, #77, #84, and #85. Facility census: 86. Findings include: a) Residents #3, #4, #12, #32, #37, #43, #46, #51, #59, #60, # 65, #77, #84, and #85 Review of the facility's influenza vaccination records, completed on 11/03/09, revealed several residents did not receive the influenza vaccine. On 11/04/09 at 1:00 p.m., Employee #88 (the infection control nurse), when interviewed, identified fourteen (14) residents (#3, #4, #12, #32, #37, #43, #46, #51, #59, #60, # 65, #77, #84, and #85) who had not yet received the influenza vaccine, as the facility had not yet obtained consent forms from their legal representatives. She also identified that she did have enough vaccines on hand to administer to all fourteen (14) residents. During this conversation, she related she only worked eight (8) hours per week and did not have enough time each week to obtain consents, give the vaccination, and complete the associated paperwork. Employee #88 identified they have had employees and residents who had exhibited flu-like symptoms. .",2015-07-01
10042,PENDLETON MANOR INC,515124,68 GOOD SAMARITAN DRIVE,FRANKLIN,WV,26807,2009-11-04,225,D,0,1,FWJG11,"Based upon review of personnel records and staff interview, the facility failed to implement procedures to screen employees for prevention of abuse and neglect, by failing to check appropriate licensing boards and/or registries. This was found for two (2) of ten (10) sampled employees, who were hire within the past twelve (12) months. Employee identifiers: #132 and #19. Facility census: 84. Findings include: a) Employee #132 Review of the personnel record of Employee #132 (the facility's director of nursing), on the afternoon of 11/02/09, revealed she began working at the facility on 12/08/08. There was no evidence that either the West Virginia Board of Examiners for Registered Professional Nurses or the West Virginia Nurse Aide Registry had been checked for findings of resident abuse or neglect that would indicate the employee was unfit for service in a nursing facility. b) Employee #19 Review of the personnel record of Employee #19 (a nursing assistant), on the afternoon of 11/03/09, revealed she had started working on 09/08/09. There was no evidence that the West Virginia Nurse Aide Registry had been checked for findings of abuse or neglect prior to 09/23/09. c) During an interview with the Person in Charge (Employee #107) on 11/04/09 at 11:35 a.m., she confirmed that there was no available verification to reflect these individuals had been properly screened prior to working with facility residents. .",2015-07-01
10200,"CLARKSBURG NURSING AND REHABILITATION CENTER, LLC",515166,801 DAVISSON RUN ROAD,CLARKSBURG,WV,26301,2009-11-11,241,E,0,1,D6IF11,"Based on an observation and staff interview, the facility did not ensure two (2) of sixteen (16) sampled residents and seven (7) residents of a random selection received care in an environment that enhanced each resident's dignity. Residents #49, #70, #10, #11, #23, #69, #56, #63, and #93 were sitting in the dining room awaiting lunch to be served for twenty (20) minutes without any activity or socialization being offered. Facility census: 95. Findings include: a) Residents #49, #70, #10, #11, #23, #69, #56, #63, and #93 Observation, on 11/10/09 at 12:05 p.m., revealed nine (9) residents sitting in the Level 1 dining room with no staff present. The residents were sitting at tables with other residents and were observed looking around the room or staring at the table. At 12:25 p.m., a group of staff members was observed coming into the dining room. They began to offer coffee, and an activity was provided. The resident's meal trays arrived at 12:30 p.m. An interview with the administrator, on 11/10/09 at 1:15 p.m., revealed an activity was to be provided to the residents at 12:15 p.m. He further stated the meal was served early today. The resident were seated in the dining room for twenty (20) minutes without staff supervision and/or activity or socialization. .",2015-06-01
10201,"CLARKSBURG NURSING AND REHABILITATION CENTER, LLC",515166,801 DAVISSON RUN ROAD,CLARKSBURG,WV,26301,2009-11-11,368,E,0,1,D6IF11,"Based on confidential resident group interview and staff interview, the facility did not ensure all residents were offered a snack at bedtime. This has the potential to affect all residents whose physician did not specifically order a bedtime snack. Facility census: 95. Findings include: a) During the confidential group meeting with residents, on 11/10/09 at 3:00 p.m., seven (7) of twenty-nine (29) residents attending the meeting reported they did not get a snack at night unless they asked for one. They further stated that, if your name was not on the list to receive a snack, one will only be provided if you ask. An interview with a nurse (Employee #81), on 11/11/09 at 10:00 a.m., revealed the nurse had sometimes worked on the afternoon shift, and if a resident requested a bedtime snack, the staff would give the resident a snack. The residents were required to ask if they wanted a snack before they were provided one. An interview with the administrator, on 11/11/09 at 10:30 a.m., revealed the staff was educated on offering snacks to residents. .",2015-06-01
10202,"CLARKSBURG NURSING AND REHABILITATION CENTER, LLC",515166,801 DAVISSON RUN ROAD,CLARKSBURG,WV,26301,2009-11-11,514,D,0,1,D6IF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure medical records were complete and accurately documented. This was true for one (1) of sixteen (16) sampled residents. A resident, whose physician had ordered dressing changes to the left arm after [MEDICAL TREATMENT], did not have completion of this dressing documented on the treatment sheets or in the nurses' notes. Resident identifier: #25. Facility census: 95. Findings include: a) Resident #25 Resident #25's medical record, when reviewed on 11/10/09 at 9:45 a.m., revealed the treatment sheets for September and October 2009 were not complete. The treatment for [REDACTED]. The clinical care supervisor (Employee #114), when interviewed on 11/11/09 at 11:30 a.m., reported the resident often refused the treatment and the treatment was completed at an alternative time to accommodate the resident. Employee #114 reviewed the September and October 2009 treatment sheets and nurses' notes and confirmed staff failed to document in the resident's clinical record (in the nurses' notes or on the treatment sheets) when the resident refused the procedure. .",2015-06-01
10203,"CLARKSBURG NURSING AND REHABILITATION CENTER, LLC",515166,801 DAVISSON RUN ROAD,CLARKSBURG,WV,26301,2009-11-11,157,D,0,1,D6IF11,"Based on record review and staff interview, the facility failed fully inform one (1) of sixteen (16) sampled residents when discontinuing Medicare coverage of a skilled service, by not identifying either the service or the reason for its discontinuance. Resident identifier: #37. Facility census: 95. Findings include: a) Resident #37 A review of the record for Resident #37 revealed she intermittently received physical therapy skilled services when ordered by the physician. After a significant change in healthcare status in May 2009, she received physical therapy services until 06/12/09. Documentation of the telephone notification of Medicare provider non-coverage, delivered on 06/04/09 to the resident's medical power of attorney representative (MPOA), stated only that ""therapy"" services were being discontinued but failed to indicate which ""therapy""; and, after the statement: ""I explained that the reason we believe Medicare probably will not pay for 'therapy' services is:________."", there was no entry. Therapy was again instituted in August 2009 and discontinued on 08/26/09. The Notice of Medicare Provider Non-coverage, provided to the MPOA on 08/29/09, failed to identify which ""therapy"" services were being discontinued and/or the reason(s) why. During an interview with the administrator at 2:30 p.m. on 11/10/09, he acknowledged, after reviewing the notice, that the reasons for non-coverage were not stated. .",2015-06-01
10204,"CLARKSBURG NURSING AND REHABILITATION CENTER, LLC",515166,801 DAVISSON RUN ROAD,CLARKSBURG,WV,26301,2009-11-11,159,D,0,1,D6IF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain written authorization, from a person with the legal authority to give such authorization, prior to managing the personal funds of two (2) of sixteen (16) sampled residents. Resident identifiers: #37 and #39. Facility census: 95. Findings include: a) Resident #37 A review of the facility's financial records found Resident #37 had a resident trust account that was being managed by the facility. The written authorization permitting the facility to handle the funds was signed by the resident's medical power of attorney representative (MPOA) to whom the resident, prior to loss of healthcare decision-making capacity, did not confer the authority to make financial decisions. The records indicated regular deposits to the account came from Black Lung benefits. The staff member responsible for handling the residents' funds (Employee #34) stated, at 11:00 a.m. on 11/10/09, that the Black Lung benefits first went to the resident's financial POA (not the same person as the MPOA), and he forwarded it the facility. Employee #34 stated the MPOA had signed the authorization, because she was present at admission, but quarterly account balance statements were sent to both the MPOA and the financial POA. It was noted that the facility could not produce a copy of the financial POA document. b) Resident #39 A review of the financial records of Resident #39 revealed this [AGE] year old female had been determined to lack the capacity to make healthcare decisions by her attending physician and had previously designated her brother as her Durable power of attorney (DPOA) and MPOA. At the time of her admission to the facility on [DATE], her DPOA indicated in writing he did not authorize the facility to handle the resident's personal funds. The facility was now handling the resident's funds, but there was no evidence of a signed authorization consenting to this. The staff member responsible for handling resident funds (Employee #34) stated, at 11:00 a.m. on 11/10/09, that she had reviewed the file and could not locate an authorization. .",2015-06-01
10205,"CLARKSBURG NURSING AND REHABILITATION CENTER, LLC",515166,801 DAVISSON RUN ROAD,CLARKSBURG,WV,26301,2009-11-11,272,D,0,1,D6IF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, confidential resident group interview, and staff interview, the facility failed to assure the accuracy of the minimum data set (MDS) for one (1) of sixteen (16) sampled residents, by failing to include the information that the resident wanders on a daily basis. Resident identifier: #39. Facility census: 95. Findings include: a) Resident #39 A review of Resident #39's clinical record revealed a [AGE] year old female with dementia. She was observed each day of the survey walking about in the hallways. At a confidential resident group meeting at 3:00 p.m. on 11/10/09, five (5) alert residents identified Resident #39 as one (1) of two (2) residents who wander throughout the facility daily. A review of the resident's minimum data set (MDS) assessments, including a comprehensive significant change in status MDS dated [DATE] and abbreviated quarterly assessments dated 07/05/09 and 10/04/09, found no evidence, in Section E4a of the MDS, of the resident's behavior of ""wandering"". Documentation found in the resident assessment protocol (RAP) for communication found: ""History of making attempts to leave facility."" The activities RAP stated: ""Resident is alert w/dementia, Wanders in and out of groups, hard to keep interest ... Resident has limitation in groups d/t (due/to) physical declining weak condition, dementia, wanders, hard to keep interests, ..."". Review of the documentation associated with the behavioral symptoms RAP, however, found ""Physically abusive; Socially inappropriate; Resists care"" with no mention of the resident's wandering. Her care plan indicated, under problems, ""Confusion, wanders."" During an interview with the director of nursing (DON) at 11:15 a.m. on 11/11/09, she acknowledged that Resident #39 walks the halls continually when she is out of bed. She agreed, after reviewing the MDS assessments, that they had failed to properly encode the resident's wandering. .",2015-06-01
10206,"CLARKSBURG NURSING AND REHABILITATION CENTER, LLC",515166,801 DAVISSON RUN ROAD,CLARKSBURG,WV,26301,2009-11-11,274,D,0,1,D6IF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to conduct a comprehensive assessment minimum data set (MDS) for one (1) of sixteen (16) sampled residents who had a significant change in health care status. Resident identifier: #39. Facility census: 95. Findings include: a) Resident #39 A review of Resident #39's medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. Staff completed comprehensive significant change in status assessment on 04/05/09 and an abbreviated quarterly assessment on 07/05/09. A review of the 07/05/09 assessment revealed changes as follows: - Item E.1. - increased from five (5) indicators to six (6). - Item E.2. - increased from (1) to (2) - Items G.1.a. and b. - increased from (2) to (3) - Item G.1.h. - increased from set-up and supervision (1/1) for eating to extensive assistance of one (1) person for eating. During an interview with the director of nursing at 11:15 a.m. on 11/11/09, she acknowledged, after reviewing the record, that 07/05/09 assessment should have been a comprehensive, instead of an abbreviated, assessment. .",2015-06-01
10207,"CLARKSBURG NURSING AND REHABILITATION CENTER, LLC",515166,801 DAVISSON RUN ROAD,CLARKSBURG,WV,26301,2009-11-11,323,E,0,1,D6IF11,"Based on observation and staff interview, the facility failed to assure a safe environment for the residents by allowing an arm chair in the main dining room to be in disrepair with a very loose arm. This had the potential to affect any resident able to sit in a chair in the dining room. Facility census: 95. Findings include: a) At 3:00 p.m. on 11/10/09, when approaching a chair in the main dining room on the second floor and starting to sit down, this surveyor stumbled when her hand was placed on the left wooden arm of the chair and the arm moved away from the chair. At the end of the meeting, the activity director was shown the chair and stated she would remove it from the room and contact maintenance to fix it. .",2015-06-01
10208,"CLARKSBURG NURSING AND REHABILITATION CENTER, LLC",515166,801 DAVISSON RUN ROAD,CLARKSBURG,WV,26301,2009-11-11,279,D,0,1,D6IF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to adequately address all the healthcare needs of one (1) of sixteen (16) sampled residents, by failing to care plan for the resident's assessed behavior of wandering. Resident identifier: #39. Facility census: 95. Findings include: a) Resident #39 A review of Resident #39's clinical record revealed a [AGE] year old female with dementia. She was observed each day of the survey walking about in the hallways. At a confidential resident group meeting at 3:00 p.m. on 11/10/09, five (5) alert residents identified Resident #39 as one (1) of two (2) residents who wander throughout the facility daily. A review of the resident's minimum data set (MDS) assessments, including a comprehensive significant change in status MDS dated [DATE] and abbreviated quarterly assessments dated 07/05/09 and 10/04/09, found no evidence, in Section E4a of the MDS, of the resident's behavior of ""wandering"". Documentation found in the resident assessment protocol (RAP) for communication found: ""History of making attempts to leave facility."" The activities RAP stated: ""Resident is alert w/dementia, Wanders in and out of groups, hard to keep interest ... Resident has limitation in groups d/t (due/to) physical declining weak condition, dementia, wanders, hard to keep interests, ..."". Review of the documentation associated with the behavioral symptoms RAP, however, found ""Physically abusive; Socially inappropriate; Resists care"" with no mention of the resident's wandering. Her care plan included, under problems: ""Confusion, wanders. Hard to keep interest."" The only goal associated with this problem statement was: ""To attend outreach group 3 x wk consistent (sic) & stay entire time w/ interest (sic)."" The interventions were addressed to the activities staff; however, there were no nursing goals or nursing interventions for this problem. During an interview with the director of nursing (DON) at 11:15 a.m. on 11/11/09, she acknowledged Resident #39 walks the halls continually when she is out of bed. The DON reported the resident cannot even sit still to eat, the physician ordered ""finger foods"" for her, and the staff offers her food all during the day while she walks. She acknowledged these were not addressed in her care plan. At 1:20 p.m. on 11/11/09, the DON presented the surveyor with a newly written care plan which addressed Resident #39's wandering. .",2015-06-01
10209,"CLARKSBURG NURSING AND REHABILITATION CENTER, LLC",515166,801 DAVISSON RUN ROAD,CLARKSBURG,WV,26301,2009-11-11,387,D,0,1,D6IF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents were seen by a physician every sixty (60) days as required. This was true for two (2) of sixteen (16) sampled residents. Resident identifiers: #93 and #39. Facility census: 95. Findings include: a) Resident #93 Resident #93's medical record, when reviewed on 11/10/09 at 3:00 p.m., revealed a [AGE] year old female who was admitted to the facility on [DATE]. The physician progress notes [REDACTED]. No visits were documented after the 08/02/09 date through the date of record review on 11/10/09. The director of nurses (DON - Employee #117), when interviewed on 11/11/09 at 11:45 a.m., confirmed the physician had not visited the resident every sixty (60) days as required. b) Resident #39 A review of Resident #39's clinical record, on 11/11/09, disclosed the resident was admitted to the facility on [DATE]. The physician progress notes [REDACTED]. The most recent physician's progress note was dated 08/31/09. No visits were documented after the 08/31/09 date through the date of record review on 11/11/09. During an interview with the DON, another nurse (Employee #115), and the administrator at 10:50 a.m. on 11/11/09, they were informed of the findings and stated they were aware of this intermittent problem and would contact the physician. .",2015-06-01
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
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
9546,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,154,D,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to inform one (1) of twenty-one (21) sampled residents of the potential risks and available alternative treatments relating to bladder elimination. An alert and oriented resident, whose indwelling Foley urinary catheter continued to be used at her request (beyond the time-limited physician's orders [REDACTED]. Resident identifier: 25. Facility census: 157. Findings include: a) Resident #25 Resident #25's medical record, when reviewed on 11/19/09 at 1:30 p.m., revealed a [AGE] year old female who was admitted to the facility on [DATE]. The resident was alert and oriented and had been determined by her physician to possess the capacity to understand and make informed healthcare decisions. The resident was on bedrest due to a fall at home resulting in fractures to the lumbar spine. The physician ordered an indwelling Foley urinary catheter for seven (7) days on 11/01/09 due to excoriation. Resident #25, when observed in bed at 1:45 p.m. on 11/19/09, had in place an indwelling urinary catheter. The resident, when interviewed, reported she did not want the catheter removed until she was off of bedrest and able to ambulate. The director of nurses (DON - Employee #165), when interviewed on 11/20/09 at 3:15 p.m., reported it was the resident's choice to keep the catheter. However, the DON did acknowledge the facility failed to inform the resident of potential risks of continuing to use an indwelling catheter over an extended period of time or alternative treatments available.",2015-10-01
9547,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,156,C,0,1,5V2011,"Based on observation and staff interview, the facility failed to include the name, address, and telephone number of the State long-term care ombudsman together in its posting of information. This practice had the potential to affect all residents and visitors. Facility census: 157. Findings include: a) On 11/17/09, an observation of the facility's posting in the front lobby, which included names and addresses of individuals who could be contacted for questions related to long term care, revealed the facility had not listed the name of the State long term care (LTC) ombudsman. On 11/20/09 at 4:00 p.m., the administrator agreed the State ombudsman's name needed listed and agreed to change the posting to correct the issue. (NOTE: On 12/02/09, the administrator faxed to the State survey agency a copy of a posting titled Information Services located elsewhere in the facility. While it did contain the State LTC ombudsman's name and telephone number, it did not contain an address. Consequently, an individual who wanted the name, telephone number, and mailing address of the State LTC ombudsman would have had to locate and access both postings to obtain complete contact information.)",2015-10-01
9548,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,158,C,0,1,5V2011,"Based on review of resident funds, staff interview, and the confidential resident group interview, the facility failed to assure residents had access to petty cash on an ongoing basis. This practice had the potential to affect all residents for whom the facility handled funds. At the time of the survey, the facility handled funds for one hundred-twelve (112) residents. Facility census: 157. Findings include: a) On 11/19/09 at 2:30 p.m., residents' accounts were reviewed with the office manager and the staff member who handled resident funds. At that time, it was revealed residents only had access to their personal funds during the facility's regular business hours and for four (4) hours each Saturday and Sunday. This was confirmed during the confidential resident group meeting held on 11/18/09.",2015-10-01
9549,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,176,D,0,1,5V2011,"Based on observation and medical record review, the facility failed to assure one (1) of twenty-one (21) facility residents was safe to self-administer drugs prior to allowing the resident to keep medication at the bedside. Resident identifier: #112. Facility census: 157. Findings include: a) Resident #112 During observation of the medication administration pass on 11/17/09 at 10:00 a.m., Resident #112 was overheard telling to the licensed practical nurse (LPN - Employee #195) that the night shift nurse gave her Aspercreme to keep in her room. Employee #195 reported the resident's statement. The assistant administrator (Employee #74) retrieved two (2) used tubes of Aspercreme from the resident's nightstand with her permission. Review of the medical record found the current minimum data set (MDS) with an assessment reference date (ARD) of 09/15/09. Review of this MDS found, in Section S1, the assessor determined the resident was not capable of safe self-administration of medications.",2015-10-01
9550,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,221,D,0,1,5V2011,"Based on random observation and staff interview, the facility failed to assure each resident was free from physical restraints imposed for staff convenience. Facility personnel allowed a chair alarm to become a physical restraint for one (1) resident of random opportunity. Resident identifier: #32. Facility census: 157. Findings include: a) Resident #32 On 11/17/09 at 4:25 p.m., this resident was observed seated in front of Building 2's nursing station. At 4:26 p.m., the resident began rising from the wheelchair, and an alarm sounded. Employee #7 ( a licensed practical nurse - LPN) immediately looked up and across the nursing station. She loudly said, Ah! Ah! Sit back in your chair! Employee #7 did not attempt to ascertain why the resident wanted up and did not direct anyone else to attempt to determine his needs. Directing the resident to sit down, instead of ascertaining the resident's needs when an alarm sounds, results in that alarm becoming a restraining device for that resident. This information was provided to the director of nursing (DON - Employee #165) at 4:35 p.m. on 11/17/09. At that time, the DON confirmed that staff should have asked the resident what he needed instead of telling the resident to sit back down.",2015-10-01
9551,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,224,E,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure residents received treatments as prescribed by their physicians. This was true for three (3) of twenty-one (21) sampled residents and six (6) random residents. There was no evidence these nine (9) residents received their scheduled treatments on 11/14/09 (7:00 a.m. - 7:00 p.m. shift) as prescribed by the physician. Resident identifiers: #16, #15, #24, #33, #42, #76, #78, #111, and #112. Facility census: 157. Findings include: a) Resident #16 Resident #16 was observed on 11/17/09 at 9:35 a.m. in his room. The treatment nurse (a registered nurse - Employee #122) was observed changing the dressing on his left lower leg. The existing dressing was observed to be dated 11/11/09. The treatment nurse confirmed the date on the dressing to be 11/11/09 and then removed the dressing which had been covering a skin tear. The area was observed to be scabbed over and free from any redness or drainage. The treatment nurse reviewed the November 2009 treatment sheet and reported the dressing was scheduled to be changed on 11/14/09. The treatment nurse reported the treatment was not initialed on 11/14/09, which would have indicated the treatment was completed as ordered by the physician. Resident #16's medical record, when reviewed on 11/17/09 at 10:30 a.m., confirmed the physician had ordered the following treatments: Cleanse area to (L) Shin with NSS, pat dry, apply OpSite Q3days (every three days) and PRN (as needed), Moisture Barrier to coccyx BID (twice daily), Moisture Barrier to ABD fold BID, and Check O2 SAT QS (every shift) if below 90% notify MD. Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator (Employee #78), when interviewed on 11/18/09 at 4:35 p.m., stated the treatment nurse (Employee #122) reported the omission of the treatments to her, an allegation of neglect was reported to the State agencies, and the facility's investigation into this was ongoing. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #16 had been reported to the State agencies. The director of nurses (DON - Employee #165), when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. b) Resident #15 Resident #15's medical record, when reviewed on 11/17/09 at 2:10 p.m., revealed the physician had ordered the following treatments: Check SPO2 every shift and PRN notify MD if Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #15's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #15 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. c) Resident #24 Resident #24's medical record, when reviewed on 11/17/09 at 2:20 p.m., revealed the physician had ordered the following treatments: Barrier cream to peri area and buttocks BID. Skin prep to bilateral heels QS D/T (due to) redness / soft. Abdominal binder at all times as tolerated, remove for care, and float heels while in bed, may remove for care. Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #24's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #24 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. d) Resident #33 Resident #33's medical record, when reviewed on 11/17/09 at 240 p.m., revealed the physician had ordered the following treatments: Check O2 SAT QS and PRN, below 90% notify MD, Greers Goo to buttocks BID, [MEDICATION NAME] cream to thigh and ABD fold BID. Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #33's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #33 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. e) Resident #42 Resident #42's medical record, when reviewed on 11/17/09 at 2:45 p.m., revealed the physician had ordered the following treatments: Moisture barrier cream to peri area and buttocks QS and PRN, Check placement of tab alert Q shift, Sensor pad to bed, check placement Q shift, and [MEDICATION NAME] cream 1% apply to entire back BID and PRN. Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #42's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #42 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. f) Resident #76 Resident #76's medical record, when reviewed on 11/17/09 at 2:50 p.m., revealed the physician had ordered the following treatments: Aspercreme to (L) hip and neck BID, Mupirocin 2% - apply around suprapubic cathter TID (three times daily) until healed [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus). Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #76's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #76 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. g) Resident # 78 Resident #78's medical record, when reviewed on 11/17/09 at 3:00 p.m., revealed the physician had ordered the following treatments: Apply [MEDICATION NAME] lotion to feet QD (every day) and as needed, [MEDICATION NAME] 2.5% with [MEDICATION NAME] lotion apply to face BID. Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #78's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #78 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. h) Resident #111 Resident #111's medical record, when reviewed on 11/17/09 at 2:15 p.m., revealed the physician had ordered the following treatment: Corn pad to right 2nd digit once daily and PRN until resolved. Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #111's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #111 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. i) Resident #112 Resident #112's medical record, when reviewed on 11/17/09 at 3:20 p.m., revealed the physician had ordered the following treatments: O2 SATS QS- if Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #112's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #112 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done.",2015-10-01
9552,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,241,D,0,1,5V2011,"Based on observation, resident interview, and staff interview, the facility failed to ensure the grooming needs of one (1) resident of random opportunity were promptly addressed. Resident identifier: #95. Facility census: 157. Findings include: a) Resident #95 On 11/18/09 at approximately 10:30 a.m., observation of Resident #95 revealed she had long hair on her chin. The resident related she had a broken left shoulder, which prevented her from doing things like trimming the hair on her chin. She said she would like to have the hair removed. On 11/18/09 at approximately 11:00 a.m., the registered nurse (Employee #146) was informed the resident wished to have the hair removed. She indicated they would assist the resident with the hair removal.",2015-10-01
9553,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,281,D,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and review of the West Virginia Nurse Practice Act, the facility failed to meet professional standards of care for one (1) of twenty-one (21) sampled residents. The facility's nursing staff failed to follow a physician's orders [REDACTED]. Facility census :157. Resident identifier: #25. Findings include: a) Resident #25 Resident #25's medical record, when reviewed on 11/19/09 at 1:30 p.m., revealed a [AGE] year old female who was admitted to the facility on [DATE]. The resident was alert and oriented and had been determined by her physician to possess the capacity to understand and make informed healthcare decisions. The resident was on bedrest due to a fall at home resulting in fractures to the lumbar spine. The physician ordered an indwelling Foley urinary catheter for seven (7) days on 11/01/09 due to excoriation. No additional physician's orders [REDACTED]. Resident #25, when observed in bed at 1:45 p.m. on 11/19/09, had in place an indwelling urinary catheter. The resident, when interviewed, reported she did not want the catheter removed until she was off of bedrest and able to ambulate. Staff interview with the director of nurses (DON - Employee #165), on 11/20/09 at 3:15 p.m., confirmed the resident did not have a current physician's orders [REDACTED]. According to the West Virginia Nurse Practice Act for Registered Professional Nurses (W.V.C. 30-70-1), Registered professional nursing shall mean the performance for compensation of any service requiring substantial specialized judgement and skill based on knowledge and application of principles of nursing derived from biological, physical and social sciences, such as responsible supervision of a patient requiring skill in observation of symptoms and reactions and the accurate recording of the facts, or the supervision and teaching of other persons with respect to such principles of nursing, or in the administration of medications and treatments AS PRESCRIBED BY a licensed physician or a licensed dentist, or the application of such nursing procedures as involve understanding of cause and effect in order to safeguard life and health of a patient and others. (Capitalization added for emphasis.)",2015-10-01
9554,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,309,D,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed, for three (3) of twenty-one (21) sampled residents with orders to have their heels floated and/or the application of pressure relieving devices, to provide necessary care and services to assure their heels were free from unrelieved pressure. Resident identifiers: #19, #118, and #15. Facility census: 157. Findings include: a) Resident #19 Review of Resident #19's medical record found a physician's orders [REDACTED]. Observations, conducted with the assistance of a nursing staff member (Employee #187) on 11/17/09 at 3:40 p.m., found a pillow had been placed beneath Resident #19's feet. The resident's right heel was resting on the pillow, and the left heel was resting directly on the bed. Employee #187 agreed the resident's heels were not being floated. b) Resident #118 Review of Resident #118's medical record found a 10/28/09 physician's orders [REDACTED]. Further review found a physician's orders [REDACTED]. 1. Observations, conducted with the assistance of a nursing staff member (Employee #187) on 11/17/09 at 3:40 p.m., found a pillow had been placed beneath Resident #118's feet. The pillow had flattened and allowed the resident's right heel to rest on the bed. Employee #187 stated the facility was utilizing specialized pillows to float residents' heels and were doing away with the HeelzUp devices. She agreed the pillow in place at the time of this observation was not assuring the resident's heels were floated. 2. During random observations of the facility on 11/19/09 at 3:15 p.m., Resident #118 was found in a geriatric chair in the main dining room. No heel lift boot was on her left foot. A subsequent observation, in the main dining room at 12:00 p.m. on 11/20/09, found Resident #118 in a geri chair with no heel lift boot on the resident's left foot as ordered by the physician. c) Resident #15 Medical record review revealed this resident had a physician's orders [REDACTED]. At 3:45 p.m. on 11/18/09, an observation was made with the director of nursing (DON), to determine if the resident's heels were being floated as ordered. When the DON lifted the sheet and blanket from the resident's feet, observation revealed the resident was wearing heel lift boots. Medical record review revealed the boots were a previous order which had been discontinued on 11/10/09, when the physician ordered the heels to be floated when the resident was in bed. The resident's heels were not being floated as ordered.",2015-10-01
9555,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,315,D,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, policy review, and staff interview, the facility failed to assure one (1) of twenty-one (21) sampled residents received services to restore as much normal bladder function as possible. This resident's bladder incontinence was not assessed, and interventions were not implemented to assist the resident to restore or improve normal bladder function. Resident identifier: #57. Facility census: 157. Findings include: a) Resident #57 Medical record review, on 11/17/09, revealed this resident was admitted to the facility on [DATE]. The admission minimum data set noted the resident was frequently incontinent of bladder. Review of the medical record revealed a bladder patterning and analysis worksheet dated 10/26/09 - 10/28/09, which had been only sporadically completed. On 11/18/09, the director of nursing (DON) was asked if additional information might be available. At 12:00 p.m. on 11/18/09, the DON reported it was facility policy to begin a bladder assessment upon admission and that the appropriate form was included in the admission information for every resident. The policy was provided and reviewed with the DON. At that time, the DON confirmed the policy had not been implemented for Resident #57; she also confirmed the assessment, which was started on 10/26/09, had also not been completed as required by facility policy. During an interview with the resident at 3:15 p.m. on 11/18/09, the resident's bladder incontinence was discussed. The resident stated she usually could feel the urge to urinate. Further interview revealed the resident would like an opportunity to be evaluated to determine to what extent her continence might be restored.",2015-10-01
9556,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,332,D,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to assure residents were free of a medication error rate of five percent (5%) or greater. Nurses failed to give ordered medication or failed to give the correct dosage of medication to two (2) of seven (7) randomly observed residents. This resulted in five (5) medication errors with an opportunity for forty (40) errors. The medication error rate was twelve and eight-tenths percent (12.8%). Resident identifiers: #112 and #66. Facility census: 157. Findings include: a) Resident #112 During observations of the medication administration pass on 11/17/09, the licensed practical nurse (LPN - Employee #195), when preparing medications for Resident #112, skipped a page in the medication administration record (MAR). The LPN did not administer [MEDICATION NAME] 40 mg, [MEDICATION NAME] 17 GM, a multivitamin, and [MEDICATION NAME] 3000 units. She did, however, initial the MAR to indicate she had administered these medications. After observing the nurse administer medications to Resident #13, she was asked to review the MAR for Resident #112. She was shown the page with the five (5) medications which she had initialed but not administered. She agreed she had missed this page when preparing the medications. b) Resident #66 During observations of the medication pass on 11/17/09 at 7:30 a.m., the LPN (Employee # 54), while preparing Resident #66's 8:00 a.m. medications, poured one (1) 25 mg tablet of [MEDICATION NAME] into the medication cup. The LPN then administered the medication to the resident. Resident #66's medical record, when reviewed on 11/17/09 at 8:15 a.m., indicated the physician had ordered [MEDICATION NAME] 75 mg twice a day. Employee #54, when interviewed on 11/17/09 at 8:20 a.m., confirmed the resident did not receive 75 mg of [MEDICATION NAME] as ordered by the physician. The LPN stated, I am going to give her the other two tablets now.",2015-10-01
9557,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,356,C,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Review of the POS [REDACTED]. Additionally, the nurse staffing data was not posted in a clear and readable format. These deficient practices had the potential to affect all residents and visitors to the facility. Facility census: 157. Findings include: a) Random observations of the facility entrance, on 11/17/09 at 10:30 a.m., found the facility had posted the nurse staffing data in a locked display case. Review of the POS [REDACTED]. Further review revealed the nurse staff data included three (3) registered nurses (RNs) on the day shift. An interview with the staffing and scheduling coordinator (Employee #145) was conducted at 11:00 a.m. on 11/17/09. When asked about the nature of the job duties performed by the three (3) RNs listed on the posting, she relayed one (1) of the RNs did treatments and the other two (2) were unit managers. When prompted, Employee #145 was unable to state any resident direct care provided by these two (2) RN unit managers. An interview with the unit manager of building 2 (Employee #40), on the afternoon of 11/19/09, elicited what duties the unit manager routinely performed. Employee #40 stated when she first comes on duty, she checks physician's orders [REDACTED]. She relayed that a part of her shift consisted of any intravenous sticks, flushing ports, and occasional feeding of residents at lunch and dinner. The facility posting indicated all duties performed by these two (2) RN unit manager constituted direct care, which was not the case. Further Review of the POS [REDACTED]. When interviewed at 11:00 a.m. on 11/17/09, Employee #145 identified this posting to mean seven (7) LPNs and one (1) treatment nurse. Posting Tx to represent an additional LPN would not be clear to residents and visitors without medical backgrounds. The facility failed to assure that only nurse staffing hours devoted to direct care were posted as required, and failed to assure the staffing data was posted at the beginning of each shift.",2015-10-01
9558,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,364,F,0,1,5V2011,"Based on taste testing, recipe review, and staff interview, the facility failed to assure foods were flavorful. Seasoning was not added as required by recipes for three (3) food products which were sampled. This practice had the potential to affect all residents who were provided nourishment from the dietary department. Facility census: 157. Finding include: a) At 11:20 p.m. on 11/18/09, foods were sampled for seasoning. Mashed potatoes, pureed broccoli, and regular broccoli did not appear to be well seasoned. The assistant dietary manager (ADM) was asked to taste test these products. The ADM tasted the products and stated the products needed more salt. At that time the ADM directed the cook to add salt to the products. Review of the recipes for these food products revealed specific directives for seasonings. Upon inquiry, the cook confirmed the recipes for these food products had not been followed that day.",2015-10-01
9559,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,368,F,0,1,5V2011,"Based on observation, review of the facility's meal schedule, and staff interview, the facility failed to assure there were no more than fourteen (14) hours between a substantial evening meal and breakfast the following day. The span between these meals was actually greater than fifteen (15) hours. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 157. Findings include: a) On 11/18/09 at 4:25 p.m., residents who resided in Building #1 were observed to have already been served the evening meal in the dining room. Review of the facility's meal schedule revealed the meals had been served according to the schedule. Further review of the schedule revealed each area for meal service was scheduled for greater than fifteen (15) hours between the evening meal and breakfast the following day. Interview with the administrator, on 11/19/09 at 3:00 p.m., revealed she was not aware the meal span requirement was that each resident was to have no more than fourteen (14) hours between the evening meal and breakfast the following day without each resident receiving a nourishing snack and without agreement from a resident group.",2015-10-01
9560,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,371,F,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 157. Findings include: a) During the initial tour of the dietary department on 11/16/09 at 1:30 p.m., a dietary employee (#171) was observed [MEDICATION NAME] no sanitation techniques and was contaminating the kitchen area as follows: 1. She touched the inside of a waste can when she tossed something into the can and then did not wash her hands. She then walked to the area where the menu was kept and touched the menu. Next she walked over to a food cart containing foods ready to be served and pushed it to another area. 2. Employee #171 was then observed washing dishes. She washed her hands, but there was no waste can in the area. When it was not clear as to how she had disposed of the paper towels, an inquiry was made of her at 1:40 p.m. on 11/16/09. She stated she had thrown the paper towels into the large barrel just outside the dish room door. The barrel was noted to be covered. Upon inquiry, Employee #171 demonstrated that she had opened the cover with her plastic apron. After this demonstration, she was observed in the walk-in cooler pushing a cart containing food ready to be served while wearing the contaminated apron. Further inquiry revealed she had also not changed her apron the first time she lifted the trash barrel lid with the apron. b) At 1:50 p.m., another dietary employee was observed using a cleaning cloth which had been obtained from the cleaning cloth container. Upon inquiry, this person stated she had not prepared the solution in the container, so she did not know whether or not the water in it contained any type of sanitizing solution. This person was asked to check the concentration of the solution but was unable to locate a test strip. Several dietary employees, including the dietary manager, searched for the test strips but were unable to locate them at that time. Further inquiry revealed no evidence the cleaning cloth solution was checked for adequate sanitizing concentration on a routine basis. There were no logs, and staff was unable to describe when this task was performed.",2015-10-01
9561,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,428,E,0,1,5V2011,"Based on record review and staff interview, the facility failed to ensure the pharmacist's report of irregularities was reviewed and acted upon by the attending physician in a timely manner. This was true for four (4) of twenty-one (21) sampled residents. Physicians were not notified of drug irregularities by the pharmacist in a timely manner. Resident identifiers: #77, #89, #57, and #95. Facility census: 157. Findings include: a) Resident #77 Resident #77's medical record, when reviewed on 11/16/09 at 4:00 p.m., indicated the consulting pharmacist reviewed the resident's drug regimen on 10/29/09 and identified a drug irregularity. The recommendation sheet was not found in the medical record. The director of nurses (DON - Employee #165), when interviewed on 11/20/09 at 11:25 a.m., confirmed the pharmacist's report of irregularities, dated 10/29/09, was not present and available for the physician to review in the medical record. The DON reported the pharmacist failed to send the report to the facility and attending physician in a timely manner. b) Resident # 89 Resident #89's medical record, when reviewed on 11/17/09 at 3:00 p.m., indicated the consulting pharmacist reviewed the resident's drug regimen on 10/28/09 and identified a drug irregularity. The recommendation sheet was not found in the medical record. The DON, when interviewed on 11/20/09 at 11:25 a.m., confirmed the pharmacist's report of irregularities, dated 10/28/09, was not present and available for the physician to review in the medical record. The DON reported the pharmacist failed to send the report to the facility and attending physician in a timely manner. c) Resident #57 Medical record review, on 11/17/09, revealed the consultant pharmacist indicated an irregularity had been identified on 10/28/09, and this information was recorded on the consultation report. This report had not been provided by the pharmacist until the DON asked for it upon request of the surveyor. d) Resident #95 The medical record review for Resident #95, conducted on 11/20/09 at approximately 3:00 p.m., revealed the resident had a medication regimen review from 10/29/09. On this review, the pharmacist marked the section See report for any noted irregularities. This report was not present on the medical record. The assistant director of nursing provided the report at approximately 4:00 p.m. on 11/20/09.",2015-10-01
9562,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,431,E,0,1,5V2011,"Based on observation, staff interview, and review of the manufacturer's package insert, the facility failed to date a multi-dose vial of Aplisol (Mantoux) when opened. This was true for one (1) medication refrigerator observed. One (1) multi-dose vial of Aplisol (Mantoux), was not labeled with the date the medication vial was initially opened. The manufacturer recommends the medication be discarded after thirty (30) days to ensure potency. This practice has the potential to affect all residents reside in the unit who received Aplisol (Mantoux) injections. Facility census: 157. Findings include: a) On 11/17/09 at 11:00 a.m., the medication refrigerator in building #1 was observed to have one (1) open multi-dose vial of Mantoux which was not labeled with the date the vial was initially opened. The director of nurses (DON - Employee #165), when interviewed on 11/17/09 at 4:30 p.m., observed the vial in the medication refrigerator and confirmed the Mantoux vial was opened and not labeled with the date opened. The DON discarded the vial. The DON, when interviewed on 11/20/09 at 2:30 p.m., reported the facility did not have a written policy regarding dating multi-dose vials of medications. The DON, when interviewed again on 11/20/09 at 3:00 p.m., provided a copy of the manufacturer's package insert. The manufacturer's package insert from JHP Pharmaceuticals states: Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. The DON confirmed multi-dose vials of Mantoux needed to be dated to ensure the medication's effectiveness.",2015-10-01
9563,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,441,E,0,1,5V2011,"Based on observation and staff interview, the facility failed to assure each staff member implemented practices to limit the potential spread of infections. A housekeeping aide did not utilize proper hand sanitization prior to completing ice pass. This practice had the potential to affect all residents who resided on B Hall. Facility census: 157. Findings include: a) At 3:40 p.m. on 11/18/09, a housekeeping aide (Employee #198) was observed passing ice on B Hall. Observation revealed she hugged a resident, then resumed passing ice without washing or otherwise sanitizing her hands. This information was immediately brought to the attention of the director of nursing (DON - Employee #165), who intervened and instructed the employee to throw out the ice, sanitize the ice chest and any affected water pitchers, then resume the ice pass with sanitized hands. Upon inquiry at 3:45 p.m. on 11/18/09, the DON confirmed the employee had not washed or hands or sanitized them by any other means.",2015-10-01
9564,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,492,F,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on medical record review and staff interview, it was determined the facility failed to provide information regarding hospice to one (1) of twenty-one (21) sampled residents. This resident had an order for [REDACTED].C.16-5C-20. Resident identifier: #5. Facility census: 157. Findings include: a) Resident #5 Medical record review, on 11/19/09, revealed the physician had ordered comfort measures only on 09/25/09. At that time, the facility did not provide information regarding hospice. The resident's physical condition improved, and the health care surrogate decided not to continue with comfort measures only. The resident's physical condition subsequently declined again. A care plan meeting was held, with the surrogate present, on 10/09/09. At that time, the surrogate decided comfort measures only was in the best interest of the resident. On 10/13/09, the physician ordered, DNR, Comfort Care, and No labs. This information was brought to the attention of the social worker at 9:25 a.m. on 11/20/09. At that time, it was revealed that hospice information had not been provided to the resident / family on either occasion in which comfort measures were ordered. --- Part II -- Based on staff interview and review of individual food service worker's permits, the facility was not in full compliance with local laws regarding food handler's cards. Three (3) of nineteen (19) dietary personnel, who were currently working, did not have a food handler's card and/or a food handler's card from the county in which the facility is located. This practice has the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 157. Findings include: a) On 11/17/09, copies of food handler's cards were reviewed for the facility's dietary employees. The copies provided did not contain the cards for three (3) dietary staff, including the current dietary manager (Employees #13, #50, and #190). An inquiry was made of the administrator (ADM), who checked on the situation and confirmed Employees #13 and #50 did not have current food handler's cards. The ADM stated Employee #190 had a food handler's card that had been issued by another county. It was unknown whether the current county had a reciprocal agreement with the other county, so the ADM contacted the local health department and learned there was no reciprocal agreement. This meant that Employee #190 also did not have a food handler's card, according to the laws of the county in which he was working.",2015-10-01
9565,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,514,D,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure each resident's medical record was accurate. An allergy was incorrectly identified for one (1) resident, and nursing notes did not reflect the current status of another resident. Resident identifiers: #15 and #89. Facility census: 157 Findings include: a) Resident #15 Medical record review, on 11/18/09, revealed this resident was admitted on [DATE]. Documentation in the record revealed the resident was allergic to plastic. It was unknown whether the allergy had been noted upon admission or at a later date. The noted allergy was of concern, because the resident had the potential to come in contact with plastic at the facility. The allergy was brought to the attention of the director of nursing (DON - Employee #165) on 11/18/09. The DON contacted the family. At 5:00 p.m. on 11/18/09, the DON reported the resident was not allergic to plastic. The resident's chart was then clarified to reflect this information. b) Resident #89 Resident #89's medical record, when reviewed on 11/17/09 at 10:00 a.m., revealed a [AGE] year old female who was readmitted to the facility on [DATE]. The resident was scheduled to receive [MEDICAL TREATMENT] three (3) times weekly at a renal center. Nursing notes, dated 11/01/09 at 6:25 p.m., stated, Sent to RGH Hospital for eval. Temp 102.5. Vomiting. Non responsive. IN an interview on 11/20/09 at 8:15 a.m., the DON acknowledged the documentation in the 11/01/09 entry was not complete and did not reflect an accurate and complete assessment of the change in the resident's condition. According to the American Health Information Management Association (AHIMA) Long Term Care (LTC) Guidelines, A complete record contains an accurate and functional representation of the actual experience of the individual in the facility. It must contain enough information to show that the facility knows the status of the individual, has adequate plans of care and provides sufficient documentation of the effects of the care provided. Documentation should provide a picture of the resident, including what resident said or did, observations and/or assessments by staff, communications with practitioners and legal representative, response to interventions/treatment. Good practice indicates that for functional and behavioral objectives the clinical record should document change toward achieving care plan goals.",2015-10-01
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
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
9465,"E.A. HAWSE NURSING AND REHABILITATION CENTER, LLC",515173,P.O BOX 70,BAKER,WV,26801,2009-12-02,279,D,0,1,7R6711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to develop appropriate plans of care, including measurable goals and nursing interventions aimed at attaining these goals, for three (3) of twelve (12) sampled residents with problems that had been identified in their comprehensive assessments. Resident identifiers: #1, #42, and #6. Facility census: 55. Findings include: a) Resident #1 A review of the medical record revealed Resident #1 was an [AGE] year old female with [DIAGNOSES REDACTED]. She received this medication almost nightly since her admission on 09/14/09, and the resident assessment protocol (RAP) summary, dated 10/02/09, indicated her care plan would address the use of psychoactive medications. At 3:00 p.m. on 11/30/09, a review of the resident's active care plan (which had been revised with a significant change on 10/02/09) revealed neither the establishment of a measurable goal for her identified problem of [MEDICAL CONDITION], nor any nursing interventions aimed at the resolution of her [MEDICAL CONDITION], although the nurses' notes documented almost nightly administration [MEDICATION NAME] with her pain medication; the nurses' also notes failed to reveal any documentation of intervention attempts other than the administration of medications. The care plan also did not address the potential problems associated with the resident receiving [MEDICAL CONDITION] medications. This was pointed out to the director of nurses (DON) at 12:00 noon on 12/01/09. The DON returned at 3:00 p.m. on 12/01/09 with a copy of a page from the resident's initial care plan which did include a plan, established on 09/16/09, for the problem of: Resident receiving [MEDICAL CONDITION] mg po qHS prn for [MEDICAL CONDITION] and is at risk for side effects. She stated this page had accidentally been omitted when the care plan was revised, but she acknowledged that neither care plan addressed the problem of [MEDICAL CONDITION]. b) Resident #42 Resident #42, when observed in the afternoon on 11/30/09, was seated in a cardiac chair in her room with her feet elevated. The resident was yelling out and moaning. When an attempt at interviewing the resident was made, the resident responded that she was hurting but could not indicate where. An interview at this time with a licensed practical nurse (LPN - Employee #47) found the resident did not like being in bed and would not stay there if put into bed. She related that the resident mostly was up in her wheelchair, and when she needed to rest, she was most comfortable in the cardiac chair. She also related that Resident #42 exhibited intermittent crying spells that included loud repetitious verbalizations of distress, often refused to go to bed, and was placed into a cardiac chair. A review of the resident's 11/10/09 care plan found no mention of the resident's refusal to go to bed and need / desire to be placed into the cardiac chair. The only care plan addressing the resident's use of the cardiac chair was during times of agitation. c) Resident #6 Review of the resident's admission minimum data set (MDS) assessment, dated 02/06/09, found this resident was assessed as being continent of bladder. A quarterly MDS, dated [DATE], indicated the resident was usually continent with occasional incontinence occurring less than weekly. A significant change in status MDS, dated [DATE], indicated the resident was incontinent daily but with some control. The 10/13/09 Bladder Incontinence Assessment and Progress notes indicated the resident had multiple intracranial meningeoma which were worsening and had a [DIAGNOSES REDACTED]. A review of the resident's 10/27/09 care plan, with the DON on the late afternoon of 12/01/09, found a care plan was not developed for the resident's worsening bladder incontinence.",2015-11-01
9466,"E.A. HAWSE NURSING AND REHABILITATION CENTER, LLC",515173,P.O BOX 70,BAKER,WV,26801,2009-12-02,309,D,0,1,7R6711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure staff, for one (1) of twelve (12) sampled residents who received as needed antianxiety and pain medications, consistently administered medications in accordance with clear parameters for their use. Resident identifier: #42. Facility census: 55 Findings include: a) Resident #42 Resident #42, when observed in the afternoon on 11/30/09, was seated in a cardiac chair in her room with her feet elevated. The resident was yelling out and moaning. When an attempt at interviewing the resident was made, the resident responded that she was hurting but could not indicate where. An interview at this time with a licensed practical nurse (LPN - Employee #47) found the resident did not like being in bed and would not stay there if put into bed. She related that the resident mostly was up in her wheelchair, and when she needed to rest, she was most comfortable in the cardiac chair. She also related that Resident #42 exhibited intermittent crying spells that included loud repetitious verbalizations of distress, often refused to go to bed, and was placed into a cardiac chair. The resident, when observed intermittently throughout the day on 12/01/09, was in a wheelchair with a self-release lap buddy. The resident was asleep by the nurse's station during the lunch observation on 12/01/09, and was asleep during most of the afternoon in the wheelchair by the nurse's station. On 12/02/09 at 9:00 a.m., the resident was observed going through the hallways of the facility yelling and chanting out without any meaningful purpose or direction. Review of the physician's orders [REDACTED]. The resident was also ordered Tylenol #3 with [MEDICATION NAME] every four (4) hours as needed Dx: DJD / Pain on 09/16/09 and Tylenol 650 mg every four (4) hours as needed - Not to exceed 4gr in 24 hrs. Not to be given within 4 hrs of Tylenol #3. Dx: Mild pain on 10/26/09. The resident was also receiving [MEDICATION NAME] 1 mg at 8:00 p.m. for anxiety / [MEDICAL CONDITION] with repeated verbalization, pacing, and inconsolable agitation (ordered on [DATE]) and [MEDICATION NAME] as needed every four (4) hours for the [DIAGNOSES REDACTED]. An interview with the director of nursing (DON), during the late afternoon on 12/01/09, found the resident was given Tylenol 650 mg whenever she had generalized mild pain. Staff assessed her via the pain management flow sheet, and the presence of three (3) discomfort indicators would mean the resident had mild pain. Review of the discomfort indicator scale found indicators included: Noisy, Negative Vocalization, Sad Facial Expression, Frightened Facial Expression, Tense Body Language, Fidgeting, and Behaviors / Acting Out. The DON explained the resident would be given Tylenol #3 with [MEDICATION NAME] for joint pain, indicating the physician's orders [REDACTED]. She said staff would administer the Tylenol #3 when the resident might say, Oh my knees. and the resident's pain would be moderate to severe as indicated by the presence of four (4) or more discomfort indicators. The DON also related the resident would be given [MEDICATION NAME] 1 mg as needed every four (4) hours if she was wandering excessively, making escalated repetitious verbalizations, or making excessive amounts of chanting without being able to redirected after non-pharmacological interventions such as redirection, foods / drinks were offered. Review of the 10/13/09 physician's progress notes found resident was taking [MEDICATION NAME] every eight (8) hours as needed for anxiety and had taken it every four (4) hours at home. The resident was exhibiting increased pain and Tylenol #3 did not seem effective. The resident seemed inconsolable at times, according to the progress notes. The resident was ordered [MEDICATION NAME] 25 mcg to be changed every seventy-two (72) hours on 10/14/09. On 10/20/09, the physician's progress notes questioned the effectiveness of the pain patch and indicated the resident was hoarse due to chanting. The notes indicated the [MEDICATION NAME] was effective short-term of anxiety and that giving [MEDICATION NAME] every four (4) hours may be necessary, since giving the [MEDICATION NAME] every eight (8) hours appeared to be wear off. The resident was also noted to have a low grade fever with cough and was ordered [MEDICATION NAME] 100 mg every twelve (12) hours for ten (10) days. On 11/10/09, the progress notes indicated the resident was noted to have [MEDICAL CONDITION] and was ordered [MEDICATION NAME] 250 mg every twelve (12) hours for ten (10) days. Review of documentation on the October and November 2009 medication administration records (MARs) and pain management flow sheets found the resident was given Tylenol #3 for generalized pain or pain when three (3) discomfort indicators were present (indicating mild pain) on four (4) occasions in October and on seven (7) occasions in November. Further review of the MARs found the as needed [MEDICATION NAME] and Tylenol #3 were given at the same time on eleven (11) occasions in October and on twelve (12) occasions in November. Review of the resident's 11/10/09 care plan for Alternation in comfort due to a history of [MEDICAL CONDITIONS] and chronic pain found interventions stating, Administer Tylenol with [MEDICATION NAME] 1 po q 4 hrs prn mild to mod(erate) pain; Tylenol 650 mg po q 4 hrs prn mild to mod pain; [MEDICATION NAME] Patch 25 mcg top(ically) q 72 hrs for pain. Two (2) other problems found in the same care plan were wandering / short attention span and agitation / combativeness. Interventions included administering [MEDICATION NAME] every four (4) hours for agitation, as well as providing diversional activities, reassurance, and distraction. An interview with the DON, on the late afternoon of 12/01/09, confirmed the resident was ordered two (2) as needed medications for pain and as needed [MEDICATION NAME] for anxiety. She agreed there were not clear parameters for the use of these medications and that staff was not consistently administering these as needed medications under the same circumstances.",2015-11-01
9669,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-12-03,161,E,0,1,U6B111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, staff interview, and interview with a representative of the State survey agency (the holder of all surety bonds), the facility failed to procure a surety bond approved by the State Attorney General as required by State law, to assure the security of all personal funds of residents deposited with the facility. This has the potential to affect all forty-nine (49) residents with funds deposited with the facility. Facility census: 102. Findings include: a) When reviewed on [DATE] at 1:00 p.m., the surety bond provided by the facility (bond # 7886) was found to have no stamp or signature indicating review and approval by the State Attorney General. When asked for evidence the bond had been approved, the administrator (Employee #128) related that the facility had no approval letter. This surveyor conducted a telephone interview with a representative of the State survey agency (the holder of all surety bonds for resident trust funds in WV nursing facilities) at 2:00 p.m. on [DATE], at which time the representative asked that a copy of the facility';s surety bond be faxed for review. A return telephone call, on [DATE] at 2:40 p.m., revealed the only bond on file with the State survey agency was bond # 7407, which expired on [DATE]. Bond # 7886 had not been reviewed, for sufficiency of form and amount, and approved by the State Attorney General as required.",2015-10-01
9670,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-12-03,225,D,0,1,U6B111,"Based on record review and staff interview, the facility failed to immediately report and/or thoroughly investigate an allegation of neglect as required. This was true for one (1) resident of random opportunity. Resident identifier: #97. Facility census: 102. Findings include: a) Resident #97 Review of the facility's forms titled Record Of Customer And Family Concerns found a form dated on 12/02/09 at 2:30 p.m., recording Resident #97's son report, on 11/13/09, that his parents' beds were unmade at 4:00 p.m., and Resident #97 was in need of a haircut and a facial shave. There was no written evidence the facility investigated and reported this allegation of neglect as required. The social worker (Employee #31), when interviewed on 12/02/09 at 3:45 p.m., acknowledged the allegation of neglect by Resident #97's son was not thoroughly investigated or reported. The director of nurses (DON - Employee #129), when interviewed on 12/03/09 at 9:45 a.m., confirmed the son's allegation of neglect was not reported or thoroughly investigated.",2015-10-01
9671,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-12-03,278,D,0,1,U6B111,"**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 eighteen (18) sampled residents, to ensure an assessment of Resident #5's urinary incontinence was accurate and complete; the assessment inaccurately identified [MEDICAL CONDITION] as a possible reversible cause of the resident's urinary incontinence. Facility census: 102. Findings include: a) Resident #5 Medical record review, on 12/01/09 at 8:30 a.m., revealed staff completed a urinary incontinence assessment of Resident #5 on 07/23/09. Review of this assessment found staff identified she had signs and symptoms of [MEDICAL CONDITION] which could have been a transient / reversible cause of her urinary incontinence. Further review of the medical record found no documentation to reflect staff implemented measures to address this [MEDICAL CONDITION] in an effort to reverse the urinary incontinence. On the afternoon of 12/01/09, the director of nursing (DON - Employee #129), when interviewed, related she would look into the matter. On the following morning, the DON said she reviewed the resident's medical record and found the assessment was incorrect; Resident #5 did not have any sign and symptoms of [MEDICAL CONDITION] at the time of the assessment, nor did she currently exhibit signs / symptoms of [MEDICAL CONDITION].",2015-10-01
9672,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-12-03,279,D,0,1,U6B111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive care plan, for one (1) of eighteen (18) sampled residents reviewed, that accurately described the care and services to be furnished to address an infection for which the resident was being treated. Resident identifier: #25. Facility census: 102. Findings include: a) Resident #25 The medical record of Resident #25, when reviewed on 11/30/09, contained information stating the resident was receiving care at an area wound care clinic for a wound to the left foot. A physician's orders [REDACTED]. Review of the resident's care plan revealed an entry, dated 09/04/09, which identified the resident as having a urinary tract infection [MEDICAL CONDITION]. The goal related to the UTI stated: Resident will be free of signs and symptoms of UTI after completion of antibiotic therapy. The approach noted to achieve the goal was: Bactrim DS BID x 14 days. The record contained no evidence to reflect the resident had a UTI at that time. The care plan made no mention of the wound infection that was present. The facility's director of nurses (DON - Employee #129), when interviewed on 12/01/09 at 11:00 a.m., was asked to provide evidence to reflect the resident's care plan was correct, the resident had a UTI on 09/04/09, and the resident's care plan was updated to address care of the infected wound. At the time of exit from the facility on 12/03/09 at 1:00 p.m., the DON was unable to provide the requested information.",2015-10-01
9673,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-12-03,280,E,0,1,U6B111,"**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 plan of care for four (4) of eighteen (18) residents reviewed following an assessed change in each resident's care and treatment. One (1) resident was receiving wound care at an outside wound clinic, and the care plan made no mention of this care. One (1) resident experienced a choking spell while eating and was sent to an area emergency room ; the care plan was not updated to reflect additional care and treatment associated with this episode. One (1) resident was receiving restorative nursing services related to the prevention of a hand contracture, and this care was not mentioned in the care plan. One (1) resident was receiving services of a contracted hospice agency, and the care plan was not updated when the reason for hospice services was changed from a terminal [DIAGNOSES REDACTED]. Resident identifiers: #25, #31, #18, and #48. Facility census: 102. Findings include: a) Resident #25 The medical record of Resident #25, when reviewed on 11/30/09, described a wound on the left foot of this resident, for which she was receiving outside care at an area wound clinic. A physician's orders [REDACTED]. Documents were on the record describing visits to the clinic on 09/18/09, 10/09/09, and 11/19/09. The resident's care plan was reviewed; no mention of this wound clinic care was found. The facility's director of nurses (DON - Employee #129), when interviewed on 12/01/09 at 11:00 a.m., confirmed the care plan had not been updated to reflect the resident's care at the wound clinic. b) Resident #31 The medical record of Resident #31, when reviewed on 12/01/09, revealed a nursing note dated 11/08/09, stating the resident was returned from the dining room where she had initially said she could not eat then began to cough up large amounts of clear, frothy sputum. The note further stated the resident's lips became bluish and the lung sounds in the lower lobes were diminished. The resident's physician was paged, and the resident was transported to a local hospital emergency room . Upon return from the emergency room , a physician's orders [REDACTED]. The resident's care plan, when reviewed, contained no evidence the plan had been updated to reflect this change in care and treatment. The DON, when interviewed on 12/02/09 at 10:30 a.m., could provide no evidence that the plan had been updated. c) Resident #18 The medical record of Resident #18, when reviewed on 12/02/09, disclosed a document entitled Rehabilitation Referral and completed by Employee #122 on 08/30/09, stating the resident was beginning to show signs of a contracture of the left hand. According to the document, a referral was made to occupational therapy (OT), and on 09/17/09, Evaluation and treatment was provided by OT staff. These OT services continued, according to documentation, until 10/28/09, at which time the resident was discharged from OT services and referred back restorative nursing services to continue care to increase skin integrity and prevent further contracture. The resident's care plan, when reviewed, contained no evidence that the plan was updated to include these changes in the resident's care and treatment. When interviewed on 12/02/09 at 10:30 a.m., the DON could provide no evidence of the care plan being updated / revised to include this care. d) Resident #48 The medical record of Resident #48, when reviewed on 11/30/09 at 3:30 p.m., disclosed this [AGE] year old female had been admitted to the facility on [DATE], and was subsequently admitted to the services of hospice on 06/08/09 with the terminal [DIAGNOSES REDACTED]. The resident's record contained two (2) care plans - one (1) completed by facility staff, and another completed by the hospice agency providing care to the resident. The facility-generated care plan, initiated on 06/12/09, identified the care and services provided by hospice and other areas of concern, including alteration in skin integrity, symptoms of cognitive impairment, total assistance with activities of daily living, behaviors, risk for injuries due to falls, potential for distressed mood symptoms, and risk for alterations in comfort. The hospice document entitled Interdisciplinary Plan of Care identified a terminal [DIAGNOSES REDACTED]. On the afternoon of 12/01/09, the hospice agency, when contacted, identified the reason for the resident's need for hospice services was changed (on 09/01/09) from dementia to [MEDICAL CONDITION]. Following this change in diagnoses, neither the facility-generated care plan nor the hospice care plan was revised to address problems associated with the terminal [DIAGNOSES REDACTED].",2015-10-01
9674,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-12-03,311,D,0,1,U6B111,"Based on medical record review and staff interview, the facility failed, for one (1) of eighteen (18) sampled residents, to provide restorative nursing services to improve and/or prevent decline in a resident's range of motion after she was discharged from physical therapy. Resident identifier: #34. Facility census: 102. Findings include: a) Resident #34 Medical record review, on 12/02/09 at 1:00 p.m., revealed Resident #34 was discharged from physical therapy on 09/15/09, after having achieved maximum functional potential, with recommendations for restorative nursing services to include range of motion, therapeutic exercise, and stretching, in addition to staff training for orthotic application. Further record review found no evidence these nursing services were provided. On the morning of 12/03/09, the director of nursing (DON - Employee #129, when interviewed and upon reviewing Resident #34's medical record, confirmed these restorative services were not provided. On the afternoon of 12/02/09, Resident #34, when interviewed, reported her knee was stiffer than it use to be, although she denied having experienced a decrease in range of motion.",2015-10-01
9675,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-12-03,312,D,0,1,U6B111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide the necessary care and services to maintain personal hygiene for one (1) of eighteen (18) sampled residents. A resident, who was dependent on staff for personal care and grooming, had visible dirt and debris underneath her fingernails. Resident identifiers: #62. Facility census: 102. Findings include: a) Resident #62 Resident #62, when observed on 12/01/09 at 10:00 a.m., 12/02/09 at 9:45 a.m., and 12/02/09 at 2:00 p.m., was noted to have visible dirt and debris underneath her fingernails. Resident #62's medical record, when reviewed on 12/01/09 at 9:00 a.m., revealed a [AGE] year old female with a [DIAGNOSES REDACTED]. The nurse aide (Employee #77), when interviewed on 12/02/09 at 2:05 p.m., acknowledged the resident's nail were dirty and need cleaning.",2015-10-01
9676,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-12-03,315,D,0,1,U6B111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to fully assess and/or provide appropriate treatment and services to maintain or restore as much bladder function as possible. This was found for one (1) of eighteen (18) sampled residents. Resident identifier: #84. Facility census: 102. Findings include: a) Resident #84 The medical record for Resident #84, when reviewed on the afternoon of 11/30/09, disclosed she was admitted to the nursing facility on 10/23/09. She was assessed as being incontinent of bladder upon admission, as documented on an admission nursing assessment. The admission nursing assessment form stated: If incontinent, complete Incontinence Assessment. When located, the Incontinence Assessment was found to have been completed twenty-four (24) days later on 11/16/09. Section B Nursing Interventions and Care Planning of Resident #84's Incontinence Assessment was blank. This section included the following action items, none of which was completed: 1. Identify the type of urinary incontinence based upon history and symptoms. 2. Identify management program and develop plan of care based on type of urinary incontinence and patient characteristics (include any medical treatment being initiated, e.g. medications). 3. Discuss plan for management with patient. Is patient willing to proceed? 4. If patient not willing, document and develop alternate plan. Under Section D Comments was written: 11/16/09 Resident has had 15 episodes of incontinence such far this month. Will initiate 3 day continence diary. The comment was signed by the assistant director of nursing (ADON - Employee #52). When located by facility staff, the three (3) day incontinence management diary was found to contain the following instructions: 1. Initiate within 72 hours of identifying incontinence or completion of treatment for [REDACTED]. 2. Three days do not need to be consecutive, but must be completed within five days. There was one entry on the form, dated 11/24/09, in which staff documented Resident #84 was checked at 2:00 p.m., 4:00 p.m., 6:30 p.m., 8:30 p.m., and 9:30 p.m. There was nothing in the chart to indicate the resident was placed on any kind of toileting plan. When interviewed on 12/02/09 at 8:40 a.m., the administrator (Employee #128) and a corporate consultant (Employee #127) confirmed Resident #84 had been assessed and determined to need evaluation for a scheduled toileting plan, but the process was never completed and, as of this date, still had not been completed.",2015-10-01
9677,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-12-03,323,D,0,1,U6B111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to implement safety measures in accordance with physician orders [REDACTED]. Resident identifier: #77. Facility census: 102. Findings include: a) Resident #77 Resident #77's medical record, when reviewed on 12/02/09 at 10:00 a.m., revealed an [AGE] year old female with a [DIAGNOSES REDACTED]. Review of the nursing notes revealed Resident #77 had falls on 09/11/09, 09/25/09, 10/16/09, 11/18/09, and 11/21/09. The comprehensive care plan, with a revision date of 08/06/09, disclosed the physician ordered hipsters to be worn at all times on 07/31/09, as a preventative measure. Resident #77, when observed in her chair on 12/02/09 at 3:30 p.m., was not wearing the hipsters. The resident was not able to be interviewed due to dementia. The nurse aide (Employee #130), when interviewed on 12/02/09 at 3:45 p.m., confirmed the resident was not wearing the hipsters as ordered. The nurse aide stated she would look for them.",2015-10-01
9678,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-12-03,428,D,0,1,U6B111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure recommendations made by the consulting pharmacist, for two (2) of eighteen (18) residents reviewed, were reported to and acted upon by the attending physician. For one (1) resident reviewed, the facility could provide no evidence to reflect a pharmacist's recommendation was communicated to the physician. For the other affected resident, there was no evidence the physician acted upon a recommendation once received. Resident identifiers: #31 and #34. Facility census: 102. Findings include: a) Resident #31 Review of Resident #31's medical record, on 12/01/09, disclosed a Consultation Report that had been provided to the facility's director of nurses (DON - Employee #129) by the consulting pharmacist on 11/06/09. The recommendation stated, Please verify [DIAGNOSES REDACTED]. The DON, when questioned about the recommendation on 12/02/09 at 10:30 a.m., stated there was no evidence the physician had been made aware of this recommendation and/or had clarified the [DIAGNOSES REDACTED]. b) Resident #34 Medical record review, on 12/02/09 at 1:00 p.m., revealed the consultant pharmacist identified a potential drug irregularity and made a recommendation on 09/11/09. The pharmacist had indicated that, if the medication's use was to be continued, the prescriber would need to document an assessment of risk factors versus benefits and the interdisciplinary team would need to provide ongoing monitoring for effectiveness and potential adverse consequences. Review of recommendation form revealed the physician signed the form but failed to date his signature or record whether he accepted or rejected the recommendation and why. Further review of the medical record revealed the medication identified in the pharmacist's report (Loratadine) continued to be used. On the morning of 12/02/09, the DON reported the physician who cared for Resident #34 only signs pharmacy recommendations and informs nursing staff of the changes he wishes to make.",2015-10-01
9679,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-12-03,441,E,0,1,U6B111,"Based upon observation and staff interview, it was determined that the facility failed to implement infection control practices to prevent the transmission of disease and infection, with respect to the distribution of ice to residents. This was found for one (1) of two (2) units observed throughout the survey. Facility census: 102. Findings include: a) On 12/02/09 at 1:15 p.m. on A wing of the facility, an uncovered ice scoop was observed lying on a wet towel on top of the cart used to store ice for the afternoon ice pass. After ice was scooped for delivery to residents' rooms, the scoop was returned to the top of the cart uncovered, for storage prior to the next pass. There was no method of protecting the scoop from contamination. When a corporate consultant (Employee #127) observed the ice scoop being stored uncovered on top of the ice cart, she confirmed this was not an acceptable infection control practice.",2015-10-01
9680,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-12-03,514,D,0,1,U6B111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility staff failed to maintain the medical records for one (1) of eighteen (18) 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 at the nursing facility. Resident identifiers: #48. Facility census: 102. Findings include: a) Resident #48 The medical record of Resident #48, when reviewed on 11/30/09 at 3:30 p.m., disclosed this [AGE] year old female was admitted to the facility on [DATE] and was subsequently admitted to the services of hospice on 06/08/09 with the terminal [DIAGNOSES REDACTED]. The hospice portion of the resident's medical record contained a document titled Interdisciplinary Group Meeting dated 06/09/09, which stated the hospice chaplain's visit frequency was 1 X month (once a month); further review disclosed no evidence the hospice chaplain had visited the resident in the last month. The document also indicated hospice social worker was to visit one (1) time a month, and there was no evidence the hospice social worker had visited the resident in the last month. On 12/01/09, the hospice was contacted, and this missing documentation was faxed to the facility to be placed on the resident's current medical record. The hospice representative also informed this surveyor the reason for hospice care was changed on 09/01/09, from dementia to [MEDICAL CONDITION]; this change was not noted in the resident's record, and the resident's care plan was not updated to reflect this. (See also citation at F280.)",2015-10-01
10356,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-12-03,514,D,0,1,5TIO12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the clinical information in one (1) of eight (8) sampled residents' records was accurate, by having physician's orders [REDACTED]. Resident identifier: #15. Facility census: 56. Findings include: a) Resident #15 A review of Resident #15's clinical record revealed a medication order handwritten onto the computer generated physician's orders [REDACTED]. The order was written adjacent to the PRN Medication area and read: ""[MEDICATION NAME] 2.5 mg po (by mouth) @ 4 pm & HS (bedtime)"". The order was undated, unsigned, and did not identify the [DIAGNOSES REDACTED]. The physician orders [REDACTED]."" The Medication Administration Record [REDACTED]@ 4 pm and HS"", and the resident was routinely receiving the medication twice daily on a regular basis. During an interview with the director of nurses at 3:05 p.m. on 12/03/09, she stated she had spoken to the nurse who transcribed the order, and the nurse reported the physician instructed her to make the medication order continuous instead of PRN. She acknowledged the order had not been transcribed per facility policy (Taking Medication and Treatment Orders) onto a verbal / telephone order form.",2015-05-01
10357,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-12-03,428,D,0,1,5TIO12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure irregularities reported by the pharmacist during the drug regimen review were acted upon for one (1) of eight (8) sampled residents. Resident #53 was receiving Ativan and Ambien, and the pharmacist identified these medications had sedative side effects and asked the physician to evaluate the need for both medications. The physician was notified of this irregularity on 09/29/09 and failed to act upon the pharmacist's recommendation. Facility census: 56. Findings include: a) Resident #53 Review of the current physician's orders [REDACTED]. A review of the Pharmacy Consult Report (dated 09/27/09) found the pharmacist identified a drug irregularity, in that both drugs had sedative side effects. The recommendation stated, ""Please provide documentation in your progress notes why this resident needs two sedating drugs at HS (bedtime). If dual drug therapy is to continue, it is recommended that: a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual..."" The physician signed the report on 10/13/09 but did not record any response. A review of the physician's progress notes for 10/17/09 and 11/23/09 failed to find evidence the physician addressed the pharmacist's recommendations. In an interview with the director of nursing on 12/03/09 at 4:00 p.m., she could not find any additional information. .",2015-05-01
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
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
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
9636,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,155,D,0,1,6HX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, Hospice staff interview, and observation, the facility failed, for one (1) of eighteen (18) residents sampled, to allow refusal of treatment. The resident, who was also under the care of Hospice services, had requested through her medical power of attorney representative (MPOA) via the Physician order [REDACTED]. IV fluids had continued for a period of at least twenty-nine (29) days following the resident's hospitalization and return to the facility, with no evidence the facility recognized the right to refuse them and/or worked in conjunction with her physician and the Hospice agency to discontinue the IV fluids. Resident identifier: #13. Facility census: 105. Findings include: a) Resident #13 The medical record of Resident #13, when reviewed on 12/15/09, disclosed this [AGE] year old female had resided at the facility since 12/22/04. Her medical [DIAGNOSES REDACTED]. She had returned to the facility from her most recent hospitalization on [DATE], having been admitted to the hospital with [REDACTED]. On 12/08/09, the resident's attending physician wrote an order for [REDACTED]. The resident's medical record, when further reviewed, revealed she did not have the capacity to make her own medical decisions, as determined by her attending physician on 09/02/08. The most recent minimum data set (MDS), with an assessment reference date of 11/26/09, in the area of Cognitive / Decisionmaking described this resident as 3, severely impaired, rarely / never made decisions. The record disclosed a POST form which stated, This is a physician's orders [REDACTED]. Any section not completed indicates full treatment for [REDACTED]. All areas of the POST form were completed on 12/10/08, with the resident's MPOA signature noted in Section F. The document was reviewed on 11/30/09 with no changes noted. The form requested under Section A - Do Not Attempt Resuscitation; under Section B - Comfort Measures; under Section C - Antibiotics; and under Section D - IV fluids for a defined trial period. In Section E, it was noted these were discussed with MPOA, and under The Basis for These Orders Is was marked Patient's best interests (patient preferences unknown). The resident's medical record did not contain a Living Will document. Observation, during a wound care treatment on the afternoon of 12/15/09, found the resident was receiving an infusion of IV fluids. The infusion was [MEDICATION NAME], and it was infusing at forty (40) cc/per hour. [MEDICATION NAME], according to RxList Inc., the Internet Drug List at www.rxlist.com, is a sterile, nonpyrogenic, moderately hypertonic intravenous injection containing [MEDICATION NAME], a nonprotein energy substrate and maintenance electrolytes. [MEDICATION NAME] is indicated for peripheral administration in adults to preserve body protein and improve nitrogen balance in well-nourished, mildly catabolic patients who require short-term [MEDICATION NAME] nutrition. The source of the implementation of the IV fluids was found to be a physician's orders [REDACTED]. The resident was non-responsive during the wound care, even when turned from side to side by staff. When questioned as to the palliative purpose of the infusing fluids, the nurse completing treatment (Employee #113) stated she wasn't sure. When asked if the fluids had prevented a further decline in the resident's condition, the nurse stated, No. The facility's director of nurses (DON - Employee #99, when interviewed related to this observation on 12/15/09 at approximately 3:00 p.m., stated she did not know if the resident's MPOA had been contacted related to the continuation of the IV fluids at the time of re-admission from the hospital or at the time of the admission to Hospice Services. She did recall there had been discussion about the IV fluids among staff. Return to the medical record divulged a social services note, dated 11/30/09, stating, POST form discussed with Daughter / MPOA on 11/30/09 (sic) with no changes. This note also stated the resident has been exhibiting behaviors of refusing / spitting out meals and medications. The social worker (Employee #140), when interviewed on the morning of 12/16/09, was asked if she was aware the resident's current care was in contradiction with the POST form with respect to the continued administration of IV fluid infusion. The social worker stated that, during the care plan meeting for this resident on 12/08/09, when the resident's MPOA and Hospice nurse were present, Hospice staff had indicated they would address this situation. She made no mention of the issue being addressed at the time of the resident's re-admission to the facility on [DATE], or at the time of the documented Review of the POS [REDACTED] On 12/16/09 at 9:30 a.m., a Hospice nurse (Employee #142) was visiting the resident in her room. This nurse was questioned as to if Hospice staff had attempted to contact the resident's MPOA about the continued infusion of IV fluids, in light of her noted desires on the resident's POST form. It had now been eight (8) days since Hospice had become involved in the resident's care. The Hospice nurse stated he thought someone had tried to contact the MPOA with no success and that he had just met the resident for the first time. He further stated the physician had been contacted by facility staff the previous evening (on 12/15/09), following questioning by this surveyor, and he wanted the IV fluids to continue. The Hospice nurse could give no reason for the continued use of IV fluids and could not describe any palliative purpose the IV fluids may be serving. The Hospice nurse also stated that discontinuing the fluids was the decision of the resident's attending physician. When asked if the Hospice medical director might not intervene in a situation similar to this, the Hospice nurse responded, No. The Hospice nurse then described the resident's attending physician as sometimes being hesitant to act upon recommendations by Hospice staff. Later on this same day at approximately 2:00 p.m., the Hospice nurse informed this surveyor that the resident's MPOA had been contacted and her desire was to discontinue the IV fluid infusion. He stated a request for that order had been communicated to the attending physician. According to Hospice Philosophy, as noted by the Hospice Patient's Alliance and found at www.hospicepatients.org/hospic28.html, When appetite declines and your loved one is refusing food, it's quite difficult to accept. We all know that you have to eat to live, but what many of us don't know is that if your body can't process the food because of a terminal illness, forcing nutrition in will not prolong life. There is a natural process in the dying: decreased appetite, decreased thirst, gradual withdrawal from the concerns of this world and focus on concerns about death and taking care of 'unfinished business' with family. The refusal of food / nutrition, according to Hospice Philosophy, is a normal part of the dying process. At the time of the resident's admission to Hospice, the resident's MPOA, with the resident's best interest in mind, agreed to accept the Hospice philosophy. Review of the documents on the resident's medical record that had been provided to the MPOA at the time of admission disclosed a document entitled Section C: Bill of Rights. This document stated, Consistent with state laws, the patient's family or guardian may exercise the patient's rights when the patient is unable to do so. Hospice organizations have an obligation to protect and promote the rights of their patients. There was no evidence, through record review or staff interview, that the facility had made efforts to coordinate with the resident's MPOA, the Hospice Agency, and the resident's attending physician to effectively honor the desire for IV fluids only for defined trial period. There was no documentation of a plan to discontinue the IV fluids, a defined time period for their use was not designated, and there was no documented purpose for their use in providing palliative / comfort care to the resident. At the time of exit from the facility at 10:00 a.m. on 12/17/09, the IV fluids continued to infuse for this resident.",2015-10-01
9637,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,161,E,0,1,6HX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, staff interview, and interview with a representative of the State licensure agency (agency designated to as holder of surety bonds for State-licensed nursing homes), the facility failed to assure the security of all personal funds of residents deposited with the facility. This was true for sixty-five (65) residents whose accounts were reviewed. Facility census: 105. Findings include: a) When reviewed on [DATE] at 1:00 p.m., the surety bond submitted by the facility (bond # 6703) was found to have no stamp or signature indicating approval by the State Attorney General's Office for sufficiency of form and amount. When asked for a letter indicating the bond had been approved by the Office of Health Facility Licensure and Certification (OHFLAC), the facility's administrator (Employee #1) indicated the facility had recently sent the original bond to the State Attorney General's Office. The administrator provided an e-mail from the Genesis Health Care corporate office, which was sent to him on [DATE], stating the original bond was just sent to the state. A telephone call was made to OHFLAC on [DATE] at 2:00 p.m., inquiring as to whether the bond had been received in OHFLAC and approved by the State Attorney General's Office. A return e-mail, on [DATE] at 4:00 p.m., stated, Surety bond number 6703 was set to expire on [DATE]. The facility has submitted a renewal bond which was stamped as received in the office on [DATE]. This renewal bond has not yet been approved by the Attorney General's Office. The facility did not have a surety bond in effect at the time of the survey, and the renewal certificate had not been requested until after the original bond had expired. This information was shared with the facility's administrator at 9:00 a.m. on [DATE], and her voiced understanding.",2015-10-01
9638,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,203,C,0,1,6HX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's uniform notification of transfer / discharge form, the facility failed to correctly communicate to all residents and responsible parties the contact information of the single State agency responsible for reviewing all appeals of the transfer / discharge decision. Instead, the uniform notice gave residents / responsible parties the option to file such an appeal with six (6) different agencies. This error in the uniform notice may lead a resident to mistakenly file an appeal request with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. Additionally, the uniform discharge notice provided incorrect information regarding the agency designated in West Virginia to provide protection and advocacy to individuals with mental [MEDICAL CONDITION] and mental illness. This deficient practice has the potential to affect all residents of the facility. Facility census: 105. Findings include: a) Review of the uniform notification of transfer / discharge form provided by the facility revealed the following: You have the right to appeal this action to: This was followed by the names and contact information of the Office of Inspector General Board of Review, the State Ombudsman, and the Regional Ombudsman. Immediately following the above list of names and addresses was: Or, for the resident with developmental disabilities or those who are mentally ill, you may contact: This was followed by the names and contact information for West Virginia Advocates, Local Mental Health and Medicaid Fraud. This uniform notification form contained the following errors: 1. The Office of Inspector General is the only agency in WV to which appeals of transfer / discharge decisions may be made. None of the five (5) other agencies identified in the notice is responsible for this activity. This error in the uniform notice may lead a resident to mistakenly file an appeal with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. 2. The single agency designated in WV to provide protection and advocacy to individuals with both mental [MEDICAL CONDITION] and mental illness is West Virginia Advocates, Inc. (not Local Mental Health). Medicaid Fraud does not provide these services.",2015-10-01
9639,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,225,E,0,1,6HX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's grievance / complaint files and staff interview, the facility did not ensure six (6) allegations of neglect were reported immediately to the State survey and certification agency, in accordance with State law. Complaints were reviewed for the previous three (3) months. This was found for six (6) of forty-three (43) complaint records reviewed. Resident identifiers: #112, #67, #113, #3, #45 and #46 (a married couple), and #108. Facility census: 105. Findings include: a) Record Review 1. Resident #112 Review of the facility's resident / family complaint file, on the afternoon of 12/15/09, found an allegation made by the daughter of Resident #112. The daughter complained she had visited on 10/05/09, and found soiled pants balled up on the floor, and the pad used to lift the resident smelled so badly from urine that it made her eyes burn. She further stated the facility was filthy. These are allegations of neglect. There was no evidence these allegations were reported to the appropriate State agency. 2. Resident #67 Review of the facility's resident / family complaint file, on the afternoon of 12/15/09, found Resident #67 had complained, to facility staff on 12/07/09, that a certified nursing assistant (CNA) told him he was not allowed out of bed when he needed to go to the bathroom. He alleged the CNA made him use the bedpan and would not help him get into his wheelchair so he could use the bathroom. This is an allegation of neglect. There was no evidence this allegation was reported to the appropriate State agency. 3. Resident #113 Review of the facility's resident / family complaint file, on the afternoon of 12/15/09, revealed Resident #113 complained, to facility staff on 11/25/09, that when she asked a CNA to take her to the dining room for the activity, the CNA stated she needed to push herself, because she needed to exercise her arms. She was upset because she was not assisted to the dining room. This is an allegation of neglect. There was no evidence this allegation was reported to the appropriate State agency. 4. Resident #3 Review of the facility's resident / family complaint file, on the afternoon of 12/15/09, revealed Resident #3's family complained, to facility staff on 11/24/09, that she was upset at how long the resident's hair had been when she was in to visit. She said she had asked numerous times for him to have his hair cut every six (6) weeks and was quoted as saying, This is neglect and I won't stand for it. This is an allegation of neglect. There was no evidence this allegation was reported to the appropriate State agency. 5. Residents #45 and 46 Review of the facility's resident / family complaint file, on the afternoon of 12/15/09, revealed Residents #45 and #46 (a married couple) complained, to facility staff on 11/02/09, that staff was not assisting them with anything. They were quoted as saying, The people you have working for you should be trained enough to know how to help a person. They also complained the bed hadn't been made in six (6) days and that they were not being given the results of labs and x-rays. These are allegations of neglect. There was no evidence these allegations were reported to the appropriate State agency. 6. Resident #108 Review of the facility's resident / family complaint file, on the afternoon of 12/15/09, revealed Resident #108's family complained, to facility staff on 12/08/09, that the resident's [MEDICAL CONDITION] was now so bad that three toes, or possibly entire foot, now had to be amputated. The family wanted to know how it got to this point without staff knowing or doing anything about it. This is an allegation of neglect. There was no evidence this allegation was reported to the appropriate State agency. b) Staff interview The facility's administrator (Employee #1), when interviewed on 12/15/09 at 2:30 p.m., stated that any complaints or concerns were reviewed by him and his management team every day, and decisions were made regarding what complaints required reporting to the appropriate State agency. Each of these complaints was discussed, and he concurred that they constituted allegations of neglect and required reporting to the appropriate State agency under State law.",2015-10-01
9640,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,246,D,0,1,6HX711,"Based on observation and staff interview, the facility failed to accommodate the individual needs of one (1) of eighteen (18) sampled residents and one (1) randomly observed resident, who were seated at a table during meals that required them to reach up in unnatural manner to obtain food from their plates. The food was not placed at height that would allow the residents to independently eat from their plates in a comfortable manner. Resident identifiers: #37 and #87. Facility census: 105. Findings include: a) Residents #37 and #87 During the noon meal in the B Dining Room on 12/15/09 at 12:30 p.m., observation found two (2) residents seated at a table that was so high, the residents had to reach up in an unusual manner to obtain food from their plates, which were at about chin level. Resident #37 was seated in an upholstered facility chair with a very low seat, and Resident #87 was seated in a small wheelchair with a seat that was too low to put her into a natural position at the table to access her plate. This observation was bought to the attention of a facility staff member and a restorative nursing assistant (Employee #81) who was seated at the table encouraging the two (2) residents (as well as several others) to eat. Employee #81 confirmed the two (2) residents being observed were part of the Restorative Feeding Program and required encouragement / reminders to eat. Employee #81, when asked if the position the residents were in in relation to their plates was one that was normally assumed by individuals while eating, stated, They're low. When asked if she thought this was an optimal position to encourage the residents to feed themselves, she stated, No, they're too low.",2015-10-01
9641,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,278,D,0,1,6HX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure a quarterly minimum data set (MDS) assessment was accurate. This was true for one (1) of eighteen (18) sampled residents, whose quarterly MDS was inaccurate relating to bowel incontinence and the presence of pressure ulcers. Resident identifier: #16. Facility census: 105. Finding include: a) Resident #16 Resident #16's medical record, when reviewed on 12/16/09 at 9:45 a.m., revealed a [AGE] year old female who was admitted to the facility on [DATE]. The resident was currently receiving treatment at a wound center for a Stage III pressure ulcer, and the resident required assistance with all personal care. Review of the facility form titled Activities Of Daily Living Flow Chart for November and December 2009 disclosed the resident was incontinent of bowels. Resident #16 was observed in her room at 4:00 p.m. on 12/15/09. The treatment nurse (Employee #114) was providing treatment to the resident's Stage III pressure ulcer on the sacrum. The resident was noted to be incontinent of bowel at that time. The quarterly MDS, with an assessment reference date of 10/08/09, indicated the resident did not have any pressure ulcers and was continent of bowels. The MDS coordinator (Employee #97), when interviewed on 12/16/09 at 2:30 p.m., acknowledged the quarterly MDS, dated [DATE], was inaccurate relating to pressure ulcers and bowel incontinence.",2015-10-01
9642,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,280,D,0,1,6HX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed, for three (3) of eighteen (18) residents reviewed, to review and revise their care plan following a change in condition and/or care needs. One (1) resident experienced a fall with a resulting fracture with no update / revision to the care plan. One (1) resident was determined to be nearing the end-of-life and was admitted to the services of Hospice with no revision to the care plan. One (1) resident's resident assessment protocol (RAP) summary stated that a care plan was necessary for the use of [MEDICAL CONDITION] medications, but the care plan did not contain this information. Resident identifiers: #66, #13, and #49. Facility census: 105. Finding include: a) Resident #66 The medical record of Resident #66, when reviewed on 12/16/09, disclosed this [AGE] year old female had multiple [DIAGNOSES REDACTED]. An incident / accident report, dated 09/05/09, stated the resident was found lying on the floor on her back with both feet in front, complaining of right leg and hip pain. The resident was transferred to a local emergency room for evaluation. A nurse's note, on 09/07/09, stated the resident's admitting [DIAGNOSES REDACTED]. The resident returned to the facility at 1:45 p.m. on 09/09/09. The resident's history and physical related to this hospitalization , when reviewed, disclosed the resident was confused as usual, her general condition was very poor, and prognosis was guarded. The document described a decline in condition over the previous several months. The resident had been admitted to the services of Hospice on 07/07/09, with an admitting [DIAGNOSES REDACTED]. The resident's plan of care was last updated on 11/30/09. A focus area for the resident was documented to be: At risk for falls r/t (related to) hx (history) of chronic pain. The goal for this focus area, which was the same goal that had been initiated on 08/15/08, stated: Resident will have no falls with injury requiring hospitalization thru next review. The interventions determined by staff to be necessary to meet these goal had not been revised since 08/15/08 and included: Evaluation of medications, monitor for orthostatic [MEDICAL CONDITION], place all personal items within reach, monitor for and assist with toileting needs. No additional interventions had been developed following the resident's fall on 09/05/09 which resulted in new fractures of the vertebrae. The only mention of the resident's fractured vertebrae was noted in another focus area which described the resident's need for assistance with activities of daily living due to cognitive loss / dementia, recent falls and has compression fractures. The only added intervention following the fall of 09/05/09 was up with assistance only. The resident was noted by the physician to be confused as usual and her [DIAGNOSES REDACTED]. Her care plan described cognitive loss and dementia which, all combined, would typically render the resident unable to call for assistance before attempting any ambulation. There was no mention of lowering the resident's bed, placing mats, etc., that may have been beneficial to the resident. b) Resident #13 The medical record of Resident #13, when reviewed on 12/15/09, disclosed this [AGE] year old female had resided at the facility since 12/22/04. Her medical [DIAGNOSES REDACTED]. The resident had returned to the facility from her most recent hospitalization on [DATE], after having been admitted to the hospital with [REDACTED]. On 12/08/09, the resident's attending physician wrote an order for [REDACTED]. The resident's available plan of care, when reviewed, made no mention of Hospice Services. The document entitled Resident Care Plan Conference, which the facility used to document attendance at resident care plan meetings, stated a conference was held on 12/08/09, with the resident's family and a Hospice nurse present. No notation on the care plan reflected any review or revision to the plan having occurred on this date. The facility's director of nurses (DON - Employee #99), was made aware of this finding at approximately 1:00 p.m. on 12/15/09. At 3:30 p.m. on 12/15/09, the DON provided documentation that had been faxed to the facility by the Hospice agency, which was entitled Plan of Care for: (name of Resident #13). The document was a generic form which had not been individualized for this resident, nor was there evidence that any of the interventions mentioned on the generic care plan had, indeed, been implemented. At the time of exit on 12/17/09, no further evidence was provided to reflect the resident's care plan had been updated to address her needs at the time of the admission to Hospice services on 12/08/09. c) Resident #49 Review of Resident #49's medical record revealed she incurred a significant change in condition, an increase in moods and behaviors, and the use of [MEDICAL CONDITION] medications following a urinary tract infection which required a hospitalization . Subsequently, a comprehensive MDS, with an assessment reference date 11/21/09, was completed to reflect the significant change in condition. The accompanying RAP summary, dated 11/29/09, noted the interdisciplinary team's decision to revise the care plan to address the use of [MEDICAL CONDITION] medications. However, the interdisciplinary team failed to develop a care plan for [MEDICAL CONDITION] medications as they said they would. Review of the medical record revealed the resident was prescribed antipsychotic, antidepressant, and antianxiety medications for daily use. The DON was informed of these findings 12/16/09 at 3:00 p.m., and by the end of the day, the care plan for Resident #49 was updated to include the use of [MEDICAL CONDITION] medications.",2015-10-01
9643,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,309,D,0,1,6HX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to administer medications ordered by the physician in a timely manner. This was evident for one (1) of eighteen (18) sampled residents. Resident identifier: #49. Facility census: 105. Findings include: a) Resident #49 Review of the medical record revealed Resident #49 was exhibiting uncommon behaviors attributed to the onset of a urinary tract infection. A urinalysis and culture and sensitivity was ordered by the physician 10/30/09, but it was not obtained until 11/03/09, due in part to the resident's lack of cooperation. An oral antibiotic ([MEDICATION NAME]) was prescribed three (3) times daily beginning 11/03/09, but it was not begun until at 8:00 a.m. on 11/04/09. The physician's order did not specify to wait until the following day to begin the antibiotic. [MEDICATION NAME] was discontinued after she was seen by the physician on 11/04/09, and new orders were given to begin [MEDICATION NAME] 0.5 mg IM (intramuscular) one (1) hour prior to [MEDICATION NAME] 1 Gram IM daily for one (1) week for a urinary tract infection. However, the injectable antibiotic was not begun until the following day, at 8:00 a.m. on 11/05/09. The physician's order 11/04/09 did not specify to wait until the following day to begin the [MEDICATION NAME]. Documentation in the evening shift nurse's notes, dated 11/04/09, recorded Resident #49 refused all evening (PM) medications, refused all PM care, and refused to eat; however, there was no documentation in the nurse's notes on 11/4/09 staff having notified the physician of the medication refusal, nor was there any documentation by the 11-7 shift of any attempts to initiate the new orders for the injectable antibiotic, nor were there any nurse's notes for the resident's condition on the 11-7 shift of 11/05/09. The urine culture and sensitivity report, dated 11/05/09, noted the organism was resistant to [MEDICATION NAME] (Bactrim), but was susceptible to [MEDICATION NAME] ([MEDICATION NAME]); [MEDICATION NAME] was discontinued at 1:00 p.m. on 11/05/09. The resident had received only two (2) of a potential five (5) opportunities to receive [MEDICATION NAME], and received only one (1) of a possible three (3) opportunities to receive [MEDICATION NAME]. Subsequently, she was admitted to the hospital on [DATE], after having received only one (1) dose of the injectable [MEDICATION NAME]. During interview with the director of nursing on 12/16/09 at 3:00 p.m., she said she would have expected the nurses to initiate medication changes more promptly.",2015-10-01
9644,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,323,E,0,1,6HX711,"Based on observation and staff interview, facility staff failed to assure the resident environment was as free as possible of accident hazards, by leaving the entry keys in the door of the medication preparation room on the A Hall and in the absence of supervision of any staff member. This practice had the potential to affect all residents who resided on the A Hall of the building. Facility census: 105. Findings include: a) During a random tour of the facility on 12/15/09 at approximately 12:15 p.m., the medication preparation room on A Hall was observed to have a set of keys hanging in the door knob. There was no staff in direct observation of the keys. The facility's administrator (Employee #1) was in the vicinity, across the hall involved in conversation with staff. The keys were bought to the attention of the administrator, who immediately removed them and stated his plan to find out who had left them there. This medication room was entered on 12/15/09 at approximately 4:00 p.m., to assess the contents of the room. Although the refrigerator for medication was locked, the shelves did display bottles of stock medications such as mild pain medication, laxatives, vitamins, etc.",2015-10-01
9645,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,371,F,0,1,6HX711,"Based on observation and staff interview, the facility failed to store and serve food under sanitary conditions. This was evident in three (3) separate instances, and had the potential to affect all residents in the facility who obtain nourishment from the dietary department. Facility census: 105. Findings include: a) Observation of the kitchen work area, during initial tour on 12/14/09 at 2:35 p.m., revealed the presence of a service technician repairing a juice dispensing machine. He wore a full, thick beard with no hair restraint prior to surveyor intervention. The director of food service (Employee #102) agreed he should have worn a beard restraint and began locating an appropriate beard cover for him to wear. b) Observation, upon initial tour on 12/14/09 at 2:30 p.m., revealed the presence of approximately one and a half (1-1/2) to two (2) dozen washed plastic glasses inverted on a plastic tray with no mat beneath them, nor any other method whereby the glasses could air dry and drain appropriately. The director of food service lifted one (1) of the glasses from the tray, which revealed the rim of the glass setting in water and a small amount of water pooled beneath the glass. She cited the reason for having no mat or anything beneath this tray of glasses to facilitate air drying was because dietary staff planned to use these glasses soon and not store them. c) Observation of the emergency food supply, on 12/14/09, revealed one (1) large can of Ravioli that was past the expiration date printed on the can from the factory. Also noted were twelve (12) large cans of sausage gravy dated 04/22/08 with black marker on the box with no manufacturer's expiration dates upon them; a box of canned tomato juice dated 08/27/08 in black ink; and a box of canned apple juice dated 08/08 in black ink; none of which had manufacturer's expiration dates printed on the cans. The director of food service said the dates in black ink represented the dates they were placed in the emergency food supply closet; they typically rotate stock every six (6) months to prevent waste; and she will remove those cans tomorrow when the food order arrives. The above findings were reported to the director of nursing at 3:00 p.m. on 12/16/09. She then asked the director of food service for the policy on food rotation. Subsequently, the policy for Emergency Menu and Food Supply Guidelines was produced, which stated the emergency food supply was to be rotated every six (6) months to maintain quality. Employee #102 stated a shipment of food arrived today, and she replaced the canned juice and sausage gravy, and had removed the outdated large can of Ravioli yesterday.",2015-10-01
9646,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,428,D,0,1,6HX711,"Based on record review and staff interview, the facility failed to ensure the physician acted upon irregularities reported by the pharmacist in the medication regimens of two (2) of eighteen (18) residents, to include documenting the rationale for declining to implement a gradual dose reduction for Resident #80's antidepressant and failing to document the risk versus benefit of continuing the use of an antipsychotic three (3) times a day for Resident #61. Resident identifiers: #80 and #61. Facility census: 105. Findings include: a) Resident #80 Review of the medical record revealed the facility's pharmacist made the recommendation, on 10/20/09, for Resident #80 to have a gradual dose reduction (GDR) of an antidepressant she had been on for the preceding six (6) months. The physician declined to order a gradual dose reduction at this time but failed to document a rationale for this decision. The director of nursing (DON) was informed of this finding at 3:00 p.m. on 12/16/09. At 4:33 p.m., she received a fax from the physician's office in response to her fax on 10/20/09, requesting the rationale for the contraindication for the GDR. It was signed and dated by the physician on 10/21/09 declining the GDR at that time, as it was deemed likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder. However, the rationale was not written. No further evidence nor physician's progress note was produced giving the rationale. b) Resident #61 Review of the medical record revealed Resident #61 was prescribed Seroquel 150 mg three (3) times daily. Further review of the medical record revealed the pharmacist made the recommendation on 07/08/09, for Resident #61 to have a re-evaluation of the current dose of Seroquel; if it is to be continued at the current dose, the pharmacist asked for the physician to document an assessment of risk versus benefit. The physician signed but did not date the pharmacist's Consultation Report, and did not document the rationale for continuing the medication in that dosage. Instead, he noted he had re-evaluated this therapy and did not wish to implement any changes, and the area to record the rationale was left blank. The DON was informed of this finding at 3:00 p.m. on 12/16/09. She noted the facility did document behaviors and employ non-pharmacological interventions for her behaviors, and the resident had monthly psychiatric visits to monitor her. However, no physician's progress notes or other documentation was produced with the prescriber's assessment of risk versus benefit indicating Seroquel at that dosage continued to be a valid therapeutic intervention for the individual, in response to the pharmacist's request for this information.",2015-10-01
9647,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,441,E,0,1,6HX711,"Based on observation and staff interview, the facility failed to implement infection control practices to provide a safe and sanitary environment to residents, by storing the ice scoop used to obtain ice for resident water pitchers on the B Hall in an unclean receptacle. This practice had the potential to affect all residents who reside on the B Hall of the facility. Facility census: 105. Findings include: a) During a random tour of the facility at approximately 12:15 p.m. on 12/15/09, the nourishment room on the B Hall was entered. This room housed an ice maker from which staff obtained ice to refill resident water pitchers. Upon closer observation, it was noted that the receptacle on the wall in which the ice scoop was held had a build up of a white substance in the bottom. The facility's administrator (Employee #1), when asked to observe the wall receptacle, confirmed the presence of debris in the bottom of the receptacle, which would touch the scoop when stored, and immediately removed the receptacle for proper cleaning.",2015-10-01
9648,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,514,D,0,1,6HX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure clinical records were accurate. The monthly physician's orders were inaccurate relating to nutritional supplements for one (1) of eighteen (18) sampled residents. Resident identifiers: #28. Facility census: 105. Findings include: a) Resident #28 Resident #28's medical record, when reviewed on 12/15/09 at 9:00 a.m., revealed a [AGE] year old male who was readmitted to the facility on [DATE], after a hospitalization for pneumonia. Review of the dietitian's nutritional assessment, dated 11/13/09, noted the dietitian's recommendation was to discontinue the Ensure supplement and start house supplement three (3) times a day. Review of the current physician's orders for December 2009 revealed the house supplement was ordered twice a day. The unit manager registered nurse (RN - Employee #86), when interviewed on 12/16/09 at 10:30 a.m., confirmed the December 2009 monthly physician's orders for the house supplement was inaccurate. The RN provided written evidence the house supplement was offered to the resident three (3) times a day per the dietitian's recommendation.",2015-10-01
9692,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,152,D,0,1,9PJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to ensure each resident's health care decisions were made by the individual appointed by the resident. Additionally, determination of the resident's incapacity did not clearly indicate the nature of the incapacity. This was true for one (1) of thirteen (13) sampled residents. Resident identifier: #17. Facility census: 72. Findings include: a) Resident #17 1. Review of the resident's medical record found the resident had appointed Individual #1 as her first choice to be her medical power of attorney representative (MPOA). She had appointed Individual #2 as the successor MPOA should Individual #1 be unable, unwilling, or disqualified to serve. Further record review found Individual #2 had signed the physician's orders [REDACTED]. However, no evidence was found in the medical record indicating Individual #1 was unwilling or unable to serve, or that he had been disqualified. On the morning of 01/07/10, Employee #95 was asked whether something had happened to Individual #1, as Individual #2 had been making the resident's health care decisions. She said she did not know but would find the answer. At 9:20 a.m. on 01/07/10, Employee #95 said she had contacted Individual #2, who said she had been making the resident's health care decisions because Individual #1 had been working a lot of overtime. 2. This resident was admitted on [DATE]. A Physician Determination of Capacity had been completed on 12/10/09, by a physician other than the resident's primary physician. The form contained the following sentence: In my opinion this patient HAS ___ or LACKS ___ sufficient mental or physical capacity to appreciate the nature and implication of health care decisions. The physician placed a checkmark in the blank beside Lacks. In a section directing Please check the nature of the incapacitation as evidenced by:, the evaluator recorded: Disorientation to person, place, and time. The word place had been circled. There was no check placed by Inability to understand or make medical decisions. This was discussed with Employee #95, who agreed it appeared the physician had indicated the resident was disoriented to place, which would not necessarily mean she was unable to understand the implications of health care decisions.",2015-10-01
9693,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,203,B,0,1,9PJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's uniform notification of transfer / discharge form and staff interview, the facility failed to correctly communicate to all residents and responsible parties the contact information of the appropriate state agencies for residents with developmental disabilities or those who are mentally ill. This error in the uniform notice has the potential to lead a resident/responsible party to contact the wrong agency to provide assistance, and may interfere in the resident's ability to exercise his or her right to contact. The uniform discharge notice provided incorrect information regarding the agency designated in West Virginia to provide protection and advocacy to individuals with mental [MEDICAL CONDITION] and mental illness. This deficient practice has the potential to affect all residents of the facility with developmental disabilities or mental illness. Facility census: 72. Findings include: a) Review of the uniform notification of transfer / discharge form provided by the facility revealed the following: Or, for the resident with developmental disabilities or those who are mentally ill, you may contact: This was followed by the names and contact information for West Virginia Advocates Local Mental Health and Medicaid Fraud. This uniform notification form contained the following errors: - The single agency designated in WV to provide protection and advocacy to individuals with both mental [MEDICAL CONDITION] and mental illness is West Virginia Advocates, Inc, not West Virginia Advocates Local Mental Health. - Medicaid Fraud does not provide protection and advocacy services to persons with mental [MEDICAL CONDITION] and/or mental illness.",2015-10-01
9694,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,225,E,0,1,9PJH11,"Part I -- Based on personnel file review and staff interview, the facility failed to obtain statewide criminal background checks for eight (8) of ten (10) sampled employees, and failed to obtain an out of state background check for one (1) employee who had lived and/or worked in another state for many years. Employee identifiers: #19, #12, #59, #39, #30, #7, #72, and #76. Facility census: 72. Findings include: a) Employees #19, #12, #59, #39, #30, #7, #72, and #76 During review of sampled personnel records 01/05/10 at 1:30 p.m., Employee #89 agreed the following eight (8) employees had no evidence of having had a statewide criminal background check through the West Virginia State Police: Employees #19, #12, #59, #39, #30, #7, #72, and #76. Employee #89 confirmed Employee #30 had no out of state criminal background check for another state in which he resided for many years. Employee #19 was a nursing assistant whose services were being obtained through a temporary staffing agency. Her personnel filed contained a card, dated 09/29/09, stating a criminal background check through the West Virginia State Police was in progress with no results. Employee #89 said she would call the agency to obtain results, but nothing more was heard on the subject. These findings were reported to the director of nursing and the administrator at 3:30 p.m. on 01/07/10. No further information was provided. --- Part II -- Based on review of the facility's complaint files and reported allegations of resident abuse / neglect, and staff interview, the facility failed to thoroughly investigate and/or report all allegations of resident abuse / neglect to State agencies as required. Four (4) of nineteen (19) Complaint / Grievance forms reviewed contained allegations of physical and/or verbal abuse, or neglect. Resident identifiers: #79, #78, #77, and #65. Facility census: 72. Findings include: a) Resident #79 1. A Complaint / Grievance form, dated as received on 01/12/09, included: Resident stated, 'The CNA (certified nursing assistant) emptied my urinal & never returned it. I needed it & it wasn't by my bed. The CNA turned me extremely hard when changing me.' It was also noted on the page the concern was reported to the administrator, director of nursing, and a registered nurse supervisor. In response to the question What other action was taken to resolve concern (be specific)? was written CNA suspended until investigation completed and CNA to be educated. 2. A handwritten page, dated 01/13/09, was attached to the Complaint / Grievance form. The page had Incident Report written at the top, as well as the resident's name and the name of a licensed social worker (no longer an employee of the facility). The report included, Stated he drinks a lot of water and cannot go to the bathroom by himself and diaper got wet. So he rang the call light for help at 11:00 pm. A tall lady came in, . She was in a hurry and had a mean, hateful attitude, she pushed (resident's first name) over on his side, with such force, that he was afraid his pelvic bone might of been broken again, it hurt him. She changed his diaper & bed pad real quick with a mean, nasty attitude. She left then came back at 12:00 midnite made a remark and accused (resident's first name) of keeping his roommate awake. After she left, he was under tremondous (sic) stress and could not find the urinal and he thought she had left the urinal in the bathroom on purpose and he did not have access to it, he felt that she did it on purpose. So he urinated in the plastic glass on the bedside table, and then he dumped it on the floor. Then he looked for the call button and could not find it, then he saw it on the chair, where the lady had set it, he asked his room mate (sic) if he could reach it and push it, but he was not able to. (Resident's first name) continued struggling and reached through the side bar and got the call light, but decided he did not want the lady to return. He did not sleep and waited until 6:00 AM for the fay shift. Then he rang the button, . He was d___ (illegible) and exhausted. (Resident's first name) said it was a violation and his room mate could verify it, because he could not sleep on account of his pain level. He will D/C (be discharged ) to home on 1-14-09 at 8:00 pm. The last page regarding this complaint / concern was an immediate fax reporting of allegations to the nurse aide registry. The only items marked on the form were No in answer to the question Is this report being submitted within 24 hours of the incident?, and UTD (unable to determine) exact date of incident in response to If No, please explain. The remainder of the form was blank. The alleged perpetrator's name did not appear on any of the three (3) pages. This report was compared to those that had been reported to State agencies, i.e., the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the Ombudsman. There was no evidence the incident had been reported. The social worker and the director of nursing identified in the report were no longer employed by the facility. b) Resident #78 A Complaint / Grievance form, dated as received on 05/17/09, included Resident had c/o (complaint of) care given her by CNA. CNA assigned to resident was (CNA's first name). Resident stated she told CNA she was wet and sheets were wet. Resident reported that CNA stated, 'Well there is a first time,' did not (symbol for change) resident, resident laid in wet bed. Employee #74 noted she had spoken with the CNA about the resident's concerns. She wrote, CNA defensive in reply - 'she doesn't like us (names of two (2) CNAs). It was also noted the resident's bed was changed and the CNA apologized. There was no evidence this allegation was reported to the required agencies. c) Resident #77 On 05/16/09, a Complaint/Grievance form was initiated for Resident #77. He reported his call bell was not answered in a timely manner, he did not get help to the bathroom, and his medications were not given at the correct time. The investigator noted she spoke with the CNA and the nurse assigned to the resident. It was not noted whether the issue had or had not been verified. From the verbiage of the report, it appeared the resident's complaints were not limited to an isolated incident; however, there was no evidence any interviews were conducted other that the resident and his spouse, one (1) CNA, and one (1) nurse. There was no evidence this was reported to the State agencies. d) Resident #65 A Complaint / Grievance form, dated as received on 02/02/09, noted, Resident was crying in her room said '(employee's name) hates me.' She said that her nurse waved her 'Finger' in my face.' The social worker (Employee #95) noted, Met with resident, she related that there was no problem, that she and her nurse have difference (sic) of opinion and that is between them. There was no evidence of interviews with the nurse or any other staff regarding the incident. There was no evidence this allegation had been reported to the State agencies. e) These issues were discussed with the Employee #95 the afternoon of 01/07/10 with no additional information provided.",2015-10-01
9695,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,272,D,0,1,9PJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, the facility failed to ensure an accurate assessment of a resident's urinary continence status had been completed. Documentation of the summary information regarding additional assessment, performed through the resident assessment protocols (RAPs), was not in agreement with the coding on the minimum data set assessment (MDS) that triggered completion of the RAP. Resident identifier: #32. Facility census: 72. Findings include: a) Resident #32 The significant change in status MDS, with an assessment reference date (ARD) of 08/12/09, indicated the resident was usually continent of bladder. The significant change in status MDS assessment, with an ARD of 10/10/09, indicated the resident was frequently incontinent of bladder. The RAP for 'Urinary Incontinence and Indwelling Catheter' completed for the latter, on page 9 of 27, included, RAP triggered by: H1b = 3 FREQUENTLY INCONTINENT. A few lines below that, under Nature of the problem / condition; a nurse had written, Resident has impaired cognition secondary to effects of [MEDICAL CONDITION] disorder she has occasional episodes of urinary incontinence. See urinary incontinence assessment 08/22/09, see CNA flow sheet 09/27/09 - 10/10/09. On page 10 of 27, the RAP was continued. In the section for Describe impact of this problem / need on the resident and your rationale for care plan decision (Include complications and risk factors and the need for referral to other health professionals): the nurse wrote, Resident triggered on this rap d/t (due to) occasional urinary incontinence. The RAP had been completed by a registered nurse (RN) whose name did not appear on the current employee list, and it was co-signed by Employee #84. Although the computer-generated RAP form had identified the resident as frequently incontinent of urine, the assessor wrote the resident was occasionally incontinent of urine. There was no indication the decline in continence had been identified by the assessor and/or attempts made to determine potentially reversible causes, nor had it been indicated the decline was transient and had only been evident during the assessment look-back period.",2015-10-01
9696,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,279,D,0,1,9PJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to ensure each resident's care plan included measurable goals and interventions that contributed to the achievement of established goals, and failed to establish care plans that addressed the individual's needs as identified by the resident's assessment. Three (3) of thirteen (13) current residents on the sample were affected. Resident identifiers: #17, #32, and #22. Facility census: 72. Findings include: a) Resident #17 1. The resident's admission minimum data set assessment (MDS), with an assessment reference date (ARD) of 12/16/09, was coded to indicate she was occasionally incontinent of bowel and bladder. The urinary incontinence resident assessment protocol (RAP) was triggered due to the occasional incontinence and the use of pads or briefs coded on the assessment. The RAP narrative, completed on 12/23/09, also noted the resident was occasionally incontinent of urine. The problem statement identified in the care plan was: (Resident #17's first name) is frequently incontinent of bowel and bladder and is unable to cognitively or physically participate in a retraining program due to cognitive loss, right [MEDICAL CONDITION]. The frequency of the incontinence, as identified on the RAP completed 12/23/09, was not reflected on the goal established on 12/23/09. 2. The resident's MDS also identified the resident required the limited assistance of one (1) for eating. The care plan goal, established on 12/23/09, was for the resident to remain independent in eating. This did not reflect the resident's functional abilities identified on the resident's assessment. The interventions included: Shower and shampoo per schedule; Change clothing when soiled; clean and clip nails; etc. The only intervention related to promoting independence in eating was: Encourage resident out of bed for all meals. 3. Several of the goal statements did not include parameters by which progress (or lack of progress) toward achievement of the goal could be determined. An example was: Resident will increase social engagement as evidenced by participation in one to one visits, small groups and unstructured involvement with peers / family / friends / staff. This did not identify a frequency so it could be determined whether there was an increase in her social engagement. 4. A problem statement was: (Resident's first name exhibits distressed mood symptoms as evidenced by: sadness / depression anxiety. The associated goal was: Will have smallest most effective dose of medication as possible thru 90 day review. There was no indication of what type of medication the resident was to receive the smallest dose. b) Resident #32 1. The resident had a significant change MDS, with an ARD of 08/12/09, the identified the resident as being usually continent of urine. The significant change MDS, with an ARD of 10/10/09, was coded as the resident being frequently incontinent of urine. The resident's current care plan did not address the increase in incontinence as identified by her assessment. 2. The care plan also included a goal of: The Resident will experience maximum peripheral circulation without complications x 90 days. The interventions for this goal were all to assess and/or monitor. There were no interventions to promote maximum peripheral circulation. 3. Another goal was: (Resident #32's first name) will make safe daily decisions / choices when provided with cues and supervision throughout review. In the problem statement, it was noted the resident exhibited poor safety awareness at times such as ambulating alone with out her walker or wheelchair. The interventions were: Approach the resident in a calm, non-threatening manner; Staff will provide consistency in daily routine; Allow the resident to make daily decisions about clothing, daily care, meal alternatives, etc.; Provide daily schedule in room; Be alert to non-verbal clues of problems. There was nothing in approaches related to ambulating safely. c) Resident #22 Review of the RAP summary, dated 12/09/09, revealed the decision to care plan in multiple areas including cognitive, communication, activities of daily living, incontinence, moods, behaviors, falls, nutrition, fluid balance, pressure ulcer, and [MEDICAL CONDITION] medication. However, review of the current care plan, provided by the director of nursing on 01/05/10, revealed care plans for only five (5) of the above eleven (11) areas cited were developed. Concerns related to communication, activities of daily living, incontinence, mood, behaviors, and [MEDICAL CONDITION] medications were not mentioned in the care plan. During interview with the director of nursing on 01/07/09 approximately 9:30 a.m., these findings were discussed. No further evidence was produced prior to exit.",2015-10-01
9697,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,280,D,0,1,9PJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, resident interview, and staff interview, the facility failed to revise each resident's care plan as changes occurred in care needs and/or the services they received. Two (2) of thirteen (13) current residents on the sample were affected. Resident identifiers: #46 and #41. Facility census: 72. Findings include: a) Resident #46 Review of the medical record revealed Resident #46 developed a Stage II pressure ulcer to the coccyx identified on 12/15/09. physician's orders [REDACTED]. Interview with a nurse (Employee #67), on 01/06/10 at 10:00 a.m., revealed this resident repeatedly had experienced the recurrent development and healing of Stage II decubitus ulcers to the coccyx due, in part, to his being non-compliant with repositioning. Review of the current care plan revealed no mention of this resident having a Stage II decubitus ulcer, nor of his being non-compliant with repositioning; rather, the care plan stated: Stage I area on coccyx will decrease in size through 90 day review. During interview with the director of nursing (DON) on 01/07/09 at approximately 9:30 a.m., this finding was discussed with no new information provided prior to exit. b) Resident #41 1. Review of the RAP, dated 10/12/09, revealed the decision to care plan for [MEDICAL CONDITION] medication, but this did not occur. Review of the current care plan did not address or mention [MEDICAL CONDITION] medication. Review of current physician's orders [REDACTED]. 2. Review of the current care plan revealed a statement to comply with diet restrictions. However, he had none. Review of current physician's orders [REDACTED]. Carb Controlled. Review of the November 2009 Report Card from the [MEDICAL TREATMENT] center revealed hand-written suggestions for a high protein diet with supplement, and binders with all meals / snacks. 3. Review of the care plan revealed an intervention to Administer [MEDICATION NAME] as ordered. However, review of physician's orders [REDACTED]. 4. Review of the current care plan revealed plans to Weigh as ordered and Monitor weight per policy and report to dietician and physician (of) significant loss or gain. The care plan did not specify how often to weigh the resident. During an interview with the resident on 01/06/09, he stated he was weighed at the [MEDICAL TREATMENT] center before and after each [MEDICAL TREATMENT] treatment three (3) days per week. The physician's orders [REDACTED]. 5. Review of admission orders [REDACTED]. Review of the care plan revealed it was not revised to include contact precautions nor the [DIAGNOSES REDACTED]. 6. During interview with the DON on 01/06/10 at 5:50 p.m., the findings of care planning not being specific enough for this resident were discussed, as well as unclear communications in the care plan regarding coordination of services between the [MEDICAL TREATMENT] center desires and the facility. The DON said they were operating on new physician orders [REDACTED]. 7. Review of the care plan revealed special precautions were not cited with respect to the location of the resident's vascular access for [MEDICAL TREATMENT], such as no blood pressure on extremity, no intramuscular injections in extremity, no limb restraint. It did, however, call for smooth clamps at bedside, 4x4 gauze pads and cloth tape at bedside. Interview with the DON and administrator, on 01/07/10 at 3:30 p.m., revealed their understanding of a vas-cath, which did not require the presence of clamps and gauze at the bedside. No further information was received regarding the above findings.",2015-10-01
9698,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,285,D,0,1,9PJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the resident's medical record, the facility failed to ensure the pre-admission screening and resident review (form PAS-2000) was completed prior to the resident's admission to ensure she was placed in the most appropriate setting. One (1) of thirteen (13) current residents on the sample was affected. Resident identifier: #17. Facility census: 72. Findings include: a) Resident #17 review of the resident's medical record revealed [REDACTED]. The PAS-2000, pages 2 through 5, had been faxed from the hospital to the facility on [DATE]. However, page 6 of the document - the Eligibility Determination - was not completed by the reviewer and faxed to the facility until 12/10/09, the day after she had been admitted . The Eligibility Determination must be completed prior to admission to the nursing home to ensure the level of care and setting are appropriate for the individual.",2015-10-01
9699,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,311,D,0,1,9PJH11,"Based on observations, the facility failed to ensure each resident received services to maintain or improve the resident's ability to eat. Three (3) residents, who were observed at random during the initial tour of the facility, were not seated or positioned in a manner to facilitate the resident's ability to feed herself. Resident identifiers: #8, #44, and #45. Facility census: 72. Findings include: a) Resident #8 At lunch time on 01/04/10, the resident was observed eating in the TV/dining area near the nurses' station. The resident was seated in a small wheelchair. Her meal had been placed on an overbed table in front of her. The plate of food had been left on the warming base atop the tray. This resulted in the resident's food being at the height of her chin. She had to raise her hand and elbow to above shoulder height to reach her food. b) Resident #44 At lunch time on 01/04/10, this resident was also observed eating in the TV/dining area near the nurses' station. The resident was seated in a recliner being fed by a staff member. The recliner had not been raised, resulting in the resident being fed while at a 45 degree angle. c) Resident #45 At lunch time on 01/04/10, this resident was observed eating in her room. The resident was seated in recliner, and her food was on an overbed table. The plate on the overbed table was at the height of the resident's nose.",2015-10-01
9700,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,314,D,0,1,9PJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide care and services in accordance with physician orders [REDACTED]. There was no evidence a dressing to Resident #46's coccyx was changed every three (3) days in December 2009 and January 2010 as ordered by the physician. Resident identifier: #46. Facility census: 72. Findings include: a) Resident #46 Review of this resident's medical record revealed a lack of evidence treatments were a Stage II pressure ulcer to the coccyx were provided as ordered by the physician. Review of physician's orders [REDACTED]. Review of Resident #46's treatment administration record (TAR), on 01/06/09, revealed an order, initiated on 12/15/09, to cleanse, dry, and apply an Exuderm dressing to the coccyx every three (3) days and as needed for a Stage II pressure ulcer. Review of the December 2009 TAR revealed the nurse initialed the TAR on 12/15/09, signifying a dressing change was completed on that date. According to the order, the dressing was to have been changed on 12/18/09 and again on 12/21/09, but neither block was initialed by a nurse to indicate these had been completed. A dressing change was initialed as completed on 12/23/09. Three (3) days later, on 12/26/09, and again on 12/29/09, there were no initials signifying dressing changes were completed on these dates. Three (3) of six (6) scheduled dressing changes did not occur in accordance with the physician's orders [REDACTED]. Review of the TAR for January 2010 revealed the dressing was scheduled to have been changed on 01/02/10 and 01/05/10; however, there was no documentation on the TAR or in the nursing notes signifying any dressing changes had been completed in January prior to 01/06/10. Interview with the nurse (Employee #67), on 01/06/09 at 10:00 a.m., revealed, on 11/27/09, the resident's left buttock was reddened and, on 12/23/09, a Stage II pressure ulcer re-opened on the resident's coccyx. Employee #67 related the wound on the coccyx repeatedly healed and reopened due, in part, to the resident's refusals to be repositioned for pressure relief. After looking at the resident's records, she agreed no dressing changes to the coccyx were documented since January 2010, and the last wound measurements she could find on the TAR were recorded on 12/23/09. She noted this resident's dressing was changed on day shift, and she typically worked another shift. Interview with the director of nursing (DON), on 01/06/09 at 10:40 a.m., revealed their former treatment nurse quit suddenly and without notice, and they were in the process filling that position. In the interim, she informed all nurses they were responsible for dressing changes for their shifts until another treatment nurse was assigned. She said she could not address why dressing changes to the coccyx were not documented, but she stated it was certainly an expectation that nurses will document what they do. Because of the problems surrounding the treatment nurse position, she stated the facility conducted a skin sweep of all residents on 12/30/09. Subsequently, the DON produced a Wound Management Tracking Tool for Resident #46 which contained measurements of the coccyx pressure ulcer (1.5 cm x 1.0 cm.) on 12/30/09. She stated this was a tool which had been available but not used until recently, as she had held the director of nursing position for only the past two (2) weeks. Besides weekly measurements to assess wound healing, she stated measures to promote the healing process for this resident included a pressure reducing mattress, a foam pillow in his wheelchair, and a house supplement twice daily. She acknowledged that his refusal to allow staff to turn him was an issue with wound healing. During observation of the dressing change on 01/06/09 at 5:00 p.m., the medication nurse (Employee #70) measured the Stage II pressure ulcer on the coccyx at 0.9 cm x 0.8 cm. Comparatively, measurements dated 12/30/09 on the Wound Management Tracking Tool were 1.5 x 1.0 cm; and measurements on the Skin Integrity Report dated 12/23/09 were 1.0 cm x 0.9 cm.",2015-10-01
9701,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,315,D,0,1,9PJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility failed to ensure each resident received treatment and services to restore as much normal bladder function as possible. Voiding diaries were not completed for two (2) residents, nor was there any analysis of patterning from available data. One (1) resident had experienced a decline in urinary continence, but there was no evidence the cause of the decline had been assessed to determine whether it was reversible. Three (3) of thirteen (13) current residents on the sample were affected. Resident identifiers: #73, #32, and #22. Facility census: 72. Findings include: a) Resident #73 This resident had been admitted to the facility on [DATE]. The resident's admission minimum data set assessment (MDS), with an assessment reference date (ARD) of 11/27/09, indicated the resident was INCONTINENT - Had inadequate control BLADDER, multiple daily episodes; . The assessment also identified the resident had deteriorated in urinary continence in the last ninety (90) days. According to documentation found on the resident assessment protocol (RAP) for urinary incontinence, Resident has a [DIAGNOSES REDACTED]. He has declined in physical functioning d/t hospitalization for UTI (urinary tract infection) and dehydration and is having total urinary incontinence. Staff is going to try toileting program but potential maybe poor d/t cognitive deficit. He is also receiving OT (occupational therapy) for toileting. See hospital summary, incontinence assessment, CNA flow sheet OT eval 11/20/09 - 11/27/09. The RAP was also checked for UTI and locomotion. In the narrative section, the assessor noted the resident did have potential for some continence and that a toileting diary would be completed. A Urinary Incontinence Assessment was completed at the time of admission on 11/20/09. The following were noted: 1. In the section for Clinical Factors, an x had been place by None for Change in urinary status. It was also marked that he did not have stress or urge incontinence or retention with overflow. 2. An x had been place by Signs and symptoms of [MEDICAL CONDITION]. The RAP guidelines identify [MEDICAL CONDITION] as an acute medical emergency. Therefore, the [MEDICAL CONDITION] should have been further assessed prior to making a determination regarding his ability to participate in retraining program. 3. The nurse had placed an x by If no clinical symptoms or transient / reversible causes identified OR unable to be reversed (e.g. meds cannot be changed), urinary incontinence is persistent. Initiate Three-Day continence Management Diary and Proceed to Section B. An x had also been placed by If clinical symptoms or reversible/transient causes identified, develop plant to treat (e.g., evaluate and treat symptomatic UTI). Notify physician for treatment orders. Re-evaluate after treatment. There was no evidence the resident was re-evaluated after his [MEDICAL CONDITION] had been assessed further or after his medications were changed. He had been admitted on [MEDICATION NAME] and [MEDICATION NAME]. The [MEDICATION NAME] had been decreased on 11/25/09. (It was noted in an interdisciplinary note the family had wanted him taken off of the medications, because he had not taken any before.) 4. On the second page of the assessment, Section B, under Action: 1. Identify the type of urinary incontinence based on history and symptoms: the nurse had written Urge, Stress, Mixed, Functional. This was not in agreement with what had been marked on the first page, where it had been marked the resident did not have urge or stress incontinence. 5. The Three-Day Continence Management Diary was reviewed. The dates on the diary were 11/22/09, 11/23/09, and 11/24/09. The form had boxes to be completed on an hourly basis from 7:00 a.m. through 6:00 a.m. - a total of twenty-four (24) boxes for each day. - On 11/22/09, the 7:00 a.m., 10:00 a.m., and 3:00 p.m. boxes were marked for episodes of urinary incontinence. He was marked as being clean and dry six (6) times between 7:00 a.m. and 3:00 p.m. The boxes for 4:00 p.m. through 10:00 p.m. were blank. Between 11:00 p.m. through 6:00 a.m., he was marked as incontinent three (3) times, and as clean and dry five (5) times. - On 11/23/09, nothing was marked in the boxes from 7:00 a.m. through 10:00 p.m. From 11:00 p.m. through 6:00 a.m., he was marked as incontinent three (3) times, and clean and dry five (5) times. - On 11/24/09, between 7:00 a.m. and 2:00 p.m., boxes were marked for episodes of urinary incontinence once for bowel incontinence, and once for urinary incontinence. He was marked as being clean and dry six (6) times between 7:00 a.m. and 2:00 p.m. The boxes for 3:00 p.m. through 10:00 p.m. were blank. Between 11:00 p.m. through 6:00 a.m., he was marked as incontinent two (2) times, and as clean and dry six (6) times. Of the seventy-two (72) hours on the three-day voiding diary, only forty-one (41) had been completed to show whether or not the resident had been incontinent. The times the diary had been completed showed he had had been clean and dry up to four (4) hours. This would indicate the resident had some control over his bladder. There was no evidence the resident's voiding pattern had been reviewed, that he had been re-evaluated once his [MEDICAL CONDITION] cleared, or once his medications had been decreased / discontinued. There was no evidence he had been evaluated to ensure he was consuming sufficient fluids to promote continence. The elements needed to determined what type of program might best suit the resident's unique needs were not in evidence. The care plan indicated he was on a scheduled toileting plan and the goal was for him to have less than two (2) urinary incontinent episodes daily. The interventions did not offer any specific intervals at which he should be toileted. The interventions instructed he be assisted to toilet upon arising, before / after meals, before going to bed and as needed and at night, when he was awaken during rounds. This was discussed with the director of nursing in mid morning on 01/07/09. b) Resident #32 Review of the resident's significant change MDS assessments, with ARDs of 08/12/09 and 10/10/09, found the resident had been assessed as usually continent of urine in August, and frequently incontinent of urine in October. The urinary incontinence RAP, completed for the 10/10/09 assessment, was noted to have triggered because she was frequently incontinent. However, the narrative sections noted the RAP had triggered because she was occasionally incontinent. There was nothing to indicate she had only been frequently incontinent during the assessment reference period. The coding on the Activities of Daily Living Flow Chart for October 2009 indicated the resident was frequently incontinent during the look-back period for the assessment. She continued to be frequently incontinent the remainder of October 2009. The only additional assessment found for urinary incontinence was a Urinary Incontinence Assessment dated 08/22/09, which noted the resident was continent. The resident's care plan did not address her urinary incontinence. c) Resident #22 Review of the medical record revealed a Three-Day Continence Management Diary dated 11/24/09 at the time of admission. The instructions on this form state the diary must be initiated within seventy-two (72) hours of identifying incontinence or completion of treatment for [REDACTED]. Further review of the diary revealed this resident was checked on 11/25/09 at 11:30 p.m. and was found to be dry. No other assessments were entered on this form, and no other Three-Day Continence Management Diary was found in the medical record. However, review of the admission MDS found the assessor coded the resident's urinary continence status in the preceding fourteen (14) days as being frequently incontinent; i.e., tended to be incontinent daily, but some control is present. These two (2) assessments are contradictory. Review of Daily Skilled Nurse's Notes, dated 12/08/09, revealed this resident was incontinent of bowel and bladder most of the time, with bladder incontinence checked for both evening and night shifts. Review of lab work, dated 11/26/09, revealed Resident #22's white blood count was elevated at 12.7 and the lymphocytes were low at 15.2, indicative of bacterial infection; UTI (urinary tract infection) was hand written beside the white blood count. The urinalysis on the preceding day showed evidence of a urinary tract infection, and a hand-written note on the urinalysis report recorded the resident was on an antibiotic twice daily for seven (7) days beginning on 11/26/09 for a urinary tract infection. Also, a hand-written note on the physician's orders [REDACTED]. Additionally, the Medication Record for November 2009 contained an order for [REDACTED]. Review of the RAP summary completed in conjunction with the admission MDS revealed the decision to care plan for the resident's urinary incontinence. However, review of the care plan revealed no focus or interventions for incontinence, nor any mention of a voiding diary for analysis of the problem. These findings were discussed with the director of nursing on 01/07/09 at 9:30 a.m., and no further information was presented prior to exit.",2015-10-01
9702,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,431,E,0,1,9PJH11,"Based on observation and staff interview, the facility failed to label / date all vials of injectable insulin when initially opened, and failed to discard vials of injectable insulin after the allowed thirty (30) day time limit after opening the vial had elapsed. This was evident for two (2) of four (4) medication carts observed in the facility and had the potential to affect diabetics who receive insulin on the 100 and 400 hallways. Facility census: 72. Findings include: a) Observation of the medication cart on the 400 wing, on 01/06/10, revealed the presence of one (1) vial of Novolin-N inscribed with the date of 11/06/09 to indicate the date it had been opened, and one (1) bottle of Novolog inscribed with the date of 11/15/09 to indicate the date it had been opened. Both vials were prescribed for Resident #12. Additionally, a vial of Novolin-R was opened and had no date inscribed on the vial to indicate when it had been opened; this was prescribed for Resident #58. The nurse (Employee #78) acknowledged staff was to inscribe the date the vials were opened and discard the vials after having been opened for thirty (30) days. b) Observation of the medication cart on the 100 hall, on 01/06/10, revealed one (1) vial of Novolog was opened and inscribed with the date of 11/28/09 for Resident #3. The nurse (Employee #58) acknowledged staff was to inscribe the date the vials were opened and discard the vials after having been opened for thirty (30) days. c) Both medication nurses discarded the above four (4) vials of insulin and planned to reorder. d) During interview with the director of nursing on 01/07/10 at approximately 9:30 a.m., she was made aware of the above findings. No new information was provided at this time.",2015-10-01
9772,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2010-01-07,225,E,0,1,24NP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of personnel files and staff interview, the facility failed to assure two (2) of ten (10) sampled employees were thoroughly screened for findings entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. This practice has the potential to affect more than an isolated number of residents. Employee identifiers: #16 and #21. Facility census: 93. Findings include: a) Employee #16 A review of the personnel file for Employee #16 revealed she was hired as a housekeeper on 11/02/09, but there was no indication this individual was screened through the WV Nurse Aide Registry for findings of resident abuse / neglect or misappropriation of resident property. b) Employee #21 A review of the personnel file for Employee #21 revealed she was hired as an activities assistant on 09/25/09, but there was no indication this individual was screened through the WV Nurse Aide Registry for findings of resident abuse / neglect or misappropriation of resident property. c) During an interview with the facility's human resources representative (Employee #128) at 2:30 p.m. on 01/05/10, she acknowledged they only checked the WV Nurse Aide Registry when a nursing assistant was being hired. .",2015-09-01
9773,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2010-01-07,253,D,0,1,24NP11,"Based on observation and staff interview, the facility's housekeeping staff failed to provide services to eliminate the lingering odor of urine for two (2) facility residents who resided in the same room. One (1) resident was a sampled resident, and the other was of random observation. Resident identifiers: #80 and #73. Facility census: 93. Findings include: a) Residents #80 and #73 On 01/05/09 at 10:00 a.m., the room of Residents #80 and #73 was entered after knocking on the door and requesting entry. Resident #80 was noted to be in her bed, dressed in a hospital gown but awake. Resident #73 was seated in a chair at the end of her bed. One (1) wheelchair was observed in the room, sitting between the beds. At that time, a definite odor of urine was noted in the room. Neither of the residents appeared to be wet with urine, neither had a catheter, and there was no obvious soiling on the floor of the room. The room was again entered at 12:10 p.m., when neither of the residents were in the room. The odor of urine remained obvious. At 2:00 p.m., upon standing at the doorway of the room, the urine odor was still noticeable. At that time, the nurse in charge of the care of the two (2) residents residing in that room (Employee #97) and was asked to enter the room and see if she could determine the source of the odor. The nurse knocked and requested permission to enter the room, entered the room, walked through the room as she spoke with both residents, and returned to the hallway. After leaving the room, she said, I think it is the wheelchair cushion. The nurse then requested housekeeping staff to clean the wheelchair cushion and, at 3:00 p.m., the nurse notified this surveyor the cushion had been cleaned. On 01/06/09 at 9:20 a.m., the room was entered. Both residents were in the room, as was the wheelchair, and there was no odor of urine detected. .",2015-09-01
9774,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2010-01-07,272,D,0,1,24NP11,"Based on record review and staff interview, the facility failed to ensure the accuracy of the minimum data set assessment (MDS) for two (2) of sixteen (16) sampled residents, by failing to encode a decline in cognition and/or encoding the wrong number / stage of pressure ulcers, with the result that care planning was not revised for one of these areas. Resident identifiers: #33 and #92. Facility census: 93. Findings include: a) Resident #33 A review of the abbreviated quarterly MDS, with an assessment reference date (ARD) of 07/16/09, found the assessor indicated in Section B4 that the resident's cognitive skills for daily decision-making was 1 (modified independence) which was no change from the comprehensive admission MDS with an ARD of 05/21/09. Review of the medical record revealed that, on 07/09/09, a decision was made by the attending physician Resident #33 no longer had the capacity to make informed healthcare decisions and a healthcare surrogate was appointed. During an interview with the social worker (Employee #130) and MDS nurses (Employees #85 and #82) at 2:00 p.m. on 01/06/10, the social worker verified there had been a cognitive decline resulting in the physician's decision, on 07/09/09, the resident now lacks capacity. Employee #82 acknowledged this entry was an error. b) Resident #92 A review of the abbreviated quarterly MDS, with an ARD of 11/05/09, found the assessor indicated, at Item M1b, the resident had two (2) Stage II pressure ulcers, and at Item M1d, there were two (2) Stage IV pressure ulcers. In Section M2, the assessor recorded there were only two (2) pressure ulcers. A review of the Wound Tracking Forms revealed an the assessment done on 11/04/09, noting the presence of one (1) Stage II pressure ulcer on the right buttock and one (1) Stage II pressure ulcer on the left buttock. There was no other skin breakdown documented. During an interview with the wound care nurse (Employee #89) and the MDS nurse (Employee #82) at 3:00 p.m. on 01/06/10, the Employee #89 presented documentation to reflect two (2) Stage IV (unstageable) heel ulcers had resolved in September 2009. Both nurses agreed the entries on the MDS in section M1b should have noted only the presence of two (2) Stage II ulcers. .",2015-09-01
9775,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2010-01-07,274,D,0,1,24NP11,"Based on record review and staff interview, the facility complete a comprehensive minimum data set assessment (MDS) for one (1) of sixteen (16) sampled residents who had a significant change in health status. Resident identifier: #92. Facility census: 93. Findings include: a) Resident #92 An abbreviated quarterly MDS, with an assessment reference date (ARD) of 11/05/09, indicated the resident required extensive assistance with the self-performance of activities of daily living (ADLs), was incontinent of urine, and was usually understood and usually understood others. A review of Resident #92's medical record revealed a deterioration of his health status was recognized in the later part of November 2009, after the quarterly MDS had been completed. On 11/23/09, the care plan team recorded, . Resident is totally dependent on staff for completion of ADL's. The notes also recorded that an indwelling urinary catheter had been inserted (which made the resident continent of urine), and the resident had experienced a cognitive loss. On 12/18/09, the resident was placed in hospice care due to his declining health and increased care needs. The resident's deterioration continued without improvement to the present. During an interview with a nurse (Employee #94) at 1:20 p.m. on 01/05/10, she stated Resident #92 still had an indwelling urinary catheter and he would sometimes repeat phrases when spoken with, but he no longer initiated conversations or responded to questions. During an interview with the MDS nurses (Employee #82 and #85) at 3:00 p.m. on 01/06/10, Employee #82 acknowledged that, in the care plan meeting of 11/23/09, they identified the resident had declined in health care status but did not do a comprehensive assessment, because they thought his condition might improve. They both agreed, after reviewing the record and consulting with another nurse who joined the meeting (Employee #89), that the resident had not improved and was probably still declining. They also agreed that a significant change in status MDS should have been completed. .",2015-09-01
9776,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2010-01-07,279,D,0,1,24NP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, the facility failed to develop, for two (2) of sixteen (16) residents reviewed, a comprehensive care plan with measurable objectives appropriate for each resident, as identified in the comprehensive assessment. Interventions intended to prevent falls for these residents were not appropriate for them based on their physical and/or mental abilities. Resident identifiers: #50 and #24. Facility census: 93. Findings include: a) Resident #50 The medical record of Resident #50, when reviewed on 01/05/10, disclosed this [AGE] year old had resided at the facility since April 2005. The resident was noted in facility's incident / accident reports to have fallen, either from her wheelchair or during ambulation, eighteen (18) times since 03/03/09. The facility implemented such interventions as the use of hip pads, bed and chair mobility alarms, a walker, and a helmet to prevent the resident from serious injury. The resident's current care plan (last updated on 12/24/09), when reviewed, found the facility identified that resident's problem with falls and risk for serious injury. Interventions developed to prevent these falls and injuries included: Encourage resident to ask staff for assistance. The resident's most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of 12/03/09, was reviewed. In Section B4 (cognitive skills for daily decision making), the resident was coded as 3, indicating the resident was severely impaired, rarely / never makes decisions. In Section C6 (ability to understand others), the resident was coded as 3, indicating she rarely / never understands. This resident, as assessed on the MDS, would not have the ability to ask staff for assistance. b) Resident #24 The medical record of Resident #24, when reviewed on 01/06/10, disclosed this [AGE] year old resident had resided at the facility since September 2008. The resident's list of [DIAGNOSES REDACTED]. The resident was noted in facility's incident / accident reports to have fallen, either from the wheelchair or while ambulating, on twelve (12) occasions since January 2009. The resident's current care plan (last updated in December 2009), when reviewed, found the facility identified that resident's problem with falls and risk for serious injury. Interventions developed to prevent these falls and injuries included: Encourage resident to ask staff for assistance before attempting to ambulate. The resident's most recent MDS, an abbreviated quarterly assessment with an ARD of 11/12/09, was reviewed. In Section B4 (cognitive skills for daily decision making), the resident was coded as 3, indicating the resident was severely impaired, rarely / never makes decisions. In Section C6 (ability to understand others), the resident was coded as 2, indicating she sometimes understands. This resident, as assessed on the MDS, would not have the ability to consistently ask staff for assistance before attempting to ambulate. .",2015-09-01
9777,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2010-01-07,280,D,0,1,24NP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to review and/or revise the care plan to address changes in healthcare needs after one (1) of sixteen (16) sampled residents began having repeated falls. Resident identifier: #33. Facility census: 93. Findings include: a) Resident #33 A review of the clinical record revealed Resident #33 was a [AGE] year old female with [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE]. She had capacity to make her own health care decisions and was alert and oriented with no communication difficulty per her minimum data set (MDS) assessments from the last year. The resident began having falls in 2009 as follows: 04/22/09, 05/15/09, 07/28/09, 08/09/09, 08/29/09, 09/24/09, 10/20/09, 11/21/09, and 12/01/09. A review of the incident / accident reports revealed eight (8) of the nine (9) falls occurred during attempts by the resident to independently self-transfer. Two (2) falls required minimal treatment (ice packs and/or abrasion treatment), and the most recent fall resulted in transfer to the emergency room for treatment of [REDACTED]. A review of the facility's Risk Management Reports, the Investigate Report for Falls, and the Risk Management Meeting minutes discussed considerations / internal risk factors to be addressed related to Resident #33's falls including: 1) responding to toileting needs, 2) unsteady gait, 3) inadequate foot support, 4) furniture / bed / wheelchair moves easily, and 5) decline in cognition. Neither the nurses' notes nor the care plan currently in effect for this resident addressed these considerations, and there was no indication the interventions that were planned had been monitored or evaluated. Four (4) of the falls involved transfer from or into the wheelchair, but there was no evidence that need for transfer training / retraining had been identified. During an interview with the resident at 1:00 p.m. on 01/06/10, she was asked what was being done to stop these falls from happening. She stated she did not have to get help unless she felt weak and staff would assist her if she asked. She did say staff wanted to use an alarm at one time, but she refused. The resident was not able to relate the facility's plan to assist her in avoiding future falls. During an interview with the social worker (Employee #130) and the MDS nurses (Employees #82 and #85) at 2:00 p.m. on 01/06/10, they acknowledged, after reviewing facility records, there was a lack of documentation of interventions to prevent falls and stated they thought various interventions had been tried but did not work. Employee #82 stated the resident usually refused interventions anyway. No additional documentation, to reflect the causal / contributing factors to her falls had been assessed with [REDACTED]. .",2015-09-01
9778,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2010-01-07,323,E,0,1,24NP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on observation, performance testing, review of facility maintenance logs, and staff interview, the facility failed to assure the environment, for residents residing on the second (2nd) floor of the facility and mobile about the floor, was as free from accident hazards as possible, by failing to secure from unauthorized access by residents areas of the facility where telephone, electrical, and nursing equipment, as well as housekeeping chemicals that may be harmful to residents, were located and/or stored. This practice has the potential to affect all residents of the 2nd floor who are independent in locomotion, whether by wheelchair or on foot. Facility census: 93. Findings include: a) Unsecured Access to Hazardous Areas During the initial tour of the facility on 01/04/10 at approximately 12:30 p.m., observation and testing found several doors on the 2nd floor of the building that had push button combination locks which were not engaged. The first such door, located on the West Hall of the 2nd floor, was labeled Soiled Utility. Observation of this room, upon entrance, found nothing stored at that time which could be considered harmful to residents. The second such door, located on the East Hall of the 2nd floor, was labeled Equipment Room. Testing of the door found the lock was not engaged. Observation of this room, upon entrance, found telephone wiring for the facility, some electrical equipment enclosed behind levered doors, and several bottles of housekeeping chemicals stored on shelves. The labels on the chemicals were noted to say, under Precautionary Statement, Danger, corrosive, causes irreversible eye damage and skin burns. Harmful if absorbed through skin. Harmful if swallowed. Do not get in eyes on skin or clothing. Wear protective eyewear, rubber gloves and protective equipment. These rooms were entered numerous times by this surveyor and in the company of a second surveyor, and the door locks did not engage. At 1:00 p.m. on 01/04/10, the facility's director of environmental services (Employee #105), when called to the area, confirmed the locks were not functional. This employee explained that checking the locks on the doors was part of a weekly checklist that either he or another maintenance employee completed. This checklist was provided and reviewed. The last time these locks were checked was on 12/30/09. The facility's incident and accident reports for the previous year were reviewed, and no incidents or accidents had occurred related to unlocked doors in the facility. --- Part II -- Based on record review, staff interview, resident interview, and policy review, the facility failed, for two (2) of sixteen (16) sampled residents, to identify and analyze the causal / contributing factors to falls, implement interventions to prevent further falls, and/or monitor the interventions for effectiveness. Resident identifiers: #33 and #48. Facility census: 93. Findings include: a) Resident #33 A review of the clinical record revealed Resident #33 was a [AGE] year old female with [DIAGNOSES REDACTED]. She was admitted to the facility on [DATE]. She had capacity to make her own health care decisions and was alert and oriented with no communication difficulty per her minimum data set (MDS) assessments from the last year. The resident began having falls in 2009 as follows: 04/22/09, 05/15/09, 07/28/09, 08/09/09, 08/29/09, 09/24/09, 10/20/09, 11/21/09, and 12/01/09. A review of the Risk Management Reports; the Investigate Report for Falls; and the Risk Management Meeting minutes revealed the following information: - On 04/22/09 - There was record of a description of fall, an assessment, and a statement that aides were questioned, but there were no interventions to prevent future falls, and the spaces to record Care Plan Revised and Care Plan in Place were blank, although the form was signed by everyone required. There were no entries regarding this fall in the Risk Management Meeting minutes. - On 05/15/09 - A note on the form stated, Investigation for causative factor completed. However, the only cause listed was attempting to transfer self to w/c (wheelchair)and the spaces to record Care Plan Revised and Care Plan in Place were blank. Only the nursing supervisor and the nurse reporting the fall signed the form to indicate they reviewed the contents. The Risk Management Meeting listed as a Plan of Action: Continue to observe. - On 07/28/09 - The probable cause of the fall was noted to be loss of balance, and the nurse who completed the form wrote, Instructed pt (patient) to call for assist as needed. However, there was no indication that an investigative report was completed and/or that the fall was reviewed by required staff or discussed at the Risk Management Meeting. - On 08/09/09 - The probable cause of the fall was noted to be unable to transfer self, but there were no suggestions for interventions or care plan revision and no signatures to indicate the circumstances surrounding this fall were further reviewed at the Risk Management Meeting. - On 08/29/09 - The probable cause of the fall was noted to be unsteady at times, lost balance, but there were no suggestions for interventions or care plan revision and no signatures to indicate the circumstances surrounding this fall were further reviewed at the Risk Management Meeting. - On 09/24/09 - The probable cause of the fall was noted to be unsteady gait, w/c (wheelchair) not locked. The investigative report was done and the risk management meeting minutes identified the following plan of action: Educate resident to call for assistance before attempting transfers and Has non-skid pad in w/c; had an unsuccessful trial with RFA (alarm). - On 10/20/09 - The probable cause of the fall was noted to be unsteady gait, and the plan of action was: Continue non-skid pad. There was no indication of review or revision of the care plan. - On 11/21/09 - The probable cause of the fall was noted to be weak, unsteady gait. There was no evidence of an investigative report being completed or of discussion of the circumstances of this fall in the Risk Management Meeting. - On 12/01/09 - The probable cause of the fall was noted to be slid out of w/c, but the investigative report was not completed, nor was there any indication of review or revision of the care plan. Of the investigative reports that were completed, the following considerations / internal risk factors to be addressed related to Resident #33's falls were identified: 1) responding to toileting needs, 2) unsteady gait, 3) inadequate foot support, 4) furniture / bed / wheelchair moves easily, and 5) decline in cognition. Neither the nurses' notes nor the care plan currently in effect for this resident addressed these considerations, and there was no indication the interventions that were planned had been monitored or evaluated. Four (4) of the falls involved transfer from or into the wheelchair, but there was no evidence that need for transfer training / retraining had been identified. During an interview with the resident at 1:00 p.m. on 01/06/10, she was asked what was being done to stop these falls from happening. She stated she did not have to get help unless she felt weak and staff would assist her if she asked. She did say staff wanted to use an alarm at one time, but she refused. The resident was not able to relate the facility's plan to assist her in avoiding future falls. The resident's annual MDS, with an assessment reference date of 05/21/09, identified the resident required limited assistance for transfer, dressing, and toilet use. The subsequent abbreviated quarterly MDS, with an ARD of 07/16/09, noted she was independent for transfer, dressing, and toilet use. In Section G3 ( for assessing balance) on both assessment, the assessor noted Resident #33 was not able to attempt test without physical help while standing. During an interview with the MDS nurse (Employee #82) at 2:25 p.m. on 01/06/10, she acknowledged, after investigating, that the resident had not been screened or assessed by physical therapy since 2008, which was prior to her falls. A review of the facility's Accident and Incident Policy (no date noted) revealed the following expectations: - Under Level II (on page 15): 4. If multiple occurrence for same resident, Risk Management Committee will aggressively review needs and care plan for modifications. - Under Level III (on page 16): 1. Director of Nursing review (sic) reports. Insures steps have been taken to prevent or minimize opportunity for reoccurrence. Evaluate for Pro-activity (sic) in addition to reactive staff responses to the incident(s). During an interview with the social worker (Employee #130) and the MDS nurses (Employees #82 and #85) at 2:00 p.m. on 01/06/10, they acknowledged, after reviewing facility records, there was a lack of documentation of interventions to prevent falls and stated they thought various interventions had been tried but did not work. Employee #82 stated the resident usually refused interventions anyway. No additional documentation, to reflect the causal / contributing factors to her falls had been assessed with [REDACTED]. b) Resident #48 A review of the clinical record revealed Resident #48 fell on [DATE] and 11/15/09. Risk Management Reports were filed and the same probable causes were listed each time (leans forward in w/c and unsteady gait), but neither report contained any evidence to reflect that causal / contributing factors to the falls were investigated or that the care plan was to be reviewed or revised, and there was no evidence to reflect the administrator or the director of nurses had reviewed the incident reports. A review of the facility's Accident and Incident Policy (no date noted) revealed (in Level III on page 16): 1. Director of Nursing review (sic) reports. Insures steps have been taken to prevent or minimize opportunity for reoccurrence. Evaluate for Pro-activity (sic) in addition to reactive staff responses to the incident(s). No additional documentation, to reflect the causal / contributing factors to her falls had been assessed with [REDACTED]. .",2015-09-01
9779,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2010-01-07,431,E,0,1,24NP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the drug manufacturer's package insert, the facility failed to ensure an expired medication was discarded. An opened multidose vial of influenza (flu) vaccine was not discarded in a timely manner as recommended by the drug's manufacturer. This was true for one (1) of two (2) medication room refrigerators observed and has the potential to affect all newly admitted residents with physician orders [REDACTED]. Findings include: a) The refrigerator in first floor East Hall medication room, when observed on [DATE] at 1:15 p.m., contained an opened multidose vial of flu vaccine dated [DATE]. Review of the drug manufacturer's package insert titled Flulaval (Influenza Virus Vaccine) Suspension for Intramuscular Injection ,[DATE] Formula found: Once entered, the multidose vial should be discarded after 28 days. A registered nurse (Employee #119), when interviewed on [DATE] at 1:25 p.m., confirmed the opened mufti-dose vial of Flulaval to be dated [DATE], and acknowledged the medication should have been discarded within twenty-eight (28) days of being entered. .",2015-09-01
9780,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2010-01-07,502,D,0,1,24NP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain laboratory testing for one (1) of sixteen (16) sampled residents as ordered by the resident's physician. Resident identifier: #69. Facility census: 93. Findings include: a) Resident #69 The medical record of Resident #69, when reviewed on 01/05/10, disclosed this [AGE] year old had resided in the facility since 2004. On 12/10/09, a physician evaluating the resident documented the resident returned from [MEDICAL TREATMENT] and is feeling tired. An examination of the resident was documented by the physician as: (sic) decreased breath sounds throughout, lowgrade fever, and altered mental status. The physician then wrote an order for [REDACTED]. Further review of the medical record and accompanying lab book for this resident provided no evidence that the lab tests had been acquired. Facility staff was questioned as to other places where the lab results might be filed. Following a review of available documentation, Employee #72 provided a document entitled Sundale Labs. This document noted, on 12/11/09, 2 people tried couldn't get. Employee #72 agreed that, when the attempt was unsuccessful, staff should have notified the ordering physician for further direction. .",2015-09-01
9781,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2010-01-07,514,D,0,1,24NP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain accurate and complete medical records. This was true for three (3) of sixteen (16) sampled residents. Medical records were incomplete in recording resident oral intake and snack consumption. An allergy to medication was inaccurately listed in the medical record, and a physician's statement was not dated. Additionally, a physician's note directed staff to continue administering a psychoactive medication for which the resident had no prescription. Resident identifiers: #87, #38, and #65. Facility census: 93. Findings include: a) Resident #87 Resident #87's medical record, when reviewed on 01/04/10, revealed a [AGE] year old female who was admitted to the facility on [DATE]. The facility form titled Condition Alert Bulletin Board stated the resident was allergic to [MEDICATION NAME]. Further review revealed a physician order, dated 12/11/09, stating, Start [MEDICATION NAME] 5/500 mg q4h prn (every four hours as needed) pain. A licensed practical nurse (LPN - Employee #125), when interviewed on 01/04/09 at 3:05 p.m., reported she had administered the medication to the resident and there had not been any adverse reaction. The LPN stated she would check with the physician and clarify the current list of allergies [REDACTED]. The director of nurses (DON - Employee #138), when interviewed on 01/06/10 at 11:45 a.m., acknowledged the physician's statement regarding current allergies [REDACTED]. b) Resident #38 Resident #38's medical record, when reviewed on 01/05/10 at 11:00 a.m., revealed an [AGE] year old female who was currently under hospice care. Review of the current physician orders [REDACTED]. Review of the facility form titled Resident Intake Record revealed the forms were not completed. The facility did not record the amount of milkshakes and evening snack the resident had consumed. A registered nurse (RN - Employee #82), when interviewed on 01/07/10 at 9:00 a.m., acknowledged the documentation of the snack and milkshakes were not recorded in the medical record. c) Resident #65 Resident #65's medical record, when reviewed on 01/04/10 at 2:30 p.m., revealed an [AGE] year old female with a [DIAGNOSES REDACTED]. Review of the current physician orders [REDACTED]. The DON, when interviewed on 01/06/10 at 11:45 a.m., acknowledged this resident was not currently prescribed [MEDICATION NAME] and the medication was inaccurately listed on the monthly visit form.",2015-09-01
9805,CAMDEN CLARK MEM HOSP,515145,800 GARFIELD AVENUE,PARKERSBURG,WV,26102,2010-01-13,279,D,0,1,K3WS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan for two (2) of seven (7) sampled residents to meet each resident's assessed medical and nursing needs. Residents #1 and #14 had complained of constipation. Both residents were receiving pain medications that would contribute to the problem of constipation. Physician orders [REDACTED]. Resident identifiers: #1 and #14. Facility census: 20. Findings include: a) Resident #1 Medical record review, on 01/11/10, disclosed this resident was admitted to the skilled nursing unit from the acute care hospital on [DATE], with [DIAGNOSES REDACTED]. Nursing notes, dated 12/14/09, documented this resident complained of constipation. Physician orders [REDACTED]. Review of physician orders [REDACTED]. Review of the resident's current comprehensive care plan found the problem of constipation had not been identified, nor were goals and approaches (both pharmacological and non-pharmacological interventions) developed for the treatment and prevention of constipation. Interview with the director of nursing (DON), on 01/13/10 at 10:00 a.m., confirmed a care plan had not been developed to address the problem of constipation for this resident. b) Resident #14 Medical record review, on 01/11/10, disclosed this resident was admitted to the skilled nursing unit from the acute care hospital on [DATE], with [DIAGNOSES REDACTED]. Nursing notes, dated 12/24/09, documented the resident received a [MEDICATION NAME] rectal suppository due to no bowel movement in over a week. Review of PRN (as needed) Medication Notes, dated 01/01/10, revealed the resident received Milk of Magnesia for constipation. A nursing note, dated 01/06/10, recorded the resident received a Fleets enema for constipation. Review of the PRN Medication Notes revealed the resident had also been given Milk of Magnesia on 01/06/10 and on 01/10/10, for constipation. Review of physician's orders [REDACTED]. physician's orders [REDACTED]. Review of the resident's current comprehensive care plan found the problem of constipation had not been identified, nor were goals and approaches (both pharmacological and non-pharmacological interventions) developed for the treatment and prevention of constipation. Interview with the DON, on 01/13/10 at 10:00 a.m., confirmed a care plan had not been developed to address the problem of constipation for this resident. .",2015-09-01
9806,CAMDEN CLARK MEM HOSP,515145,800 GARFIELD AVENUE,PARKERSBURG,WV,26102,2010-01-13,428,D,0,1,K3WS11,"Based on medical record review and staff interview, the facility failed to ensure the physician replied to the pharmacist's recommendation on the Monthly Drug Regimen Review for one (1) of seven (7) sampled residents. During the drug regimen review dated 12/17/09, the consultant pharmacist identified two (2) drug irregularities for Resident #1 and recommended switching to other drugs to treat this resident for osteoporosis and hypertension. The physician had signed the review but failed to document the rationale for not implementing the recommended changes. Resident identifier:#1. Facility census: 20. Findings include: a) Resident #1 Review of the recommendations from the consultant pharmacist to the physician, dated 12/17/09, found the pharmacist had identified two (2) irregularities in this resident's drug regimen and reported them to the physician. The pharmacist identified that Fosamax, a drug for osteoporosis, was contraindicated for patients with CrCl (creatinine clearance) less that 35 ml/min. This resident's CrCl was 27.6 ml/min. The pharmacist recommended switching to another drug. The pharmacist also identified the antihypertensive drug being used for this resident had been discontinued and recommended starting an alternative drug considered advantageous for patients with renal insufficiency. Further review found the physician had signed the recommendations but did not document the rationale for not implementing the recommended changes. When interviewed on 01/13/10 at 10:00 a.m., the director of nursing agreed the physician had not documented any reason for not implementing the recommended changes.",2015-09-01
10549,CAREHAVEN OF PLEASANTS,515191,PO BOX 625,BELMONT,WV,26134,2010-01-13,514,D,0,1,938012,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure medical records were complete and accurate for two (2) of nine (9) sampled residents. Resident #30's medical record did not accurately document the frequency of resident behaviors and notification of the resident's medical power of attorney representative (MPOA) of a change in the plan of care. An order was inaccurately transcribed on the monthly physician's orders [REDACTED].#11 with respect to an indwelling Foley suprapubic catheter. Resident identifiers: #30 and #11. Facility census: 62. Findings include: a) Resident #30 Resident #30 was observed on 01/12/10 at 3:00 p.m. in bed. The mattress was noted on the floor with bilateral sensor alarm floor mats. The resident was unable to be interviewed due to dementia. Resident #30's medical record, when reviewed on 01/12/10 at 12:40 p.m., revealed a [AGE] year old resident who was admitted to the facility on [DATE]. The resident, whose physician determined lacked the capacity to make medical decision, had dementia, depression, and agitation. The resident also had a history of [REDACTED]. A physician order, dated 01/08/10, stated, ""D/C (discontinue) Low Bed, Mattress to floor to promote safety Re: fall intervention."" Review of the social worker progress notes and nurses' nurses did not show evidence the resident's MPOA was aware of and in agreement with this intervention to prevent injuries related to future falls. Review of the physician's orders [REDACTED]."" Review of the facility form titled ""Behavior / Intervention Monthly Flow Record"" for December 2009, when reviewed, did not find record of any episodes of ""agitation / combative"" behaviors occurring during the month. The social worker progress notes for December 2009 failed to document any increased frequency of behaviors. Review of the nurses' notes found an entry, dated 12/15/09, stating, ""3:50 Resident very agitated, being combative with staff."" There were no additional documentation in the medical record regarding increased behaviors. The director of nurses (DON - Employee #1), when interviewed on 01/12/10 at 3:45 p.m., acknowledged the medical record was incomplete and inaccurate. The DON reported the resident did have increased agitation and behaviors in December 2009, and the facility staff failed to document the behaviors accurately on the behavior flow record. The DON confirmed the resident's MPOA was contacted and was in agreement with the most recent fall intervention of the mattress on the floor. The DON reported she spoke with the resident's MPOA herself and acknowledged she failed to document the MPOA's agreement with the plan of care. b) Resident #11 Resident #11's medical record, when reviewed on 01/12/10 at 8:30 a.m., revealed a [AGE] year old female who was admitted to the facility on [DATE]. The resident had a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]."" Review of the current January 2010 monthly physician's orders [REDACTED]."" The DON, when interviewed on 01/12/10 at 3:45 p.m., acknowledged the monthly physician's orders [REDACTED]. Resident #11, when observed in bed on 01/13/10 at 3:00 p.m., had a 20 Fr with a 30 cc balloon suprapubic catheter in place.",2015-02-01
10130,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2010-01-14,279,D,0,1,CSOG11,"**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 twenty-one (21) sampled residents that described the services to be furnished to attain or maintain the resident's highest practicable physical well-being. Resident #33 had current physician orders [REDACTED]. Observation revealed these orders were not being followed, and there was no mention of these orders in the resident's care plan. Facility census: 106. Findings include: a) Resident #33 Review of the resident's medical record found current orders for the resident to have thickened liquids and for her not to be given straws. Observations, on 01/13/10 at approximately 2:30 p.m. and at 9:05 a.m. on 01/14/10, found plain (unthickened) water in the resident's pitcher and two (2) sippy cups. A straw had been placed in the resident's insulated water pitcher, and a used straw was lying on the overbed table next to the pitcher and cups. Review of the resident's care plan, found on the nursing unit, did not find anything regarding the use of thickened liquids or that she was not to use straws. .",2015-06-01
10131,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2010-01-14,364,E,0,1,CSOG11,"Based on observation and staff interview, the facility failed to serve pureed foods in a manner that maintained an attractive and pleasing appearance. Pureed foods for lunch, served on 01/13/10, lacked color and were not, therefore, attractive. This had the potential to affect approximately twenty (20) current residents who were listed as receiving a pureed diet on a diet list supplied to surveyors. Resident identifiers: #51, #94, #74, #100, #19, #91, #76, #41, #20, #54, #68, #63, #4, #5, #35, #10, #67, #27, #28, and #32. Facility census: 106. Findings include: a) Residents #51, #94, #74, #100, #19, #91, #76, #41, #20, #54, #68, #63, #4, #5, #35, #10, #67, #27, #28, and #32 Observation of the lunch meal, on 01/13/10, found pureed diets consisted of pork, mashed potatoes, and sauerkraut. All of these items were very neutral in color and, when served on a white plate, did not offer a presentation that was colorful and attractive. This was discussed with the dietary manager and the cook on the morning of 01/14/10. The cook agreed color of the overall meal was very bland in appearance and that paprika should have been sprinkled on the potatoes, noting that a new employee had been serving and may have forgotten to add the paprika for color. .",2015-06-01
10132,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2010-01-14,371,F,0,1,CSOG11,"Based on observation and staff interview, the facility failed to ensure food was distributed and/or served under sanitary conditions, by failing to ensure dish and flatware were effectively sanitized between uses. The water temperature of the dishwasher during the rinse cycle was exceeding the recommended maximum limit of 194 degrees Fahrenheit (F), thereby turning the rinse water to vapor before effectively sanitizing the dish and flatware. This practice was not in compliance with the USDA Food Code and had the potential to affect all residents who receive foods by oral means and have dishware cleaned in this central location. Facility census: 106. Findings include: a) During the initial tour on the late afternoon of 01/11/10, the surveyor observed the dish machine gauges to determine the water temperature during the rinse cycle. It was found to be over 200 degrees F. This was discussed with the dietary manager on 01/12/10. The dietary manager later contacted a vendor, who came and adjusted the temperature of the machine down slightly. According to the 2005 Food Code, ""4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. ""(A) Except as specified in (symbol for paragraph) (B) of this section, in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90oC (194oF), or less than: ""(1) For a stationary rack, single temperature machine, 74oC (165oF); or ""(2) For all other machines, 82oC (180oF)."" .",2015-06-01
10133,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2010-01-14,431,E,0,1,CSOG11,"Based on observation, staff interview, and policy and procedure review, the facility did not dispose of outdated / expired medications. The treatment carts for two (2) different units contained expired medications. This had the potential to affect all residents residing on Unit 3 and Unit 2 who had orders for treatments. Facility census: 106. Findings include: a) Observation, with the unit manager (Employee #92) on 01/13/10 at 12:22 p.m., revealed the treatment cart for Unit 3 contained two (2) outdated medications for Residents #64 and #111. Resident #64 had a tube of Premarin cream with an expiration date of 12/2009. Resident #111, who no longer resided at the facility, had a tube of Psorcon ointment that had been filled by the pharmacy in August 2008. The same treatment cart also contained an unlabeled container of Nystatin powder that had expired in 12/2009. The unit manager (Employee #92) agreed the medications were expired and should not have been left in the treatment cart. b) Observation, with the treatment nurse (Employee #64) on 01/13/10 at 2:30 p.m., revealed the treatment cart for Unit 2 contained hand sanitizer with an expiration date of 12/2009. Employee #64 agreed the hand sanitizer was expired and should not have been left in the treatment cart. c) When interviewed at 9:00 a.m. on 01/14/10, the director of nursing (DON - Employee #10) also stated expired medications should not be kept in a treatment cart. .",2015-06-01
10134,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2010-01-14,323,E,0,1,CSOG11,"Based on observation and staff interview, the facility failed to secure the door to the dirty utility room (which contained potentially hazardous lab specimens) against unauthorized access by residents. This had the potential to affect all residents residing on Unit I who may wander into the dirty utility room. Facility census: 106. Findings include: a) Observation on Unit I, made during the initial tour on 01/11/10 at 4:55 p.m., found the door to the dirty utility room was unlocked and partially open. Inside the room were lab specimens (body fluids) that had been obtained and were sitting out on the counter. In an interview on 01/14/10 at 9:15 a.m., the environmental services director (Employee #40) agreed the door should be locked at all times and the lab specimens should not have been left on the counter. .",2015-06-01
10135,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2010-01-14,441,E,0,1,CSOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility's infection control program failed to ensure a safe environment for residents, staff, and visitors. During the initial tour of the facility, three (3) residents were identified as being on some type of isolation precaution. Staff was not aware of what type of infection and/or its location. No signage had been posted to ensure staff knew what type of protective gear was required and/or what limitations might need to be imposed on resident activities. There was nothing to alert visitors that a resident in the room had an infection and/or, at a minimum, that they needed to check with staff before entering the room. Additionally, an open undated box of thickened water was found in a resident's room; the product was not to be stored at ambient temperature for more than eight (8) hours. Also, a soiled bedpan was found on the floor in the bathroom of a resident room. Resident identifiers: #97, #86, #58, #33, #14, and #94. Facility census: 106. Findings include: a) Residents #97, #86, and #58 During the initial tour of the facility, specifically the 400 hall, from approximately 4:50 p.m. to 5:20 p.m., isolation carts were noted outside of three (3) resident rooms. No signage of any type was posted outside of the rooms to identify what type of isolation precautions needed to be employed. Employee #56 (a nurse) was passing medications on the 400 hall. She was asked what type of isolation and what type of infection the residents had. For Resident #97, she said she was not sure but thought he had an infected wound. For Resident #86, she again said she was not sure but thought it was a respiratory infection. For Resident #58, she was not sure - she said the resident was new and had been admitted the day before. At approximately 5:10 p.m., Employee #57 (a nursing assistant) was asked about these residents and their infections. She said she thought Resident #86 was on precautions for his sputum; she thought Resident #58 had a laceration on his head and it might be infected, but she was not sure; and Resident #97, she thought, had an infection in his colostomy. A short while later, Employee #57 came to the surveyor's work area and said Resident #97 had MRSA (Methicillin-resistant Staphylococcus aureus) in his urine. During the post-tour conference, another surveyor stated she had seen staff copying ""Stop"" signs. Subsequent observations that evening found signs had been posted on each of the referenced residents doors. The signs had a large ""Stop"" sign and instructed to check with the nurse before entering. At 1:30 p.m. on 01/14/09, the administrator said she knew the signs had been posted the week before. She did not know why they had been removed. In the discussion with the administrator, it was acknowledged that posting of signage, beyond ones instructing those entering the room to check with the nurse first, had been considered a confidentiality issue. However, the guidelines issued by the Centers for Medicare and Medicaid had been revised in 2009, and the type of precautions had to be posted. (The revision to the regulatory requirements for F441 had been issued 09/25/09 and became effective 09/30/09.) The importance of communicating pertinent information regarding the location and type of infection to caregivers was also discussed as related to HIPAA requirements. The revised guidelines include: ""It is essential both to communicate transmission-based precautions to all health care personnel, and for personnel to comply with requirements. Pertinent signage (i.e., isolation precautions) and verbal reporting between staff can enhance compliance with transmission-based precautions to help minimize the transmission of infections within the facility. ""It is important to use the standard approaches, as defined by the CDC for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precaution determines the type of PPE (personal protective equipment) to be used. Communication (e.g., verbal reports, signage) regarding the particular type of precaution to be utilized is important. When transmission-based precautions are in place, PPE should be readily available. Proper hand washing remains a key preventive measure, regardless of the type of transmission-based precaution employed."" b) Resident #33 At 2:30 p.m. on 01/13/09, a 48 ounce box of Lyon's nectar thick water was observed on the chest of drawers next to the resident's bed. The box had been opened, but the date and time it had been opened had not been noted. An identifying mark was made on the box for future identifying purposes. At 9:05 a.m. on 01/14/09, the box of water was again observed. It was verified it was the same box seen the previous afternoon. 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. This was brought to the attention of Employee #43 at 9:10 a.m. on 01/14/09. He agreed the box should have been timed and dated. The product was poured down the sink at that time. c) Observation, made on the initial tour of facility on 01/11/10 at 4:55 p.m., found dirty bedpan on the floor beside the toilet in the bathroom of room [ROOM NUMBER] on Unit 1. In an interview with the director of nursing (DON - Employee #10) on 01/14/10 at 9:50 a.m., she agreed the dirty bedpan should not have been left on the floor in the bathroom. .",2015-06-01
10136,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2010-01-14,514,D,0,1,CSOG11,"Based on record review and staff interview, the facility failed to ensure one (1) of nineteen (19) sampled residents' clinical record contained complete and accurately documentation. Resident identifier: #22. Facility census: 106. Findings include: a) Resident #22 Review of Resident #22's medical record, on 01/12/10 at 3:00 p.m., revealed greater than one hundred (100) omissions on the Activities of Daily Living Flow Chart on day shift. In an interview on 01/14/10 at 8:55 a.m., the unit manager (Employee #92) agreed there were omissions on the ADL flow chart and the majority of omissions involved day shift.",2015-06-01
10137,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2010-01-14,156,E,0,1,CSOG11,"Based on observation and staff interview, the facility failed to ensure the required posting regarding how to apply for Medicaid and Medicare benefits was prominently displayed for public viewing. This practice had the potential to affect more than an isolated number of residents. Facility census: 106. Findings include: a) On 01/14/10 at approximately 12:00 p.m., a tour of the facility revealed the postings for how to apply for Medicaid and Medicare benefits were not present anywhere in the facility. On 01/14/10 at approximately 2:00 p.m., the admissions director (Employee #80) agreed the postings were not where she had originally thought they were. She said visitors were removing them. Employee #80 stated she would arrange to have this information put back on the bulletin board for resident and public viewing. .",2015-06-01
10138,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2010-01-14,272,D,0,1,CSOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to conduct comprehensive assessments that were accurate and complete for two (2) of twenty-one (21) sampled residents. Resident identifiers: #99 and #97. Facility census: 106. Findings include: a) Resident #99 On 01/12/10 at approximately 3:00 p.m., medical record review for Resident #99 revealed that a dietary assessment had not been completed. Resident #99 was admitted to the facility on [DATE], and he had a [DIAGNOSES REDACTED]. The dietary manager (Employee #33) reviewed the resident's medical record on 01/12/10 at approximately 3:30 p.m., and agreed the dietary assessment had not been completed. She indicated the facility expected these assessments to be completed within seventy two (72) hours of admission. b) Resident #97 Review of the resident's minimum data set assessment, with an assessment reference date of 12/07/09, found the resident had been coded as totally dependent on staff for bed mobility in G1. Transfers had been coded, in Section G1, as having not occurred. Item G6b of the assessment had been coded to indicate the resident used the side rails to assist in bed mobility and/or for transfers. If the resident were totally dependent for bed mobility, he would not have assisted in this activity. Similarly, if the resident was not transferred, he would not have had the opportunity to use the side rails for this activity. .",2015-06-01
10139,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2010-01-14,250,D,0,1,CSOG11,"**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 two (2) of twenty-one (21) sampled residents received medically-related social services in order to maintain the highest practicable well being. Resident #102's decision-making responsibilities were assigned to her medical power of attorney representative (MPOA) without her knowledge and without a determination that she was unable to make her own informed healthcare decisions; her MPOA also changed her advance directives, and these changes were not communicated to the resident. Additionally, the facility failed to arrange for an audiology consult for Resident #73 once a physician's orders [REDACTED]. Facility census: 106. Findings include: a) Resident #102 Record review found a physician's orders [REDACTED]. The resident was determined to have capacity to make her own medical decisions on 06/01/08. Further record review found a POST form, dated 12/21/09 and signed by Resident #102's MPOA, indicating the resident was now to receive ""Do Not Attempt Resuscitation (DNR)"" and ""Comfort Measures"". Review of the social services notes, nursing notes, and physician's progress notes, from 12/21/09 through 01/12/10, did not find any documentation that the resident's ability to make her own medical decisions was re-evaluated or changed since the determination of capacity was made on 06/01/08. The resident, when interviewed on 01/11/10 at 2:00 p.m., was able to converse and answer questions appropriately. An interview with the social worker, on the afternoon of 01/12/10, related that, at the end of last year, Resident #102 had suffered a stroke and her overall health condition declined. However, since then, the resident's condition had gotten better. She was not sure if the resident's capacity to make her own health care decisions had been re-evaluated by the physician. Review of the 12/31/09 physician's progress notes found the resident was not eating or drinking and was near the end-of-life. On 01/04/10, the progress notes indicated the resident had ""CHF (congestive heart failure) v/s Acute Coronary Syndrome"" and a very poor prognosis overall. On 01/11/10, the progress notes noted the resident was ""much more alert, talking more..."" The most recent care plan found in the care plan book was dated 02/02/09. It stated, ""Resident is long term with a code status of 'full code'."" The last care plan review was 11/20/09, as indicated on the bottom of the care plan. On 01/13/10 at 3:15 p.m., the social worker provided a revised care plan, dated 12/21/09, that reflected the resident's code status was now ""DNR"". There was no care plan addressing the resident's ""comfort measures"" or that the resident no longer retained the capacity to make her own health care decisions. At this time, the social worker also provided a social services progress note dated 01/12/10 at 19:39 (5:39 p.m.), stating, ""Spoke with (Resident #102) today with (name of another party). We discussed that while she was very sick and she was unable to make decisions for herself and during that time we let her niece (poa) make decisions for her. Informed her that her niece made her DNR. (Resident #102) understands and agrees with the code status. Later I discussed with (resident) alone that her niece also signed a post form make her comfort measures and that hospice was offered / declined. (Resident) says that she understands and currently agrees to these arrangements. I informed her that Dr. (name) would be in tomorrow and will relook at her capacity, she understands."" Also provided at this time was a physician's progress note, dated 01/13/10, stating, ""Late entry. Pt back from hospital, intermittently confused. Unable to consistently give informed consent. Made pt. incapacitated following CVA. Discussed with pt the reasons why and that her niece alone will be helping with her medical decisions. Pt understands. Kept saying 'I'm just tired.'"" b) Resident #73 Resident #73's medical record, when reviewed on 01/12/10, revealed a telephone physician's orders [REDACTED]."" The order was recorded by Employee #43, a licensed practical nurse (LPN). According to Employee #13 (unit manager / registered nurse), the LPN wrote down the order and did not know social services needed contacted in order to schedule the appointment. Apparently, he thought someone else would schedule the exam. On 01/12/10, the social worker (Employee #121) stated she would arrange to have the resident seen by the audiologist. .",2015-06-01
10140,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2010-01-14,309,G,0,1,CSOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and direct observation, the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care. One (1) resident did not receive adequate nutrition to prevent weight loss, ensure adequate hydration, and to prevent potentially avoidable pressure ulcers from developing. The resident, who received his nutrition and fluids via gastrostomy tube, had a significant weight loss in the first eighteen (18) days of admission. On the eighteenth day of admission, he was found to have three (3) small Stage II pressure ulcers. Also on the eighteenth day of admission, the resident was transferred to the hospital where he was diagnosed with [REDACTED]."" A second resident had physician's orders [REDACTED]. For a third resident, a lap buddy was not removed during meals in accordance with the resident's care plan. Three (3) of nineteen (19) current residents on the sample were affected. Resident identifiers: #30, #33, and #18. Facility census: 106. Findings include: a) Resident #30 This [AGE] year old man was admitted to the facility on [DATE]. His admitting [DIAGNOSES REDACTED]. The following demonstrates the resident, who was maintained on feedings and fluids via gastrostomy tube, lost at least 9.3 pounds between his admission on 08/11/09 and his hospitalization on [DATE]. The registered dietitian (RD) had assessed the resident's tube feeding regimen as not being sufficient and had made recommendations on 08/17/09, but there was no evidence this was communicated to the physician in a timely manner. Also during this period, the resident developed Stage II pressure ulcers, and his laboratory studies, during his hospitalization [DATE] to 08/31/09, demonstrated he was significantly dehydrated. -- 1. His weight, on 8/11/09, was recorded as 131.2 pounds. This was later determined by the facility staff to be inaccurate. His weight, on 08/13/09, was recorded as 176.6 pounds. Subsequent weights were: 08/17/09 - 173.4 pounds 08/20/09 - 174.0 pounds 08/27/09 - 167.3 pounds (hospitalized from [DATE] to 08/31/09) 09/01/09 - 166.0 pounds 09/11/09 - 170.0 pounds 09/17/09 - 168.8 pounds 09/24/09 - 164.8 pounds 10/01/09 - 166.8 pounds 10/08/09 - 164.8 pounds 10/15/09 - 164.2 pounds 10/29/09 - 160.8 pounds 11/04/09 - 161.8 pounds 11/12/09 - 161.0 pounds 11/19/09 - 160.2 pounds 12/03/09 - 157.6 pounds 12/10/09 - 157.8 pounds 12/17/09 - 155.8 pounds 12/23/09 - 155.2 pounds 12/31/09 - 157.4 pounds 01/06/10 - 154.8 pounds -- 2. During this span of time, the resident's nutrition and hydration were maintained via gastrostomy tube. At the time of admission on 08/11/09, an ""Enteral Protocol"" sheet indicated the resident was to receive a bolus via pump of 240 ml at a rate of 240 ml per hour. The form identified the total nutrition would be 960 ml/hr. The total calories were not listed, nor was the tube feeding formula identified. The form noted the resident was to receive 200 ml of water every six (6) hours for a total of 800 ml of flush. The total volume of nutrient and flush was written as 1760 ml/24 hours. The amount of free water was not identified. Depending on the Glucerna formula used, the free water content would vary. Glucerna 1.0 has approximately 85.3% water; Glucerna 1.2 has approximately 80.5% water; and Glucerna 1.5 has 75.9% water. The higher the caloric density, the less water in the formula. -- 3. A computer generated admission order sheet had an order for [REDACTED]. -- 4. The RD completed an assessment on 08/14/09. Under diet order, she entered ""Glucerna 240 cc via GT bolus over 1 hr q (every) 6 hours, flush 200 ml each feeding. Provides ~ (approximately) 948 kcals, 40 g protein, 808 ml fluid. Flushes provide an additional 800 ml."" The RD's assessment listed the resident's height as 66 inches, his weight as 178, and his ideal body weight as 142 pounds. She calculated his caloric requirement based on actual body weight as 2131 and his fluid at 30 ml/kg as 2430 cc. In Section N of the assessment, in response to the question ""Are nutritional needs met via current intake"", the assessor entered ""No"". Under ""Additional assessment data and identification of nutrition problem(s)"", the RD noted ""... Wt (weight) upon admission to center 8/11/09 noted as 131# however question the reliability given wt above on 08/13/09, and wt per WVDHHR records as 190#. Braden score indicates at high risk for developing pressure sores. No intolerance noted per nursing to current tube feeding. Glucose noted elevated as above, [MEDICATION NAME] WNL (within normal limits). Current tube feeding provides only 12 kcals/kg, 0.5 g/kg protein, 20 ml/kg fluid (including flushes) per most recent wt . ..."" This section continued with ""... [MEDICATION NAME] 1.2 @ goal rate of 105 ml/hr x 16 hours would provide ~2016 kcals, 94 g protein, 284 g CHO (carbohydrate), 1271 ml fluid. Flushes as ordered 200 ml q 6 hrs provide an additional 800 ml fluid. Supplies ~25 kcals/kg, 1.2 g/kg protein, 26 ml/kg fluid per most recent wt. ..."" -- 5. A form entitled ""RD Recommendations"" (in large bold print) was found in the section for physician's orders [REDACTED]. The resident's name was listed under ""Resident"". In the column for ""Recommendations"", the RD had entered, ""Question reliability of wts - recommend rewt (reweigh) (8/11/09 131#, 8/13/09 178#. ... Current tube feeding provides only 12 kcals/kg, 0.5 g/kg protein, 20 ml/kg fluid (including flushes) per most recent wt. ... Recommend [MEDICATION NAME] 1.2 @ goal rate of 105 ml/hr x 16 hours would provide ~2016 kcals, 94 g protein, 284 g CHO (carbohydrate), 1271 ml fluid. Flushes as ordered 200 ml q 6 hrs provide an additional 800 ml fluid. Supplies ~25 kcals/kg, 1.2 g/kg protein, 26 ml/kg fluid per most recent wt. ... Notify RD when po (by mouth) diet introduced for adjustments to tube feeding."" In the last column of the form entitled ""Responsible Party"" was noted, ""Nursing to MD order. ST (speech therapy) to notify if po diet introduced."" There was no evidence this recommendation, which would have more than doubled the resident's calorie and fluid intake, was communicated to the physician in a timely manner. -- 6. There was no evidence the resident's enteral feedings and fluids were increased prior to 08/29/09, when he was found to have pressure ulcers. -- 7. A nursing entry, at 10:00 a.m. on 08/29/09, noted, ""CNA (certified nursing assistant) reported to this nurse that resident had an open area to coccyx. This Nurse went into room and found 3 stage two's (sic) to coccyx. (1) 2.6 long x .5 (2) 3.2 long x 1.3 wide, (3) 2 cm long x .6 wide. Tx (treatment) written and applied."" The admission nursing entry, written on 08/11/09, had not noted any reddened or open areas on the coccyx. None of the nursing entries indicated the resident had refused to be turned and repositioned. There were no entries indicating the resident had any precursors of impending skin breakdown. Prior to the resident developing pressure ulcers, the ""Braden Scale - For Predicting Pressure Sore Risk"" form had been completed on 08/11/09 and 08/18/09. On both dates, the resident was scored as 12. The form noted, ""Total score of 12 or less represents HIGH RISK."" On 09/28/09 at 1:00 p.m., a nurse wrote, ""Area to coccyx closed. Buttocks red excoriated. New orders for Greer's Goo. Exuderm dcd (discontinued)."" On 10/14/09 at 0700 (7:00 a.m.), a nurse noted, ""Area to coccyx reopened .1 cm x 0.3 cm x 0.1 cm deep. ..."" (It was noted to have healed again on 11/01/09.) On 01/14/10 at approximately 10:00 a.m., the resident's pressure ulcer development was briefly discussed with Employee #10. She was asked to find any documentation that would demonstrate the resident's pressure ulcers had been unavoidable. At 10:45 a.m., Employee #10 provided a copy of the Braden Scales that had been completed - showing the resident was at high risk for pressure sore development - and a copy of the RD's assessment from 08/14/09. She stated the resident was incontinent also. It was pointed out that many of the residents were incontinent (sixty-one (61) of one hundred-six (106) residents in the facility were identified as incontinent on the CMS-802 - Roster / Sample Matrix) and at high risk of pressure sore development. No additional information was provided. -- 8. On 08/29/09 at 3:30 p.m., the resident was found to have a decrease in his responsiveness. His blood sugar was checked and a reading of 'high' was obtained. Insulin (15 units) was given per sliding scale coverage. His blood pressure was 138/82, respirations 20, his heart rate was 135, and his oxygen saturation was 93%. The physician was notified. At 4:20 p.m., the resident's blood sugar was down to 485, and at 5:00 p.m. it was 458. At 5:20 p.m., the resident's blood sugar was again read as 'high'. The nurse noted he was ""Still [MEDICAL CONDITION]."" The resident's wife requested he be sent to the hospital. He left the facility by ambulance at 5:40 p.m. and was admitted to the hospital. -- 9. The RD noted, in her assessment on 08/14/09, the resident's BUN (blood urea nitrogen) had been 22 and his creatinine 1.4, according to labs from the hospital (prior to his admission on 08/11/09). (The normal range for BUN is 7 to 20 milligrams per deciliter (mg/dL). The normal range may vary slightly from lab to lab.) The hospital discharge summary, for 08/31/09, listed one (1) of his [DIAGNOSES REDACTED]. In the history portion of discharge summary, it was noted, ""... He came to the ER with a glucose over 500, and an altered mental status. He was quite dehydrated... His BUN was 71 and his creatinine."" Under ""Hospital Course"" was noted, ""... His blood sugar came down nicely. His BUN also improved over the 36 hour hospital stay, to the point that on the morning of discharge his BUN was only 34, creatinine 1.1. ..."" -- 10. Errors in calculations were found in ""Enteral Protocol"" forms that were included in the medical record section for physician's orders [REDACTED]. a. A second type of ""Enteral Protocol"" form was used to record the times when tube feedings and flushes were given. The physician's orders [REDACTED].@ 4 p.m. off at 10:00 a.m. Flush tube /c 200 ml water 5 times a day,"" yet there were only four (4) times a day marked on the record where nurses initialed to indicate the flushes had been given. The flushes as ordered by the physician should have equaled 1000 cc in 24 hours, but the form had ""Total Vol: 1200 ML/24 hours."" b. The first type of ""Enteral Protocol"" form (with the physician's orders [REDACTED]. For example, the form dated 12/29/09 indicated the resident was to receive Glucerna 1.5 at 75 cc 18 hours a day. The total nutrient was listed as 1271 ml/24 hours, but should have been 1350 ml/24 hours. The total calories was listed as 2016, but should have been 2025 calories/24 hours. The form indicated the resident was to receive 200 ml of flush every 6 hours. The space for total flush in twenty-four (24) hours was blank. Then, in the space for ""Total volume of nutrient + flush"", a nurse had written ""2471"" ml/24 hours. However, using her numbers of 1271 ml/24 hours + 800 cc flush, the total should have been ""2071"", or 400 cc/24 hours less than the nurse had calculated. The total of the flush and nutrient should have been 2150 ml/24 hours. c. Another ""Enteral Protocol"" form found with the physician's orders [REDACTED]. The nurse entered ""1200"" in the space for total flush. It should have been 800 cc/24 hours. d. Intake and output records were often incomplete, so the correlation between what was ordered and what was given could not be ascertained. --- b) Resident #33 1. On 01/13/10 at approximately 2:00 p.m., the resident's medical record, when reviewed, revealed the physician had ordered a regular advanced mechanical soft diet. The orders also included ""Fluid Consistency: Thick liquids - Nectar Special Instructions: No straws."" The start date for these orders was listed as 12/08/09. 2. Observation of the resident's room, on 01/13/09 at approximately 2:30 p.m., found the resident's insulated water pitcher contained unthickened ice water, and a straw had been inserted in the opening in the top of the pitcher and bent as though used to provide a drink to the resident. A second straw was lying on the resident's overbed table. There were also two (2) sippy cups on the over-bed table. Both cups also contained unthickened water. A packet of thickener was also noted on the overbed table. It had not been opened. A box of nectar-thick water sat on the resident's chest of drawers, partially obscured by other items on the chest. The viscosity of this product was checked and used to confirm that the water in the pitcher and the two (2) sippy cups was plain, unthickened water. 3. On 01/14/10 at 9:05 a.m., the resident's room was again observed. Again, there was unthickened water in the water pitcher and the two (2) sippy cups. The packet of thickener remained unopened. A bent straw was in the pitcher. At approximately 9:10 a.m. on 01/14/10, Employee #43 was asked to go to the resident's room. He agreed the resident was not to have straws and should have thickened fluids. --- c) Resident #18 Observations of the noon meal, in the restorative dining room on 01/12/10, found Resident #18 seated at the table with a lap buddy in place while a staff member was feeding her. The surveyor, at that time, questioned the staff regarding the use of the lap buddy, and Employee #28 stated the resident was supposed to be without the lap buddy at meals and activities. Employee #28 stated, ""I just forgot to take it off."" A review of the resident's most recent care plan in the medical record found the resident was ""dependent on staff to assist with ADL's (activity of daily living) d/t (due to) cognitive deficits"" and that a lap buddy was to be used ""when up in w/c (wheelchair), release with meals and supervised activities."" This intervention had not been followed. .",2015-06-01
10043,PENDLETON MANOR INC,515124,68 GOOD SAMARITAN DRIVE,FRANKLIN,WV,26807,2010-01-20,514,D,0,1,FWJG12,"Based on medical record review and staff interview, the facility failed to ensure the medical record of one (1) of twenty-one (21) sampled residents was accurate and complete. Resident identifier: #46. Facility census: 90. Findings include: a) Resident #46 Medical record review, on 01/20/10 at 11:10 a.m., disclosed the resident's December 2009 Medication Administration Record [REDACTED]. On 01/20/10 at 4:00 p.m., the facility's director of nursing (Employee #132), nurse manager (Employee #55), and administrator (Employee #141) were informed of this, and no additional information was provided these findings prior to the surveyor exiting the building.",2015-07-01
10044,PENDLETON MANOR INC,515124,68 GOOD SAMARITAN DRIVE,FRANKLIN,WV,26807,2010-01-20,318,D,0,1,FWJG12,"Based on medical record review and staff interview, the facility failed to ensure one (1) of twenty-one (21) sampled residents received services to maintain or prevent the decline in range of motion, in accordance with physician orders, for the months of November and December 2009. Resident identifier: #46. Facility census: 90. Findings include: a) Resident #46 Medical record review, on 01/20/10 at 11:10 a.m., disclosed the physical therapist observed Resident #46 on 11/01/09, at which time the physical therapist identified three (3) problems: decreased right ankle range of motion; decreased right ankle strength; and decreased ambulation distance. The physical therapy department established the following three (3) goals for the resident: increase right ankle range of motion; increase right ankle strength to allow for more normal gait; and increase ambulation distance with normal heel to toe gait pattern. To attain these goals, the following exercises were to be provided: right ankle dorsiflexion stretch three (3) times, thirty (30) seconds each, five (5) times a week; BAPS board dorsiflexion / plantar flexion and circles two (2) sets of ten (10) repetitions, five (5) time a week; and slant board stretch, standing three (3) times, thirty (30) seconds each, five (5) times a week. Review of the resident's rehabilitation / restorative care plan / approach for the month of November 2009 found these exercises were completed only two (2) times during the entire month, on 11/05/09 and 11/20/09. No documentation was found in the medical record concerning why these services were not provided as ordered. Review of the rehabilitation / restorative care plan / approach for the month of December 2009 found these services were provided only four (4) times during the entire month, on 12/03/09, 12/08/09, 12/18/09, and 12/27/09. It was noted the resident refused services only on two (2) occasions, 12/01/09 and 12/10/09. On 01/20/09 at 4:00 p.m., the nurse manager (Employee #55) and the director of nursing (Employee #132), when interviewed, revealed they were having trouble with the restorative service program, and some residents did not receive services. The reported they were in the process of correcting this situation. .",2015-07-01
10426,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-01-20,441,F,0,1,Z0GS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's infection control policy and procedures, review of the facility's infection control log, and staff interview, the facility failed to establish and implement an infection control program which includes a system to effectively isolate residents known to have a contagious infection, to monitor and investigate causes of infection (nosocomial and community acquired) and their manner of spread, and to analyze clusters, changes in prevalent organisms, or increases in the rate of infection. The facility failed to maintain a separate record of infection that identifies each resident with an infection, states the date of infection, the causative agent, the origin or site of infection, and describes what cautionary measures were taken to prevent the spread of the infection within the facility. This practice was noted in the review of one (1) of twenty-seven (27) sampled residents but had the potential to affect all residents of the facility. Resident identifier: #81. Facility census: 93. Findings include: a) Resident #81 The medical record of Resident #81, when reviewed on 01/13/10, disclosed the resident had been admitted to the facility in May 2008. The resident's medical [DIAGNOSES REDACTED]. The resident, who had been admitted from a nursing home in another state, was 74-years old. Interviews with staff, on 01/13/10, disclosed the resident had been near death for the past several days and death was expected at any time. Review of the facility's infection control log revealed numerous ""Communicable Disease Reports"" for this resident. Such a report was to be maintained for each resident with an infection and included information related to when the infection developed, where it developed, what was the site of the infection, what was the result of the culture, and additional comments. According to these reports, this resident had experienced a wound infection and was hospitalized in July 2009. During hospitalization , the wound cultured positive for Methicillin-resistant Staphylococcus aureus (MRSA). The communicable disease report stated only that the resident was readmitted to a ""semi-private"" room upon return to the facility. The resident, according to the Communicable Disease Reports, became reinfected on 10/13/09 and 12/04/09, with MRSA being present each time. The facility's wound care nurse (Employee #6), when interviewed on 01/19/10 at 11:00 a.m., stated that, when Resident #81 returned from hospital around 08/01/09, he was placed in contact isolation in the room with his current roommate and had been housed with that resident since then. The nurse further stated the resident's roommate had an indwelling Foley urinary catheter and, as far as she was aware, had no history of having MRSA. The nurse felt that Resident #81's infection was contained to the wound by the dressing and that he was not able to move about the room and transfer the infection. She did confirm the same care giver would be assigned to care for two (2) residents in the same room, and the resident's roommate was mobile in the room in his wheelchair. Review of wound care sheets revealed the resident's foot wound was draining at the time of his return from the hospital on [DATE]. The facility's procedure for cohorting infected residents was requested and received. The policy stated, ""When a private room is not available, an infected patient is placed with an appropriate roommate. Patients infected by the same micro-organisms usually share a room, provided they are not infected with other potentially transmissible micro-organisms and the likelihood of reinfection with the same organism is minimal."" Further review of the facility's infection control log disclosed that, although all infections were noted and quarterly reports were developed, these reports were only a compilation of what infections had occurred in the previous quarter, whether they were nosocomial, and the culture results if known. The records did not reflect analysis and tracking by facility staff to determine trends, etc., nor was there evidence that the facility's infection control data were used when determining roommate placement. There was no method to determine what infections were active in-house at any given point in time. .",2015-04-01
10427,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-01-20,315,D,0,1,Z0GS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure one (1) of twenty-seven (27) sampled residents received the appropriate care and services to prevent urinary tract infections (UTIs) to the greatest extent possible while using an indwelling Foley urinary catheter. The resident was observed sitting in his wheelchair with his urinary collection bag and the attached tubing uncovered and dragging on the floor. Review of infection control records divulged the resident had experienced three (3) UTIs in the previous twelve (12) months. Resident identifier: #7. Facility census: 93. Findings include: a) Resident #7 The medical record of Resident #7, when reviewed on 01/14/10, disclosed the resident had been admitted to the facility in 1999 and, at the time of admission, he had an indwelling Foley urinary catheter. The [DIAGNOSES REDACTED]. On 01/18/10 at 10:00 a.m., this resident was observed to be sitting in the area of the facility described by staff to be the ""Dining / Activity"" Room. At that time, the resident's urinary collection bag as well as the tubing connecting the collection bag to the Foley catheter was uncovered and dragging on the floor under his wheelchair. At approximately 11:00 a.m., observation found the catheter collection bag had been enclosed in a bag and was no longer dragging the floor. The facility's infection control records were reviewed. This review disclosed the resident had experienced three (3) UTIs in the previous twelve (12) months. The facility's infection control nurse (Employee #6), when interviewed related to this observation on the morning of 01/20/10, confirmed the urinary collection bag and tubing should not be on the ground. .",2015-04-01
10428,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-01-20,272,E,0,1,Z0GS11,"**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 the minimum data set (MDS) assessments for three (3) of twenty-seven (27) sampled residents and/or failed to complete a comprehensive assessment of six (6) of six (6) sampled residents who were using physical restraints, prior to the imitation of the restraint use. Resident identifiers: #87, #59, #48, #79, #32, and #3. Facility census: 93. Findings include: a) Resident #87 A review of Resident #87's medical record revealed an [AGE] year old male with [DIAGNOSES REDACTED]. The medical record also contained a physician's orders [REDACTED]. During an interview with a licensed practical nurse (LPN - Employee #49) at 3:00 p.m. on 01/13/10, she stated the resident was restless, rocked back and forth in the wheelchair even when it was still, and liked to keep moving. She stated the seatbelt restraint did keep him from getting out of the chair. She did not recall that any other type of restraint had ever been tried. The restraint had been in use since 10/03/08. A review of the record failed to disclose that an assessment had been completed prior to the use of the restraint, to determine the presence of a specific medical symptom requiring the restraint, and there was no indication in the record of how the restraint was to treat a medical symptom. The resident was observed in his wheelchair with the seatbelt in place at 3:00 p.m. on 01/13/10 and at 1:00 p.m. on 01/19/10. A review of the fourteen (14) page care plan, which was last reviewed and revised by the facility on 01/06/10, failed to reveal any plan, goal, or nursing interventions to ensure the appropriate use of the seatbelt restraint to maintain the resident's highest practicable physical and psychosocial well-being. During an interview with the director of nursing (DON), the social worker, and a nurse (Employee #16) at 10:25 a.m. on 01/20/10, Employee #16 acknowledged that restraint use had been left out of the care plan and stated they would attempt to locate an assessment done prior to the use of the restraint, but at the time of exit, none had been presented. b) Resident #59 A review of Resident #59's medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. At present, the resident had a ""soft belt"" when up in the wheelchair, because she attempted to stand and/or ambulate without staff assistance. The use of this device was addressed in the care plan last reviewed and revised by the facility on 01/15/10. The care plan indicated that, in the past, both a trunk restraint and a Merry Walker were tried without success, but there was no evidence in the record that an assessment was made prior to restraint use to determine the presence of a specific medical symptom requiring the restraint, and there was no indication in the record of how the restraint would treat a medical symptom. During an interview with the DON, the social worker, and Employees #16 and #41 (both nurses) at 10:25 a.m. on 01/20/10, the social worker stated an assessment was described in the care plan, but no specific assessment was completed when the physician ordered a restraint. Employee #41 stated their risk management consultants, who had been present in the facility earlier in the week, had recommended they do monitoring of the residents with restraints, and they had already begun this and presented examples of this monitoring. The monitoring did not include a prior assessment. c) Resident #48 A review of Resident #48's medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. She had a history in the facility of falls and wandering. Resident #48 was observed at 11:00 a.m. on 01/14/10, at 1:30 p.m. on 01/19/10, and at other times during the survey, in her wheelchair with a seatbelt in place, moving herself about in the facility. A review of the record revealed no evidence that an assessment had been made prior to restraint use to determine the presence of a specific medical symptom requiring the restraint, and there was no indication in the record of how the restraint would treat a medical symptom. During an interview with the DON, the social worker, and Employees #41 and #16 at 10:25 a.m. on 01/20/10, they acknowledged Resident #48 did have a seatbelt and that the facility had not been doing assessments prior to restraint use, but they related their risk management consultants had recommended they do monitoring of the residents with restraints, and they had already begun this and presented examples of this monitoring. The monitoring did not include a prior assessment. d) Resident #79 Observation, at 2:30 p.m. on 01/11/10, revealed this resident was wearing a self-release belt while in his wheelchair. This device was observed attached to the resident, while in the wheelchair, throughout the survey. Medical record review, on 01/19/10, revealed the resident was ordered the device as a safety device. The device was not identified as a restraint in the medical record and was not identified as a restraint on the minimum data set (MDS) assessments dated 07/07/07, 10/07/09, and 01/07/09. A document entitled ""Release of Physician and Nursing Home"" was in the medical record. It was dated 04/23/08. This document was signed by the responsible party and released the facility from responsibility regarding the use of the device. It was not a consent for the use of the device. In addition, this document did not describe the specific device and/or its risks and benefits for the resident. Interview with the restorative nurse, at 1:00 p.m. on 01/19/10, revealed the facility did not consider the device a restraint, because it was a self-releasing device. The nurse stated, ""He is confused and unable to understand. He does not know to stop fiddling with his belt."" The resident's confusion was confirmed during medical record review. There was no identification of a specific medical symptom that would require the use of a restraint and /or how the use of a restraint would best treat a medical symptom, protect the resident's safety, and assist the resident in attaining or maintaining his highest practicable level of physical and psychosocial well being. There was no evidence of interventions prior to the use of a restraint, no evaluation for the need for the restraint, no evidence the type of restraint the resident might require was assessed, and no care planning regarding restraint reduction. Since the facility did not consider the device a restraint, it was not identified as such on the MDS. Therefore, the physical restraint resident assessment protocol (RAP) did not trigger for further assessment. e) Resident #32 Observation, at 2:30 p.m. on 01/11/10, revealed this resident was wearing a self-release belt while in his wheelchair. This device was observed attached to the resident, while in the wheelchair, throughout the survey. Medical record review, on 01/19/10, revealed the resident was ordered the device as a safety device. The device was not identified as a restraint in the medical record and was not identified as a restraint on the significant change MDS dated [DATE], or the quarterly MDS dated [DATE]. A document entitled ""Release of Physician and Nursing Home"" was in the medical record. This document was signed by the responsible party and released the facility from responsibility regarding the use of the device. It was not a consent for the use of the device. In addition, this document did not describe the specific device and/or its risks and benefits for the resident. Interview with the restorative nurse, at 1:00 p.m. on 01/19/10, revealed the facility did not consider the device a restraint, because it was a self-releasing device. The nurse stated the resident was confused and did not understand the use of the belt. The resident's confusion was confirmed during medical record review. There was no identification of a specific medical symptom that would require the use of a restraint and /or how the use of a restraint would best treat a medical symptom, protect the resident's safety, and assist the resident in attaining or maintaining his highest practicable level of physical and psychosocial well being. There was no evidence of interventions prior to the use of a restraint, no evaluation for the need for the restraint, no evidence the type of restraint the resident might require was assessed, and no care planning regarding restraint reduction. Since the facility did not consider the device a restraint, it was not identified as such on the MDS. Therefore, the physical restraint RAP did not trigger when the significant change MDS was completed on 09/26/09. f) Resident #3 Review of the medical record for Resident #3 revealed no evidence of a consent for use of a physical restraint which described the potential risks and benefits of restraint options under consideration and potential negative outcomes. Review of the medical record found no evidence of specific pre-restraint assessment. Review of the physical restraint RAP, dated 01/22/09, revealed no mention of the use of bilateral full length siderails which this resident used daily while in bed, although it did note the use of a trunk restraint, specifically a soft belt restraint when up in the wheelchair. Although a physical therapy evaluation was ordered by the physician, with a subsequent order dated 01/12/10 for occupational therapy (OT) five (5) times per week for four (4) weeks, the current care plan (as copied by facility staff and provided to the surveyor on 01/20/10) did not reflect the physician's orders [REDACTED]. During an interview with the DON and other facility staff on 01/20/10 at 10:30 a.m., findings related to restraint use were discussed. At this time, it was found that new forms related to restraint use were recently ordered by the facility and may soon be utilized. .",2015-04-01
10429,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-01-20,279,E,0,1,Z0GS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and resident interview, the facility failed to develop comprehensive care plans containing measurable objectives and timetables to meet the assessed needs of each resident. This affected seven (7) of twenty-seven (27) sampled residents. Resident identifiers: #97, #59, #87, #32, #79, #69, and #61. Facility census: 93. Findings include: a) Resident #97 A review of Resident #97's clinical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. She had had four (4) acute care admissions since August 2009, all involving either infections and/or venous access site repairs and/or relocations. In an interview, at 4:00 p.m. on 01/12/10, with the resident (who was alert / oriented and had the capacity to understand and make her own informed healthcare decisions), she stated she had been to [MEDICAL TREATMENT] earlier that day and discussed the routine she followed on Tuesday, Thursday, and Saturday each week. She stated she had an intravenous (IV) port in her left chest and another in her left arm. She stated the sites were checked when she was at [MEDICAL TREATMENT]. She traveled there by ambulance. The care plan did reference the [MEDICAL TREATMENT] as a part of the renal diagnosis, but it failed to establish a measurable goal for the [MEDICAL TREATMENT] treatments and did not address the transportation arrangements, the dietary plans for the days of [MEDICAL TREATMENT], or any plans for care and monitoring of the venous access sites. The care plan only mentioned the site of the PICC line in the left chest and did not acknowledge the presence of the other IV. During an interview with the care plan nurse (Employee #61) at 11:50 a.m. on 01/18/10, she acknowledged the care plan failed to address the items cited above, but she stated she assumed the [MEDICAL TREATMENT] center was responsible for monitoring what they did. b) Resident #59 A review of Resident #59's medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. At present, the resident had a ""soft belt"" when up in the wheelchair, because she attempted to stand and/or ambulate without staff assistance. The use of this device was addressed in the care plan last reviewed and revised by the facility on 01/15/10. The care plan indicated that, in the past, both a trunk restraint and a Merry Walker were tried without success, but there was no evidence in the record that an assessment was made prior to restraint use to determine the presence of a specific medical symptom requiring the restraint, there was no indication in the record of how the restraint would treat a medical symptom, and there was no plan for the gradual reduction of restraint use. During an interview with the director of nursing (DON), the social worker, and Employees #16 and #41 (both nurses) at 10:25 a.m. on 01/20/10, the social worker stated an assessment was described in the care plan, but no specific assessment was completed when the physician ordered a restraint. Employee #41 stated their risk management consultants, who had been present in the facility earlier in the week, had recommended they do monitoring of the residents with restraints, and they had already begun this and presented examples of this monitoring. c) Resident #87 A review of Resident #87's medical record revealed an [AGE] year old male with [DIAGNOSES REDACTED]. The medical record also contained a physician's orders [REDACTED]. During an interview with a licensed practical nurse (LPN - Employee #49) at 3:00 p.m. on 01/13/10, she stated the resident was restless, rocked back and forth in the wheelchair even when it was still, and liked to keep moving. She stated the seatbelt restraint did keep him from getting out of the chair. She did not recall that any other type of restraint had ever been tried. The restraint had been in use since 10/03/08. A review of the record failed to disclose that an assessment had been completed prior to the use of the restraint, to determine the presence of a specific medical symptom requiring the restraint, and there was no indication in the record of how the restraint was to treat a medical symptom. The resident was observed in his wheelchair with the seatbelt in place at 3:00 p.m. on 01/13/10 and at 1:00 p.m. on 01/19/10. A review of the fourteen (14) page care plan, which was last reviewed and revised by the facility on 01/06/10, failed to reveal any plan, goal, or nursing interventions to ensure the appropriate use of the seatbelt restraint to maintain the resident's highest practicable physical and psychosocial well-being, nor was there a plan for the gradual reduction of its use. During an interview with the DON, the social worker, and Employee #16 at 10:25 a.m. on 01/20/10, Employee #16 acknowledged that restraint use had been left out of the care plan and stated they would attempt to locate an assessment done prior to the use of the restraint, but at the time of exit, none had been presented. All of the staff members acknowledged that, although the resident did at times manage to loosen the restraint, it was a random action. d) Resident #79 Observation, at 2:30 p.m. on 01/11/10, revealed this resident was wearing a self-release belt while in his wheelchair. This device was observed attached to the resident, while in the wheelchair, throughout the survey. Medical record review, on 01/19/10, revealed the resident was ordered the device as a safety device. The device was not identified as a restraint in the medical record and was not identified as a restraint on the minimum data set (MDS) assessments dated 07/07/07, 10/07/09, and 01/07/09. Interview with the restorative nurse, at 1:00 p.m. on 01/19/10, revealed the facility did not consider the device a restraint, because it was a self-releasing device. The nurse stated, ""He is confused and unable to understand. He does not know to stop fiddling with his belt."" The resident's confusion was confirmed during medical record review. There was no identification of a specific medical symptom that would require the use of a restraint and /or how the use of a restraint would best treat a medical symptom, protect the resident's safety, and assist the resident in attaining or maintaining his highest practicable level of physical and psychosocial well being. Review of the resident's current care plan revealed the care plan did not indicate the need for a restraint. Additionally, there was no plan to reduce the use of the restraints through a systematic and gradual process (e.g. gradually increasing the time for ambulation and muscle strengthening activities), to ensure the resident's safety while treating the resident's medical symptoms. Interview with the DON and MDS coordinator, at 10:30 a.m. on 01/20/10, confirmed that care planning, as required for restraints, had not been implemented for this resident. e) Resident #32 Observation, at 2:30 p.m. on 01/11/10, revealed this resident was wearing a self-release belt while in his wheelchair. This device was observed attached to the resident, while in the wheelchair, throughout the survey. Medical record review, on 01/19/10, revealed the resident was ordered the device as a safety device. The device was not identified as a restraint in the medical record and was not identified as a restraint on the significant change MDS dated [DATE], or the quarterly MDS dated [DATE]. Interview with the restorative nurse, at 1:00 p.m. on 01/19/10, revealed the facility did not consider the device a restraint, because it was a self-releasing device. The nurse stated the resident was confused and did not understand the use of the belt. The resident's confusion was confirmed during medical record review. There was no identification of a specific medical symptom that would require the use of a restraint and /or how the use of a restraint would best treat a medical symptom, protect the resident's safety, and assist the resident in attaining or maintaining his highest practicable level of physical and psychosocial well being. Review of the resident's current care plan revealed the care plan did not indicate the need for a restraint. Additionally, there was no plan to reduce the use of the restraints through a systematic and gradual process (e.g. gradually increasing the time for ambulation and muscle strengthening activities), to ensure the resident's safety while treating the resident's medical symptoms. Interview with the DON and MDS coordinator, at 10:30 a.m. on 01/20/10, confirmed that care planning, as required for restraints, had not been implemented for this resident. f) Resident #69 During an interview with this resident at 9:45 a.m. on 01/12/10, the resident expressed a need for new eyeglasses. He stated his old ones were ""not strong enough"". The resident stated he worked puzzles and was having difficulty seeing during this activity. Review of the resident's MDS assessments revealed vision had not been a problem identified on the 02/03/09, 05/06/09, or 08/06/09 assessments; however, vision was identified as a problem on the 11/06/09 MDS. Review of the resident's care plan revealed no plan regarding the resident's vision. g) Resident #61 During an interview with Resident #61 on 01/12/10, the resident reported his dentures were ""pinching"" his mouth. When questioned further, he stated he had reported the pinching to staff and ""they're working on them"". The medical record of Resident #61, when reviewed on 01/14/10, disclosed documentation reflecting the resident first complained of mouth discomfort in April 2009. At that time, facility staff made an appointment for the resident at the Veterans Administration (VA) Hospital, and work was begun to alleviate the mouth pain. Extractions were completed, then it appeared a new partial had to be made. The resident had been making regular dental visits to the VA since that time. In December 2009, an appointment was missed due to the resident being out of the facility on a home visit. A return appointment was scheduled. The care plan for Resident #61 was reviewed. The plan had been most recently updated on 11/27/09. The plan made no mention of the resident's dental needs, mouth discomfort, or recurring visits to the VA Hospital for dental care. The DON, when questioned related to these findings on the morning of 01/18/10, provided from the resident's thinned chart an episodic care plan dated 04/03/09, which stated the resident had experienced mouth pain, teeth were extracted at the VA, and the resident received pain medication following the extractions. The DON confirmed the current care plan did not contain information related to the on-going dental care this resident was receiving. .",2015-04-01
10430,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-01-20,221,E,0,1,Z0GS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observation, and record review, the facility failed to assure physical restraints were being used only for treatment of [REDACTED]. Resident identifiers: #87, #59, #48, #79, #32, and #3. Facility census: 93. Findings include: a) Resident #87 A review of Resident #87's medical record revealed an [AGE] year old male with [DIAGNOSES REDACTED]. The medical record also contained a physician's orders [REDACTED]. During an interview with a licensed practical nurse (LPN - Employee #49) at 3:00 p.m. on 01/13/10, she stated the resident was restless, rocked back and forth in the wheelchair even when it was still, and liked to keep moving. She stated the seatbelt restraint did keep him from getting out of the chair. She did not recall that any other type of restraint had ever been tried. The restraint had been in use since 10/03/08. A review of the record failed to disclose that an assessment had been completed prior to the use of the restraint, to determine the presence of a specific medical symptom requiring the restraint, and there was no indication in the record of how the restraint was to treat a medical symptom. The resident was observed in his wheelchair with the seatbelt in place at 3:00 p.m. on 01/13/10 and at 1:00 p.m. on 01/19/10. A review of the fourteen (14) page care plan, which was last reviewed and revised by the facility on 01/06/10, failed to reveal any plan, goal, or nursing interventions to ensure the appropriate use of the seatbelt restraint to maintain the resident's highest practicable physical and psychosocial well-being. During an interview with the director of nursing (DON), the social worker, and a nurse (Employee #16) at 10:25 a.m. on 01/20/10, Employee #16 acknowledged that restraint use had been left out of the care plan and stated they would attempt to locate an assessment done prior to the use of the restraint, but at the time of exit, none had been presented. b) Resident #59 A review of Resident #59's medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. At present, the resident had a ""soft belt"" when up in the wheelchair, because she attempted to stand and/or ambulate without staff assistance. The use of this device was addressed in the care plan last reviewed and revised by the facility on 01/15/10. The care plan indicated that, in the past, both a trunk restraint and a Merry Walker were tried without success, but there was no evidence in the record that an assessment was made prior to restraint use to determine the presence of a specific medical symptom requiring the restraint, and there was no indication in the record of how the restraint would treat a medical symptom. During an interview with the DON, the social worker, and Employees #16 and #41 (both nurses) at 10:25 a.m. on 01/20/10, the social worker stated an assessment was described in the care plan, but no specific assessment was completed when the physician ordered a restraint. Employee #41 stated their risk management consultants, who had been present in the facility earlier in the week, had recommended they do monitoring of the residents with restraints, and they had already begun this and presented examples of this monitoring. The monitoring did not include a prior assessment. c) Resident #48 A review of Resident #48's medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. She had a history in the facility of falls and wandering. Resident #48 was observed at 11:00 a.m. on 01/14/10, at 1:30 p.m. on 01/19/10, and at other times during the survey, in her wheelchair with a seatbelt in place, moving herself about in the facility. A review of the record revealed no evidence that an assessment had been made prior to restraint use to determine the presence of a specific medical symptom requiring the restraint, and there was no indication in the record of how the restraint would treat a medical symptom. During an interview with the DON, the social worker, and Employees #41 and #16 at 10:25 a.m. on 01/20/10, they acknowledged Resident #48 did have a seatbelt and that the facility had not been doing assessments prior to restraint use, but they related their risk management consultants had recommended they do monitoring of the residents with restraints, and they had already begun this and presented examples of this monitoring. The monitoring did not include a prior assessment. d) Resident #79 Observation, at 2:30 p.m. on 01/11/10, revealed this resident was wearing a self-release belt while in his wheelchair. This device was observed attached to the resident, while in the wheelchair, throughout the survey. Medical record review, on 01/19/10, revealed the resident was ordered the device as a safety device. The device was not identified as a restraint in the medical record and was not identified as a restraint on the minimum data set (MDS) assessments dated 07/07/07, 10/07/09, and 01/07/09. A document entitled ""Release of Physician and Nursing Home"" was in the medical record. It was dated 04/23/08. This document was signed by the responsible party and released the facility from responsibility regarding the use of the device. It was not a consent for the use of the device. In addition, this document did not describe the specific device and/or its risks and benefits for the resident. Interview with the restorative nurse, at 1:00 p.m. on 01/19/10, revealed the facility did not consider the device a restraint, because it was a self-releasing device. The nurse stated, ""He is confused and unable to understand. He does not know to stop fiddling with his belt."" The resident's confusion was confirmed during medical record review. There was no identification of a specific medical symptom that would require the use of a restraint and /or how the use of a restraint would best treat a medical symptom, protect the resident's safety, and assist the resident in attaining or maintaining his highest practicable level of physical and psychosocial well being. There was no evidence of interventions prior to the use of a restraint, no evaluation for the need for the restraint, no evidence the type of restraint the resident might require was assessed, and no care planning regarding restraint reduction. Since the facility did not consider the device a restraint, it was not identified as such on the MDS. Therefore, the physical restraint resident assessment protocol (RAP) did not trigger for further assessment. e) Resident #32 Observation, at 2:30 p.m. on 01/11/10, revealed this resident was wearing a self-release belt while in his wheelchair. This device was observed attached to the resident, while in the wheelchair, throughout the survey. Medical record review, on 01/19/10, revealed the resident was ordered the device as a safety device. The device was not identified as a restraint in the medical record and was not identified as a restraint on the significant change MDS dated [DATE], or the quarterly MDS dated [DATE]. A document entitled ""Release of Physician and Nursing Home"" was in the medical record. This document was signed by the responsible party and released the facility from responsibility regarding the use of the device. It was not a consent for the use of the device. In addition, this document did not describe the specific device and/or its risks and benefits for the resident. Interview with the restorative nurse, at 1:00 p.m. on 01/19/10, revealed the facility did not consider the device a restraint, because it was a self-releasing device. The nurse stated the resident was confused and did not understand the use of the belt. The resident's confusion was confirmed during medical record review. There was no identification of a specific medical symptom that would require the use of a restraint and /or how the use of a restraint would best treat a medical symptom, protect the resident's safety, and assist the resident in attaining or maintaining his highest practicable level of physical and psychosocial well being. There was no evidence of interventions prior to the use of a restraint, no evaluation for the need for the restraint, no evidence the type of restraint the resident might require was assessed, and no care planning regarding restraint reduction. Since the facility did not consider the device a restraint, it was not identified as such on the MDS. Therefore, the physical restraint RAP did not trigger when the significant change MDS was completed on 09/26/09. f) Resident #3 Review of the medical record for Resident #3 revealed no evidence of a consent for use of a physical restraint which described the potential risks and benefits of restraint options under consideration and potential negative outcomes. Review of the medical record found no evidence of specific pre-restraint assessment. Review of the physical restraint RAP, dated 01/22/09, revealed no mention of the use of bilateral full length siderails which this resident used daily while in bed, although it did note the use of a trunk restraint, specifically a soft belt restraint when up in the wheelchair. Although a physical therapy evaluation was ordered by the physician, with a subsequent order dated 01/12/10 for occupational therapy (OT) five (5) times per week for four (4) weeks, the current care plan (as copied by facility staff and provided to the surveyor on 01/20/10) did not reflect the physician's orders [REDACTED]. During an interview with the DON and other facility staff on 01/20/10 at 10:30 a.m., findings related to restraint use were discussed. At this time, it was found that new forms related to restraint use were recently ordered by the facility and may soon be utilized. .",2015-04-01
10431,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-01-20,280,D,0,1,Z0GS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to revise the care plan as needed when there were changes in the use of physical restraints for one (1) of twenty-seven (27) sampled residents. Resident identifier: #48. Facility census: 93. Findings include: a) Resident #48 A review of Resident #48's medical record revealed this [AGE] year old female with [DIAGNOSES REDACTED]. She was observed, at 11:00 a.m. on 01/14/10, at 1:30 p.m. on 01/19/10, and at other times during the survey, in her wheelchair with a seatbelt in place, moving herself about in the facility. A review of the record revealed no evidence of an assessment made prior to restraint use to determine the presence of a specific medical symptom requiring the restraint, and there was no indication in the record of how the restraint would treat the medical symptom. However, there was a physician's orders [REDACTED]. During an interview with the director of nursing (DON), the social worker, and two (2) nurses (Employees #41 and #16) at 10:25 a.m. on 01/20/10, they acknowledged Resident #48 did have a seatbelt and that their risk management consultants (who had been present earlier in the week) had recommended they do monitoring of the residents with restraints. They related they had already begun this and presented examples of this monitoring, but these interventions had not yet been added to the care plan. .",2015-04-01
10432,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-01-20,313,D,0,1,Z0GS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to assure one (1) of twenty-seven (27) sampled residents was evaluated for visual appliances. Resident identifier: #69. Facility census: 93. Findings include: a) Resident #69 During an interview with this resident at 9:45 a.m. on 01/12/10, the resident expressed a need for new eyeglasses. He stated his old ones were ""not strong enough"". The resident stated he worked puzzles and was having difficulty seeing during this activity. Review of the resident's minimum data set (MDS) revealed vision had not been a problem identified on the 02/03/09, 05/06/09, or 08/06/09 assessments; however, vision was identified as a problem on the 11/06/09 MDS. Review of the resident's care plan revealed no plan regarding the resident's vision. On 01/14/10 at 2:20 p.m., an interview was conducted with the social worker (SW) regarding the resident's eyesight and eyeglasses. During the interview, the SW asked the MDS nurse to join the conversation. At that time, the MDS coordinator stated she believed the resident had mentioned ""he was having a difficult time seeing to work the puzzles."" Neither the SW or the MDS coordinator thought the resident currently had glasses. The SW stated the resident had had an eye appointment scheduled for 03/08/09 but refused to go. At the time of the survey, the facility had not followed up on the resident's eye care needs, even though the MDS dated [DATE] indicated there had been a decline in the resident's vision. At 3:00 p.m. on 01/14/10, the MDS coordinator reported she had visited the resident. She stated he did have glasses, and he would like to see an eye doctor. The MDS coordinator stated he told her, during the visit, he was having difficulty seeing to work his puzzles. .",2015-04-01
10433,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-01-20,309,D,0,1,Z0GS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, review of facility policy, and review of a newsletter sent to all WV licensed nursing homes and Medicare and/or Medicaid certified nursing facilities (dated April 2005), the facility failed to ensure a resident with two (2) vascular access sites for [MEDICAL TREATMENT] received the necessary care and services to prevent potential complications by not assessing and/or monitoring these sites for one (1) of twenty-seven (27) sampled residents. Resident identifier: #97. Facility census: 93. Findings include: a) Resident #97 A review of Resident #97's clinical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. She had had four (4) acute care admissions since August 2009, all involving either infections and/or venous access site repairs and/or relocations. In an interview, at 4:00 p.m. on 01/12/10, with the resident (who was alert / oriented and had the capacity to understand and make her own informed healthcare decisions), she stated she had been to [MEDICAL TREATMENT] earlier that day and discussed the routine she followed on Tuesday, Thursday, and Saturday each week. She stated she had an intravenous (IV) port in her left chest and another in her left arm. She stated the sites were checked when she was at [MEDICAL TREATMENT]. She traveled there by ambulance. A review of the nurses' notes from the [MEDICAL TREATMENT] center (dated 10/15/09 through 12/31/09), the facility's nurses' notes (dated 10/27/09 through 01/17/10); and the treatment notes failed to find mention of the location or physical status of these ports. There was no evidence in the record to indicate either the care provided to and/or monitoring of these IV access sites. When the nurse (Employee #16) was asked the location of the IV sites at 10:00 a.m. on 01/20/10, she stated she was only aware of the site on the left chest. The care plan did address the [MEDICAL TREATMENT] but failed to establish a measurable goal for the [MEDICAL TREATMENT] treatments and/or did not include any plans for the care and monitoring of the two (2) venous access sites. The care plan only mentioned the site of the PICC line in the left chest and did not acknowledge the presence of the other IV. During an interview with the care plan nurse (Employee #61) at 11:50 a.m. on 01/18/10, she acknowledged the care plan failed to address the items cited above, but she stated she assumed the [MEDICAL TREATMENT] center was responsible for monitoring what they did. In an interview with the director of nursing (DON), the social worker, and a registered nurse (Employee #48) at 11:15 a.m. on 01/18/10, they were asked to provide documented evidence of the location, date of insertion, and monitoring of the two (2) venous access sites for this resident. Employee #48 stated she knew the resident had an access port in the left chest, and she thought it was being removed the next day because of infection, but she could not describe the site and said she had not seen it. The social worker and Employee #48 returned at 11:45 a.m., after reviewing the chart, and presented a full body assessment completed by Employee #48 on 11/18/09, that documented both of the present IV access sites, but no one could identify the dates of insertion, only that they were present on readmission after a hospitalization in November 2009. The DON and the care plan nurse joined the interview at 11:50 a.m. on 01/18/10, and the DON stated there was no documentation of assessments of the sites at the facility, because there was an order for [REDACTED]. The facility policies entitled ""[MEDICAL TREATMENT]"" and ""Nurses Guidelines for [MEDICAL TREATMENT] Patients"" were both reviewed, and both were found to include monitoring and assessment of the access sites by the nursing staff. This was acknowledged by the DON, when she supplied the policies on 01/20/10. According to an article in the Long Term Care News (a newsletter sent to all WV licensed nursing homes and Medicare and/or Medicaid certified nursing facilities by the State survey agency), dated April 2005: ""The [MEDICAL TREATMENT] Resident in the Nursing Home ""Several facilities have received deficiencies associated with the care of residents receiving outpatient [MEDICAL TREATMENT]. Among the concerns identified on survey is the failure of nursing home staff to routinely assess the [MEDICAL TREATMENT] resident's vascular access, resulting in citations at F224 and F309 at levels of actual harm. ""It should be noted that the vascular access, whether it is an AV graft, fistula or shunt, a femoral or [MEDICATION NAME] venous catheter, etc., ""belongs"" to the resident and NOT to the [MEDICAL TREATMENT] center. ""As with any other special care need, the expectation is that the nursing facility routinely monitor the resident's vascular access for signs and symptoms of dysfunction and/or infection, rather than relying solely on the [MEDICAL TREATMENT] center (which may only see the resident 2 or 3 times a week) to identify any complications. ""The Survey Procedures direct the surveyor, when reviewing residents receiving [MEDICAL TREATMENT], to determine: ""- Whether medications are given at times for maximum effect; ""- Whether staff knows how to manage emergencies and complications, including hemorrhaging and infection; and ""- Whether facility staff is aware of the care of the resident's vascular access, infection control, and the nature and management of [MEDICAL CONDITION] (including nutritional needs, emotional and social well-being, and aspects to monitor). ""The surveyor will also look for evidence of good communication between the nursing home and the [MEDICAL TREATMENT] center with respect to the resident's coordinate plan of care."" .",2015-04-01
10434,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-01-20,225,E,0,1,Z0GS11,"Based on personnel record review, staff interview, and review of the facility's resident abuse policy and procedure, the facility failed to check the nurse aide abuse registry upon initial hire for three (3) of ten (10) randomly sampled employees. Employee identifiers: #1, #35, and #91. Facility census: 93. Findings include: a) Employee #1 Employee #1 (a nurse) was hired on 03/04/08. Review of the personnel file for this employee found no evidence of a Nurse Aide Abuse Registry check upon initial hire. On 01/19/10 at 12:54 p.m., Employee #46 completed a Nursing Assistant Registry Search for this employee and not matches were found. b) Employee #35 Employee #35 (a nurse) was hired on 11/04/09. Review of the personnel file for this employee found no evidence of a Nurse Aide Abuse Registry check upon initial hire. On 01/19/10 at 10:04 a.m., Employee #46 completed a Nursing Assistant Registry check for this employee and no matches were found. c) Employee #91 Employee #91 (a nurse) was hired on 07/20/07. Review of the personnel file for this employee found no evidence of a Nurse Aide Abuse Registry check upon initial hire. On 01/19/10 at 12:55 p.m., Employee #46 completed a Nursing Assistant Registry Search for this employee, and no substantiated findings of abuse, neglect or misappropriation of resident property were on file with the West Virginia Nurse Aide Abuse Registry during her time as a former certified nursing assistant. d) Review of the facility's resident abuse policy and procedure found, on page 2 under the heading ""Screening"", the facility's plan to ""Screen potential employees for a history of abuse, neglect or mistreating residents as defined by the applicable requirements . ... This includes attempting to obtain information from previous employers and/or current employers, and checking with the appropriate licensing boards and registries."" e) During interview with the director of nursing (DON) and Employee #46 on 01/19/10 at 1:00 p.m., they reported they thought nurses would be checked by the nursing school and/or licensing board for any history of abuse or neglect allegations prior to becoming licensed, and they were not aware they needed to check through the Nurse Aide Abuse Registry for all licensed practical nurses and registered nurses. .",2015-04-01
10435,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-01-20,241,E,0,1,Z0GS11,"Based on observation and confidential resident interview, the facility failed to assure dignity during dining. The dining areas were institutional in appearance. This practice had the potential to affect all residents who had their meals in the dining rooms. Additionally, Resident #88 waited a long period of time after other residents were served before he received his meal; Resident #3 was fed by staff standing above her; and Resident #74 was not provided with an appropriate surface from which to feed himself. Facility census: 93. Findings include: a) During the evening observation of resident dining on 01/11/10, and at noon throughout the survey, observations revealed the dining areas were 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. One (1) dining area had a round table with attached stools. On 01/18/10 at noon, one (1) resident, who asked to remain anonymous, was seated at this table. He stated, ""These seats are hard to sit on."" He was sitting sideways to eat. Four (4) of four (4) residents seated at the round table were observed sitting sideways on the stools and not with their legs under the table. No one was observed encouraging or assisting the residents to position themselves more comfortably. b) Resident #88 During the evening meal on 01/11/10 at 5:00 p.m., observation found Resident #88 sitting in a chair with a dinner tray in place to prevent standing. This chair was positioned in the room in such a manner as to allow the resident to observe all other residents partaking of their meals. The resident was not offered fluids nor did any staff converse with him until approximately 5:25 p.m., at which time he was given his dinner tray. When his tray was provided, the resident ate very quickly, consuming the entire meal within five (5) minutes. c) Residents #3 and #74 1. Observation of the noon meal, on 01/18/10 at approximately 12:10 p.m., found Resident #3 sitting in her wheelchair in the dining room with a soft lap belt in place confining this resident to her wheelchair. At that time, a nursing assistant (Employee #62) approached the resident to begin to feed her. After placing the resident's clothing protector on her, the nursing assistant placed the resident's food tray on a table to her right, where approximately five (5) to seven (7) other residents were eating, and began to feed the resident from the tray while standing above her. Employee #62 was approached by this surveyor and questioned as to how she was trained to feed residents during her nurse aide training. The nursing assistant confirmed she was trained to sit at the level of the resident while feeding them, but she just did not have room to do so at that point. The facility's activities director (Employee #66), who was present in the dining room while the residents ate, was asked if there were sufficient overbed stands to meet the needs of the residents. Employee #66 replied each resident had a stand in their room. Shortly thereafter, Resident #3 was observed being fed from an overbed stand by Employee #62. 2. During the noon meal on 01/18/10 at approximately 12:10 p.m., observation found Resident #74 sitting in the corner of the dining area referred to by staff as the ""Dining / Activity Room"". He was seated next to the piano. At approximately 12:15 p.m., Resident #74 was observed to be eating from his dinner tray while it sat on the bench of the piano. He was not provided with a surface from which to eat which would allow him to sit at a normal height (one from which he could easily reach his food). When the resident was approximately half-way through his meal, facility staff was noted to provide him with an overbed stand from which to eat. 3. At 12:20 p.m. on 01/18/10, the facility's assistant administrator (Employee #22), after having been informed of these observations, agreed that Resident #3 should not have been fed by staff standing above her and that Resident #74 should have been provided with an appropriate surface from which to eat. .",2015-04-01
10436,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-01-20,364,E,0,1,Z0GS11,"Based on observation, food temperature measurements, and staff interview, the facility failed to assure foods were served at the proper temperature on B Hall. The food cart was not properly heating to maintain adequate food temperatures at the point of service. This practice had the potential to affect all residents who were provided their meals on the B Hall cart. Facility census: 93. Findings include: a) Observation, at 12:00 p.m. on 01/18/10, revealed all food carts were loaded and waiting to be taken to the residents. According to the cook (Employee #45), B cart was the first cart loaded, and it had been loaded since 11:15 a.m. The cook was asked to take the temperature of the foods on the first tray placed on the cart. The spaghetti was 116 degrees Fahrenheit (F). The cook was asked to take the temperature of another serving of spaghetti from the same cart. The spaghetti on this tray was 119 degrees F. According to the cook, the spaghetti was more than 170 degrees F when she placed it on the cart. The cook was asked to take temperatures of the spaghetti on the next two (2) carts which had been loaded. The spaghetti on these carts registered between 150 and 160 degrees F. During the evaluation of temperatures, the dietary manager (DM), who was present, stated B cart had been recently repaired. Upon inquiry, the DM stated no one had tested the foods after the repair, to assure the cart was functioning properly. The facility had not assured B Hall food cart was functioning properly to maintain appropriate food temperatures at the point of service for residents who received their meals from this cart. .",2015-04-01
10437,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-01-20,371,F,0,1,Z0GS11,"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 have the potential to affect all facility residents who receive nourishment from the dietary department. Facility census: 93. Findings include: a) During dishwashing on 01/13/10 at 9:00 a.m., observation found plastic cups and tumblers inverted onto trays prior to air drying. Moisture was observed trapped within the tumblers and cups, creating a medium for bacterial growth. b) At 9:46 a.m. on 01/13/10, the soap dispenser for the dishwasher was empty. This had not been noticed by the employee washing dishes (Employee #10). The assistant administrator passed by and told Employee #10 the dishwasher was out of soap, and that he would get the soap for her. Employee #10 continued using the dishwasher machine, even after being told it was out of soap. c) At 12:00 p.m. on 01/18/10, cups and tumblers were again observed inverted on trays prior to air drying. The dietary manager was present and confirmed staff should have allowed the items to air dry prior to inverting them on trays. .",2015-04-01
10438,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-01-20,203,C,0,1,Z0GS11,"Based on review of the uniform notice provided to residents at the time of transfer / discharge related to their right to appeal that transfer / discharge, the facility failed to provide accurate information as stated in this requirement. Several agencies were erroneously identified in this uniform notice. This practice has the potential to affect all residents of the facility. Facility census: 93. Findings include a) Review of the facility's ""Notification of Transfer or Discharge"", which was provided by the facility to all residents upon transfer / discharge from the facility, revealed the document did not provide the correct information for a resident wishing to appeal the transfer / discharge decision. The required information, as stated in Federal regulation, includes the name, address, and telephone number of the State long-term care ombudsman; for nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals; and for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals. The uniform notice provided by the facility erroneously identified, as agencies to which an appeal of a transfer / discharge decision may be made, Adult Protective Services, Legal Aid Society, State Board of Regents, and the area long term care ombudsman. The last page of the information incorrectly directed that a copy of the appeal be sent to OHFLAC (Office of Health Care Licensure and Certification) and to the Office of Medical Services; there is no statutory requirement for copies of appeals to be sent to either of these offices. The sole State agency having the authority to rule on appeals of a transfer / discharge decision in West Virginia is the Board of Review within the Office of Inspector General, which was not correctly identified anywhere in the facility's uniform notice. .",2015-04-01
10187,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2010-01-28,279,D,0,1,MFK411,"**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 three (3) of eighteen (18) sampled residents, that included measurable goals when two (2) residents had been identified with a weight loss; the third (3) resident's care plan failed to include all the identified care needs. Resident identifiers: #3, #89, and #45. Facility census: 100. Findings include: a) Resident #3 Review of Resident #3's vital signs and weight record, on 01/26/10, revealed a weight loss of 19#, from 157# on 10/03/09 to 138# on 01/05/10. The current care plan goal was: ""Weight will maintain within stable range over the next review without significant wt (weight) change (155-165#)."" The goal failed to address the weight loss, nor was the goal (as written) measurable, in that no baseline information was provided against which progress could be measured. In an interview on 01/28/10, the registered dietitian (RD) acknowledged this was not a measurable goal. b) Resident #89 Review, on 01/26/10, of Resident #89's minimum data set assessment ((MDS) dated [DATE], revealed (in Section K - Oral / Nutritional Status) there had been a weight loss. Review of the care plan, dated 11/16/09, found it did identify the weight loss. The goal was: ""Resident's weight change will be minimized over the next review period and remain within stable range."" However, the facility failed to develop a measurable goal for this identified weight loss, in that no baseline information was provided against which progress could be measured. In an interview on 01/28/10, the RD acknowledged this was not a measurable goal. c) Resident #45 A review of Resident #45's medical record revealed she had been receiving [MEDICATION NAME] 50 mg daily for depression since 11/03/08, and [MEDICATION NAME] 5 mg daily for treatment of [REDACTED]. This was acknowledged in both the 10/04/09 annual MDS and the 01/03/10 quarterly MDS. The assessor recorded in the resident assessment protocol (RAP) summary of the 10/17/09 MDS that the use of [MEDICAL CONDITION] medications would be addressed in the care plan. However, a review of the current care plan, which showed updates through 12/29/09, found no mention of psychoactive drug use. There was no problem statement recognizing the potential complications of [MEDICAL CONDITION] medication use; no measurable goals had been established aimed at assuring the highest level of functioning for this resident; and no nursing interventions were established aimed at achieving such a goal. ""Use of [MEDICATION NAME]"" was handwritten under the problem of depression, which had interventions including: ""Medications as ordered."" and ""Monitor medication for effectiveness and side effects."" The care plan for depression and anxiety contained a single intervention in regards to medication stating: ""Administer medication as per MD orders."" During an interview with the MDS coordinator (Employee #27) and the acting director of nursing (Employee #41) at 9:00 a.m. on 01/27/10, they acknowledged, after reviewing the resident's care plan and the RAP documentation, that the use of [MEDICAL CONDITION] drugs had been excluded from the care plan. .",2015-06-01
10188,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2010-01-28,371,F,0,1,MFK411,"Based on observation and staff interview, the facility failed to store, prepare, distribute and serve foods under sanitary conditions, as evidenced by observations of a jacket on a cart used to store clean dishes, cups not being completely aired-dried, food packages not being resealed after use, and steam table wells found to be rusted. These practices had the potential to affect all residents receiving oral nourishment from the kitchen. Facility census: 95. Finding include: a) Observation of the kitchen, beginning at 1:00 p.m. on 01/26/10, revealed a free-standing cart used for storing clean dishes partially covered with a large green cloth. On top of the cover was a ladies winter jacket that appeared to be thrown across the cover. The dishes were not being properly stored b) Two (2) large trays of cups observed on a storage cart had not been completely air dried, allowing a moist medium for the growth of bacteria. The dietary manager acknowledged the cups were not dry, and the cups were sent back to be rewashed and air dried completely. c) Two (2) boxes of food products (pancake mix and yellow cake) were observed to be stored on a lower shelf of the long food preparation table. The two (2) boxes had been opened and had not been resealed. The dietary managed acknowledged the boxes should be resealed. d) Observation of the four (4) steam table wells revealed all were rusty and could not be properly cleaned. .",2015-06-01
10189,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2010-01-28,514,F,0,1,MFK411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain complete, accurate, accessible, and/or organized medical records as demonstrated by failure to have the minimum data set (MDS) assessments with the records or in organized files for all residents; and failure to have a dated physician signature on a ""do not resuscitate"" order for one (1) of eighteen (18) sampled residents. Resident identifier: #3. Facility census: 100. Findings include: a) All residents During a meeting at 5:00 p.m. on 01/25/10, the surveyors identified they had not located any minimum data set assessment (MDS) and/or resident assessment protocol (RAP) on the sampled residents' charts. Two (2) surveyors had been told the MDS and RAPs were kept in a file at the nurses' station, but when checked, they either were not there or the one in the file was not current. When requested, the MDS and RAPs were supplied, usually within an hour or two (2) by the nurse (Employee #27) who was designated by the facility as the MDS coordinator. On 01/26/10, the surveyors noted that, when the most recent MDS was delivered, the computer print date was 01/26/10, although in each instance there were original staff signatures with the dates prior to the print date. For example: - Resident #29 - The significant change in status MDS, with an assessment reference date (ARD) of 09/01/09, was printed on 01/26/10, but the signatures were dated for 09/01/09. - Resident #45 - The quarterly MDS, with an ARD of 01/03/10, was printed on 01/25/10, but the signatures were dated for 01/04/10. During an interview with Employee #27 in her office at 12:20 p.m. on 01/26/10, this surveyor asked her why the current MDS assessments were not with the charts and why the ones presented to us were newly printed with backdated signatures. She pointed to a wheeled basket-type cart in her office containing stacks of paperwork and stated they were all there but had not been filed and, because it was time consuming, she was just printing them off the computer and having them signed by the appropriate staff and backdated to when they were ""originally done"". She stated all of them had been submitted to Medicare in a timely manner. She added she had been assured by administration it was acceptable to keep them in her office. At 1:15 p.m. on 01/26/10, a surveyor made a search for the MDS assessments of the thirty-four (34) residents on the 100 hall. Eight (8) residents had none, and the most recent MDS of those present was dated 07/26/10 (for Resident #1). The 400 hall, located two (2) levels below the MDS office, was checked at 1:00 p.m. on 01/27/10, and only three (3) of these ten (10) residents had an MDS on the floor, with the most recent dated 04/16/09. The director of nursing (DON) was present during this search. During an interview with the administrator at 10:00 a.m. on 01/27/10, when informed of these findings, he stated he was not aware of the severity of the problem, although he agreed the problem did exist. b) Review of Resident #3's medical record, on 01/26/10, revealed the Physician order [REDACTED]. This finding was acknowledged by the assistant director of nursing. .",2015-06-01
10190,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2010-01-28,329,D,0,1,MFK411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure each resident's drug regimen was free from unnecessary drugs used for an excessive duration without an attempt to gradually reduce the dosage and in the absence of adequate indications for its use, for one (1) of eighteen (18) sampled residents who had been receiving an antipsychotic drug since October 2008 for an unexplained ""[MEDICAL CONDITION]"" with no attempts to reduce the dosage. Resident identifier: #45. Facility census: 100. Findings include: a) Resident #45 Review of Resident #45's clinical record revealed the resident had been receiving [MEDICATION NAME] 5 mg daily for treatment of [REDACTED]. The consultant pharmacist, during the monthly review of medications, recommended a dosage reduction on 02/19/09, and again on 03/30/09. The first recommendation was not acknowledged by the physician, and the second recommendation resulted only in the entry, ""No change"". The resident continued to receive this medication at the same dosage. These recommendations and responses were discussed with the consultant pharmacist during a short interview the afternoon of 01/26/10, who stated she would review the record and attempt to locate a reason for the lack of a GDR; however, none had been provided prior to exit. A review of the pharmacy insert supplied with [MEDICATION NAME] found a recommendation for behavior monitoring. Staff identified the resident was to be monitored for the behavioral signs and symptoms of general restlessness, worried / anxious looks, and/or grabbing at objects. Review of the resident's behavior monitoring records for November 2009, December 2009, and January 2010 found no evidence this resident displayed any of these signs / symptoms. The resident's 10/04/09 annual minimum data set (MDS) assessment noted the resident exhibited zero mood and/or behavioral symptoms during the assessment reference period, and the 01/03/10 quarterly MDS noted only the behavior of ""wandering"", which was not a target behavior for which this medication had been prescribed. During an interview with the medical director, the director of nursing (DON), and the assistant director of nursing at 8:25 a.m. on 01/28/10, the above was explained. The medical director stated he understood the resident's attending physician (who was not the medical director) was obligated to address the pharmacy recommendations with either a reduction or an explanation for declining the recommendation. He stated he would talk to the pharmacist about some education for the physicians. The nurses present, after reviewing the resident's record, could not produce any documentation to support the physician's decision rejecting the recommended GDR. .",2015-06-01
10191,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2010-01-28,428,D,0,1,MFK411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the physician acted upon recommendations by the consultant pharmacist with respect to attempting a gradual dose reduction (GDR) of any antipsychotic medication for one (1) of eighteen (18) sampled residents. Resident identifier: #45. Facility census: 100. Findings include: a) Resident #45 Review of Resident #45's clinical record revealed the resident had been receiving Zyprexa 5 mg daily for treatment of [REDACTED]. The consultant pharmacist, during the monthly review of medications, recommended a dosage reduction on 02/19/09, and again on 03/30/09. The first recommendation was not acknowledged by the physician, and the second recommendation resulted only in the entry, ""No change"". The resident continued to receive this medication at the same dosage. These recommendations and responses were discussed with the consultant pharmacist during a short interview the afternoon of 01/26/10, who stated she would review the record and attempt to locate a reason for the lack of a GDR; however, none had been provided prior to exit. During an interview with the medical director, the director of nursing (DON), and the assistant director of nursing at 8:25 a.m. on 01/28/10, the above was explained. The medical director stated he understood the resident's attending physician (who was not the medical director) was obligated to address the pharmacy recommendations with either a reduction or an explanation for declining the recommendation. He stated he would talk to the pharmacist about some education for the physicians. The nurses present, after reviewing the resident's record, could not produce any documentation to support the physician's decision rejecting the recommended GDR. .",2015-06-01
10192,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2010-01-28,156,D,0,1,MFK411,"Based on record review, review of the denial notice letters, and staff interview, the facility failed to include the identification of the service being denied and/or the reason for the denial in the letter provided by the facility to the resident and/or responsible party, informing them of services not covered under Medicare for one (1) or eighteen (18) sampled and two (2) of three (3) random residents whose Medicare notification letters were reviewed; and/or failed to inform the responsibility party of rights related to the formulation of advance directives for one (1) of eighteen (18) sampled residents. Resident identifiers: #29, #41, #34, and #53. Facility census: 100. Findings include: a) Resident #29 A review of the medical record revealed that, upon admission to the nursing home on 06/02/08, Resident #29 had been determined by a physician to have the capacity to make healthcare decisions, and Resident #29 expressed a desire for a ""Do Not Resuscitate"" (DNR) order. Since this admission, he lost the capacity to make his own healthcare decision. As of 12/30/08, his physician appointed a health care surrogate (HCS) to make these decisions on his behalf, in accordance with his known wishes as required by State law. Further review, however, found no evidence to reflect the facility fully informed the HCS of the resident's DNR decision. During an interview with the social worker at 1:45 p.m. on 01/27/10, she acknowledged she had not discussed the resident's code status with the HCS, but she stated she would do this as soon as possible. b) Residents #41, #34, and #53 A review of the Medicare denial letters for the aforementioned residents revealed the facility failed to indicate which skilled service was being discontinued and the reason(s) for this non-coverage. When this was discussed with the administrator at 9:30 a.m. on 01/27/10, he agreed this information was not present. A follow-up interview with a nurse (Employee #27) confirmed this information was not being included in the denial notices at present, as she was not aware it was required. .",2015-06-01
10193,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2010-01-28,159,E,0,1,MFK411,"Based on financial record review and staff interview, the facility failed to implement a system to allow residents to obtain personal funds in amounts less than $50.00 at any time. This had the potential to affect all seventy-four (74) residents with monies held for them by the facility. Facility census: 100. Findings include: a) A review of the resident account information revealed the facility managed personal funds for seventy-four (74) residents. The facility maintained a petty cash box at the facility in the amount of $500.00. During an interview with the individual responsible for handling resident funds at the facility at 11:30 a.m. on 01/28/10, Employee #89 stated petty cash was available daily until 8:00 p.m.; after that time, they would have to call her at home. She also acknowledged there was no requirement for her to be available after hours. She stated she would rectify this as soon as possible. .",2015-06-01
10194,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2010-01-28,272,D,0,1,MFK411,"Based on record review and staff interview, the facility failed to provide adequate summary information for the resident assessment protocols (RAPs) for two (2) of eighteen (18) sampled residents, by not providing dates and/or locations where this information could be found in the clinical record. Resident identifiers: #60 and #45. Facility census: 100. Findings include: a) Resident #60 A review of the resident's 01/11/10 significant change in status minimum data set assessment(MDS) revealed, in Section V (Resident Assessment Protocol Summary), the following entry under ""Location and Date of RAP Assessment Documentation"" for each triggered RAP: ""See RAP 1/13/10"". When these individual RAPs were reviewed, the only information found related to ""Location of Documentation"" was ""RAP WS dated 1/13/10"". b) Resident #45 A review of the 10/04/09 annual minimum data set (MDS) revealed, in Section V, the following entry under ""Location and Date of RAP Assessment Documentation"" for each triggered RAP: ""See RAP 10/8/09"". When these individual RAPs were reviewed, the only information found related to ""Location of Documentation"" was ""See RAP 10/8/09"". c) During an interview with the acting director of nursing (Employee #41), who was also the registered nurse coordinator for the RAP assessment process, and a licensed practical nurse (Employee #27), who was listed by the facility as the MDS coordinator, at 9:00 a.m. on 01/27/10, they acknowledged that, in these two (2) instances, the sources of RAP information were not entered. Employee #27 pointed out on another sample that she usually listed the location of the information in a narrative summary of all the triggered RAPs under the first RAP entry. .",2015-06-01
10195,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2010-01-28,286,F,0,1,MFK411,"Based on record review, observation, and staff interview, the facility failed to maintain the previous fifteen (15) months of assessment data in the resident's active record and/or accessible to all professional staff members. This has the potential to affect all residents. Facility census 100. Findings include: a) During a meeting at 5:00 p.m. on 01/25/10, the surveyors identified they had not located any minimum data set assessment (MDS) and/or resident assessment protocol (RAP) on the sampled residents' charts. Two (2) surveyors had been told the MDS and RAPs were kept in a file at the nurses' station, but when checked, they either were not there or the one in the file was not current. When requested, the MDS and RAPs were supplied, usually within an hour or two (2) by the nurse (Employee #27) who was designated by the facility as the MDS coordinator. On 01/26/10, the surveyors noted that, when the most recent MDS was delivered, the computer print date was 01/26/10, although in each instance there were original staff signatures with the dates prior to the print date. For example: - Resident #29 - The significant change in status MDS, with an assessment reference date (ARD) of 09/01/09, was printed on 01/26/10, but the signatures were dated for 09/01/09. - Resident #45 - The quarterly MDS, with an ARD of 01/03/10, was printed on 01/25/10, but the signatures were dated for 01/04/10. During an interview with Employee #27 in her office at 12:20 p.m. on 01/26/10, this surveyor asked her why the current MDS assessments were not with the charts and why the ones presented to us were newly printed with backdated signatures. She pointed to a wheeled basket-type cart in her office containing stacks of paperwork and stated they were all there but had not been filed and, because it was time consuming, she was just printing them off the computer and having them signed by the appropriate staff and backdated to when they were ""originally done"". She stated all of them had been submitted to Medicare in a timely manner. She added she had been assured by administration it was acceptable to keep them in her office. At 1:15 p.m. on 01/26/10, a surveyor made a search for the MDS assessments of the thirty-four (34) residents on the 100 hall. Eight (8) residents had none, and the most recent MDS of those present was dated 07/26/10 (for Resident #1). The 400 hall, located two (2) levels below the MDS office, was checked at 1:00 p.m. on 01/27/10, and only three (3) of these ten (10) residents had an MDS on the floor, with the most recent dated 04/16/09. The director of nursing (DON) was present during this search. During an interview with the administrator at 10:00 a.m. on 01/27/10, when informed of these findings, he stated he was not aware of the severity of the problem, although he agreed the problem did exist. .",2015-06-01
10196,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2010-01-28,323,K,0,1,MFK411,"Based on observation and performance testing, record review, and staff interview, the facility failed to provide an environment as free as possible of accident hazards, by failing to ensure the delayed-egress magnetic locks on three (3) designated doors of emergency egress automatically released upon application of a force of greater than 15 lbf for greater than three (3) seconds and/or upon activation of the fire alarm, when tested with the application of force at 9:30 a.m. on 01/26/10, and again with the onset of the fire alarm system at 10:30 a.m. on 01/26/10. Two (2) of the doors (double doors) were located on the 300 hall (one level down from the main entry level of the facility), and the third door was located at the end of the 100 hall next to room 101 (on the entry level). This placed in immediate jeopardy eighteen (18) residents on the 300 hall and nine (9) residents on the 100 - 109 hall (a total of twenty-seven (27) residents, including four (4) of eighteen (18) sampled residents)) and any visitors on these units at that time, as neither the residents nor visitors would have been able to exit the facility through the affected doors without a staff member being present to manually unlock the doors. The facility was aware these delayed-egress locks were not functioning as designed as early as 11/04/09, when a contracted service company identified these concerns during an inspection of the facility's fire alarm system, yet no affirmative action had been taken to ensure this identified problem had been corrected at that time. At 11:15 a.m. on 01/26/10, the life safety code surveyor informed the survey team that, while testing the fire alarm system, he had discovered three (3) of the doors of egress would not unlock automatically when the fire alarm sounded. He stated the facility's immediate action, after surveyor intervention, was to disarm the door locks on these doors and post an employee at each of them to prevent unauthorized exit. At 11:45 a.m., direct observation verified an employee was stationed at each exit. At this time, the survey team verified the circumstances that created immediate jeopardy had been mitigated. At 1:05 p.m. on 01/26/10, the life safety code surveyor relayed he had informed the State survey and certification agency's program manager of the situation. During an interview with the administrator, the maintenance director, and a corporate representative at 1:10 p.m. on 01/26/09, the survey team leader notified them that immediate jeopardy had existed at the time the life-safety surveyor identified the delayed-egress locks on three (3) emergency exit doors did not automatically release when tested , and that the immediate jeopardy was removed when the delayed-egress locks on the affected doors were disarmed and staff was posted at each door. Upon removal of the immediate jeopardy, a deficient practice remained until the locks were repaired and/or other systems were put into place to prevent unauthorized exit of residents through these doors, which posed the potential for more than minimal harm affecting more than an isolated number of residents. Facility census: 100. Findings include: a) The most recent facility fire alarm inspection report, which was provided by the facility upon request, was reviewed at approximately 3:00 p.m. on 01/25/10. This fire alarm inspection was conducted by SimplexGrinnell and bore the date of 11/04/09. Review of this report revealed, under the title of ""Recommendation"", the following: ""The access control doors located on the ground floor entrance by the nurse station, the ground floor stairs by the nurse station, first floor by room 101 and first floor break room exit do not release automatically during the on set of a fire alarm. SimplexGrinnell recommends that these doors do release automatically during the on set of a fire alarm."" b) When questioned, on 01/25/10 at approximately 4:00 p.m., if the facility had corrected the issue pertaining to automatic release of these doors upon activation of the fire alarm system, the facility's plant operations director stated he was not sure and would research his files for an answer. c) During a tour of the facility on 01/26/10 at approximately 9:30 a.m., the emergency release process was tested on the double outside egress doors located near the Station 3 Nurse Station (identified as the ground floor above). These doors failed to initiate an irreversible release process when a force greater than 15 lbf was applied for a period of greater than three (3) seconds. When questioned if he had been able to locate any documentation indicating the automatic release during a fire alarm activation issue had been corrected, the plant operations director stated he had not. d) At the request of the life-safety code surveyor on 01/26/10 at approximately 10:30 a.m., the facility's fire alarm system was activated. At this time, the double outside egress doors located near the Station 3 Nurse Station were tested and were found to be locked. The remaining delayed-egress locks listed on the fire alarm inspection reported, and others, were tested at this time with the following additional findings: - The designated outside exit door near resident room #101 was locked and had failed to release with the fire alarm. - The stairway door located near the Station 3 Nurse Station was locked and had failed to release failed to release with the fire alarm; however, this door was not situated within the designated means of egress and was, therefore, not a delayed-egress lock. - The designated outside exit door located near the break room was difficult to open (bound within the door frame); however, the delayed-egress lock had released. At 11:15 a.m. on 01/26/10, the life safety code surveyor informed the survey team that, while testing the fire alarm system, he had discovered three (3) of the doors of egress would not unlock automatically when the fire alarm sounded. He stated the facility's immediate action, after surveyor intervention, was to disarm the door locks on these doors and post an employee at each of them to prevent unauthorized exit. At 11:45 a.m., direct observation verified an employee was stationed at each exit. At this time, the survey team verified the circumstances that created immediate jeopardy had been mitigated. At 1:05 p.m. on 01/26/10, the life safety code surveyor relayed he had informed the State survey and certification agency's program manager of the situation. During an interview with the administrator, the maintenance director, and a corporate representative at 1:10 p.m. on 01/26/09, the survey team leader notified them that immediate jeopardy had existed at the time the life-safety surveyor identified the delayed-egress locks on three (3) emergency exit doors did not automatically release when tested , and that the immediate jeopardy was removed when the delayed-egress locks on the affected doors were disarmed and staff was posted at each door. The survey team leader informed the facility's representatives of the needs to provide an action plan. The action plan was delivered at 3:00 p.m. on the same day and read as follows: ""Corrective Action For Resident Affected: ""Immediately upon notification of malfunction with the delayed egress system for the Station 1 Emergency Exit and the Station 3 Entrance doors, the locking mechanism was disabled. ""Immediately upon disarming the locking mechanism at the egress doors, a staff member was posted at each malfunctioning door to maintain safety and supervise the entrance / exit area. ""An outside contractor was called to initiate repairs of the delayed egress system at the Station 1 Emergency Exit door and the Station 3 Entrance / Exit door."" Prior to leaving the facility for the day at 5:00 p.m., the maintenance director stated the 300 hall doors were working appropriately and, while the 100 hall door had not been placed on the fire alarm system, it now sounded a loud alarm when opened. On 01/27/10, the life safety code surveyor confirmed, after additional testing of the fire alarm, the doors were not functioning as required and presented to the team leader a copy of the work order from the service company stating this. Upon removal of the immediate jeopardy, a deficient practice remained until the locks were repaired and/or other systems were put into place to prevent unauthorized exit of residents through these doors, which posed the potential for more than minimal harm affecting more than an isolated number of residents. .",2015-06-01
10197,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2010-01-28,520,K,0,1,MFK411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and performance testing, record review, and staff interview, the facility failed to develop and implement plans of action to correct quality deficiencies of which it was aware, to ensure the resident environment was as free as possible of accident hazards. A fire inspection report, provided to the facility by a contracted service company and dated 11/04/09, identified ""access control doors"" equipped with delayed-egress locks did not automatically release as designed upon activation of the fire alarm system. Interview with the plant operations director, on the morning of 01/26/10, found he was unable to locate any documentation indicating the automatic release during a fire alarm activation issue had been corrected in reaction to the 11/04/09 fire inspection report. Performance testing, on the morning of 01/26/10, found the delayed-egress magnetic locks of three (3) designated doors of emergency egress failed to automatically release as intended upon application of a force of greater than 15 lbf for greater than three (3) seconds and/or upon activation of the fire alarm. Two (2) of the doors (double doors) were located on the 300 hall (one level down from the main entry level of the facility), and the third door was located at the end of the 100 hall next to room [ROOM NUMBER] (on the entry level). This placed in immediate jeopardy eighteen (18) residents on the 300 hall and nine (9) residents on the 100 - 109 hall (a total of twenty-seven (27) residents, including four (4) of eighteen (18) sampled residents)) and any visitors on these units at that time, as neither the residents nor visitors would have been able to exit the facility through the affected doors without a staff member being present to manually unlock the doors. The facility was aware these delayed-egress locks were not functioning as designed as early as 11/04/09, when the contracted service company identified these concerns during an inspection of the facility's fire alarm system, yet no affirmative action had been taken to ensure this identified problem had been corrected at that time. At 11:15 a.m. on 01/26/10, the life safety code surveyor informed the survey team that, while testing the fire alarm system, he had discovered three (3) of the doors of egress would not unlock automatically when the fire alarm sounded. He stated the facility's immediate action, after surveyor intervention, was to disarm the door locks on these doors and post an employee at each of them to prevent unauthorized exit. At 11:45 a.m., direct observation verified an employee was stationed at each exit. At this time, the survey team verified the circumstances that created immediate jeopardy had been mitigated. At 1:05 p.m. on 01/26/10, the life safety code surveyor relayed he had informed the State survey and certification agency's program manager of the situation. During an interview with the administrator, the maintenance director, and a corporate representative at 1:10 p.m. on 01/26/09, the survey team leader notified them that immediate jeopardy had existed at the time the life-safety surveyor identified the delayed-egress locks on three (3) emergency exit doors did not automatically release when tested , and that the immediate jeopardy was removed when the delayed-egress locks on the affected doors were disarmed and staff was posted at each door. Upon removal of the immediate jeopardy, a deficient practice remained until the locks were repaired and/or other systems were put into place to prevent unauthorized exit of residents through these doors, which posed the potential for more than minimal harm affecting more than an isolated number of residents. Facility census: 100. Findings include: a) The most recent facility fire alarm inspection report, which was provided by the facility upon request, was reviewed at approximately 3:00 p.m. on 01/25/10. This fire alarm inspection was conducted by SimplexGrinnell and bore the date of 11/04/09. Review of this report revealed, under the title of ""Recommendation"", the following: ""The access control doors located on the ground floor entrance by the nurse station, the ground floor stairs by the nurse station, first floor by room [ROOM NUMBER] and first floor break room exit do not release automatically during the onset of a fire alarm. SimplexGrinnell recommends that these doors do release automatically during the onset of a fire alarm."" b) When questioned, on 01/25/10 at approximately 4:00 p.m., if the facility had corrected the issue pertaining to automatic release of these doors upon activation of the fire alarm system, the facility's plant operations director stated he was not sure and would research his files for an answer. c) During a tour of the facility on 01/26/10 at approximately 9:30 a.m., the emergency release process was tested on the double outside egress doors located near the Station 3 Nurse Station (identified as the ground floor above). These doors failed to initiate an irreversible release process when a force greater than 15 lbf was applied for a period of greater than three (3) seconds. When questioned if he had been able to locate any documentation indicating the automatic release during a fire alarm activation issue had been corrected, the plant operations director stated he had not. d) At the request of the life-safety code surveyor on 01/26/10 at approximately 10:30 a.m., the facility's fire alarm system was activated. At this time, the double outside egress doors located near the Station 3 Nurse Station were tested and were found to be locked. The remaining delayed-egress locks listed on the fire alarm inspection reported, and others, were tested at this time with the following additional findings: - The designated outside exit door near resident room [ROOM NUMBER] was locked and had failed to release with the fire alarm. - The stairway door located near the Station 3 Nurse Station was locked and had failed to release failed to release with the fire alarm; however, this door was not situated within the designated means of egress and was, therefore, not a delayed-egress lock. - The designated outside exit door located near the break room was difficult to open (bound within the door frame); however, the delayed-egress lock had released. e) At 11:15 a.m. on 01/26/10, the life safety code surveyor informed the survey team that, while testing the fire alarm system, he had discovered three (3) of the doors of egress would not unlock automatically when the fire alarm sounded. He stated the facility's immediate action, after surveyor intervention, was to disarm the door locks on these doors and post an employee at each of them to prevent unauthorized exit. At 11:45 a.m., direct observation verified an employee was stationed at each exit. At this time, the survey team verified the circumstances that created immediate jeopardy had been mitigated. During an interview with the administrator, the maintenance director, and a corporate representative at 1:10 p.m. on 01/26/09, the survey team leader notified them that immediate jeopardy had existed at the time the life-safety surveyor identified the delayed-egress locks on three (3) emergency exit doors did not automatically release when tested , and that the immediate jeopardy was removed when the delayed-egress locks on the affected doors were disarmed and staff was posted at each door. (See also citation at F323.) f) The facility was aware of this quality deficiency as early as 11/04/09, but there was no evidence the facility developed / implemented a plan of action to correct this problem until after the life-safety code surveyor intervened on 01/26/10. .",2015-06-01
10198,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2010-01-28,490,K,0,1,MFK411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and performance testing, record review, and staff interview, the facility was not administered in an manner that enabled it to use its resources effectively and efficiently to maintain a resident environment as free as possible of accident hazards. A fire inspection report, provided to the facility by a contracted service company and dated 11/04/09, identified ""access control doors"" equipped with delayed-egress locks did not automatically release as designed upon activation of the fire alarm system. Interview with the plant operations director, on the morning of 01/26/10, found he was unable to locate any documentation indicating the automatic release during a fire alarm activation issue had been corrected in reaction to the 11/04/09 fire inspection report. Performance testing, on the morning of 01/26/10, found the delayed-egress magnetic locks of three (3) designated doors of emergency egress failed to automatically release as intended upon application of a force of greater than 15 lbf for greater than three (3) seconds and/or upon activation of the fire alarm. Two (2) of the doors (double doors) were located on the 300 hall (one level down from the main entry level of the facility), and the third door was located at the end of the 100 hall next to room [ROOM NUMBER] (on the entry level). This placed in immediate jeopardy eighteen (18) residents on the 300 hall and nine (9) residents on the 100 - 109 hall (a total of twenty-seven (27) residents, including four (4) of eighteen (18) sampled residents)) and any visitors on these units at that time, as neither the residents nor visitors would have been able to exit the facility through the affected doors without a staff member being present to manually unlock the doors. The facility was aware these delayed-egress locks were not functioning as designed as early as 11/04/09, when the contracted service company identified these concerns during an inspection of the facility's fire alarm system, yet no affirmative action had been taken to ensure this identified problem had been corrected at that time. At 11:15 a.m. on 01/26/10, the life safety code surveyor informed the survey team that, while testing the fire alarm system, he had discovered three (3) of the doors of egress would not unlock automatically when the fire alarm sounded. He stated the facility's immediate action, after surveyor intervention, was to disarm the door locks on these doors and post an employee at each of them to prevent unauthorized exit. At 11:45 a.m., direct observation verified an employee was stationed at each exit. At this time, the survey team verified the circumstances that created immediate jeopardy had been mitigated. At 1:05 p.m. on 01/26/10, the life safety code surveyor relayed he had informed the State survey and certification agency's program manager of the situation. During an interview with the administrator, the maintenance director, and a corporate representative at 1:10 p.m. on 01/26/09, the survey team leader notified them that immediate jeopardy had existed at the time the life-safety surveyor identified the delayed-egress locks on three (3) emergency exit doors did not automatically release when tested , and that the immediate jeopardy was removed when the delayed-egress locks on the affected doors were disarmed and staff was posted at each door. Upon removal of the immediate jeopardy, a deficient practice remained until the locks were repaired and/or other systems were put into place to prevent unauthorized exit of residents through these doors, which posed the potential for more than minimal harm affecting more than an isolated number of residents. Facility census: 100. Findings include: a) The most recent facility fire alarm inspection report, which was provided by the facility upon request, was reviewed at approximately 3:00 p.m. on 01/25/10. This fire alarm inspection was conducted by SimplexGrinnell and bore the date of 11/04/09. Review of this report revealed, under the title of ""Recommendation"", the following: ""The access control doors located on the ground floor entrance by the nurse station, the ground floor stairs by the nurse station, first floor by room [ROOM NUMBER] and first floor break room exit do not release automatically during the onset of a fire alarm. SimplexGrinnell recommends that these doors do release automatically during the onset of a fire alarm."" b) When questioned, on 01/25/10 at approximately 4:00 p.m., if the facility had corrected the issue pertaining to automatic release of these doors upon activation of the fire alarm system, the facility's plant operations director stated he was not sure and would research his files for an answer. c) During a tour of the facility on 01/26/10 at approximately 9:30 a.m., the emergency release process was tested on the double outside egress doors located near the Station 3 Nurse Station (identified as the ground floor above). These doors failed to initiate an irreversible release process when a force greater than 15 lbf was applied for a period of greater than three (3) seconds. When questioned if he had been able to locate any documentation indicating the automatic release during a fire alarm activation issue had been corrected, the plant operations director stated he had not. d) At the request of the life-safety code surveyor on 01/26/10 at approximately 10:30 a.m., the facility's fire alarm system was activated. At this time, the double outside egress doors located near the Station 3 Nurse Station were tested and were found to be locked. The remaining delayed-egress locks listed on the fire alarm inspection reported, and others, were tested at this time with the following additional findings: - The designated outside exit door near resident room [ROOM NUMBER] was locked and had failed to release with the fire alarm. - The stairway door located near the Station 3 Nurse Station was locked and had failed to release failed to release with the fire alarm; however, this door was not situated within the designated means of egress and was, therefore, not a delayed-egress lock. - The designated outside exit door located near the break room was difficult to open (bound within the door frame); however, the delayed-egress lock had released. e) At 11:15 a.m. on 01/26/10, the life safety code surveyor informed the survey team that, while testing the fire alarm system, he had discovered three (3) of the doors of egress would not unlock automatically when the fire alarm sounded. He stated the facility's immediate action, after surveyor intervention, was to disarm the door locks on these doors and post an employee at each of them to prevent unauthorized exit. At 11:45 a.m., direct observation verified an employee was stationed at each exit. At this time, the survey team verified the circumstances that created immediate jeopardy had been mitigated. During an interview with the administrator, the maintenance director, and a corporate representative at 1:10 p.m. on 01/26/09, the survey team leader notified them that immediate jeopardy had existed at the time the life-safety surveyor identified the delayed-egress locks on three (3) emergency exit doors did not automatically release when tested , and that the immediate jeopardy was removed when the delayed-egress locks on the affected doors were disarmed and staff was posted at each door. (See also citation at F323.) f) The facility was aware of this quality deficiency as early as 11/04/09, but there was no evidence the facility developed / implemented a plan of action to correct this problem until after the life-safety code surveyor intervened on 01/26/10. (See also citation at F520.) .",2015-06-01
10199,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2010-01-28,309,G,0,1,MFK411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of facility policies and procedures, and the State's legislative rule related to the duties of a registered professional nurse, the facility failed to complete and/or communicate to the physician the results of a comprehensive nursing assessment following falls involving two (2) of eighteen (18) sampled residents, both of whom expressed complaints of severe pain after their falls. Both residents were later found to have sustained fractures associated with the falls, and the failure to perform and/or communicate the results of a comprehensive nursing assessment to the physician immediately after the falls resulted in delayed identification and treatment of [REDACTED].#84 and #71. Facility census: 100. Findings include: a) Resident #84 Review of Resident #84's medical record revealed the resident fell from the bed to the floor at 7:50 a.m. on 09/16/09, sustaining two (2) skin tears. The skin tears were cleaned and dressed, staff assisted the resident was assisted to chair, and neurological checks were initiated. The medical record did not contain any evidence to reflect the resident's range of motion was assessed prior to transferring the resident from the floor to the chair. Upon further review, vital signs were obtained at 10:00 a.m. on 09/16/09, and nursing documentation noted the resident was complaining of pain to the right groin area. This documentation revealed that passive range of motion was successful with the left leg; however, passive range of motion to the right leg was unsuccessful due to the resident's complaints of pain at a level of ""10"" (based on a scale of 1 to 10). At 10:30 a.m., the nurse contacted the physician, who ordered [MEDICATION NAME] for pain, a low bed, and floor mats, as well as labs. The medical record revealed the next entry occurred at 8:45 a.m. on 9/17/09, when the resident complained of pain with movement. The right leg appeared externally rotated with [MEDICAL CONDITION] noted in the groin area. The physician, when contacted, ordered the resident be sent out to the emergency room for evaluation. The resident was transported via 911 at 9:20 a.m., more than twenty-five (25) hours after the fall. The resident was diagnosed with [REDACTED]. b) Resident #71 Review of Resident #71's medical record revealed the resident sustained [REDACTED]. The medical record did not contain any evidence to reflect the resident's range of motion was assessed prior to transferring the resident from the floor to the geri chair. Review of the 12/22/09 Comprehensive Evaluation of Change in Condition form found the vital signs recorded at 11:30 a.m. were identical as those recorded as taken at 10:30 a.m. listed on the original Accident/Incident report done at 11:15 a.m. There was no evidence that neuro checks were initiated or that the resident was immediately and thoroughly assessed. In addition, there was no evidence that neuro checks were completed again until the 3/11 shift, as documented on the 12/22/09 Comprehensive Evaluation of Change in Condition report. The physician ' s 12/22/09 progress noted assessment of the resident ' s open wounds, but did not address the resident ' s comprehensive assessment post fall for injury. There was no evidence in the medical record or the Comprehensive Evaluation of Change in Condition report on 12/23/09 from 7:00 a.m. to 7:30 p.m. to indicate that follow up physical and neurological assessments were completed to assess for post fall injuries. The resident received scheduled [MEDICATION NAME] 5/500 mg every four (4) hours. Neuro checks were not initiated until after the resident returned from the hospital on [DATE] at 11:35 p.m. The medical record revealed the resident was not sent out to the hospital until 8:25 p.m. on 12/23/09, more than twenty-four (24) hours after the initial fall. The medical record revealed the resident was "" yelling out and crying "" in pain at 7:30 p.m. and was unable to move her right leg freely; the physician was then contacted and orders were received to have the resident sent out to the emergency room for evaluation. The resident was diagnosed with [REDACTED]. c) On 01/28/10 at 8:20 a.m., an interview was done with the director of nursing (DON), assistant director of nursing (ADON), and the medical director (Employees #41, #90, and #128, respectively), regarding the two (2) residents mentioned above. This surveyor reviewed with them findings from the medical records of both residents, which did not demonstrate that a range of motion assessment was performed prior to moving the residents from the floor to the chair. During the interview the director of nursing acknowledged that a range of assessment was not performed prior to moving the residents immediately after the fall. A potential delay in treatment was caused by the failure to perform comprehensive assessments. d) Review of information provided by the facility found the following: 1) The facility form titled Resident Examination and Assessment, revised 10/16/08, and received on 01/26/10 at 4:00 p.m. was reviewed. Section E, Musculoskeletal System: stated, "" Observe the resident ' s gait, mobility, and range of motion. Observe for joint deformity, contractures, muscle tone, and any signs of fracture. "" Section D, Neurological system: stated, "" Notice the strength and equality of hand grasps and if the resident is able to move all his/her extremities. "" 2) The Nursing Policy and Procedures, Subject: Fall Prevention, dated 01/08, and received on 01/26/10 at 3:45 p.m. was reviewed. Section 5; Practice Guidelines, stated, "" ...If a fall occurs, the qualified staff assesses for injury from the fall, immediately investigates the reason and determines the intervention to prevent future falls. "" 3) On 01/29/10 at 11:00 a.m. the DON presented a page titled, Lippincott Manual, Policy dated 06/09. It stated, "" The Lippincott Manual of Nursing Practice shall act as the Facilities comprehensive reference for general nursing practice and standard procedures. "" The information presented did not include any specific policies or procedures regarding physical assessments post fall. e) According to Title 19 Legislative Rule Board of Examiners for Registered Professional Nurses: Series 10-Standards For Professional Nursing Practice: 2.1. The registered professional nurse shall conduct and document nursing assessments of the health status of individuals or groups by: 2.1.1. Collecting objective and subjective data from observations, examinations, interviews, and written records in an accurate and timely manner. 2.4. The registered professional nurse shall develop and modify the plan of care based on assessment and nursing [DIAGNOSES REDACTED]. This includes: 2.4.2. Prescribing nursing intervention(s) based upon the nursing [DIAGNOSES REDACTED]. 2.4.3. Identifying measures to maintain comfort, to support human functions and responses, to maintain an environment conducive to well being, and to provide health teaching and counseling. 2.5 The registered professional nurse shall implement the plan of care by: 2.5.1. Initiating nursing interventions through: 2.5.1. a. Writing nursing orders and/or directives; 2.5.1. b. Providing direct care; 2.5.1. c. Assisting with care 2.5.3. Documenting nursing interventions and responses to care. .",2015-06-01
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
10021,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2010-02-11,225,D,0,1,4T1611,". Based on a review of personnel files and staff interview, the facility failed to thoroughly screen one (1) of ten (10) sampled employees for findings of abuse or neglect, by failing to make an inquiry to the WV Nurse Aide Registry as required before the new employee was permitted to begin work at the facility. Employee identifier: #75. Facility census: 50. Findings include: a) Employee #75 A review of the personnel file for Employee #75, on the morning of 02/09/10, revealed that she was hired as a nursing assistant on 10/05/09. However, there was no evidence to reflect this individual was screened through the WV Nurse Aide Registry for findings of resident abuse / neglect. When interviewed on 02/09/10 at 3:00 p.m., the director of nursing (Employee #7) confirmed there was no evidence the required registry check was made prior to the employment of Employee #75. .",2015-07-01
10022,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2010-02-11,496,D,0,1,4T1611,". Based on review of sampled personnel records and staff interview, the facility failed to receive registry verification that individuals met competency evaluation requirements before allowing them to serve as nurse aides. This was found for one (1) of ten (10) records reviewed. Employee identifier: #75. Facility census: 50. Findings include: a) Employee #75 Review of the personnel records of Employee #75 (a nursing assistant), on the morning of 02/09/10, revealed she started working on 10/05/09. The facility had no evidence this nursing assistant was registered with the WV Nurse Aide Registry as having completed the State-required minimum training and competency evaluation. During an interview on 02/09/10 at 3:00 p.m., the director of nursing (DON - Employee #7) confirmed that Employee #75 had been performing direct patient care while the facility had no verification she had successfully completed the training and competency evaluation as required by the State. .",2015-07-01
10023,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2010-02-11,152,D,0,1,4T1611,". Based on medical record review and staff interview, the facility failed to ensure the rights of one (1) of twelve (12) sampled residents, who had been determined to lack capacity to make informed health care decisions, were exercised by an individual appointed in accordance with State law. The physician appointed two (2) individuals to serve jointly as Resident #49's health care surrogate (HCS); however, WV State Code 16-30-8 allows a physician to appoint only one (1) HCS. Additionally, the facility allowed a family member who had not been appointed to the role of HCS to make health care decisions on Resident #49's behalf. Facility census: 50. Findings include: a) Resident #49 Medical record review revealed the physician appointed two (2) persons to serve jointly as Resident #49's HCS, to make health care decisions for this resident. In addition, record review also revealed health care decisions were being made by the resident's mother, who was had not been appointed to serve as HCS. In an interview with the administrator and the person in charge of resident funds (Employee #5) at 2:15 p.m. on 02/10/10, they acknowledged understanding the State law only allows for the appointment of one (1) person to serve as HCS for an incapacitated individual, and they acknowledged the resident's mother was not the resident's legal representative. They state they would see that all staff was made aware of this. According to WV Code 16-30-8. Selection of a surrogate.: ""(a) If no representative or court-appointed guardian is authorized or capable and willing to serve, the attending physician or advanced nurse practitioner is authorized to select a health care surrogate."" ""(b)(1) Where there are multiple possible surrogate decisionmakers at the same priority level, the attending physician or the advanced nurse practitioner shall, after reasonable inquiry, select as the surrogate the person who reasonably appears to be best qualified."" This State law does not allow for the simultaneous appointment of more than one (1) person to serve jointly as HCS for an incapacitated individual. .",2015-07-01
10024,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2010-02-11,156,D,0,1,4T1611,". Based on record review and staff interview, the facility failed to provide to written notification to one (1) of five (5) randomly reviewed residents, who had been discharged from Medicare-covered skilled services, when the skilled services were discontinued and the resident's payer status changed. Resident identifier: #7. Facility census: 50. Findings include: a) Resident #7 A review of facility records reveals Resident #7 was discharged from Medicare-covered skilled services on 10/11/09, but there was no evidence she received a liability notice to inform her of the reason for the discontinuation of skilled services. This was verified by the nurse case manager (Employee #9) at 3:10 p.m. on 02/09/10, who stated that, because the resident had exhausted her one hundred (100) skilled days, she did not receive an notice. A request was made to the nurse to supply evidence the resident or her responsible party had been notified of this change in payer status. During an interview with the director of nurses, Employee #9, and the administrator at 11:10 a.m. on 02/11/10, Employee #9 acknowledged, after reviewing the record, that she could not state the responsible party had been clearly notified of the change in Resident #9's payer status. .",2015-07-01
10025,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2010-02-11,159,D,0,1,4T1611,". Based on record review and staff interview, the facility failed to obtain valid written authorizations prior to handling the personal funds of two (2) of twelve (12) sampled residents, and failed to provide quarterly statements of account activity to one (1) of these residents, who was alert and oriented. Resident identifiers: #49 and #44. Facility census: 50. Findings include: a) Resident #49 A review of the financial records revealed the written authorization on file allowing the facility to manage the personal funds of this resident, who has been determined to lack the capacity to make health care decisions, was signed by her mother, who was the resident's health care surrogate (HCS) on admission to the facility. The WV Health Care Decisions Act does not convey to a HCS the authority to make decisions on behalf of an incapacitated individual other than those related to health care (e.g., financial decisions). b) Resident #44 A review of the clinical records for Resident #44 revealed she was alert and oriented to person, place, and time and had been determined by the physician to have the capacity to make her own healthcare decisions. Review of the resident's financial records found the resident's daughter signed the authorization for the facility to manage the resident's personal funds. Upon questioning at 11:30 a.m. on 02/09/10, the office manager (Employee #5) also stated the quarterly statements of account activity were mailed to the daughter. She verified she does not supply a statement to the resident, although she agreed the resident would understand the statement. During an interview with the administrator and the office manager at 2:15 p.m. on 02/10/10, they acknowledged the resident should have been informed of her financial status and given the option to make her own decisions about her personal funds. They related that this matter would be referred to the social worker next week, upon her return from vacation. Employee #5 also stated she would ensure the resident started receiving quarterly statements. .",2015-07-01
10026,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2010-02-11,371,F,0,1,4T1611,". Based on observation and staff interview, the facility failed to ensure the proper sanitation of the kitchen area to prevent potential contamination of food products by inadequate cleaning of the equipment. This had the potential to affect all residents. Facility census: 50. Findings include: a) During the general tour of the kitchen and dry storage room at 12:50 p.m. on 02/08/10, observation found the inner aspect of the steam table to be dirty, with dried food debris and stains visible. The backsplash of the stove was also covered with baked and dried food stains. During service of the noon meal at 11:15 a.m. on 02/09/10, observation found the steam table to be cleaner, but the stove was still very stained. The dietary manager was present during both observations and stated there was a schedule for cleaning the steam table, but it had been overlooked. She agreed the backsplash needed to be cleaned. .",2015-07-01
10027,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2010-02-11,387,D,0,1,4T1611,". Based on record review and staff interview, the facility failed to assure one (1) of twelve (12) sampled residents was seen by a physician at least once in every sixty (60) days. Resident identifier: #1. Facility census: 50. Findings include: a) Resident #1 A review of the clinical record, completed on 02/09/10, revealed the last entry by a physician was dated 10/02/09. A review of the nurses' notes failed to reveal any other visits. During an interview with the director of nurses (DON) and the administrator at 11:10 a.m. on 02/11/10, the DON stated she had reviewed the record and questioned the nurses, but she could not show evidence to reflect the physician had seen the resident since 10/02/09. The administrator stated he would notify the physician and the quality assurance committee of this problem. .",2015-07-01
10028,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2010-02-11,278,D,0,1,4T1611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure the accuracy of the minimum data set (MDS) assessments by failing to accurately encode the resident's skin condition and/or [MEDICAL TREATMENT] treatments on two (2) different assessments for one (1) of twelve (12) sampled residents. Resident identifier: #13. Facility census: 50. Findings include: a) Resident #13 1. A review of the clinical record revealed, in Section M4 of the 08/14/09 admission MDS, no entry for ""Surgical wounds"", although the admission nursing assessment dated [DATE] stated the resident was admitted with [DIAGNOSES REDACTED]. 2. A review of the clinical record also revealed, in Item P1b of the 11/13/09 quarterly MDS, no entry to indicate the resident received [MEDICAL TREATMENT], although the resident had orders for and received [MEDICAL TREATMENT] three (3) times weekly on a continuing basis. 3. In an interview with the director of nurses at 1:20 p.m. on 02/10/10, she reviewed the assessments and stated these were oversights and they would be corrected. .",2015-07-01
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
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
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
9363,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-02-25,156,D,0,1,2RPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to inform the responsible parties of two (2) of thirty-two (32) Stage II sampled residents when Medicare-covered skilled treatments were discontinued and/or the reason(s) for the services being discontinued. Resident identifiers: #102 and #63. Facility census: 87. Findings include: a) Resident #102 A review of the medical record revealed that resident #102, who was admitted on [DATE], had received therapy services from 10/19/09 through 11/28/09. Althought the responsible party was notified by letter that the resident's Medicare Part A benefit days had exhausted on 11/28/09, there was no evidence in the medical record to show that the responsible party had been notified which services had been discontinued and no medical reason was given for the stoppage. The physical therapy (PT) notes written on 11/18/09, state: d/c (discontinue) PT - all goals met, and the occupational therapy (OT) notes written on 11/26/09, stated that the goals were partially met; but, neither indicated that this had been discussed with the family. The nurses notes from 11/24/09 - 12/03/09 were reviewed without any evidence of discussion with resident and/or family regarding the changes in the resident's care. During an interview with the director of nursing and the assistant director of nursing at 2:00 p.m. on 02/24/10, they stated that they could find no documentation that an explanation of which services were being discontinued and the reason for this had been given to the family, although they stated that they were sure it had been done. b) Resident #63 A review of the medical record revealed that resident #63, who was admitted on [DATE], received physical therapy (PT) and occupational therapy (OT) services from 09/15/09 - 12/21/09. A review of the nurses notes from 12/15/09 - 01/06/10 and of the PT and OT discharge notes failed to reveal any evidence that the resident and/or family had been notified of which services had been discontinued and/or of the reason for this discontinuance. The Notice of Exclusions from Medicare Benefits letter was reviewed, but it did not explain which services or the reason either. During an interview with the director of nursing and the assistant director of nursing at 2:00 p.m. on 02/24/10, they stated that they could find no documentation that an explanation of which services were being discontinued and the reason for this had been given to the family, although they stated that they were sure it had been done.",2015-11-01
9364,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-02-25,157,D,0,1,2RPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, record review, and staff interview, the facility failed to assure proper notification of the physician and the resident ' s responsible party when changes occurred in a resident's health care status and/or services. This was evident for one (1) of thirty-two (32) Stage II sampled residents. Resident identifier: #58. Facility census: 87. Findings include: a) Resident #58 During a family interview on 02/21/10 at 4:29 p.m., Resident #58's wife stated he was admitted to the hospital on [DATE], due to complications of a urinary tract infection [MEDICAL CONDITION]. At that time, she was allegedly told by the emergency room (ER) physician that his UTI, which had been diagnosed earlier that week at the facility (01/22/10), showed a colony count greater than 100,000. The wife stated she had signed the pink POST (Physician order [REDACTED]. The resident was subsequently hospitalized and treated for [REDACTED]. Review of the physician's progress note, dated 01/12/10, revealed, H/O (history of)[MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) UTI: monitor for symptoms. There is also a handwritten note stating, Family wants pt. (patient) to be kept comfortable and avoid re-hospitalization s. Medical record review revealed a nurse's note in the resident's electronic medical record, dated 01/19/10, stating the certified physician's assistant (PA-C) was in the facility and ordered a urinalysis, complete blood count, and other labs, and the wife was aware. The nurse (Employee #1) found this note in the computer on 02/24/10 at 10:10 a.m., but record review did not find the note had been printed and placed inside the medical record. The note did not say why the lab testing was ordered. A nurse's note, dated 01/21/10, stated the physician was notified of the lab results on 01/20/10, and culture results were pending. A urine culture and sensitivity (C&S) report, dated 01/22/10, noting [MEDICAL CONDITION] culture of greater than 100,000, was signed by the PA-C, with a notation stating: Will not Tx (treat). A nurse's note, dated 01/23/10 at 7:22 p.m., recorded a change in the resident's condition; the physician was notified of drainage under the foreskin and reddened skin, an antifungal powder ([MEDICATION NAME]) was ordered, and the spouse made aware. Medical record review revealed no nursing documentation entered on 01/24/10. Employee #1 checked the computer, on 02/24/10 at 10:10 a.m., and found there were also no nursing notes in the computer for that date. Medical record review revealed a nurse's notes, dated 01/25/10 at 1:55 a.m., citing the resident had frequent loose stools. There was no documentation of the physician having been notified. Nurses' notes, dated 01/25/10 at 10:43 a.m. and 1:45 p.m., cited the resident refused breakfast (and the offer of an alternative) and lunch (and alternative), but there was no documentation the physician was notified. By comparison, a weekly charting note, dated 01/21/10 at 1:19 a.m., indicated appetite good. A nurse's notes, dated 01/25/10 at 9:37 p.m., revealed the spouse asked for PRN (as needed) [MEDICATION NAME] (an opioid pain medication) at 3:20 p.m. and at 8:30 p.m., which was in addition to his scheduled [MEDICATION NAME] every six (6) hours at noon, 6:00 p.m., midnight, and 6:00 a.m. The nurse also documented at this time that his penis was oozing yellow drainage and she (p)ut it in the Dr. (name) to look at it tomorrow. Will monitor. Medical record review, for all nurses' notes entered on 01/25/10, found no entries indicating a physician was notified of any of these changes in condition. A nurse's note, dated 01/26/10 at 10:16 a.m., stated the spouse called at 8:10 a.m. to see how he was doing and was told he did not eat breakfast but rather let it run out of his mouth, and he ingested only 75% of the medications that were crushed and placed in thick liquids. At this point, the wife asked that the PA-C be called to inform him she wanted the resident sent out to the hospital. This was done, and the resident left the facility at 9:30 a.m. Review of the resident's care plan, dated 01/16/09, found the following problem area: Potential for UTI due to UTI hx. (history). Interventions included: Assess for signs / symptoms of UTI and Notify MD (medical doctor) of problems / changes. Additionally, the care plan listed a problem of: Potential for complications due [MEDICAL CONDITION], with an intervention of: Keep MD informed. The discharge summary, dated 01/29/10, noted: The plan is to keep him comfortable. It seems that this [MEDICAL CONDITION]-Resistant Staphylococcus Aureus urinary tract infection was causing some discomfort and, therefore, seems appropriate to receive antibiotic treatment for [REDACTED]. There was also a notation indicating the spouse was comfortable with this plan per phone discussion. Review of the physician's progress note, dated 02/02/10, found a summary of the preceding two (2) weeks and a notation that the patient had a complication [MEDICAL CONDITION] UTI. The physician noted the patient was comfortable and [MEDICAL CONDITION] did not require treatment, but eventually the patient did have some symptoms of the UTI and since would require an inpatient consult the patient was treated in (the) hospital. The pt returned to baseline. Interview with the administrator and the director of nursing, on 02/24/10 at 4:15 p.m., revealed the physician was aware of the urine C&S of greater than 100,000 [MEDICAL CONDITION], and the physician was not going to treat the UTI, because the resident was asymptomatic. The resident had no flank pain, no fever, no symptoms, and had been diagnosed with [REDACTED]. They said the spouse was not notified of the results of the urine culture on 01/22/10, because the doctor did not see the need to treat an [MEDICAL CONDITION] on a patient who had a history of [REDACTED]. They agreed that, when he developed pus, this was a symptom, and he was sent to the ER the same morning as when the doctor was notified of the spouse's request to send him out. They said they did not re-culture the urine, as he has been colonized and treated with intravenous (IV) antibiotics. Since he has remained asymptomatic, his isolation was discontinued on the morning of 02/24/10.",2015-11-01
9365,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-02-25,241,D,0,1,2RPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to provide care in a manner that maintained each resident's dignity during dining, as evidenced by one (1) of thirty-two (32) Stage II residents who did not receive proper set-up assistance with her utensils and was eating with her fingers prior to surveyor intervention. Resident identifier: #13. Facility census: 87. Findings include: a) Resident #13 Observation of the evening meal, on 02/22/10 at approximately 5:30 p.m., found Resident #13 sitting at the dining room table dipping her fingers into bowls of pureed green bean salad and pudding and eating from her fingers. Staff was lined up at the food cart approximately 10 feet from where Resident #13 was sitting, and other staff members were assisting other residents. After the fourth time Resident #13 was observed eating from her fingers, staff was asked if she was able to use eating utensils. An unidentified nursing assistant said, Yes, she does, if someone opens up her silverware for her. She then opened the silverware pack, and the resident began feeding herself with a spoon. Review of Resident #13's care plan revealed an intervention to set up tray, encourage 75 - 100% of food intake, as the resident was at nutritional risk with [DIAGNOSES REDACTED].",2015-11-01
9366,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-02-25,278,D,0,1,2RPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview, the facility failed to ensure the accuracy of two (2) of thirty-two (32) Stage II residents with respect to bladder continence and the daily use of physical restraints. Resident identifiers: #80 and #122. Facility census: 87. Findings include: a) Resident #80 Interview with the resident, on during the mid-afternoon of 02/23/10, found the resident was aware of the need to void and did let staff know when she needed to use the rest room. Review of Resident #80's quarterly minimum data set (MDS), with an assessment reference date of 12/30/09, found, in Section H1, bladder incontinence was inaccurately assessed as 3 - frequently incontinent (tending to be incontinent daily, but some control present). Review of the Resident Continent Log, for the fourteen-day lookback period from 12/16/10 through 12/29/09, found the resident was only incontinent once each day on 12/17/09, 12/20/09, 12/25/09, 12/26/09, and 12/29/09, and twice on 12/23/09. During an interview with the MDS nurse (Employee #99) on 02/24/10 at 10 a.m., she said she made a mistake on the MDS and the resident was incontinent less than daily, with three (3) episodes of urinary incontinence during the first week of observation and four (4) during the second week. b) Resident #122 A review of the medical record revealed that Resident #122, who was admitted to the facility on [DATE], had been using a Vail enclosed bed system with zippered screened sides since admission, due to his constant movement. Additionally, whenever he was out of bed, he was in a Broda chair with either a pelvic or thigh restraint in place. These measures were confirmed by the nurse (Employee #9) at 3:00 p.m. on 02/22/10. His care plan addressed the daily use of these restraints, but his admission MDS indicated only that a trunk restraint was in use less than daily. When this was reviewed with the MDS nurse on 02/24/10, she agreed the resident used a physical restraint daily and the entry was an error.",2015-11-01
9367,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-02-25,279,D,0,1,2RPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and medical record review, the facility failed to develop care plans to meet the known needs of two (2) of thirty two (32) Stage II sampled residents. Resident #80 had vision limitations due to [MEDICAL CONDITION] which were not addressed in her care plan, and Resident #127 was admitted with orders for outpatient [MEDICAL TREATMENT] three (3) times a week, and this was not addressed in her interim care plan. Resident identifiers: #80 and #127. Facility census: 87. Findings include: a) Resident #80 In interviews in her room on the mid-afternoon of 02/23/10 and again on 02/25/10 at 9:30 a.m., Resident #80 related she had [MEDICAL CONDITION] and her vision was limited. This limitation interfered with her ability to clearly see her food and to get about in the facility. She said she got around by feeling for most things. During an interview on 02/24/10, the director of nursing said Resident #80 liked to have the window blinds in her room closed due to her [MEDICAL CONDITION]. Review of Resident #80's most current care plan, dated 10/05/09, found the resident was noted to have [MEDICAL CONDITION], but there was no description of how the [MEDICAL CONDITION] limited the resident's ability to see, nor were there any interventions identified for staff to use to assist her with these limitations. b) Resident #127 A review of the medical record, on 02/24/10, revealed Resident #127 was admitted , on 02/17/10, with [DIAGNOSES REDACTED]. An interim care plan was present in the record, but it did not address the resident's [MEDICAL TREATMENT] needs, including nursing interventions for the monitoring and care of the venous access site and monitoring of the resident's fluid status. The care plan for Hydration / Fluid Maintenance Risk was marked N/A (not applicable) and left blank. In an interview with a licensed practical nurse (LPN - Employee #19) at 5:20 p.m. on 02/21/10, she stated the resident went to outpatient [MEDICAL TREATMENT] on Monday, Wednesday, and Friday and had done so since admission. During an interview with the assistant director of nursing (ADON) at 1:00 p.m. on 02/24/10, she acknowledged, after reviewing the care plan, that there was nothing about the [MEDICAL TREATMENT] and it had just been overlooked. The ADON returned on the following morning to state the resident's care plan had been updated to include [MEDICAL TREATMENT] and now also addressed fluid needs and monitoring.",2015-11-01
9368,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-02-25,280,D,0,1,2RPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to revise a comprehensive care plan when a resident's status changed. The facility did not revise or update the care plan for a resident who developed two (2) Stage II pressure ulcers following admission to the facility. This was true for one (1) of thirty-two (32) Stage II sampled residents. Resident identifier: #10. Facility census: 87. Findings include: a) Resident #10 Resident #10's medical record, when reviewed on 02/23/10 at 3:00 p.m., revealed an [AGE] year old female who was admitted to the facility on [DATE], for care and rehabilitation therapy following a recent fall resulting in a fractured humerus. Review of the facility form titled Immediate Plan Of Care, dated 02/17/10, found the resident was a Pressure Ulcer Risk. The care plan was not revised or updated on 02/19/10, when the resident developed two (2) Stage II pressure ulcers on her buttocks. The care plan did not identify the presence of the pressure ulcers, nor did it contain the interventions currently ordered to promote wound healing. The care plan nurse (Employee #99), when interviewed on 02/24/10 at 9:15 a.m., confirmed the resident's current care plan did not address the presence or current treatment / interventions ordered to promote healing of the two (2) pressure ulcers. Resident #10 was observed on 02/24/10 at 10:35 a.m. while in bed. The registered nurse (RN - Employee #1) was observed providing treatment to the pressure ulcers. The resident was observed to have three (3) Stage II pressure ulcers - two (2) on the right buttocks and one (1) on the sacrum. The assistant director of nurses (ADON - Employee #59), when interviewed on 02/24/10 at 2:30 p.m., acknowledged the resident had developed a new Stage II pressure ulcer since the last weekly skin assessment on 02/22/10. The ADON notified the physician, and a new treatment to the sacrum was ordered.",2015-11-01
9369,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-02-25,281,D,0,1,2RPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review, and observation, the facility failed to ensure physician's orders and the administration of medications met professional standards of care. This was true for three (3) of thirty-two (3) Stage II sampled residents. A physician's order for pain medication did not state the frequency the medication was to be administered. an order for [REDACTED]. Resident identifiers: #10, #44, and #80. Facility census: 87. Finding include: a) Resident #10 Resident #10's medical record, when reviewed on 02/24/10 at 10:00 a.m., revealed an [AGE] year old female with a history of a recent fall resulting in a fractured humerus. The resident's left arm was fractured, and she was admitted to the facility on [DATE] for care and rehabilitation services. Review of the admission physician orders, dated 02/17/10, revealed an order for [REDACTED]. Review of the February 2010 Medication Administration Record [REDACTED]. The assistant director of nurses (ADON - Employee #59), when interviewed on 02/24/10 at 3:35 p.m., acknowledged the current [MEDICATION NAME] order did not specify the frequency at which staff was to administer the medication. The ADON provided a computer-printed physician's telephone order, dated 02/17/10. The order, which was not signed by the physician, stated: [MEDICATION NAME] 50 mg tab 1 tab po Q6 hrs PRN for 812.41 Fractured humerus. A clarification order was subsequently obtained on 02/24/10. Review of the facility's medication policy titled LTC Facility's Pharmacy Services and Procedure Manual found: 1.1. A new order must include: . 1.1.3 Drug name, strength, dosage, time or frequency, and route of administration. b) Resident #44 Observation of the morning medication pass found Resident #44 in bed at 8:45 a.m. on 02/22/10. The medication nurse (Employee #13), when administering the resident's 8:30 a.m. medications, omitted a dose of [MEDICATION NAME] 500 mg. Review of the resident's current physician's orders found an order, dated 02/16/10, for: [MEDICATION NAME] 500 mg qd (every day ) x ( times) 7 days. Review of the February 2010 MAR found the resident had only received six (6) doses of the antibiotic. Employee #13, when interviewed on 02/22/10 at 9:42 a.m., acknowledged the [MEDICATION NAME] dose was not given and should have been administered. c) Resident #80 1. The February 2010 MAR indicated [REDACTED]. However, the order on the MAR indicated [REDACTED]. Review of the monthly recapitulation (recap) of physician's orders for February 2010 found the same information. 2. The February 2010 MAR indicated [REDACTED]. Neither document specified the number of drops to be given or to which eye the drops were to be administered. 3. An interview with the ADON, on 02/24/10 at 2:00 p.m., confirmed the orders needed to be clarified.",2015-11-01
9370,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-02-25,328,D,0,1,2RPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to assure all residents received respiratory treatment and care as ordered by the physician. This was evident for one (1) of thirty-two (32) Stage II sampled residents who was observed wearing a nasal canula connected to an empty oxygen tank. Resident identifier: #4. Facility census: 87. Findings include: a) Resident #4 Observation, on 02/21/10 at 5:17 p.m., found Resident #4 sleeping in his wheelchair in the dining room awaiting his evening meal. He was wearing a nasal canula which was connected to a portable oxygen tank attached to the back of his wheelchair. Inspection of the oxygen regulator found the tank was empty. When this situation was reported to the nurse (Employee #75) at this time, she sent a nursing assistant for a full tank of oxygen. Nine (9) minutes later (at 5:26 p.m.), the portable tank was replaced with a full tank of oxygen. Review of Resident #4's care plan revealed a problem area regarding injury risk related to hazards of oxygen administration; interventions included to keep oxygen on continuously and check especially during naps. Review of physician's orders [REDACTED].",2015-11-01
9371,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-02-25,371,F,0,1,2RPR11,"Based on observation and staff interview, the facility failed to store or serve food under sanitary conditions. This was evident in the emergency food supply area, which contained dented canned food items and a dirty floor, and had the potential to affect all residents who received nourishment from the facility's kitchen. This was also evident by staff applying dirty table coverings onto the residents' dining room tables and had the potential to affect all residents who consumed meals in the restorative dining room. Facility census: 87. Findings include: a) Inspection of the emergency food storage area, on 02/24/10 at 12:00 p.m., revealed three (3) dented 6-pound cans of fruit in the plastic storage bins. One (1) can of pears was dented at the seam and had discoloration on the white label where something wet had soaked into or leaked onto the label. One (1) can of apricots also was dented at the seam. One (1) can of applesauce was dented horizontally on the side of the can about 3 inches wide which traversed the seam. The dietary manager, who was present during the inspection, removed those three (3) cans of food immediately. She said the emergency food supply was rotated every six (6) months. These three (3) cans were dated February 2010, indicating they had recently been restocked. Additionally, the floor in the emergency food supply area had an area of a brackish-colored, sticky substance. The dietary manager explained there previously had been a shelf that had been removed over that area. She obtained paper towels to cover the area to keep us from sticking in it until staff could come clean the floor. b) At 10:00 a.m. on 02/24/10, observation found a dietary worker (Employee #66) in the hallway pushing snack carts and carrying table cloths over one (1) arm, when she dropped a table cloth to the floor. She retrieved the cloth from the floor and returned it to the stack over her arm. She then continued to the North dining area, where she covered the tables with the table cloths in her arms. This observation was relayed to the dietary manager at 2:00 p.m. on 02/24/10.",2015-11-01
9372,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-02-25,431,E,0,1,2RPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and a review of the facility's pharmacy manual, the facility failed to ensure drugs and biologicals used in the facility were labeled with expiration dates and failed to ensure outdated medications were discarded. This occurred for the intravenous (IV) cart and both treatment carts in the facility and had the potential to affect more than an isolated number of residents. Facility census: 87. Findings include: a) On [DATE] at 10:00 a.m., observation of the IV cart located at the South nursing station, with a licensed practical nurse (LPN - Employee #10) found the cart contained two (2) packages of Cipro IV, with a date of ,[DATE] on the bottom of the package and a date of [DATE] on the pharmacy label. Also found were a bag of Sodium Chloride 0.9% IV that expired in [DATE], four (4) bottles of Kefzol 1 gm powder with an expiration date of [DATE] on one (1) of the bottles and [DATE] on the other three (3) bottles, and a bottle of Heparin flush 100U per ml/30ml with an expiration date of [DATE]. At the same time, observation of the treatment cart at the South nursing station found a bottle of opened saline was observed without a date indicating when the bottle had been opened. These items were taken by Employee #10 and shown to the director of nursing at 10:30 a.m. on [DATE]. b) The treatment cart for the North nursing station, when observed on [DATE] at 10:45 a.m., held open containers of normal saline solution, hydrogen peroxide, and alcohol. The opened stock multidose containers of normal saline solution, hydrogen peroxide and alcohol were not properly labeled with the date initially opened. Additionally, Resident #76's Preparation H ointment was noted to have an expiration date of [DATE]. The treatment nurse (Employee #13), when interviewed on [DATE] at 10:50 a.m., acknowledged the normal saline solution, hydrogen peroxide, and alcohol solutions were opened and not properly labeled with a date opened. The LPN reported it was the facility's policy to label the stock solutions with the date opened and to discard these opened bottles after thirty (30) days. The treatment nurse confirmed Resident #76's medication was expired, and she discarded the tube of Preparation H and the bottles of normal saline, hydrogen peroxide, and rubbing alcohol solutions in the trash. Resident #76's medical record, when reviewed on [DATE] at 4:00 p.m., noted the resident had a current physician's orders [REDACTED].",2015-11-01
9373,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-02-25,441,D,0,1,2RPR11,"Based on observation, policy review, and staff interview, the facility failed to ensure one (1) of two (2) nurses observed used good infection control techniques while obtaining blood sugars for Resident #19. Facility census: 87. Findings include: a) Resident #19 During observations on 02/21/10 at 3:21 p.m., the licensed practical nurse (LPN - Employee #18) donned a pair of gloves, opened the medication cart drawer, and removed a glucometer, lancet, and glucometer strip. The LPN then disinfected the glucometer and, without changing her gloves, checked the resident's blood sugar level using the lancet, the glucometer strip, and glucometer. A review of the facility's policy titled Blood Sampling - Capillary (Finger Sticks) (revised October 2009) found the nurse should have washed her hands and donned gloves just before utilizing the glucose monitoring device for the resident, and then washed her hands after cleaning the device. This observation was reviewed with the director of nursing at 2:30 p.m. on 02/24/10.",2015-11-01
9374,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-02-25,492,F,0,1,2RPR11,"Based on personnel record review, staff interview, and policy review, the facility failed to assure all currently employed dietary personnel had food handler's cards issued by the local health department prior to working in food service. This was evident for one (1) of fourteen (14) dietary employees and had the potential to affect all residents in the facility who received nourishment from the dietary kitchen. Employee identifier: #71. Facility census: 87. Findings include: a) Employee #71 Interview with dietary manager (Employee #61), on 02/24/10 at 2:40 p.m., revealed one (1) of fourteen (14) dietary employees listed on the employee roster, which was supplied to surveyors by the facility, had no food handler's card. Review of the employee roster revealed Employee #71 was hired 01/04/10 and was a full-time employee. Review of food handler's cards for all currently employed dietary personnel revealed the absence of a food handler's card for Employee #71. Interview with dietary manager, on 02/24/10 at 2:40 p.m., found Employee #71 had been scheduled to attend a food handler's class twice, but each time was cancelled due to inclement weather, and she has no valid card. Interview with a representative of the Monongalia County Health Department, on 02/24/10 at 2:50 p.m., confirmed there was no food handler's card or temporary card on file at the local health department for Employee #71. She stated all food service employees in Monongalia County must have a food handler's card before they can work in food service. She stated food service workers were allowed to come in and apply for a temporary card until they can procure a food handler's card, but Employee #71 did not do this. During interview with the dietary manager, on 02/24/10 at 3:00 p.m., she stated she just spoke with the Monongalia County Health Department, and they now have a date for Employee #71 to go to the health department to get her card. Interview with the administrator and the director of nursing, on 02/24/10 at 4:15 p.m., revealed they were made aware today of the lack of food handler's cards as listed above. On 02/25/10 at 9:05 a.m., the administrator produced a policy which stated the facility follows all state and local regulations concerning initial hire for dietary associates, and, if required, posts a valid food handler's card for each dietary associate in the department at all times. It also stated, under Personnel files, the facility will keep current food handler's cards in personnel files on all department associates.",2015-11-01
9375,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-02-25,502,D,0,1,2RPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain physician-ordered laboratory testing for one (1) of thirty-two (32) Stage II sampled residents. Resident identifier: #6. Facility census: 87. Findings include: a) Resident #6 Record review revealed a physician's orders [REDACTED].#6, to monitor the effects of medications. Further record review revealed fasting glucose results for 06/15/09 and 12/14/09, but none for September 2009. Interview with the director of nursing (Employee #58), on 02/23/10 at 10:50 a.m., revealed that fasting glucoses were drawn and sent to the hospital for testing, and she could produce results for only 06/15/09 and 12/14/09. She stated they missed the September 2009 glucose blood draw.",2015-11-01
9376,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-02-25,514,D,0,1,2RPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain complete, accurate, and systematically organized medical records for two (2) of thirty-two (32) Stage II sampled residents, by continuing to document services that had been discontinued and/or by failing to assemble the nurses notes in an organized manner by date in the clinical record. Resident identifiers: #102 and #74. Facility census: 87. Findings include: a) Resident #102 A review of the clinical record revealed Resident #102, who was admitted on [DATE], had received therapy services from 10/19/09 through 11/28/09. The physical therapy (PT) notes, dated 11/18/09, stated, D/C (discontinue) PT - all goals met. The occupational therapy (OT) notes, dated on 11/26/09, stated these services were also discontinued with the goals partially met. However, an entry in the nursing notes by a nurse (Employee #3), dated 11/30/09, stated, Attends PT / OT / ST (speech therapy) regularly, see therapy notes for progress. On 12/01/09, this same nurse repeated the same entry, and on 12/03/09, another nurse (Employee #1) also recorded, Attended PT / OT / ST this AM (morning). During an interview with the director of nursing (DON) and the assistant director of nursing (ADON) at 2:00 p.m. on 02/24/10, they verified PT and OT services had been discontinued when the resident's benefit days were exhausted. They had no explanation for the contradictory entries in the nursing notes. b) Resident #74 A review of the clinical record for Resident #74 revealed nursing notes written by a nurse (Employee #16) on 09/25/09 were inserted between the notes written 09/13/09 and 09/14/09. During an interview with the DON at 9:15 a.m. on 02/25/10, she reviewed the notes and explained that each nurse was responsible for mounting her typed notes into the chart, and she confirmed the notes were entered in the wrong sequence.",2015-11-01
9681,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-02-25,176,D,0,1,WXCT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, review of the facility's policy and procedure for Self-Administration of Medication, and staff interview, the interdisciplinary team failed to identify who would be responsible for the documentation of administration of medications by a resident who kept medications at her bedside. The resident had physician's orders [REDACTED]. [REDACTED]. One (1) of eighteen (18) current residents on the sample was affected. Resident identifier: #46. Facility census: 101. Findings include: a) Resident #46 Review of the resident's medical record found physician's orders [REDACTED].>- Pro-Air HFA (MDI - multi-dose inhaler) - Use PRN (as needed) as directed; Dx (diagnosis) [MEDICAL CONDITIONS]; Resident may keep medication at bedside; - [MEDICATION NAME] Inhaler ([MEDICATION NAME]-[MEDICATION NAME]) MDI - Use PRN as directed; Dx [MEDICAL CONDITION]; Resident may keep medication at bedside; - [MEDICATION NAME] Propionate 50 mcg Nasal spray 2 sprays into each nostril Q (every) Day and PRN. Resident may keep medication @ bedside; and - Vicks Nasal Inhaler - Use in nostrils as directed. Resident may keep at bedside. The orders for these four (4) medications to be kept at the resident's bedside were dated 11/12/09. There was no evidence to reflect the interdisciplinary team had ascertained whether the resident understood how often each of the medications could be used and in what dosage. Additionally, each of the medications was listed on the Medication Administration Record, [REDACTED]. However, there was no documented evidence to reflect the resident had actually used the medications. This information would be needed to ascertain how often the resident self-administered each medication to ensure proper usage. Also, the number of times the inhaler was used would be needed, as the manufacturer's instructions include the inhaler should not be used for more than two hundred (200) sprays. The facility's policy and procedure for Self-Administration of Medication indicated the unit charge nurse was to interview the resident each shift to verify all ordered self-administered medications were taken. A check mark was to be placed on the Medication Administration Record [REDACTED] The instructions for [MEDICATION NAME] and Pro-Air HFA inhalers included individuals with [MEDICAL CONDITION] or diabetes may need special considerations with regards to dosage. The resident's [DIAGNOSES REDACTED]. Therefore, monitoring the frequency of use of the inhalers was needed. In mid-morning on 02/25/10, the director of nursing was asked how the use of the medications was to be documented. She was unable to provide an answer at that time.",2015-10-01
9682,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-02-25,225,E,0,1,WXCT11,"Based on record review, staff interview, and review of a newsletter sent to all Medicare / Medicaid certified nursing facilities and licensed nursing homes in WV by the State survey agency in November 2004, the facility failed to screen individuals prior to permitting them to start employment, in an effort to uncover personal histories of criminal convictions that would render them unfit for service in a nursing facility. This was evident in five (5) of five (5) sampled employees' personnel files. Employee identifiers: #2, #24, #32, #45, and #76. Facility census: 101. Findings include: a) Employees #2, #24, #32, #45, and #76 Review of sampled employees' personnel files found the facility had obtained fingerprints of the employees identified above, but the facility had not yet submitted them to the WV State Police to initiate their criminal background checks. These employees had been hired and started working on 02/16/10. They were going through orientation while the survey was in progress from 02/22/10 through 02/25/10. Employee #27, when questioned regarding this issue in the afternoon of 02/23/10, stated these individuals had just finished orientation, and the fingerprints had been obtained as part of the orientation process, but they had not been sent as yet to the WV State Police. Employee #111 (the facility's administrator) was informed of this issue later in the survey, and no further evidence was provided by the time of exit to indicate the criminal background checks had been initiated as of this time. b) The State survey agency (Office of Health Facility Licensure and Certification - OHFLAC) notified all Medicare / Medicaid certified nursing facilities and licensed nursing homes in WV, in a newsletter sent to all providers in November 2004, of the following: . 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. This facility permitted these five (5) individuals to begin work without first having initiated a criminal background investigation on each of them.",2015-10-01
9683,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-02-25,246,D,0,1,WXCT11,"Based on observations, resident interview, and staff interview, the facility failed to provide each resident with reasonable accommodation of needs. Two (2) residents on the second floor were observed to be seated in wheelchairs without support for their feet. The balls of one (1) of the resident's feet would touch the floor at times, but the whole foot could not rest on the floor; at other times, her feet did not reach the floor. The other resident's feet dangled just off of the floor. This created pressure on the backs of the residents' legs and had the potential to interfere with circulation as well as affect their ability to shift their weight. Without something on which to rest the feet, there was also a potential for the residents to develop foot drop. One (1) of eighteen (18) current residents on the sample, and one (1) resident who was observed at random, were affected. Resident identifiers: #23 and #19. Facility census: 101. Findings include: a) Resident #23 This resident was periodically observed up in a wheelchair on 02/23/10, 02/24/10, and 02/25/10. She was observed to propel the wheelchair with her hands. The height of the wheelchair did not allow her feet to rest on the floor. On 02/25/10 at approximately 10:15 a.m., observation found the resident seated in her wheelchair in the dining / activity room on the second floor. When asked if she ever had something on which to rest her feet, she said, No. She said they had told her she need to use her feet. She said she could not put her feet on the floor. When asked if she thought footrests would help, she replied, Yes, my legs get tired. At that time, her feet were at least two (2) to three (3) inches off of the floor. It was thought the addition of pressure relieving cushions in the wheelchair may have affected the seating height. b) Resident #19 This resident was observed periodically on 02/23/10, 02/24/10, and 02/25/10, while up in her wheelchair. She would maneuver about using her hands to move the wheels of the chair or would use the handrail in the hall with which to pull herself in the chair. At times, the balls of her feet would be in contact with the floor; at other times, her feet were several inches off of the floor. This resident was also discussed with the director of nursing at 10:25 a.m. on 02/25/10. She said she would take care of the problem.",2015-10-01
9684,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-02-25,272,D,0,1,WXCT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to ensure each resident's comprehensive assessment was accurately coded and / or failed to record documentation of the summary information regarding the additional assessment performed through the resident assessment protocols (RAPs) as required. Two (2) of thirteen (13) current residents on the Phase I sample were found to have deficits identified with relation to the completion of the RAPs. Items coded on the assessment for one (1) resident were not necessarily the same as those reflected in the RAP documentation. The RAPs for both residents did not include the documentation of assessment information in support of the clinical decision-making relevant to the RAP. Resident identifiers: #71 and #46. Facility census: 101. Findings include: a) Resident #46 1. Review of the resident's annual minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/09/10, found the assessor encoded her as being continent of urine in Section H of the assessment. This would indicate the resident had complete control of her bladder, even if that control was a result of prompted voiding, habit training, etc. The assessor also marked Item H3g to indicate pads and/or briefs were used. The requirements for coding H3g are: Any type of absorbent, disposable or reusable undergarment or item, whether worn by the resident (e.g., incontinence garments, adult brief) or placed on the bed or chair for protection from incontinence. Does not include the routine use of pads on beds when a resident is never or rarely incontinent. Therefore, if the resident was coded as being continent of urine, item H3g (pads / briefs) should not have been marked, as it is excluded if the resident was rarely or never incontinent of urine. The assessor also encoded the resident as being usually continent of bowel, which would mean she was incontinent of bowel less than weekly. The RAP for urinary incontinence triggered because H3g (use of pads / briefs) had been checked. The assessor had noted, Resident with occasional incontinence episodes. No significant change in status for the reason for not proceeding to care plan. The documentation on the RAP did not indicate the pads / briefs were used due to bowel incontinence. The documentation on the urinary incontinence RAP should have referred to urinary incontinence. This would indicate the documentation on the RAP was in disagreement with the coding for urinary continence on the MDS assessment. 2. The activities of daily living (ADL) RAP triggered, because the assessor encoded the following in Section G of the MDS: a. Bed Mobility - Not Independent (limited assistance) b. Transfer - Not Independent (limited assistance) c. Walk in Room - Not Independent (limited assistance) d. Locomotion on Unit - Not Independent (extensive assistance) e. Locomotion off Unit - Not Independent (extensive assistance) f. Dressing - Not Independent (extensive assistance) g. Eating - Not Independent (total dependence) h. Toilet Use - Not Independent (extensive assistance) i. Personal Hygiene - Not Independent (extensive assistance) j. Bathing - Not Independent (total dependence) The assessor noted a care plan would not be developed, because: Resident requires limited to extensive assistance with ADL's (sic). She has had not significant changes in status. She fatigues easily due to [MEDICAL CONDITIONS]. There was no indication in the additional assessment piece with regard to how much the resident was affected by her [MEDICAL CONDITION]. There was no evidence of consideration of the possibility that her ADLs might be adapted to allow her to participate more in various activities within the confines of her respiratory problems. There was no evidence of consideration of what measures might be employed to prevent further decline should improvement not be possible. There was no evidence the ADL supplement had been utilized in further assessing the resident's potential for improvement or whether she needed a plan to prevent further decline. 3. The resident's assessment also triggered the RAP for mood state. This RAP triggered due to the assessor encoding the resident as having exhibited the following indicators up to five (5) days a week: a. Resident makes negative statements b. Repetitive questions c. Repetitive verbalizations d. Persistent anger with self or others e. Self-deprecation f. Expressions of what appear to be unrealistic fears g. Recurrent statements that something terrible is about to happen h. Repetitive health complaints i. Repetitive anxious complaints/concerns j. Unpleasant mood in mornings k. [MEDICAL CONDITION]/change in usual sleep pattern l. Repetitive physical movements m. Mood persistence The form on which the RAP summary, or additional assessment information, included a section to describe Nature of the condition. Here, the assessor had written: Resident with multiple behaivors (sic). She has dx (diagnosis) of anxiety and depression. She prefers to stay in her room at all times, however when staff assist her she wants them to stay in the room with her for and extended amount of time. She has multiple repetitive health concerns and anxiousness. The additional assessment indicated she was at risk for side effects of medications use. For Factors to be considered in care planning, the assessor had written: Staff were to monitor for possible side effects of medication. The items that caused the RAP to trigger were not fully addressed. There was nothing regarding her problems with sleep, her fears, etc. Consideration of the triggering factors would be needed to develop an individualized care plan. b) Resident #71 1. The RAP for nutritional status triggered for this resident based on the coding of his admission MDS assessment with an ARD of 01/11/10. The RAP triggered, because he was assessed as leaving 25% or more of his food uneaten at most meals, he was receiving a mechanically altered therapeutic diet, and he had pressure ulcers. The additional assessment consisted of noting the intake is very low of foods and fluids as the nature of the condition; can lose weight and dhydration (sic) is a factor as the complications and risk factors; and for factors to be considered in care planning, maintain a watch on the take and the food and fluids high supplements and 2cal (sic). There was no evidence that consideration was given to the impact of the resident's diagnoses, as described in the RAP guidelines for factors that may impede the resident's ability to consume food. For example, the resident had a [DIAGNOSES REDACTED]. The assessment also indicated the resident had [MEDICAL CONDITION] and hypertension. These, too, may impact the resident's food intake. He was also encoded as having pressure ulcers, which would impact his nutritional needs. The RAP guidelines offer these areas as ones to be included in the assessment, but there was no mention of these in the additional assessment. Additionally, he was admitted with a left [MEDICAL CONDITION] that was not healing and with possible infection. 2. Similarly, the RAPs for other triggered areas did not reflect the additional assessment information that would have led to an individualized care plan to assist the resident in attaining or maintaining his highest practicable level of well-being. c) These issues were discussed with the director of nursing (Employee #86) at 10:00 a.m. on 02/25/10, and with the second floor RN assessment coordinator (Employee #121) at 10:15 a.m. on 02/25/10.",2015-10-01
9685,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-02-25,279,E,0,1,WXCT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to develop a care plan based on the needs identified by each resident's comprehensive assessment that included measurable goals and described the services to be furnished to assist the resident in attaining or maintaining his or her highest practicable level of well-being. Areas such as task segmentation were not incorporated into the individual's care plan. Goals were established without interventions to lend to the achievement of the stated goal. This affected five (5) of eighteen (18) sampled residents. Resident identifiers: #71, #46 #13, #98, and #23. Facility census: 01. Findings include: a) Resident #71 1. The resident's care plan included a problem of: Resident is status [REDACTED]. Intermittent confusion. Has had a fall since admission. Has complaints of pain and constipation. Dx DM and [MEDICAL CONDITION], A-fib, [MEDICAL CONDITION], HTN. ([DIAGNOSES REDACTED]. At risk for additional skin breakdown. The goal associated with this problem statement was: Resident will improve ADL (activities of daily living) ability to require limited to minimal assistance with ADL's (sic) within the next review. The interventions were for physical therapy (PT) and occupational therapy (PT) five (5) days a week for four (4) weeks, to be up as tolerated in a geri-chair, to give medications, check his blood sugars, for a return appointment with a physician, and to transfer him with two (2) person assist and mechanical lift. The above goal did not include parameters by which to establish his baseline ADL abilities. His admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/11/10, indicated he required the extensive assistance of staff for bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. He was totally dependent for locomotion on and off of the unit and bathing. Although he was to receive OT and PT five (5) days a week according to the interventions, nursing staff would need to provide care most of the time. Guidance regarding how tasks were to be accomplished was not provided for the direct care staff. The assessment indicated the resident and staff felt the resident was capable of increased independence in at least some ADLs. The care plan did not address the areas where the resident and staff felt improvement could be made. Additionally, the assessment also identified that ADL tasks had been broken into subtasks so the resident could perform them. The care plan did not note what ADL tasks had been broken into subtasks and how this had been accomplished, to ensure continued, consistent delivery of care. This would be needed to provide the resident with an optimal chance of succeeding in reaching the goal to improve his abilities in performing his own ADLs. 2. The resident was identified on his assessment as having a Stage II and a Stage IV (actually was not an open area, but suspected deep tissue injury) pressure ulcers present upon admission to the facility. The only interventions relating to the pressure ulcers were the treatment orders. The assessment had indicated the resident was to have pressure relieving devices while in bed and to be on a turning and positioning program. Page 3-167 of the Resident Assessment Instrument User Manual for MDS 2.0 instructs: Turning / Repositioning Program - Includes a continuous, consistent program for changing the resident ' s position and realigning the body. 'Program' is defined as 'a specific approach that is organized, planned, documented, monitored, and evaluated.' The care plan did not provide specific approaches that were organized, planned, or documented. 3. Another goal was: Resident will have no episodes of excessive bleeing (sic) or bruising through the next review. The interventions were for [MEDICATION NAME] 5 mg to be given orally every day, a PT/INR (a lab test to monitor whether the dosages of the anticoagulants were within the needed ranges), and [MEDICATION NAME] 40 mg subcutaneously until the INR was above 2. The interventions were only related to giving the medications that had the potential to cause excessive bleeding and bruising. None of the interventions would prevent excessive bleeding or bruising. 4. Resident will remain free of infection through next review was a goal written for the problem of [MEDICAL CONDITION] and use of an indwelling Foley catheter. The interventions were for a #16 Foley catheter to continuous closed drainage, a privacy bag for the collection bag, and to monitor and report signs and symptoms of infection. These interventions would not prevent urinary tract infections. 5. The resident's readmission orders [REDACTED]. The care plan did not address this wound. -- b) Resident #46 1. A Stage I pressure ulcer was encoded on the resident's annual MDS with an ARD of 02/05/10. The resident assessment protocol (RAP) summary noted the resident had a Stage I pressure ulcer to her right ear. It was noted the resident preferred to stay in bed most of the time, and she would occasionally get up in her chair for a short time. The assessor noted the resident preferred to lay on her right side, because she said she could not breathe when she lay on her left side. It was also identified the resident was at risk for additional skin breakdown. The RAP summary indicated a care plan would be developed for the pressure ulcer. Review of the care plan did not find a goal or interventions related to the pressure ulcer or prevention of skin breakdown. 2. The pressure ulcer RAP identified the resident had stated she could not breathe when lying on her left side. Although the resident's respiratory problems were addressed in the care plan, the resident's statement regarding being unable to breathe when on her left side had not been incorporated into the care plan. 3. A problem of Resident wishes to self medicate was included in the care plan. The interventions were to monitor the resident's self-medicating, noted what medications were allowed to be at the resident's bedside, and to assist the resident as necessary. There were no instructions regarding the use of the medications. Additionally, the physician had ordered Gas-x PRN DX: gastric bloating. Resident may keep at bedside on 10/24/09. This medication was not identified in the care plan. The care plan did not identify how the medication was to be stored and how the documentation of the administration of the medications would be accomplished. Review of the current Medication Administration Record [REDACTED]. The care plan interventions noted the use of the medications would be monitored, but there was no evidence this was being done. This was discussed, in mid-morning on 02/25/10, with the administrator and the director of nursing (DON). The administrator and DON stated the resident had a locked box in which to store the medications, but they could not identify how the actual drug usage was being monitored. 4. The resident's assessment indicated she had moderate pain daily. Review of the resident's medical record identified changes had been made to the resident's [MEDICATION NAME] orders in an effort to provide relief of pain. The only intervention for pain management was for [MEDICATION NAME]. No non-pharmacologic interventions were identified. -- c) Resident #13 1. A goal of To continue to be free of delusions or socially inappropriate behavior through next review had been established on 02/25/10. The interventions included lab tests, observation of common side effects of medications, monitoring and reevaluating the effectiveness of medications, drug regimen reviews by the pharmacist, monitoring for gradual dose reduction, and administering four (4) medications. No interventions were provided regarding how staff should respond should the resident be socially inappropriate or indicate she was having delusions. 2. A goal was written for Resident will require bowel protocol no more than twice a month. The interventions included administration of medications, monitoring for bowel movements, noting if the resident had difficulty in passing stool, and to add prunes or prune juice, whole wheat bread, oatmeal or whole grain cereal at breakfast. There was no intervention to ensure the resident ingested sufficient fluids to meet her needs. Based her body weight, she would need approximately 3100 cc daily. Additionally, her quarterly assessment, with an ARD of 11/15/10, indicated she was ambulatory with set-up help only and could ambulate with a walker. The care plan did not include assisting the resident to the commode to facilitate elimination. -- d) Resident #98 1. A goal of Resident's complaints / concerns will be resolved to his satisfaction through the next review. This goal was not stated in measurable terms. The interventions were to give him [MEDICATION NAME] 50 mg every eight (8) hours, encourage him to participate in activities and groups, and to give [MEDICATION NAME] 0.5 mg twice a day. These interventions did not related to the stated goal regarding resolution of his complaints / concerns. -- e) Resident #23 1. A goal of Will make at least three (3) decisions daily about ADL care, activities to participate in, or where to take her meals throughout the next 90 days had been established 02/15/08. The interventions were for [MEDICATION NAME], and [MEDICATION NAME] to be given, for her to have oxygen, and that she could be off of oxygen for transport or showers. These interventions did not relate to the goal for the resident to make three (3) decisions daily. 2. Another goal was: Resident will express relief of discomfort after interventions. The only intervention was to medicate her with [MEDICATION NAME] 50 mg every four (4) hours. No non-pharmacological interventions were identified that might be attempted to make her more comfortable. 3. A goal of Resident will not require bowel protocol more than three times monthly through the next review was written. The interventions were to give her [MEDICATION NAME] two (2) tabs daily and use the standing orders for constipation. The interventions did not address how bowel movements might be promoted without the use of medications, i.e., ensuring her fluid intake was sufficient, positioning, etc.",2015-10-01
9686,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-02-25,309,D,0,1,WXCT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide necessary goods and services to attain or maintain the highest practicable physical well-being of each resident for three (3) of twenty-one (21) sampled residents. Staff did not follow the facility's bowel protocol as approved by the physician for Residents #14 and #55, and staff failed to monitor Resident #4's blood pressure as ordered during a hypotensive episode. Resident identifiers: #14, #55, and #4. Facility census: 101. Findings include: a) Resident #14 Review of the medical record found nursing staff administered milk of magnesia (MOM) to Resident #14 per the physician's standing order, on 02/22/10 at 8:00 a.m., for no bowel movements for three (3) days. Review of the standing order present on the medical record found the following: FOR CONSTIPATION (i.e., no bowel movement within 3 days period) 1. 30 cc Milk of Magnesia with at least 8 oz water by 7-3 shift. 2. If no results in 8 hrs., give [MEDICATION NAME] rectal suppository. 3. If no results from rectal suppository in 8 hrs. give Fleets enema. 4. If no results from enema, contact physician for further follow-up. Review of the nursing note, dated 01/22/10 at 3:00 p.m., documented, No results from MOM. The medical record contained no evidence that nursing staff followed the facility's bowel protocol by administering the [MEDICATION NAME] rectal suppository at 4:00 p.m. as per the physician's standing order. An interview with the director of nursing (DON), on the afternoon of 02/23/10, confirmed that staff should have administered a [MEDICATION NAME] rectal suppository at 4:00 p.m. on 01/22/10. b) Resident #55 Review of the medical record found nursing staff administered MOM 30 cc per the physician's standing order, at 8:00 a.m. on 01/06/10, for no bowel movement for three (3) days. The nursing note, written at 3:00 p.m. on 01/06/10, documented, No results from MOM. The medical record contained no evidence that nursing staff administered a [MEDICATION NAME] rectal suppository at 4:00 p.m. in accordance with the standing orders and the facility's bowel protocol. An interview with the DON, on the afternoon of 02/24/10, confirmed the resident should have received a [MEDICATION NAME] rectal suppository at 4:00 p.m. on 01/06/10. c) Resident #4 Review of the medical record found a nursing note, dated 02/10/10 at 7:45 a.m., documenting Resident #4's blood pressure to be 87/51 mm/Hg. The physician ordered staff to monitor the resident's blood pressure every two (2) hours for twelve (12) hours and report if the resident's systolic fell below 90 mm/Hg. The medical record contained no evidence that nursing staff followed the physician's orders [REDACTED].",2015-10-01
9687,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-02-25,371,F,0,1,WXCT11,"Based on observation and staff interview, dietary staff was not using sanitary techniques during dishwashing to prevent contamination of clean dishware coming out of the dishroom. This practice has the potential to affect all resident who consume food by oral means, as all food is served from this central location. Facility census: 101. Findings include: a) Observations in the dietary department, after breakfast service on 02/24/10, found Employee #115 and another dietary employee in the dishroom scrapping trays and washing dishes. Employee #115 took dirty trays out of the tray cart and scraped food into the trash, then handed the dirty dishes to the other employee to place in racks for washing. Employee #115 was not wearing any type of protective clothing over her work clothes. Employee #115 then proceeded to change gloves after handling dirty dishes, putting on clean gloves to handle clean dishes as they came out of the dishwashing machine. During this activity, Employee #115 held clean dishes against her clothing as she took them to the plate lowerator and other areas where they were to be stored. This presented the opportunity for cross-contamination of the clean items as she held them next to her soiled clothing. A staff member from a sister facility, who assisting the dietary manager in training, was present at the time, and the surveyor discussed the issue with her. She immediately spoke with Employee #115 about the sanitation implications.",2015-10-01
9688,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-02-25,425,D,0,1,WXCT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, the facility failed to assure two (2) of twenty-one (21) sampled residents received medications ordered by the physician in a timely manner. Resident identifiers: #4 and #46. Facility census: 101. Findings include: a) Resident #4 Review of the medical record found a physician's orders [REDACTED]. Review of the medication sheet found staff was to administer Zyvox at 9:00 a.m. and 9:00 p.m. beginning on 02/21/10. The resident did not receive the 9:00 p.m. dose of Zyvox on 02/21/10. b) Resident #46 Review of the resident's medical record found a physician's orders [REDACTED]. The order had been written at 12:46 p.m. on 02/12/10. Review of the Medication Administration Record [REDACTED].",2015-10-01
9689,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-02-25,431,E,0,1,WXCT11,"Based on observation, review of facility policy, and staff interview, the facility failed to provide pharmaceutical services to meet professional standards of quality. The facility failed to maintain the first floor medication room in an orderly and secure manner in accordance with facility policy, failed to perform daily temperature check of the medication room refrigerators, and failed to assure that injectable medications were dated when opened. This deficient practice had the potential to affect more than an isolated number of residents currently residing in the facility. Facility census: 101. Findings include: a) Inspection of the first floor medication room found various intravenous (IV) medications and solutions piled haphazardly on the counter in the medication room. The stack of IV solutions and medications were of sufficient height to block access to the emergency medication boxes. It was further noted that the emergency medication boxes were not locked. Review of facility policy entitled DRUG STORAGE- GENERAL INFORMATION, provided by the director of nursing (DON - Employee #86) on the afternoon of 02/24/10, found the following language: 3. Medications shall be stored in an orderly manner in cabinets, drawers, or carts of sufficient size to prevent crowding of medications. 19. Access doors, cabinets, drawers, and medication boxes are to be locked when not in use. The DON agreed that staff should not have stacked the IV medications on the counter and the emergency drug boxes should have been locked. b) An inspection of the temperature log for the first floor refrigerator, on the afternoon of 02/23/10, revealed staff had not recorded daily temperatures to assure medications were stored at an appropriate temperature. b) The medication refrigerator on the second floor was also checked for recordation of temperature monitoring. Between 11/11/09 and 02/24/10, the temperature of the refrigerator had been noted on only twenty (20) of one hundred and six (106) days.",2015-10-01
9690,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-02-25,441,F,0,1,WXCT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on observations, review of medical records, review of facility policies and procedures, and staff interviews, the facility's Infection Control Program had not ensured policies and procedures had been developed and implemented for isolation techniques. The facility's policies and procedure manual included isolation procedures (transmission-based precautions) dated 06/01/97, which did not reflect current guidance from the Centers for Disease Control and Prevention (CDC) with regard to isolation. Staff did not practice handwashing when indicated and/or in accordance with CDC guidelines for hand hygiene. Additionally, when a visitor exited an isolation room while still wearing a gown and gloves, staff did not intercede. Resident identifiers: #13, #71, #96, and other residents on the second floor who may have been affected by the deficient practices. Facility census: 101. Findings include: a) Transmission-Based Precautions Review of the facility's policies and procedures for transmission-based precautions found they had not been updated since 06/01/97. They included a procedure for airborne precautions which did not identify that a negative pressure room would be required for implementation of this type of precaution. In an interview in mid-morning on 02/25/10, the administrator confirmed the facility did not have a room with negative pressure. b) On 02/22/10 at approximately 3:30 p.m., Resident #13 was noted to have a sign on her door directing visitors to check at the nurses' station before entering her room. Two (2) nursing assistants (Employees #1 and #39), when asked what type of precautions the resident required, stated the resident was receiving chemotherapy and needed to be protected from getting an infection. When asked what was required, they both said you had to wash your hands. Employee #1 said you needed to wear a mask, and Employee #39 said you needed to wear a mask and a gown. Review of the facility's policies and procedures for transmission-based precautions found there was no policy and procedure for preventative precautions. c) Resident #71 On 02/22/10 at approximately 3:30 p.m., observation found Resident #71 also had a sign on his door directing visitors to see the nurse before entering the room. The unit charge nurse (Employee #94), when interviewed, said the resident had [DIAGNOSES REDACTED]. NOTE: Clostridium difficile is a spore-forming, gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B. It is a common cause of antibiotic-associated diarrhea (AAD). It is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the [DIAGNOSES REDACTED]icile spores. [DIAGNOSES REDACTED]icile spores are transferred to patients mainly via the hands of persons who have touched a contaminated surface or item. On 02/24/10, in mid afternoon, a visitor was observed to come out of Resident #71's room while wearing a gown and gloves. She went to the nurses' station and requested assistance from staff. When asked, the visitor acknowledged she had been in the resident's room. The visitor returned to the resident's room and exited a few minutes later without the gown and gloves. Another visitor told her to run and grab her coat. The visitor re-entered the room and retrieved her coat from a chair near the foot of the resident's bed. She exited the room with her coat and without washing her hands. It is essential both to communicate transmission-based precautions to all health care personnel, and for personnel to comply with requirements. Pertinent signage (i.e., isolation precautions) and verbal reporting between staff can enhance compliance with transmission-based precautions to help minimize the transmission of infections within the facility. It would also be important for visitors to comply with the precautionary measures. Additionally, it was noted the personal protective equipment had been placed inside of the resident's room. The Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007 includes, Healthcare personnel caring for patients on Contact Precautions should wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE before room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE, [DIAGNOSES REDACTED]icile, Norovirus and other intestinal tract pathogens; RSV). d) Resident #96 1. On 02/25/10 at approximately 10:45 a.m., Employee #94 was observed providing a treatment to the pressure ulcer on the resident's coccygeal area. When she cleansed the area, she wiped from proximal to distal (clean to dirty), then went back over the open area with the same surface of the sponge. When she dried the wound, she again went from clean to dirty, then back over the clean area. 2. Additionally, after washing her hands, the nurse used both hands to make a little ball of the paper towels she had used to turn off the water faucet. This created a potential to recontaminate her hands. After completing the treatment, the nurse washed her hands for less than three (3) seconds before exiting the room. This would not be of sufficient duration to properly cleanse the hands. The 2002 hand hygiene recommendations from CDC include: 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. 3. A roll of tape had been placed on the underpad located beneath the resident's buttocks. After completing the treatment, the nurse placed the roll of tape in her uniform pocket. When this was discussed with the nurse, in early afternoon on 02/25/10, she reported she had thrown the tape away. However, by putting the roll of tape in her pocket, she had created a potential for introducing microorganisms into her pocket, which could later be transferred to other residents and/or objects. --- Part II -- Based on observation, medical record review, and staff interview, the facility failed to assure staff members utilized appropriate infection control techniques to prevent the potential spread of [DIAGNOSES REDACTED]. throughout the first floor resident environment. Resident #4 was ordered to be placed in contact isolation for [DIAGNOSES REDACTED]. infection. Staff members utilized floor cleaner not approved for use against [DIAGNOSES REDACTED]. spoors, failed to perform hand hygiene after being in contact with potentially contaminated articles in the resident's room, failed to utilize dedicated equipment for obtaining vital signs, and failed to utilize personal protective equipment (PPE) in accordance with recommendations for contact isolation. This deficient practice had the potential to affect all residents, visitors, and staff on the first floor of the facility. Resident identifier: #4. Facility census: 101. Findings include: a) Resident #4 1. During the initial tour of the facility on 02/22/10 at 3:00 p.m., observation found a sign instructing individuals to see the nurse prior to entering the room was placed on the resident's door frame. The unit charge nurse (Employee #100), when asked why the sign was posted on Resident #4's door at 3:10 p.m. on 02/22/10, stated the resident was placed under contact isolation. When asked what PPE was to be utilized related to the contact isolation, Employee #100 stated individuals entering the room were to don a mask, gown, and gloves. Review of the medical record found Resident #4 was readmitted to the facility from an acute care hospital on [DATE], with [DIAGNOSES REDACTED]. infection and [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE) in her urine. She was placed in a private room under contact isolation procedures. Random observation of housekeeping services in Resident #4's room, on 02/23/10 at 9:45 a.m., found the individual cleaning the resident's room (Employee #85) was mopping the floor. The staff member did not have on a protective gown. The environmental services supervisor (Employee #18) was interviewed at 9:00 a.m. on 02/25/10. When asked about the solution utilized to cleanse the floors of Resident #4's room, Employee #18 stated the housekeeper (Employee #85) utilized a floor cleaner not effective in killing[DIAGNOSES REDACTED] spoors and should have used a bleach solution. 2. On 02/24/10 at 12:15 p.m., a nursing assistant (Employee #46) obtained residents' vital signs utilizing a wheeled cart containing a blood pressure cuff and tympanic thermometer. This staff member was observed to enter multiple resident rooms, including Resident #4's room. The unit charge nurse (Employee #100) was how asked staff was to obtain Resident #4's vital signs. Employee #100 stated the resident had her own blood pressure cuff, thermometer, and stethoscope permanently located in her room. She was asked to locate the items. Employee #100 donned protective equipment located in the room and searched for the equipment. She was unable to locate the items to be dedicated for Resident #4's use.",2015-10-01
9691,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-02-25,514,D,0,1,WXCT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain each resident's medical record in accordance with accepted professional standards and practices to ensure they were complete and accurately documented for two (2) of twenty-one (21) sampled residents. Resident identifiers: #55 and #102. Facility census: 101. Findings include: a) Resident #55 1. During observation of the medication administration pass on 02/24/10 at 8:40 a.m., nursing staff administered as needed (PRN) [MEDICATION NAME] to Resident #55. Review of the pain management flow sheet did not document the resident's pain on a 1-10 scale prior to administering the medication and did not document the efficacy of the medication at 30 minute and 2 hour intervals as prescribed by the flow sheet for 02/06/10, 02/10/10, and 02/11/10. 2. Review of a 01/06/10 nursing note written at 8:00 a.m. documented staff administered 30 cc of Milk of Magnesia (MOM) to Resident #55 for constipation. Nursing staff did not document giving this medication of the medication administration record. b) Resident #102 Review of the medical record found the diabetic monitoring sheet documented that nursing staff administered [MEDICATION NAME] at 12:30 p.m. and 12:45 p.m. Staff did not document the 12:45 p.m. dose on the medication administration record. Review of nursing notes written on 01/11/10 at 10:20 a.m. and 10:30 a.m. documented administering [MEDICATION NAME] to Resident #102. Staff did not document the administration of this medication on the diabetic monitoring sheet nor the medication administration sheet. An interview with the director of nursing (DON) on the morning of 02/24/10 confirmed staff should have documented the administration of [MEDICATION NAME] on the diabetic monitoring sheet and medication administration sheet.",2015-10-01
9649,SISTERSVILLE CENTER,515131,"201 WOOD STREET OPERATIONS, LLC",SISTERSVILLE,WV,26175,2010-03-04,278,D,0,1,4O1Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to ensure the accuracy of a resident's assessments with respect to limitations in range of motion and loss of voluntary movement of extremities. This was found for one (1) of eleven (11) residents whose records were reviewed. Resident identifier: #9. Facility census: 52. Findings include: a) Resident #9 The medical record of Resident #9, when reviewed on 03/01/10 at 3:30 p.m., disclosed a minimum data set (MDS) assessment dated [DATE], in which the assessor recorded he had no limitation of range of motion (ROM) and partial loss of voluntary movement of the arm, hand, leg, foot, and other. A review of additional MDS assessments, on 03/02/10, found the following entries: - MDS of 07/10/09 noted the resident to have no limitation of ROM and partial loss of voluntary movement of the arm, hand, and leg. - MDS of 10/09/09 noted the resident to have no limitation of ROM and no loss of voluntary movement. - MDS of 01/18/10 noted the resident to have limitation of ROM on one (1) side and full loss of voluntary movement of the arm, hand, leg, and foot. The resident had a [DIAGNOSES REDACTED]. A review of the medical record found no documentation of a change in the resident's condition in nurses' notes, care planning, or physician's orders [REDACTED]. When interviewed on 03/02/10 at 11:00 a.m., the facility's MDS coordinator (Employee # 982) stated that there had been no change in the resident's condition and that none of the MDS assessments had been correctly completed until the MDS of 01/18/10. This was also confirmed by the facility's director of nurses (DON - Employee # 914) at 9:00 a.m. on 03/04/10. She stated there had been no change in the resident's condition.",2015-10-01
9650,SISTERSVILLE CENTER,515131,"201 WOOD STREET OPERATIONS, LLC",SISTERSVILLE,WV,26175,2010-03-04,353,E,0,1,4O1Y11,"Based upon observation, resident interview, and staff interview, the facility failed to deploy sufficient nursing staff on a daily basis to provide care in a manner and in an environment that enhances quality of life. This had the potential to affect approximately eighteen (18) residents who customarily chose to have their evening meals in the dining rooms. Facility census: 52. Findings include: a) On 03/02/10 at approximately 2:30 p.m., facility staff was heard in the vicinity of the nurses' station discussing that all residents would have dinner in their rooms that evening. On 03/02/10 at 3:00 p.m., surveyors asked the facility's director of nursing (DON - Employee # 914) the reason residents would not be served dinner in the dining rooms. She stated this restriction was due to the low census. b) During an interview on 03/03/10 at 10:50 a.m., Resident #10, who was observed eating in the dining room during the survey, said dinner was usually served in the dining rooms, but on occasion, the residents had to eat in their rooms. She said that she liked to eat in the dining room, because she loves people, likes company, and it makes her feel more like eating. During an interview on 03/03/10 at 11:00 a.m., Resident #47 stated she liked eating in the dining room and getting to visit with other residents, but sometimes they did not get to if they did not have enough staff. c) An interview with a dietary employee (Employee # 726), on 03/04/10, revealed residents all had also eaten dinner in their rooms on the evening of 03/03/10. d) The DON, when interviewed on 03/04/10 at 9:30 a.m., was asked why residents were not permitted to eat dinner in the dining rooms on the evenings of 03/02/10 and 03/03/10. She stated it was because of the low census. She indicated she did not feel it was safe to have meals in the dining rooms when there were only four (4) nursing assistants on the 3:00 p.m. to 11:00 p.m. shift, so meals were, instead, served to all residents in their rooms. When asked, the DON reported there was no written policy and procedure for dining in the dining rooms and no written policy and procedure for staff reductions due to low census. The DON stated she had a chart which was given to her that indicates appropriate nursing staffing levels by census. The facility had sixty-eight (68) available beds. She related that, when the census dropped below fifty-five (55) residents, the 3:00 p.m. to 11:00 p.m. shift nursing assistant staffing level was reduced from five (5) to four (4) and all residents were required to eat dinner in their rooms. At a census of fifty-five (55), the nursing assistant staffing level was to be at five (5), at which point she felt it was safe to resume serving the residents their evening meals in the dining rooms. She said that a typical evening meal would find ten (10) residents in the main dining room and eight (8) residents in the smaller dining room, when the census was at least fifty-five (55). She confirmed that sufficient staffing was available to schedule five (5) nursing assistants to work the 3:00 p.m. to 11:00 p.m. shift on the evenings of 03/02/10 and 03/03/10, but the higher staff level was not utilized by the facility due to planned staff reductions designed to meet budgetary expectations. Therefore, the customary dining experience for these residents was not made available to them, which had the potential to adversely affect their quality of life. .",2015-10-01
9651,SISTERSVILLE CENTER,515131,"201 WOOD STREET OPERATIONS, LLC",SISTERSVILLE,WV,26175,2010-03-04,514,E,0,1,4O1Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure the accuracy of fluid intake and output documentation for two (2) residents who receive gastrointestinal tube feedings ([DEVICE] feedings). This had the potential to affect all residents who receive [DEVICE] feedings. Resident identifiers: #40 and #28. Facility census: 52. Findings include: a) Resident #40 Resident #40's medical record, when reviewed, revealed the fluid intake documentation for this resident was documented as NPO (nothing by mouth). There were no totals for twenty-four (24) hour time frames that listed the resident's fluid intake and output. Further review of the medical record revealed the laboratory findings for the resident were within acceptable parameters. No signs or symptoms of dehydration were present. Per the resident's current care plan, staff was to monitor the intake and output in order to prevent dehydration. The licensed nurses were documenting on the Medication Administration Record [REDACTED]. b) Resident #28 Resident #28's medical record, when reviewed, revealed the fluid intake documentation for this resident was documented as NPO (nothing by mouth). There were no totals for twenty-four (24) hour time frames that listed the resident's fluid intake and output. Further review of the medical record revealed the laboratory findings for the resident were within acceptable parameters. No signs or symptoms of dehydration were present. Per the resident's current care plan, staff was to monitor the intake and output in order to prevent dehydration. The licensed nurses were documenting on the MAR indicated [REDACTED]. c) The March 2010 monthly physician orders [REDACTED]. The facility's policy and procedure for Enteral Protocol was obtained at 11:00 a.m. on 03/02/10. The protocol directed staff to document the amount of formula infused per feeding. In an interview with the director of nursing (DON - Employee # 914), at 8:50 a.m. on 03/03/10, the DON agreed documentation of fluid intake for these residents was absent.",2015-10-01
10006,"MERCER NURSING AND REHABILITATION CENTER, LLC",515052,PO BOX 410,BLUEFIELD,WV,24701,2010-03-04,241,D,0,1,6XNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to ensure the dignity of two (2) residents were preserved and honored, by staff mocking the behavior of Resident #20, and staff labeling a [MEDICATION NAME] medication patch with the date after affixing it to the body of Resident #15. Resident identifiers: #20 and #15. Facility census: 53. Findings include: a) Resident #20 On 03/03/10 at approximately 2:00 p.m., while waiting for the resident group meeting to commence in the dining room on the facility second floor, observation found Employee #6 (a nurse aide) going down the hallway mocking Resident #20's verbal behaviors. Resident #20 had called out ""help me, help me, somebody help me"" over and over again for a period of time. This behavior occurred frequently with Resident #20. On 03/03/10 at approximately 4:00 p.m., the administrator became aware of the above incident. She reported she would talk to the employee about his behavior. On 03/04/10 at approximately 8:00 a.m., the administrator related she had spoken with the employee regarding his inappropriate actions. The employee told the administrator he experienced a rough day on 03/03/10 and the comments he made were regarding his own frustrations. The administrator agreed the employee needed to refrain from expressing vocal frustrations where other residents or family members can overhear them. b) Resident #15 Review of the medical record found Resident #15 received a [MEDICATION NAME] 0.4 mg each morning. During observations of the medication pass on 03/03/10 at 9:45 a.m., the nurse (Employee #18) applied the [MEDICATION NAME] on the resident's left upper chest. She then removed a marker from her uniform pocket and wrote on the patch while it was affixed to the resident. .",2015-07-01
10007,"MERCER NURSING AND REHABILITATION CENTER, LLC",515052,PO BOX 410,BLUEFIELD,WV,24701,2010-03-04,250,D,0,1,6XNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to ensure one (1) of eleven (11) residents received medically-related social services to assist with acquiring clothing suitable for daily wear. Resident identifier: #21. Facility census: 53. Findings include: a) Resident #21 On 03/01/10 and on 03/02/10, observations of Resident #21 found him wearing hospital gowns and bottoms. The resident was so dressed as he wheeled around the hallways in his wheelchair and attended therapy services. The medical record revealed the resident came to the facility on [DATE]. Employee #36 (a licensed practical nurse) said she did not think the resident had any clothes and that, due to his height, the facility probably did not have any clothes to fit him. Upon interview, the social worker indicated the resident was placed with the facility as part of an adult protective service (APS) intervention, and an APS worker had came to the facility to complete admission process. She said the APS worker acknowledged the resident needed clothing but, thus far, she had not brought any clothes for Resident #21. Upon medical record review, the social work notes did not contain any documentation of communication with the APS worker regarding the resident's clothing situation. On 03/02/10 at approximately 10:00 a.m., during an interview with the social worker, she agreed she had not attempted to locate any clothing for the resident and also confirmed the APS worker had not brought any clothing to the facility. At this time, she placed a call to the APS worker and left a message regarding Resident #21's need for clothing. Subsequent record review revealed a note, entered by the social worker on 03/02/10, stating, ""SW (social worker) left message for DHHR (department of health and human resources) worker regarding need for clothes. RN (registered nurse) (name) called and made contact with her. (APS worker's name) states she would go to Salvation Army to get clothes. Said he did not have any appropriate clothes at his home. CNA (certified nursing assistant) looked in 'no name clothes' none his size."" On 03/02/10 at 4:20 p.m., the social worker said the APS worker had called and said she could bring the facility a $100 voucher to purchase clothes for Resident #21. .",2015-07-01
10008,"MERCER NURSING AND REHABILITATION CENTER, LLC",515052,PO BOX 410,BLUEFIELD,WV,24701,2010-03-04,322,D,0,1,6XNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, and facility policy review, the facility failed to assure licensed nurses administered medications via gastrostomy tube in a manner to avoid potential complications for one (1) of seven (7) residents identified as having a gastrostomy tube ([DEVICE]). Resident identifier: #15. Facility census: 53. Findings include: a) Resident #15 Observation found a licensed nurse (Employee #18) administering medications to Resident #15 via [DEVICE]) at 9:45 a.m. on 03/03/10. She attempted to flush the resident's [DEVICE] utilizing a 60 cc syringe filled with approximately 30 cc of water. When the water did not drain into the tube, the nurse placed the plunger into the 60 cc syringe and exerted pressure to force the water through the tube. The nurse then administered each medication separately with flushes of water between administrations. The resident received a total of eleven (11) medications - [MEDICATION NAME] 5 mg, [MEDICATION NAME] 150 mg, Aspirin 325 mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 0.25 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 60 cc, Folic Acid 1 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 75 mg, and Vitamin B6 100 mg. Employee #18 allowed the [DEVICE] to empty between each administration of medications, flushes, and fluids. This procedure allowed air to enter the resident's stomach each time the nurse allowed the tube to drain. Resident #15 belched / hiccupped during the administration of medications via his [DEVICE]. When asked if he noticed any problems when he got his medications, the resident stated, ""It always makes me gassy, and I get hiccups when I get my medicine."" Employee #95 provided the facility's policy related to [DEVICE] medication administration at 10:45 a.m. on 03/03/10. Review of the policy entitled ""Administering Medications through (sic) a Gastrostomy Tube"" (revised September 2003) revealed, in the section entitled ""Steps in the Procedure"", the following: ""21. Administer medications by gravity flow... Clamp tubing (or begin flush) before the tubing drains completely."" .",2015-07-01
10009,"MERCER NURSING AND REHABILITATION CENTER, LLC",515052,PO BOX 410,BLUEFIELD,WV,24701,2010-03-04,371,F,0,1,6XNG11,". Based on observation and staff interview, the facility failed to prepare, distribute, and serve food under sanitary conditions. This deficient practice had the potential to affect all residents receiving an oral diet. Facility census: 53. Findings include: a) Observations of the noon meal service in the dietary department, on 02/02/10 at approximately 12:15 p.m., found a dietary staff member's hair was not secured in a manner to prevent unintentional contact with the food while serving from the steam table (Employee #22). The staff member's hair was not secured in the back where tendrils and curls were noted to be loose upon her neck. b) Random observation of the ice machine adjacent to the dietary department, on 03/04/10 at 10:40 a.m., found a large plastic ice scoop lying on top of the ice with the handle in direct contact with the ice. .",2015-07-01
10010,"MERCER NURSING AND REHABILITATION CENTER, LLC",515052,PO BOX 410,BLUEFIELD,WV,24701,2010-03-04,425,D,0,1,6XNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide pharmaceutical services to assure one (1) of eleven (11) residents received ordered medications in a timely manner. Resident identifier: #40. Facility census: 53. Findings include: a) Resident #40 Review of Resident #40's medical record found a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Documentation on the MAR indicated [REDACTED]. An interview with the director of nursing (DON - Employee #96), on 03/03/10 at 12:00 p.m., revealed the facility's back-up pharmacy closes at 5:00 p.m., and orders placed after 3:00 p.m. to their contracted pharmacy are not delivered until approximately 3:00 a.m. She also reported Doxycycline was not among the drugs kept in the emergency drug box. .",2015-07-01
10011,"MERCER NURSING AND REHABILITATION CENTER, LLC",515052,PO BOX 410,BLUEFIELD,WV,24701,2010-03-04,502,D,0,1,6XNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide or obtain laboratory services to meet the needs of one (1) of eleven (11) sampled residents. Resident identifier: #40. Facility census: 53. Findings include: a) Resident #40 Review of Resident #40's medical record found a physician's orders [REDACTED]. Further review found no evidence the resident had been provided with this laboratory service. A review of the resident's bowel history found staff had an opportunity to provide the serial test for blood in the resident's bowel movements on 02/01/10 during the 7:00 a.m. to 3:00 p.m. shift, on 02/02/10 on the 7:00 a.m. to 3:00 p.m. shift, and on the night and morning shifts on 02/04/10. An interview with the director of nursing (DON - Employee #96) confirmed the facility did not provide or obtain this ordered laboratory test. .",2015-07-01
10012,"MERCER NURSING AND REHABILITATION CENTER, LLC",515052,PO BOX 410,BLUEFIELD,WV,24701,2010-03-04,312,E,0,1,6XNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on confidential resident group interview, observation, review of resident bathing information, and staff interview, the facility failed to assure twelve (12) of fifty-three (53) facility residents, with physician's orders [REDACTED]. Resident identifiers: #37, #14, #15, #9, #18, #20, #23, #27, #38, #44, #47, and #50. Facility census: 53. Findings include: a) Confidential Resident Group Meeting (resident identifiers withheld to maintain resident privacy) During the confidential resident group meeting held on the afternoon of 03/03/10, residents stated they wanted to take showers. When asked why they couldn't take showers, they stated the shower bed they had to use for taking showers was broken. b) Resident #37 Following the complaints concerning the lack of showering equipment, Resident #37 was observed in his wheelchair in the resident hallway. Observation found the resident had white scaly patches crusted in and around his ears and hairline. Flakes of skin were noted to be hanging from his eyebrows and the tufts of hair growing from his ears. Review of the medical record found the resident was ordered specialized shampoo and lotions to be applied on shower days. Staff members present in the hallway noted the surveyor looking at the resident. An observation the following morning, at 7:30 a.m., noted the resident's dried, crusty, scaly patches were no longer in evidence. c) The unit charge nurse (Employee #65), was interviewed at 4:45 p.m. on 03/03/10. When asked why the residents did not have a shower bed, she stated it needed a new part. When asked which residents this would affect, she stated all residents who used a mechanical lift for transfers would also need to use the shower bed for showers. On 03/04/10 at 8:00 a.m., nursing assistant Employee #62 was interviewed. She stated that staff had been unable to shower residents who use a mechanical lift for about ten (10) days. d) The director of nursing (DON - Employee #96) was asked to provide a list of all residents who require the use of a shower bed with evidence of showers given during the last two (2) weeks. She provided the list at 9:00 a.m. on 03/04/10, which included Residents #37, #14, #15, #9, #18, #20, #23, #27, #38, #44, #47, and #50. It was noted that all of these residents had physician orders [REDACTED]. None of the residents had received a shower since 02/18/10. e) At 7:30 a.m. on 03/04/10, environmental services assistant (Employee #12) was asked if he had any knowledge concerning the problems with the shower beds. He stated, ""The shower beds keep breaking down."" The last time it broke down, he gave the part numbers to the environmental services supervisor (Employee #46) one (1) day last week, but Employee #12 could not verify that the needed parts were ordered. Employee #46, when interviewed at 9:20 a.m. on 03/04/10, stated the facility had two (2) shower beds, both of which required new parts. She stated the bariatric shower bed has needed a new wheel assembly for approximately two (2) weeks. When asked to provide evidence the necessary replacement parts were ordered in a timely manner, she provided an order confirmation dated 03/03/10. .",2015-07-01
10013,"MERCER NURSING AND REHABILITATION CENTER, LLC",515052,PO BOX 410,BLUEFIELD,WV,24701,2010-03-04,309,D,0,1,6XNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation of the medication administration pass, medical record review, facility policy review, and staff interview, the facility failed to assure licensed nurses administered medication in an accurate dose and within acceptable time parameters for two (2) of five (5) residents observed during this medication pass. Resident identifiers: #22 and #15. Facility census: 53. Findings include: a) Resident #22 During observation of the medication administration pass on 03/02/10 at 7:45 a.m., the nurse (Employee #36) prepared the resident's ordered medications for administration. Employee #36 removed a packet of medication from the top of the medication cart. The medication was identified as [MEDICATION NAME] 20 mg. Employee #36 removed one (1) tablet of [MEDICATION NAME] 20 mg from the packet and placed it into a medication cup. After also placing [MEDICATION NAME] 5 mg, Calcium with Vitamin D 600 mg, [MEDICATION NAME] 150 mg, a Multivitamin with minerals, and KDur 20 meq into the cup, Employee #36 locked her medication cart, picked up the cup containing medications, and prepared to leave the cart. Employee #36 was asked if those were the medications she was going to administer to Resident #22. Employee #36 responded in the affirmative. She was asked to reference the Medication Administration Record [REDACTED]. She agreed the resident should receive two (2) [MEDICATION NAME] 20 mg tablets. Review of the medical record found a current physician's orders [REDACTED]. b) Resident #15 An observation of the medication administration pass, on 03/03/10 at 9:45 a.m., found the nurse (Employee #18) administered [MEDICATION NAME] 5 mg via the resident's gastrostomy tube. Review of the MAR found the [MEDICATION NAME] was ordered to be administered at 7:00 a.m. Review of the facility's policy entitled, ""ADMINISTERING MEDICATIONS THROUGH A GASTROSTOMY TUBE"" (revised September 2003), under the section entitled ""General Guidelines"", found the following: ""...6. Administer medications within one (1) hour before or after their scheduled time."" .",2015-07-01
10082,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,502,E,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure laboratory tests were completed as ordered by the physician. This was true for four (4) of twenty-three (23) sampled residents' records. The facility failed to obtain laboratory test timely for Residents #45, #92, #115, and #108. Facility census: 112. Findings include: a) Resident #45 Resident #45's medical record, when reviewed on 03/02/10 at 8:45 a.m., revealed a [AGE] year old female with a history of [MEDICAL CONDITION]. Review of the current physician orders, dated 02/17/10, revealed the physician ordered a complete blood count (CBC) test monthly. Review of the laboratory test results revealed the CBC test was not done as ordered. The registered nurse (RN - Employee #25), when interviewed on 03/02/10 at 9:30 a.m., confirmed the CBC was not completed for 02/2010 as ordered. b) Resident #92 Resident #92's medical record, when reviewed on 03/02/10 at 10:00 a.m., revealed a [AGE] year old female who was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the current physician orders [REDACTED]. Review of the laboratory test results revealed the [MEDICAL CONDITION] level was not done as ordered. Employee #25, when interviewed on 03/2/10 at 3:30 p.m., confirmed the [MEDICAL CONDITION] test was not completed as ordered. c) Resident #115 Resident #115's closed medical record, when reviewed on 03/04/10 at 10:00 a.m., revealed a [AGE] year old resident with end stage [MEDICAL CONDITION]. The resident received outpatient [MEDICAL TREATMENT] treatments three (3) times a week at a [MEDICAL TREATMENT] center. Review of the 08/17/09 physician orders [REDACTED]. Review of the medical record noted there was no hematological laboratory results in the medical record. The director of nurses (DON - Employee #2 ), when interviewed on 03/04/10 at 11:37 a.m., acknowledged the PTT test were not completed as ordered by the physician. d) Resident #108 Review of Resident #108's medical record, on 03/02/10, revealed a physician's orders [REDACTED]. Further review of the medical record revealed the most recent lab results for BUN, creatinine, and electrolytes were dated 08/31/09. There were no lab results for November 2009 or February 2010. Interview with medical records staff (Employee #12), on 03/02/10, revealed there were no lab results for the BUN, creatinine, or electrolytes found on the resident's thinned chart. These findings were reported to the DON on 03/02/10 at approximately 11:15 a.m.; subsequently, she stated she would contact the physician and request an order for [REDACTED].) .",2015-07-01
10083,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,507,D,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure laboratory reports were maintained on file in each resident's medical record. This was true for two (2) of twenty-three (23) sampled residents. Resident identifiers: #115 and #28. Facility census: 112. Findings include: a) Resident #115 Resident #115's closed medical record, when reviewed on 03/04/10 at 10:00 a.m., revealed a [AGE] year old resident with end-stage [MEDICAL CONDITION]. The resident received outpatient [MEDICAL TREATMENT] treatments three (3) times a week. Review of the 08/17/09 physician orders [REDACTED]. Review of the medical record found no hematological laboratory results in the medical record. The director of nurses (DON - Employee #2), when interviewed on 03/04/10 at 11:40 a.m., acknowledged the laboratory tests were not maintained in the medical record as required. b) Resident #25 Record review revealed, on 06/02/09, the physician ordered a complete blood count (CBC) each month, magnesium every three (3) months, fasting blood sugars each month, and magnesium and transferrin every three (3) months. Review of the medical record only found a lab report for a CBC dated 08/31/09; reports for fasting blood sugars dated 10/29/09, 12/17/09, 01/14/10, and 02/14/10; and reports for magnesium and transferrin for 08/31/09 only. The DON, on 03/02/10 at 4:00 p.m., reported the missing labs were pulled from the computer. .",2015-07-01
10084,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,161,E,0,1,FFCS11,". Based on record review and staff interview, the facility failed to obtain a current surety bond to protect all personal funds of residents deposited with the facility. This had the potential to affect all residents who elected to have their funds managed by the facility. Facility census: 112. Findings include: a) Shortly after entrance to the facility, facility staff provided requested information regarding the surety bond. Review of the surety bond revealed an accompanying letter from the Office of Health Facility Licensure and Certification (OHFLAC - the State agency designated to serve as the holder of such bonds for nursing homes in WV) dated 01/11/10, relaying a request from the Attorney General's Office to make necessary corrections and return the surety bond to the OHFLAC. Furthermore, the letter instructed the facility to contact the Attorney General's Office for any further questions regarding the corrections. Interview with the business office director (Employee #3), on 03/04/10 at 9:30 a.m., revealed the surety bond was signed by the representative authorized by the corporation to do so, although he was neither the president or vice-president of the corporation nor owner or general partner of the company as specified by the Attorney General's office. She said the corporate office takes care of this, not the facility, and they were in the process of trying to clarify this. On 03/04/10 at 10:15 a.m., a representative from OHFLAC, when interviewed, reported that, as of this date, the facility's surety bond covering the period of 08/15/09 through 08/15/10 had not been approved by the Attorney General's Office. .",2015-07-01
10085,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,203,E,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review, the facility failed to provide correct contact information on its uniform transfer / discharge notice for the State long-term care ombudsman and the single State agency responsible for the protection and advocacy of persons with [DIAGNOSES REDACTED]. This had the potential to affect any resident who might need to contact these organizations. Facility census: 112. Finding include: a) Resident #114 Closed record review of Resident #114 revealed she was given a uniform transfer / discharge notice which contained inaccurate information. The notice she received directed persons with a developmental disability or mental illness to contact the ""West Virginia Developmental Disabilities Council"" for assistance. However, the single agency designated in West Virginia to provide protection and advocacy to individuals with both mental [MEDICAL CONDITION] and mental illness is ""West Virginia Advocates, Inc."" (not West Virginia Developmental Disabilities Council). Also, the appeals notice lacked the name of the State long-term care ombudsman, although it did list the name of the regional ombudsman. .",2015-07-01
10086,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,281,D,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and record review, the facility failed to ensure two (2) of twenty (20) sampled residents received medications in accordance with physician orders. Resident identifiers: #35 and #81. Facility census: 112. Findings include: a) Resident #35 Observation of the medication pass, on 03/02/10 at 8:45 a.m., with the licensed practical nurse (LPN - Employee #204), found she administered [MEDICATION NAME] 100 mg to Resident #35. Review of the March 2010 monthly recapitulation of physician's orders [REDACTED]. During the observation and review of the medication with the nurse on 03/02/10 at 9:00 a.m., she stated, ""I owe her (Resident #35) a half tablet."" b) Resident #81 Medication pass observation, on 03/01/10 at 4:20 p.m., found Resident #81 received Calcium 500 mg from a bottle of stock medication. At 5:00 p.m., the nurse (Employee #25) passing medications stated she should have given this resident Calcium 500 mg with 200 mg Vitamin D from a bottle of stock medication, but took from the wrong bottle. During reconciliation, the physician's orders [REDACTED]. .",2015-07-01
10087,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,441,F,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on a review of the facility's hand hygiene procedure and staff interview, the facility failed to establish handwashing guidelines in accordance with current professional standards of practice as recommended by the Centers for Disease Control and Prevention (CDC). This had the potential to affect all residents. Facility census: 122. Findings include: a) Review of the facility's hand hygiene procedure found, at Step 6, ""Rub hand together vigorously for 10-15 seconds, generating fraction on all surfaces of the hands and fingers."" The policy was reviewed with the director of nursing on 03/03/10 at 12:00 p.m., at which time it was discussed that current CDC guidelines for hand washing indicate hands should be rubbed together for 15-20 seconds. --- Part II -- Based on record review, staff interview, and policy review, the facility failed to follow its own policy on [DIAGNOSES REDACTED] (TB) screening to assure all newly admitted residents were tested and found to be free of this communicable disease. This was evident for one (1) of three (3) residents' closed records. Resident identifier: #114. Facility census: 112. Findings include: a) Resident #114 Review of the facility's policy on TB screening (dated November 2008) revealed all new residents must have a 2-step Mantoux Purified Protein Derivative (PPD) on admission. The first step is to be completed within seven (7) days of admission or according State / Federal regulation, and the second step is to be completed within seven (7) to twenty-one (21) days after a negative result from the first step or according to State / Federal regulation, always following the more strict requirement. The administration and results are then to be documented on the TB Screening Record in millimeters (mm). Review of Resident #114's medical record, on 03/04/10, revealed the Step 1 PPD was administered on 09/21/09 in the left forearm to be read on 09/23/09; however, on 09/23/09, the results of the test were not read as evidenced by a blank space where the area of ""mm of induration"" was supposed to have been recorded and by a blank space where the nurse was supposed to have initialed as having read the results. Additionally, the Step 2 PPD was scheduled to be given on 10/05/09 and read on 10/07/09, but spaces were left blank regarding the manufacturer, lot number, dose, nurse's initials when the PPD was given, and ""mm of induration"" and nurse's initials when read, signifying that a second PPD was not given. Interview with a nurse (Employee #25), on 03/04/10 at approximately 10:00 a.m., revealed the PPD tests were also recorded on the medication administration record (MAR). Review of the resident's September 2009 MAR for 09/21/10 found a typed notation to ""check PPD on 09/23/09"", but the space to record the results on 09/23/09 was left blank. Employee #25 agreed there was no documentation of test results for the Step 1 PPD. Review of the October 2009 MAR revealed a PPD was initialed as having been given on 10/05/09, and there was a minus (-) sign on 10/07/09 with a nurse's initials signifying a negative PPD result. The 10/07/09 PPD test result was not recorded on the TB Screening Record, and there was no evidence of a second step having been completed seven (7) to twenty-one (21) days after the only PPD on record. .",2015-07-01
10088,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,309,G,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, resident interview, staff interview, and physician interview, the facility failed to provide necessary care and services to assist one (1) of twenty (20) sampled residents in attaining or maintaining her highest practicable level of physical well-being, by failing to obtain routine laboratory testing as ordered by the physician for a resident with a [DIAGNOSES REDACTED].#108, who was subsequently found to be dehydrated and hyperkalemic. Labs, obtained only after surveyor intervention, revealed the resident was dehydrated and hyperkalemic (elevated serum potassium level), and the physician discontinued the diuretic therapy and ordered the administration of intravenous IV fluids (to rehydrate the resident), medications to alter the resident's serum potassium level, and repeat labs. During this period of active physician intervention, the facility failed to document periodic nursing assessments (including vital signs) and the resident's response to treatment. Resident identifier: #108. Facility census: 112. Findings include: a) Resident #108 Review of Resident #108's medical record revealed an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. 1. Record review, on 03/02/10, revealed physician orders [REDACTED]. However, the most recent test results, dated 08/31/09, revealed the following abnormal lab values: - Potassium - high at 5.6 (normal range 3.5 - 5.2) - Chloride - high at 115 (normal range 97 - 108) - Carbon [MEDICATION NAME] - low at 17 (normal range 20 - 32) - BUN - high at 39 (normal range 5 - 26) - Creatinine - high at 3.02 (normal range 0.57 - 1.00) - Estimated Glomerular Flow Rate (eGRF - a test for monitoring kidney function) - low at 15 (normal range > 59) (Note: Abnormally high values of BUN, creatinine, and potassium are indicative of impaired kidney function; abnormally low values of eGFR are indicative of kidney damage. Abnormally high values of BUN, creatinine, and potassium are also indicative of dehydration.) Further record review revealed the addition of a diuretic, [MEDICATION NAME] 40 mg daily, which was initiated on 12/02/09. No lab results were available for November 2009 or February 2010. Observation of, and interview with, this resident, on 03/02/10 at 8:30 a.m., revealed a pleasantly confused lady who was clean in appearance and well groomed. During this conversation, she threw back the covers and spoke of her TED hose lying at the foot of her bed, saying she would need them on. Both of her legs were [MEDICAL CONDITION], more so on the left, and her finger made an imprint on her left lower thigh when she touched it. On 03/02/10, a medical records person (Employee #12) reviewed the resident's thinned record on file and was unable to find the physician-ordered laboratory tests listed above since 08/31/09. On 03/02/10 at approximately 11:15 a.m., these findings were reported to the director of nursing (DON), who stated she would notify the physician and request an order for [REDACTED]. 2. Medical record review, on 03/03/10, revealed a physician notification form dated 03/02/10 at 11:45, regarding the missing November 2009 and February 2010 labs (BUN, creatinine, and electrolytes). Labs, collected at 12:04 p.m. and reported at 2:12 p.m. on 03/02/10, yielded the following abnormal results: - Potassium - high at 6.1 (normal range 3.5 - 5.2) - Chloride - high at 111 (normal range 97 - 108) - BUN - high at 51 (normal range 5 - 26) - Creatinine - high at 3.53 (normal range 0.57 - 1.00) - eGRF - low at 12 (normal range > 59) Upon notification of these abnormal results, the physician gave orders, on 03/02/10 (with no timed entry for the telephone order), to discontinue the [MEDICATION NAME], give Potassium Chloride 30 meq (additional potassium for an individual who already had an abnormally high serum potassium level), and administer 1000 cc intravenous fluids of D5W (5% [MEDICATION NAME] and water) at a rate of 100 cc per hour with repeat labs in the morning. Review of the Medication Administration Record [REDACTED]. 3. Record review, on 03/04/10, revealed repeat labs, collected at 7:23 a.m. and reported at 12:13 p.m. on 03/03/10, yielded the following abnormal results: - BUN - high at 49 (normal range 5 - 26) - Creatinine - high at 3.29 (normal range 0.57 - 1.00) - eGFR - low at 13 (normal range > 59) Review of physician's orders [REDACTED]. Review of nursing notes found an entry, dated 03/03/10 at noon, stating, ""2nd (second) blood draw done to confirm K+ (potassium) level before administering [MEDICATION NAME]."" A subsequent entry, at 2:00 p.m. on 03/03/10, noted an elevated potassium level of 5.8 with [MEDICATION NAME] given. Another entry, also at 2:00 p.m. on 03/03/10, noted more lab work was scheduled for the morning. 4. Labs, collected at 1:21 a.m. and reported on 03/04/10 (time of report not noted), yielded the following abnormal results: - Potassium - within normal limits at 4.8 (normal range 3.5 - 5.2) - BUN - high at 45 (normal range 5 - 26) - Creatinine - high at 3.42 (normal range 0.57 - 1.00) - eGFR - low at 13 (normal range > 59) 5. Interview with the nurse (Employee #38), on 03/04/10 at 11:45 a.m., revealed the facility uses a tickler file in a file box at each nurse's station to record the months or the weeks in a month when repeating lab work is due for specific residents. When asked, she said this is the third hall in which this resident has resided since admission to the facility last year. 6. Interview with the assistant director of nursing (ADON - Employee #4), on 03/04/10 at 2:00 p.m., revealed they were wondering about the physician's orders [REDACTED].#21 at home today and asked if she understood the order correctly (in reference to discontinuing the [MEDICATION NAME], giving IV fluids, and administering potassium chloride); Employee #21 replied in the affirmative. According to the ADON, Employee #21 said she called the physician the next morning, on 03/03/10, before giving the [MEDICATION NAME]. 7. During interview with the physician on 03/04/10 at 2:15 p.m., he said his primary focus initially was to hydrate the resident. He said the nurse told him about the 6.1 potassium level 03/02/10. When asked about the order for potassium chloride, he explained he knew the potassium level would drop when she was re-hydrated. 8. Review of nursing notes for 03/02/10, 03/03/10, and the night shift on 03/04/10, found no assessments or vital signs documented during the time the resident was being re-hydrated and being treated for [REDACTED]. 9. Review of the resident assessment protocol (RAP) summary on the resident's comprehensive admission assessment (dated as completed on 06/06/09) found the interdisciplinary care team decided to not address dehydration / fluid maintenance on this resident's care plan, even though her admitting [DIAGNOSES REDACTED]. Review of the current care plan revealed the problem statement: ""At nutritional risk r/t (related to): Therapeutic diet r/t Stg IV CRF (Stage IV [MEDICAL CONDITION])."" There was a box to also mark ""Dehydration"", but the interdisciplinary care team chose not to mark this. The goals associated with this problem statement were: ""Resident will consume at least 75% of most meals"" and ""Weight will remain stable +/- 5 lbs adm (admission weight) 135 lb (also noted +3 [MEDICAL CONDITION] to BLE (bilateral lower extremities)"". The interventions to assist the resident in achieving these goals included: ""Monitor labs as ordered / available."" .",2015-07-01
10089,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,225,E,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on personnel record review and staff interview, the facility failed to screen individuals, prior to permitting them to have resident contact, for convictions of abuse, neglect, or mistreatment residents by a court of law and/or findings entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. Five (5) of five (5) contracted nursing employees reviewed did not have evidence of a statewide background check (Employees #97, #103, #108, #111, and #113), and there was no evidence of screening against the State nurse aide registry for four (4) of five (5) contracted employees and one (1) of five (5) regular employee reviewed (Employees #38, #97, #108, #111, and #113). Facility census: 112. Findings include: a) Employees #97, #103, #108, #111, and #113 Review of sampled personnel files, with the payroll clerk at 4:00 p.m. on 03/03/10, failed to find evidence of statewide background checks for contracted Employees #97, #103, #108, #111, and #113, in an effort to uncover information about any past criminal prosecutions that would indicate unfitness for service in a nursing facility caring for vulnerable adults. On 03/04/10 at 10:00 a.m., the payroll clerk confirmed there were no statewide background checks completed for these individuals. b) Employees #38, #97, #108, #111, and #113 Review of sampled personnel files, with the payroll clerk at 4:00 p.m. on 03/03/10, failed to find evidence the State nurse aide registry was checked for Employees #38, #97, #108, #111, and #113. On 03/04/10 at 10:00 a.m., the payroll clerk confirmed the State nurse aide registry had not been checked for these individuals. .",2015-07-01
10090,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,156,E,0,1,FFCS11,". Based on observation and staff interview, the facility failed to post the correct names, addresses, and telephone numbers of all pertinent State agencies. Incorrect contact information was posted for the State survey and certification agency and the local Medicaid office. This had the potential to affect any resident who might need to contact these agencies. Facility census: 112. Findings include: a) Observation of the posted contact information for pertinent State agencies, in the company of the administrator at 10:30 a.m. on 03/04/10, found the following: 1. The address of the State survey and certification agency was incorrect. 2. The address and telephone number of the local Medicaid office address were incorrect. The administrator confirmed these errors at the time of the observation. .",2015-07-01
10091,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,329,D,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the drug regimen of one (1) of twenty (20) sampled residents was free from unnecessary drugs. Resident #28 was ordered [MEDICATION NAME] 0.5 mg on 01/15/10 for Mild Mental [MEDICAL CONDITION] in the absence of adequate indications for it use. Facility census: 112. Findings include: a) Resident #28 Record review revealed Resident #28 was admitted to the facility on [DATE], and the hospital discharge summary for that date indicated the resident was receiving [MEDICATION NAME] 0.5 mg prior to admission to the facility. Copies of hospital records on the resident's medical record, when reviewed, contained no information explaining why the resident required this medication. The resident's 01/15/10 admission physician's orders [REDACTED]. Review of the physician's progress notes from 01/15/10 forward failed to find any documentation of the indications for use of the [MEDICATION NAME]. Review of the resident's 01/26/10 care plan found the resident was receiving [MEDICATION NAME] for ""MR with behaviors"" and ""Behavioral symptoms drug is intended to treat: Resists care"". This information was reviewed with the director of nursing on 03/04/10 at 4:00 p.m., and she agreed the indications for giving this resident [MEDICATION NAME] were inadequate. She reported having reviewed the medical record and finding no additional information concerning this matter. .",2015-07-01
10092,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,248,E,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on confidential resident group interview, resident interview, and staff interview, the facility failed to provide an ongoing program of activities designed to meet the interests and psychosocial well-being of each resident. This was evident by six (6) of eight (8) residents in attendance at a confidential group meeting who reported they were unable to participate in outings as a group and for one (1) of twenty (20) sampled residents (#6) who reported being unable to participate in outings as desired. Facility census: 112. Findings include: a) During a confidential resident group meeting on 03/02/10 at 10:30 a.m., six (6) of eight (8) residents in attendance reported they had never been able to attend outings as a group outside the facility as they desired. When asked, several of the residents reported they would like to visit the local Senior Center but noted transporting more than one (1) or two (2) residents in wheelchairs on the transit bus would be a problem. Group members stated the facility had no van of its own. During a confidential interview with an employee on 03/03/10 at approximately 3:00 p.m., this employee confirmed no group outings had been held for residents for at least the past two (2) years. Interview with the assistant activity director (Employee #6), on 03/04/10 at 11:15 a.m. revealed, only a few residents over the past few years have asked her about having a group outing. She stated the activities department has contacted the Marion County Transit Authority to transport individual residents for such things as shopping at Wal-Mart when requested, but the facility has not requested the Transit Authority to transport a group of residents at the same time. Interview with the activity director (Employee #10), on 03/04/10 at 2:45 p.m., revealed there have been no group outings since she has been working at the facility in July 2009. She recalled last year, in August or September, residents mentioned wanting group outings. However, she said, due to difficulties with transporting numerous residents on the Transit Authority bus, associated legalities, the need for having enough staff to accompany the residents, etc., she explained to residents the barriers to having group outing. Since that time, Employee #10 reported no one had mentioned it to her again. She acknowledged the facility had no van or bus of their own for transporting residents. She stated she would be glad to put this request for group outings ""on the table"" at the next resident council meeting to see what residents want and to see if the facility can help meet those needs. b) Resident #6 Resident #6's medical record, when reviewed on 03/03/10 at 10:00 a.m., revealed a [AGE] year old male who was admitted to the facility on [DATE]. The physician determined the resident possessed the capacity to understand and make his own medical decisions. The resident was non-ambulatory due to paralysis and utilized a motorized wheelchair for mobility. This alert and oriented resident, when interviewed on 03/03/10 at 2:30 p.m., revealed he attended some of the planned activities offered by the facility. The resident stated the facility did not provide outings and stated, ""I wish they would. It would be nice to get out once in a while."" The resident reported that, if the facility would offer facility outings, ""I would like to go."" .",2015-07-01
10093,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,327,G,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, resident interview, staff interview, and physician interview, the facility failed to provide necessary care and services to assist one (1) of twenty (20) sampled residents to ensure the resident maintained acceptable parameters of fluid and electrolyte balance, by failing to develop and implement a care plan to address fluid and electrolyte balance for a resident with a [DIAGNOSES REDACTED]. These failures resulted in actual harm to Resident #108, who was subsequently found to be dehydrated and hyperkalemic. Labs, obtained only after surveyor intervention, revealed the resident was dehydrated and hyperkalemic (elevated serum potassium level), and the physician discontinued the diuretic therapy and ordered the administration of intravenous IV fluids (to rehydrate the resident), medications to alter the resident's serum potassium level, and repeat labs. Resident identifier: #108. Facility census: 112. Findings include: a) Resident #108 Review of Resident #108's medical record revealed an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. 1. Record review, on 03/02/10, revealed physician orders [REDACTED]. However, the most recent test results, dated 08/31/09, revealed the following abnormal lab values: - Potassium - high at 5.6 (normal range 3.5 - 5.2) - Chloride - high at 115 (normal range 97 - 108) - Carbon [MEDICATION NAME] - low at 17 (normal range 20 - 32) - BUN - high at 39 (normal range 5 - 26) - Creatinine - high at 3.02 (normal range 0.57 - 1.00) - Estimated Glomerular Flow Rate (eGRF - a test for monitoring kidney function) - low at 15 (normal range > 59) (Note: Abnormally high values of BUN, creatinine, and potassium are indicative of impaired kidney function; abnormally low values of eGFR are indicative of kidney damage. Abnormally high values of BUN, creatinine, and potassium are also indicative of dehydration.) Further record review revealed the addition of a diuretic, [MEDICATION NAME] 40 mg daily, which was initiated on 12/02/09. No lab results were available for November 2009 or February 2010. Observation of, and interview with, this resident, on 03/02/10 at 8:30 a.m., revealed a pleasantly confused lady who was clean in appearance and well groomed. During this conversation, she threw back the covers and spoke of her TED hose lying at the foot of her bed, saying she would need them on. Both of her legs were [MEDICAL CONDITION], more so on the left, and her finger made an imprint on her left lower thigh when she touched it. On 03/02/10, a medical records person (Employee #12) reviewed the resident's thinned record on file and was unable to find the physician-ordered laboratory tests listed above since 08/31/09. On 03/02/10 at approximately 11:15 a.m., these findings were reported to the director of nursing (DON), who stated she would notify the physician and request an order for [REDACTED]. 2. Medical record review, on 03/03/10, revealed a physician notification form dated 03/02/10 at 11:45, regarding the missing November 2009 and February 2010 labs (BUN, creatinine, and electrolytes). Labs, collected at 12:04 p.m. and reported at 2:12 p.m. on 03/02/10, yielded the following abnormal results: - Potassium - high at 6.1 (normal range 3.5 - 5.2) - Chloride - high at 111 (normal range 97 - 108) - BUN - high at 51 (normal range 5 - 26) - Creatinine - high at 3.53 (normal range 0.57 - 1.00) - eGRF - low at 12 (normal range > 59) Upon notification of these abnormal results, the physician gave orders, on 03/02/10 (with no timed entry for the telephone order), to discontinue the [MEDICATION NAME], give Potassium Chloride 30 meq (additional potassium for an individual who already had an abnormally high serum potassium level), and administer 1000 cc intravenous fluids of D5W (5% [MEDICATION NAME] and water) at a rate of 100 cc per hour with repeat labs in the morning. Review of the Medication Administration Record [REDACTED]. 3. Record review, on 03/04/10, revealed repeat labs, collected at 7:23 a.m. and reported at 12:13 p.m. on 03/03/10, yielded the following abnormal results: - BUN - high at 49 (normal range 5 - 26) - Creatinine - high at 3.29 (normal range 0.57 - 1.00) - eGFR - low at 13 (normal range > 59) Review of physician's orders [REDACTED]. Review of nursing notes found an entry, dated 03/03/10 at noon, stating, ""2nd (second) blood draw done to confirm K+ (potassium) level before administering [MEDICATION NAME]."" A subsequent entry, at 2:00 p.m. on 03/03/10, noted an elevated potassium level of 5.8 with [MEDICATION NAME] given. Another entry, also at 2:00 p.m. on 03/03/10, noted more lab work was scheduled for the morning. 4. Labs, collected at 1:21 a.m. and reported on 03/04/10 (time of report not noted), yielded the following abnormal results: - Potassium - within normal limits at 4.8 (normal range 3.5 - 5.2) - BUN - high at 45 (normal range 5 - 26) - Creatinine - high at 3.42 (normal range 0.57 - 1.00) - eGFR - low at 13 (normal range > 59) 5. During interview with the physician on 03/04/10 at 2:15 p.m., he said his primary focus initially was to hydrate the resident. He said the nurse told him about the 6.1 potassium level 03/02/10. When asked about the order for potassium chloride, he explained he knew the potassium level would drop when she was re-hydrated. 6. Review of the resident assessment protocol (RAP) summary on the resident's comprehensive admission assessment (dated as completed on 06/06/09) found the interdisciplinary care team decided to not address dehydration / fluid maintenance on this resident's care plan, even though her admitting [DIAGNOSES REDACTED]. Review of the current care plan revealed the problem statement: ""At nutritional risk r/t (related to): Therapeutic diet r/t Stg IV CRF (Stage IV [MEDICAL CONDITION])."" There was a box to also mark ""Dehydration"", but the interdisciplinary care team chose not to mark this. The goals associated with this problem statement were: ""Resident will consume at least 75% of most meals"" and ""Weight will remain stable +/- 5 lbs adm (admission weight) 135 lb (also noted +3 [MEDICAL CONDITION] to BLE (bilateral lower extremities)"". The interventions to assist the resident in achieving these goals included: ""Monitor labs as ordered / available."" .",2015-07-01
10094,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,279,D,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, resident interview, and staff interview, the facility failed to provide necessary care and services to assist one (1) of twenty (20) sampled residents to ensure the resident maintained acceptable parameters of fluid and electrolyte balance, by failing to develop and implement a care plan to address fluid and electrolyte balance for a resident with a [DIAGNOSES REDACTED]. Resident identifier: #108. Facility census: 112. Findings include: a) Resident #108 Review of Resident #108's medical record revealed an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. 1. Record review, on 03/02/10, revealed physician orders [REDACTED]. However, the most recent test results, dated 08/31/09, revealed the following abnormal lab values: - Potassium - high at 5.6 (normal range 3.5 - 5.2) - Chloride - high at 115 (normal range 97 - 108) - Carbon [MEDICATION NAME] - low at 17 (normal range 20 - 32) - BUN - high at 39 (normal range 5 - 26) - Creatinine - high at 3.02 (normal range 0.57 - 1.00) - Estimated Glomerular Flow Rate (eGRF - a test for monitoring kidney function) - low at 15 (normal range > 59) (Note: Abnormally high values of BUN, creatinine, and potassium are indicative of impaired kidney function; abnormally low values of eGFR are indicative of kidney damage. Abnormally high values of BUN, creatinine, and potassium are also indicative of dehydration.) Further record review revealed the addition of a diuretic, [MEDICATION NAME] 40 mg daily, which was initiated on 12/02/09. No lab results were available for November 2009 or February 2010. Observation of, and interview with, this resident, on 03/02/10 at 8:30 a.m., revealed a pleasantly confused lady who was clean in appearance and well groomed. During this conversation, she threw back the covers and spoke of her TED hose lying at the foot of her bed, saying she would need them on. Both of her legs were [MEDICAL CONDITION], more so on the left, and her finger made an imprint on her left lower thigh when she touched it. On 03/02/10, a medical records person (Employee #12) reviewed the resident's thinned record on file and was unable to find the physician-ordered laboratory tests listed above since 08/31/09. On 03/02/10 at approximately 11:15 a.m., these findings were reported to the director of nursing (DON), who stated she would notify the physician and request an order for [REDACTED]. 2. Medical record review, on 03/03/10, revealed a physician notification form dated 03/02/10 at 11:45, regarding the missing November 2009 and February 2010 labs (BUN, creatinine, and electrolytes). Labs, collected at 12:04 p.m. and reported at 2:12 p.m. on 03/02/10, yielded the following abnormal results: - Potassium - high at 6.1 (normal range 3.5 - 5.2) - Chloride - high at 111 (normal range 97 - 108) - BUN - high at 51 (normal range 5 - 26) - Creatinine - high at 3.53 (normal range 0.57 - 1.00) - eGRF - low at 12 (normal range > 59) Upon notification of these abnormal results, the physician gave orders, on 03/02/10 (with no timed entry for the telephone order), to discontinue the [MEDICATION NAME], give Potassium Chloride 30 meq (additional potassium for an individual who already had an abnormally high serum potassium level), and administer 1000 cc intravenous fluids of D5W (5% [MEDICATION NAME] and water) at a rate of 100 cc per hour with repeat labs in the morning. 3. Record review, on 03/04/10, revealed repeat labs, collected at 7:23 a.m. and reported at 12:13 p.m. on 03/03/10, yielded the following abnormal results: - BUN - high at 49 (normal range 5 - 26) - Creatinine - high at 3.29 (normal range 0.57 - 1.00) - eGFR - low at 13 (normal range > 59) Review of physician's orders [REDACTED]. Review of nursing notes found an entry, dated 03/03/10 at noon, stating, ""2nd (second) blood draw done to confirm K+ (potassium) level before administering [MEDICATION NAME]."" A subsequent entry, at 2:00 p.m. on 03/03/10, noted an elevated potassium level of 5.8 with [MEDICATION NAME] given. Another entry, also at 2:00 p.m. on 03/03/10, noted more lab work was scheduled for the morning. 4. Labs, collected at 1:21 a.m. and reported on 03/04/10 (time of report not noted), yielded the following abnormal results: - Potassium - within normal limits at 4.8 (normal range 3.5 - 5.2) - BUN - high at 45 (normal range 5 - 26) - Creatinine - high at 3.42 (normal range 0.57 - 1.00) - eGFR - low at 13 (normal range > 59) 5. Review of the resident assessment protocol (RAP) summary on the resident's comprehensive admission assessment (dated as completed on 06/06/09) found the interdisciplinary care team decided to not address dehydration / fluid maintenance on this resident's care plan, even though her admitting [DIAGNOSES REDACTED]. Review of the current care plan revealed the problem statement: ""At nutritional risk r/t (related to): Therapeutic diet r/t Stg IV CRF (Stage IV [MEDICAL CONDITION])."" There was a box to also mark ""Dehydration"", but the interdisciplinary care team chose not to mark this. The goals associated with this problem statement were: ""Resident will consume at least 75% of most meals"" and ""Weight will remain stable +/- 5 lbs adm (admission weight) 135 lb (also noted +3 [MEDICAL CONDITION] to BLE (bilateral lower extremities)"". The interventions to assist the resident in achieving these goals included: ""Monitor labs as ordered / available."" .",2015-07-01
9607,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,160,D,0,1,I2AU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to convey, within thirty (30) days, personal funds for a resident who had expired. This was noted for one (1) of five (5) residents reviewed for this aspect of personal funds. The resident expired on [DATE]. As of [DATE], the funds had not been conveyed to the resident's estate. Resident identifier: A. Facility census: 55. Findings include: a) Resident A On [DATE], review of the resident funds, with the administrator, found an account balance of $831.68 for this expired resident, who expired on [DATE]. At 2:00 p.m. on [DATE], the administrator confirmed these funds had not yet been conveyed to the resident's estate.",2015-10-01
9608,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,225,E,0,1,I2AU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record review and staff interview, the facility failed to be thorough in their investigation of the past history for one (1) of ten (10) employees whom the facility hired. The facility failed to make an inquiry of the State nurse aide registry for Employee #11. This practice had the potential to affect more than an isolated number of residents. Facility census: 55. Findings include: a) Employee #11 On 03/04/10, ten (10) sampled employee personnel files, when reviewed with the facility's human resource director (HRD), revealed Employee #11 was hired on 05/26/09. There was no evidence an inquiry was made of the nurse aide registry, to identify findings concerning abuse, neglect, mistreatment of [REDACTED]. When this information could not be located by the HRD, the HRD contacted the director of nursing (DON), in case the DON had this information. At 3:00 p.m. on 03/04/10, the HRD and DON reported this screening had not been done for Employee #11.",2015-10-01
9609,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,241,D,0,1,I2AU11,"Based on random observations, the facility failed to each resident was treated with dignity. A volunteer insisted on a resident wearing a clothing protector despite the resident's repeated protestations. Resident identifier: #55. Facility census: 55. Findings include: a) Resident #55 At lunch time in the dining room on 03/04/10, observation found Resident #55 seated at a table with two (2) other residents. A staff member had placed clothing protectors on the other two (2) residents earlier, but Resident #55 had declined. A volunteer moved about the dining room interacting with residents. When she reached the table at which Resident #55 sat at 11:35 a.m., the volunteer picked up a clothing protector that had been lying folded on the table in front of an empty chair. She moved to place it on the resident, and the resident said, I don't want that. Despite the resident's repeated statements that she did not want the clothing protector, the volunteer persisted in trying to persuade the resident to allow her to put the clothing protector on her (the resident) in case she would spill her food. The volunteer tried to place the protector around the resident's neck, and the resident pulled it away. The volunteer then put it in the resident's lap. After the volunteer left the table, the resident again said, I don't want that, folded the clothing protector, and put it back on the table where it had been initially. This incident was reported to the social worker in late morning on 03/05/10. She said it was something that definitely needed to be addressed. .",2015-10-01
9610,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,272,E,0,1,I2AU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, resident interviews, and observations, the facility failed to ensure the interdisciplinary team provided documentation of summary information regarding the additional assessment performed through the resident assessment protocols (RAPs) which contained sufficient evidence areas to reflect triggered by the minimum data set (MDS) assessments had been fully explored for the individual. Additionally, the information documented in the RAPs did not demonstrate the rationale for the care planning decisions. Five (5) of twelve (12) current residents on the sample were affected. Resident identifiers: #32, #25, #17, #16, and #22. Facility census: 55. Findings include: a) Resident #32 Review of the Urinary Incontinence and Indwelling Catheter RAP found it had triggered due to Indwelling catheter having been coded on the admission assessment with an assessment reference date (ARD) of 12/14/09. The assessment also indicated the resident was continent of bowel. In the narrative section, the assessor documented the following, Problem - potential for infection Contributing factors - use of indwelling cath upon admission but was DC (discontinued) after 2 days and remains continent of urine thus far, has stage one pressure ulcer to coccyx upon admission to facility Risks - infection Referrals, catheter removal, toilet as ordered and provide incontinent (sic) care as needed, skin care as ordered, monitor labs and weights as ordered, offer fluids at and between meals. The physician ordered the catheter be removed on 12/09/09. The nurses' notes indicated the catheter had been removed and the resident was voiding. The RAP notation indicated the resident was voiding continently. The RAP also noted possible reversible problems to be reviewed in evaluating the need for a catheter or evaluating incontinence. Check marks had been placed beside of locomotion, [MEDICAL CONDITIONS], and psychoactive medications. There was no evidence of further assessment with regard to how locomotion, medications, [MEDICAL CONDITION] her ability to be continent of urine. It was noted the resident was to be toileted as ordered. The physician's orders [REDACTED]. The assessor noted the resident had been continent after the removal of the urinary catheter. The catheter had been removed on 12/09/09, and the assessment reference period ended at midnight on 12/14/09. That would have been nearly six (6) days since the catheter had been removed. The documentation on the RAP noted the resident had been continent during that period. The rationale for proceeding to care planning was not clear. It was not clear what the objective of the care plan was to be. Although the resident was identified as being continent after the removal of the indwelling catheter, the resulting care plan addressed prevention of complications of incontinence, not maintaining her continence status. b) Resident #25 1. The resident's admission MDS, with an ARD of 01/22/10, triggered the RAP for urinary incontinence. The resident had been coded as having inadequate control of his bladder, having multiple episodes of urinary incontinence daily. The assessment also indicated the resident had experienced a deterioration in urinary continence in the last ninety (90) days. The assessor documented the contributing factors as: [MEDICAL CONDITION] with left sided weakness, impaired mobility, diabetes, diuretic use, use of sedative for sleep r/t (related to) [MEDICAL CONDITION]. Although these factors were contributing, they were not necessarily the cause of the incontinence. There was no indication there had been an analysis of his voiding patterns, whether he felt the urge to void, whether he had a urinary tract infection, whether he was ingesting sufficient fluids, etc. 2. The resident's assessment also triggered the RAP for vision. The RAP triggered because the assessor coded his vision as: Impaired - sees large print, but not regular print in newspapers / books. The RAP included a section for issues and problems to be reviewed that might suggest a need for intervention. In this section, [MEDICATION NAME] degeneration, neurological [DIAGNOSES REDACTED]. There was no evidence any of these areas had been explored. There was no indication he had been assessed to see whether his glasses were still effective in correcting his vision, how much his [MEDICATION NAME] degeneration affected his vision, whether there was any effect on his vision secondary to his diabetes, or whether his mood might be affecting his vision. There was no indication when he needed to wear his glasses, i.e., to read, when walking, etc. This information would be needed in order to establish an individualized care plan. c) Resident #17 This resident's admission MDS, with an ARD of 02/11/10, was coded to indicate his vision was: Impaired - sees large print, but not regular print in newspapers / books. The section of the RAP for issues and problems to be reviewed, that might suggest a need for intervention, had been checked for neurological [DIAGNOSES REDACTED]. There was no evidence of an assessment of these items. Although the assessment had not been coded in Section I for [MEDICAL CONDITION], this was noted to be a contributing factor. There was no indication to what extent his [MEDICAL CONDITION] affected his vision. It was not noted whether the resident's glasses were appropriate to meet his needs. d) Resident #22 This resident was admitted to the facility on [DATE]. In Section H of the resident's admission MDS, with an ARD of 10/07/09, the assessor indicated the resident was incontinent of bladder (multiple daily episodes) in the last fourteen (14) days. This triggered the RAP for urinary incontinence Review of documentation associated with that RAP revealed the facility identified the causal factors for the resident's incontinence; however, there was no evidence the facility explored these factors to demonstrate the rationale for a care plan decision or to establish an individualized plan regarding the resident's incontinence, at the time of the survey, the resident remained incontinent. e) Resident #16 This resident was admitted to the facility on [DATE]. In Section H of the admission MDS with an ARD date of 08/18/09, the assessor indicated the resident was incontinent of bladder (multiple daily episodes) in the last fourteen (14) days. This should have triggered the RAP for urinary incontinence. Review of the RAP for urinary incontinence revealed it was not completed. There was no evidence the facility identified this error or identified causal factors for the resident's incontinence. At the time of the survey, the resident remained incontinent.",2015-10-01
9611,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,279,E,0,1,I2AU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, staff interviews, and family interview, the facility failed to develop a comprehensive care plan for each resident that included measurable objectives and described the services to be provided to assist the resident to attain his or her highest practicable level of well-being. Goals were not established for items identified on the assessment that would require the development of a program, i.e., no care plan was developed although a resident was assessed as being on a planned weight loss program. Goals were established without parameters to render them measurable and/or to provide guidance to caregivers. Rehabilitative goals were identified, but the care plan was primarily directed toward maintenance of current abilities and/or for staff to meet the resident's needs. Four (4) of twelve (12) current residents on the sample were affected. Resident identifiers: #11, #32, #25, and #21. Facility census: 55. Findings include: a) Resident #11 1. The quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/04/10, identified the resident was on a planned weight change program. No care plan had been established regarding what change was desired regarding the resident's weight. The interdisciplinary team established a goal, dated 10/12/09, for: Will consume / tolerate 75% of meals with no S/S (signs/symptoms) of aspiration this quarter. The interventions were related to positioning, honoring food preferences, to monitor and report her weight, etc. There was nothing to indicate how much weight the resident was to lose or gain and how fast the weight loss or gain was to occur. Neither her current nor target weights were identified in the care plan. For this item to be coded in K5h, the MDS manual instructs: On Planned Weight Change Program - Resident is receiving a program of which the documented purpose and goal are to facilitate weight gain or loss (e.g., double portions; high calorie supplements; reduced calories; 10 grams fat). 2. A goal had been established for: Restore / Maintain adequate hydration. The amount of fluids the resident required was not noted in the care plan to let caregivers know how much fluid the resident needed on a daily basis. 3. Another goal was: Will be discharged to home when rehabilitation/self care goals are met. The care plan goals were primarily for maintenance / prevention of declines and/or to have her needs met by staff. The rehabilitative / self care goals that needed to be met to enable her to go home could not be identified. It was noted a new preadmission screening (PAS) had been completed after the resident's admission. The social worker explained, in an interview at 9:30 a.m. on 03/05/10, they thought the resident still might be able to go home; they just were not sure at present, so a long-term PAS had been completed. She said they had still care planned for her to go home, there was still hope. 4. Goals were not always resident oriented. For example, a goal of Will receive assistance necessary to meet ADL (activities of daily living) needs was staff oriented as they would be the ones to provide the assistance. b) Resident #32 1. The resident's MDS, with an ARD of 12/14/09, triggered the resident assessment protocol for dehydration / fluid maintenance. Review of the dietary note, for 12/17/09, found the dietitian had noted, . Is holding back on fluids so she doesn't have to go to the bathroom. Encouraged fluids & PO (by mouth) intake to promote healing, . Will address fluid issue /c (with) nursing. Nothing was found in the care plan that incorporated this information. 2. Activities goals were written for: Will express satisfaction will (sic) leisure choices and participation when asked by activity staff and Will involve self in independent activities of choice and attend group activities as chooses. Neither of these goals were stated in measurable terms. 3. The activities of daily living (ADL) goals were: Will not develop any complications related to decreased mobility and Will participate in self-care tasks at the highest practicable level of functioning. These goals were not measurable as stated. 4. Many other goals were not stated in measurable terms, i.e., Will be enabled tro (sic) socialize with other through normal daily routine; Find way around own room / unit; Recognize persons with whom routinely have contact; Ability to reminisce about past major events/ experiences and so on. 5. A care plan goal to prevent dehydration had been established. The dietary assessment noted the resident was status [REDACTED]. There was no guidance provided in the care plan with regard to how much fluid the resident needed on a daily basis to maintain hydration. On 12/19/10, the resident was noted to have Milky thick urine return documented in the nurses' notes when she was catheterized. c) Resident #25 1. A goal for the resident to return home had been established. There was no plan to make sure the resident understood and/or educate him about his diet for his non-insulin dependent diabetes 2. The resident's assessment identified a problem of urinary incontinence. This problem was primarily addressed in relation to other goals, i.e. falls. The care plan included he was to be toileted every two (2) hours as ordered by the physician. However, a plan had not been established based on his voiding patterns as these had not been assessed. d) Resident #21 1. During a conversation with the resident's family, concern about the resident being walked enough was expressed. 2. Review of the resident's care plan found a goal of will walk 300 ft with / without assistance of device/person on level surface and/or carpet. The only intervention was Will refer to the Therapy Plan of Treatment in the medical record for more detail. 3. The Rehabilitation Screen, was reviewed. On 12/24/09, the physical therapist had noted the resident was confused and unable to follow commands. Nursing assistants (NAs) were walking her without difficulty. It was noted she was not appropriate for training at that time. On 12/28/09, the occupational therapist (OT) noted: Unable to follow commands - Functioning at max capacity. No OT needs at this time. In an interview on 03/05/10 at 2:05 p.m., Employee #9 (the physical therapist) said she had just screened the resident. She had watched the NAs walk her and at that time she could walk from a chair near the nurses' station to the dining room. In mid-morning on 03/05/10, two (2) NA (Employees #44 and #38) were asked, in separate interviews, about the resident's ability to walk. Both said the resident was just walked from her bed or chair to the bathroom. 4. This resident's care plan also included goals that were not measurable. Examples were: Will express satisfaction will (sic) leisure choices and participation when asked by activity staff and Will adjust positively to the facility by participating in either independent or group activities of interest ___ days each week. In the latter example, the number of days had not been identified.",2015-10-01
9612,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,280,D,0,1,I2AU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to review / revise care plans when there was clinical change in condition that impacted the resident's care needs. One (1) resident had an increase in episodes of bowel incontinence after admission, but the care plan was not revised. Another resident was admitted with an indwelling urinary catheter, which was discontinued shortly after admission; the care plan addressed urinary incontinence and was not revised when a catheter was reinserted. Two (2) of twelve (12) current residents were affected. Resident identifiers: #11 and #32. Facility census: 55. Findings include: a) Resident #11 The resident's admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/08/09, was coded to indicate the resident was occasionally incontinent of bowel. The quarterly assessment, with an ARD of 01/04/10, indicated she was incontinent of bowel all, or almost all, of the time. A care plan had been established based on the admission assessment. It included an intervention to toilet the resident upon arising, before / after meals, and at bedtime and as needed. The care plan had not been updated to address the increase in incontinence. There were no interventions established that would promote bowel continence. b) Resident #32 The resident was admitted to the facility on [DATE]. At the time of admission, she had an indwelling urinary catheter. The catheter was discontinued on 12/09/09. A care plan was established for no complications due to incontinence and for: Will be maintained in as clean and dry dignified state as possible within confines of urinary dysfunction. On 12/19/09, a catheter was reinserted. The care plan had not been revised, as of 03/05/10, to reflect the use of the catheter. c) These issues were discussed with the director of nursing in mid-morning, and the assessment coordinator (Employee 42) at 3:10 p.m. on 03/05/10. They agreed the care plans should have been updated.",2015-10-01
9613,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,309,D,0,1,I2AU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to provide a resident with the necessary care and services to maintain her highest practicable level of physical well-being. There was no evidence a resident had been identified as having [MEDICAL CONDITION] prior to the physician ordering [MEDICATION NAME], a diuretic. There was no evidence the efficacy of the [MEDICATION NAME] was assessed after implementation. One (1) of twelve (12) current residents on the sample was affected. Resident identifier: #32. Facility census: 55. Findings include: a) Resident #32 On 01/27/09, the physician noted the resident had [MEDICAL CONDITION] and ordered [MEDICATION NAME] 40 mg every day. Review of the nurses' notes, prior to 01/27/10, found nothing in the nursing entries regarding the presence of [MEDICAL CONDITION]. [MEDICAL CONDITION] had been noted in the dietary notes on 12/08/09 and 12/17/09, Review of the nursing entries after the implementation of the [MEDICATION NAME] found no evidence the diuretic had been monitored for effectiveness. This was discussed with minimum data set (MDS) assessment nurse (Employee #42) on 03/05/10 at 3:10 p.m., and with DON mid-morning. They were unable to locate any nursing documentation to verify the [MEDICAL CONDITION] had been identified and monitored by nursing.",2015-10-01
9614,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,311,E,0,1,I2AU11,"Based on family interview, review of medical records, and staff interview, the facility failed to provide each resident with the appropriate treatment and services to maintain or improve his or her ability to ambulate. It was learned the facility had no formal restorative program. Restorative needs were communicated to direct care givers by a Resident Information Worksheet. One (1) of twelve (12) current residents on the current sample was found to not be receiving services maintained her abilities to ambulate and to feed herself. Resident identifier: #21 and any resident needing restorative nursing services. Facility census: 55. Findings include: a) Resident #21 On 03/04/10 at approximately 1:25 p.m., the resident's family members were interviewed. During the conversation, one (1) of the family commented she thought the resident had declined, but she was not sure it was avoidable. She said the resident was not able to walk much and was getting to where she could not feed herself. The family member commented the resident had therapy while in another health care facility, but she had not been receiving therapy or restorative services here. The resident was reported to have done pretty well while receiving therapy. Review of the resident's medical record found no indication she was receiving therapy or restorative nursing services to maintain her abilities to perform activities of daily living (ADLs) as independently as possible. Review of the resident's care plan found a goal of: Will walk 300 ft with / without assistance of device / person on level surface and/or carpet. The only intervention listed was: Will refer to the Therapy Plan of Treatment in the medical record for more detail. Review of the Rehabilitation Screen, completed on 12/24/09, found the physical therapist noted the resident was confused and unable to follow commands and nursing assistants (NAs) were walking her without difficulty. It was noted she was not appropriate for training at that time. The occupation therapist (OT) had made a notation on the Rehabilitation Screen, on 12/28/09: Unable to follow commands - Functioning at max capacity. No OT needs at this time. In an interview on 03/05/10 at 2:05 p.m., Employee #9 (the physical therapist) said she had just screened the resident. She had watched the NAs walk the resident from a chair near the nurses' station to the dining room, and the resident had done pretty well. In mid morning on 03/05/10, two (2) NAs (Employees #44 and #38) were asked, in separate interviews, about the resident's ability to walk. Both said the resident was just walked from her bed or chair to the bathroom in her room. They said, sometimes, the resident walked pretty well, and on other days, she did not. Review of the resident's comprehensive admission minimum data set (MDS) assessment, with an assessment reference date of 12/29/09, found she had been assessed as requiring extensive assistance for walking in her room or in the corridor. She was assessed as requiring supervision and setup help for eating. The resident assessment protocol (RAP), a more in-depth assessment of problematic areas, for ADLs was reviewed. A problem of the resident's need for extensive assistance for ADLs and mobility was noted. Referrals were to be made for PT and OT to evaluate as needed, and nursing was to assist with all ADLs and mobility. This additional assessment piece did not explore or address the potential for improvement, or maintenance, of the resident's abilities to ambulate and/or feed herself. The care plan for ADLs did not address ambulation and eating beyond to encourage her to participate in self-care and to Assist her with daily hygiene, grooming, oral care and eating as needed. A goal was established for falls, and the only intervention related to ambulation was to assist her as needed. When asked how the needs of each resident were communicated to the direct caregivers, a form was referenced that had information listed for each resident - the Resident Information Worksheet. Review of the information listed on the Resident Information Worksheet for Resident #21 found she was to have an alarm when she was in her wheelchair, her heels floated, have a chair cushion, be turned and repositioned every two (2) hours, have a specialty mattress, and be on a toileting program. Although other residents were marked in a section on the form for Transfer / ambulation, nothing was marked in this section for Resident #21. There was no program in place to provide, and ensure provision of, restorative nursing services. There was no methodology in place to evaluate the resident's abilities and optimize the potential for improvement, or if not possible, maintenance of current levels of function. In an interview at 2:10 p.m. on 03/04/10, Employee #13 said the facility did not have a restorative nursing program. This was later confirmed by the director of nursing.",2015-10-01
9615,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,315,E,0,1,I2AU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, resident interview, and staff interview, the facility failed to ensure a resident was not catheterized unless the resident's clinical condition demonstrated the catheter was necessary. An indwelling Foley urinary catheter was inserted in a female resident after said she was unable to void, and 150 to 200 cc of urine was obtained upon catheterization. A urine culture and sensitivity (C&S) had been ordered the day before but was never obtained. Three (3) other residents were not evaluated for the potential to regain, or prevent decline in, urinary continence status. Four (4) of twelve (12) current residents on the sample was affected. Resident identifiers: #32, #25, #22, and #16. Facility census: 55. Findings include: a) Resident #32 Review of the medical record revealed this resident had been admitted to the facility from a hospital on [DATE]. At the time of admission, the resident had a Foley catheter. The physician had written an order for [REDACTED]. The assessor had documented: Contributing factors - use of cath upon admission but was DC (discontinued) after 2 days and remains continent of urine thus far. on the resident assessment protocol (RAP) for urinary incontinence and indwelling catheter completed 12/18/09. The physician wrote an order, on 12/18/09, for a urinalysis and urine C&S to be done. This order was not carried out. On 12/19/10 at 10:30 a.m., a nurse noted, #16 Fr (French) foley (sic) catheter inserted with approximately 150 - 200 cc milky thick urine return. Pt (patient) stated she had been trying to void all morning. Cath left in place due to [MEDICAL CONDITION]. There was no indication the resident had been positioned to facilitate voiding prior to being catheterized. The notation was made at 10:30 a.m., with no indication of what the resident meant by all morning or establishing when the resident had last voided. In a notation on 12/22/09, a nurse had noted The resident had been noted to be continent of urine in the RAP. She had not had any noted difficulties voiding after the catheter was removed on 12/09/09, until 12/19/09. A urine C&S had been ordered on [DATE], the day before a catheter was again inserted. She was catheterized on 12/19/09, for urine that was described as milky thick urine. The urine C&S report was not found in the resident's medical record. On 03/04/10, the director of nursing was asked to see if she could locate the report. She reported, on the morning of 03/05/10, the C&S had not been done. Another urine C&S was obtained on 01/21/10. The report noted the resident had: Proteus mirabilis / penneri greater than 100,000 colony forming units per mL and Escherichia coli, identified by automated biochemical system 50,000 - 100,000 colony forming units per mL. No tx (treatment) due to indwelling F/C . had been noted on the C&S report form. There was no evidence the facility was aware the 12/18/09 urine C&S had not been done as ordered prior to surveyor intervention. There was no evidence the resident had been evaluated to determine whether she had [MEDICAL CONDITION] or whether she just had been unable to void due to the thick urine. The urine return was 150 - 200 cc; there was no evidence her fluid intake had been evaluated for the time prior to the catheter being inserted, nor was there evidence efforts had been made regarding how long it had been since the resident had last voided. In an interview in mid-morning, the director of nursing said it was the facility's policy to leave the catheter in when there was over 200 cc of residual. It was discussed that, in this instance, it was not residual. On 03/05/10 at 10:25 a.m., the resident was interviewed. When asked about the catheter, she said it was aggravating. Later in the conversation, she said she had meant it was aggravating for the staff. The resident also said she could tell when the bag was full, because there was pressure. She said she had not had to have one (a catheter) before, that they had put it in while she was in the hospital, and had to put it back after she came to the nursing home. b) Resident #25 The resident was admitted to the facility on [DATE]. His admission minimum data set (MDS) assessment was coded to indicate he had inadequate control of his bladder and had multiple episodes of urinary incontinence daily. The assessment also indicated he had deteriorated in urinary continence status as compared to ninety (90) days ago. The MDS was also coded to indicate the resident had been placed on a scheduled toileting plan. However, no assessment had been performed in an attempt to identify the reason for the decline, or from what type of program the resident might best benefit. No voiding patterning had been conducted to see whether there was a pattern to his episodes of incontinence around which a plan might be established. It was not established whether the resident felt the urge to void. c) Resident #22 This resident was admitted to the facility on [DATE]. In Section H of the resident's admission MDS, with an ARD of 10/07/09, the assessor indicated the resident was incontinent of bladder (multiple daily episodes) in the last fourteen (14) days. This triggered the RAP for urinary incontinence Review of documentation associated with that RAP revealed the facility identified the causal factors for the resident's incontinence; however, there was no evidence the facility explored these factors to demonstrate the rationale for a care plan decision or to establish an individualized plan regarding the resident's incontinence. Review of the resident's current care plan, initiated 10/15/09, revealed no plan to assist the resident in regaining continence. The only intervention for the resident's bladder incontinence was: Check for incontinence frequently and provide incontinent care as needed. There was no care plan relative to bladder retraining or for an individualized toileting program. The resident was incontinent at the time of the survey. d) Resident #16 This resident was admitted to the facility on [DATE]. In Section H of the admission MDS with an ARD date of 08/18/09, the assessor indicated the resident was incontinent of bladder (multiple daily episodes) in the last fourteen (14) days. This should have triggered the RAP for urinary incontinence. Review of the RAP for urinary incontinence revealed it was not completed. There was no evidence the facility identified this error or identified causal factors for the resident's incontinence. Review of the resident's current care plan, initiated on 10/09/09, revealed no plan to assist the resident in regaining continence. The interventions for the resident's bladder incontinence included: Check for incontinence frequently and provide incontinent care as needed, and Reassess as needed for possible removal of catheter and bladder retraining or toileting plan. At the time of the survey, the resident's catheter had been removed. There was no evidence of an assessment for bladder retraining or for an individualized toileting program. The resident was incontinent at the time of the survey.",2015-10-01
9616,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,325,D,0,1,I2AU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to assure one (1) of fourteen (14) sampled residents received a therapeutic diet as ordered. The resident had an order for [REDACTED].#5. Facility census: 55. Findings include: a) Resident #5 Medical record review, on 03/03/10, revealed this resident had a physician's orders [REDACTED]. On 03/03/10, this information was observed posted on a cabinet door in the kitchen. At 11:10 a.m. on 03/03/10, observation in the dietary department revealed Employee #56 was getting a pureed pie ready for service. Upon inquiry, Employee #56 stated he had pureed the pie with milk. During preparation of this resident's meal tray at 12:20 p.m. on 03/03/10, observation revealed the resident's tray card did not indicate a lactose free diet. The pie (which was pureed with milk) was placed on the resident's tray. As a dietary staff member was placing the tray for service, the surveyor intervened, so the resident would not receive the milk product. The dietary personnel serving the meal was unaware the resident was supposed to have lactose free products.",2015-10-01
9617,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,362,F,0,1,I2AU11,"Based on observation, food and equipment temperature measurements, staff interview, and the resident group interview, the facility failed to assure sufficient support personnel to prepare and serve meals at proper temperatures and at appropriate times, and to assure proper sanitary techniques were utilized. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 55. Findings include: a) According to the scheduled meal times provided upon entrance, the last tray at each noon meal is served at 11:40 a.m. daily. Observation revealed the last noon meal tray was not served until 12:20 p.m. on 03/03/10. At 3:00 p.m. on 03/03/10, a resident group interview was held. During the interview, residents unanimously voiced their meals were never served timely. b) During the noon meal observation at 11:05 a.m. on 03/03/10, temperatures were taken of foods which had already been placed on the steam table. Pureed chili was 132 degrees Fahrenheit (F). Upon inquiry, the cook who prepared the chili stated the product had not been reheated after processing. (See citation at F371.) c) On 03/02/10 at 9:15 a.m., a dietary staff member (Employee #30) was observed using the dish machine. Observation revealed the rinse temperature was 198 degrees F. According to the 2005 Food Code, the rinse temperature should not exceed a maximum of 194 degrees F to assure proper cleaning and sanitization. Review of the documentation of the rinse cycle temperatures, for the morning of 03/02/10, revealed Employee #30 had documented the temperature as 198 degrees F. Upon inquiry, Employee #30 stated she had not informed anyone the rinse temperature was too hot. Review of February 2010 dish machine rinse temperature recordings revealed the rinse temperature was recorded at above 194 degrees F on twenty-five (25) of twenty-eight (28)days. (See citation at F371.) d) At 11:10 a.m. on 03/03/10, a dietary staff member (Employee #56) was asked to check the concentration of the sanitizing solution in the pot washing sink. Employee #56 did not know the procedure to perform this task. (See citation at F371.) e) Upon entrance on 03/02/10, an inquiry was made of the administrator (ADM), regarding who currently held the position of dietary manager (DM). Employee #24 was identified as the facility's dietary manager. Upon initial tour of the dietary department at 9:15 a.m. on 03/02/10, a dietary staff member (Employee #39) was asked if the DM was available. Employee #39 stated she thought the DM was planning to come in tomorrow. Inquiry revealed Employee #39 was filling in for the DM, because the DM was on family medical leave. Further inquiry revealed Employee #39 was not a certified dietary manager. The following day, on 03/03/10, the human resource manager was asked to provide evidence of how many hours a week the DM was present in the department. Review of this information revealed the DM had worked a minimum of no (0) hours to a maximum of twenty-six (26) hours in each eighty (80) hour pay period between 08/30/09 and 02/27/10. In seventeen (17) of twenty-three (23) pay periods reviewed, the DM worked less than twenty (20) hours in each eighty (80) hour pay period. This information was confirmed by the DM at 12:00 p.m. on 03/03/10. It was determined the facility failed to employ the services of a qualified dietary manager on a full-time basis to assure the orderly operation of the dietary department. (See citation at F492.) NOTE: THIS IS A REPEAT DEFICIENCY, HAVING PREVIOUSLY BEEN CITED DURING THE LAST ANNUAL SURVEY ON 01/30/09.",2015-10-01
9618,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,363,C,0,1,I2AU11,"Based on menu review, observation, and staff interview, the facility failed to assure menus were followed. The menu plan called for garnishes for chili; however, the garnishes were not served. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 55 Findings include: a) Review of the menu, for the noon meal on 03/03/10, revealed regular chili was supposed to have a cheese and onion garnish, and pureed chili was supposed to have one (1) tablespoon of cheese sauce on top. Observation of the meal revealed there were no onions on the regular chili and no cheese sauce on the pureed chili. An inquiry was made of the cook who prepared the meal, at 1:00 p.m. on 03/03/10. The cook stated she had not noticed these items on the menu. NOTE: THIS IS A REPEAT DEFICIENCY, HAVING PREVIOUSLY BEEN CITED DURING THE LAST ANNUAL SURVEY ON 01/30/09.",2015-10-01
9619,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,364,C,0,1,I2AU11,"Based on observation, the facility failed to assure cornbread was served at the proper temperature. Both regular and pureed cornbread were served cold. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 55. Findings include: a) Observation of the preparation and service of the noon meal, on 03/03/10, revealed neither the regular or pureed cornbread was held by a method to assure the product was hot upon receipt by the residents. The regular cornbread was removed from the oven, after baking, and left for more than thirty (30) minutes uncovered on an unheated stove top. It was then taken to the steam table and placed on top of a lid on the steam table. The cornbread was not held by any method to maintain a hot temperature. The pureed cornbread was observed sitting uncovered on a sink drain from 10:30 a.m. until it was taken to the steam table at 11:25 a.m. It was also placed on top of a lid on the steam table and was not held by any method to maintain a hot temperature.",2015-10-01
9620,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,371,F,0,1,I2AU11,"Based on observations and 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: 55. Findings include: a) On 03/02/10 at 9:15 a.m., a dietary staff member (Employee #30) was observed using the dish machine. Observation revealed the rinse temperature was 198 degrees Fahrenheit (F). According to the 2005 Food Code, the rinse temperature should not exceed a maximum of 194 degrees F to assure proper cleaning and sanitization. Review of the documentation of the rinse cycle temperatures, for the morning of 03/02/10, revealed Employee #30 had documented the temperature as 198 degrees F. Upon inquiry, Employee #30 stated she had not informed anyone the rinse temperature was too hot. Review of February 2010 dish machine rinse temperature recordings revealed the rinse temperature was recorded at above 194 degrees F on twenty-five (25) of twenty-eight (28)days. b) At 9:15 a.m. on 03/02/10, observation of coffee cups revealed they contained a dark substance which could be scraped off with a fingernail. c) The exhaust vents in the dish room contained a large coating of dusty debris when observed at 9:15 a.m. on 03/03/10. d) On 03/03/10 at 10:30 a.m., an uncovered product was observed on the drain board of the vegetable sink. The sink contained a variety of vegetable peelings. The product remained on the drain board, uncovered, until a cook retrieved it at 11:25 a.m. and placed it on a lid on the steam table. Inquiry revealed this product was the pureed cornbread prepared for the residents for that meal. e) During the noon meal observation at 11:05 a.m. on 03/03/10, temperatures were taken of foods which had already been placed on the steam table. Pureed chili was 132 degrees Fahrenheit (F). Upon inquiry, the cook who prepared the chili stated the product had not been reheated after processing. f) At 11:10 a.m. on 03/03/10, a dietary staff member (Employee #56) was asked to check the concentration of the sanitizing solution in the pot washing sink. Employee #56 did not know the procedure to perform this task. g) Milk and other dairy products were held on a tray on a shelf at the serving line on 03/03/10, during the service of the noon meal. No means for maintaining cold temperatures was utilized. At 11:45 a.m., a dietary employee was asked to take the temperature of one (1) of the milk products. It was 45 degrees F. NOTE: THIS IS A REPEAT DEFICIENCY, HAVING PREVIOUSLY BEEN CITED DURING THE LAST ANNUAL SURVEY ON 01/30/09.",2015-10-01
9621,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,406,D,0,1,I2AU11,"Based on review of medical records and staff interviews, the facility failed to provide speech-language pathology services for one (1) of twelve (12) current residents on the sample. The speech-language pathologist (SLP) had identified the resident might be a candidate for services once a full-time SLP was hired. Resident identifier: #11. Facility census: 55. Findings include: a) Resident #11 Review of the resident's medical record found an entry by the SLP (Employee #21), dated 01/05/10. The therapist wrote, SLP spoke with Resident's son regarding request for reeval(uation) for swallow eval & diet upgrade. SLP educated son that now SLP did (symbol for not) feel comfortable up grading diet at this time. Resident has diagnosis (sic) of Paralysis Agitans, muscle weakness and dementia. The facility is also in the process of hiring a full-time SLP, at that time I (current PRN (as needed) SLP) feel that a new eval and therapy may be appropriate (symbol for secondary) to the ability to have SLP warrant tx (treatment) daily to ensure safe management of diet to (down arrow for decreased) risk of aspiration, etc. Son is aware of plan and in agreeance (sic). SLP to rescreen once fulltime (sic) therapist is hired. On 03/05/10 at 9:30 a.m., the social worker was asked who the SLP was. She named Employee #21. This individual was hired 09/21/09 and was noted to be working on an as needed basis. According to the information provided by the facility on the CMS-671, the SLP had been in the facility eight (8) hours in the two (2) weeks prior to the survey. Review of the CMS-802, completed by the facility, found twenty-five (25) of the fifty-five (55) current residents had been identified as having swallowing problems. This number would include any residents for whom interventions had been successful in resolving their swallowing problems; however, it is also indicative of the number of residents who had problems related to swallowing and for whom the services of an SLP might be required.",2015-10-01
9622,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,441,F,0,1,I2AU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, review of Centers for Disease Control and Prevention (CDC) guidelines, and review of product ingredients, the facility failed to develop and implement an infection control program to prevent and control, to the extent possible, the spread of infections within the facility. This practice had the potential to affect all facility residents. Resident identifiers: #30 and #5. Facility census: 55. Findings include: a) Medical record review, on 03/03/10, revealed the possibility that a resident had Clostridium difficile (C. diff). It was later determined the resident did not have [DIAGNOSES REDACTED]. The facility isolated the resident but used a sanitizing agent which was not effective against [DIAGNOSES REDACTED] spores. According to CDC guidelines, the only product which effectively kills these spores is sodium hypochlorite (bleach). Review of the ingredients contained in the facility's sanitizing product revealed it did not contain bleach, nor did it indicate it was effective for killing the infectious [DIAGNOSES REDACTED] spores. On 03/04/10 at 10:00 a.m., this was discussed with the housekeeping (HK) supervisor, who stated he would have to contact the company to verify the finding. At 12:00 p.m. on 03/04/10, the HK supervisor acknowledged the product the facility was using was not effective for the eradication of [DIAGNOSES REDACTED]. b) Resident #30 Employee #17 was observed administering medications to this resident on 03/03/10, during morning medication pass. After pouring the resident's medications, the nurse entered the room and raised the head of the resident's bed. She returned to the medication cart and went to the nurses' station to clarify an order. After the medication issue was clarified, she prepared the last medication and gave it to the resident. She then lowered the head of the bed and returned to the medication cart. The nurse began to prepare medications for the next resident without having washed her hands. c) Resident #5 This resident was on contact precautions due to having [DIAGNOSES REDACTED]. Throughout the survey, observation found personal protective equipment (PPE) maintained inside of the resident's room. The Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007 issued by the CDC includes, Healthcare personnel caring for patients on Contact Precautions should wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE before room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE, [DIAGNOSES REDACTED]icile, noroviruses and other intestinal tract pathogens; RSV).",2015-10-01
9623,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,492,F,0,1,I2AU11,"Based on staff interview and review of facility payroll records, the facility failed to assure a qualified dietary manager was employed on a full time basis when no dietitian was available to assume the duties for the orderly operation of the dietary department. This requirement is in accordance with 64CSR13-8.15.a.2 of the West Virginia Nursing Home Licensure rule. This deficient practice had the potential to affect all residents who received an oral diet. Facility census: 55. Findings include: a) Upon entrance on 03/02/10, an inquiry was made of the administrator (ADM), regarding who currently held the position of dietary manager (DM). Employee #24 was identified as the facility's dietary manager. Upon initial tour of the dietary department at 9:15 a.m. on 03/02/10, a dietary staff member (Employee #39) was asked if the DM was available. Employee #39 stated she thought the DM was planning to come in tomorrow. Inquiry revealed Employee #39 was filling in for the DM, because the DM was on family medical leave. Further inquiry revealed Employee #39 was not a certified dietary manager. The following day, on 03/03/10, the human resource manager was asked to provide evidence of how many hours a week the DM was present in the department. Review of this information revealed the DM had worked a minimum of no (0) hours to a maximum of twenty-six (26) hours in each eighty (80) hour pay period between 08/30/09 and 02/27/10. In seventeen (17) of twenty-three (23) pay periods reviewed, the DM worked less than twenty (20) hours in each eighty (80) hour pay period. This information was confirmed by the DM at 12:00 p.m. on 03/03/10. It was determined the facility failed to employ the services of a qualified dietary manager on a full-time basis to assure the orderly operation of the dietary department. NOTE: THIS IS A REPEAT DEFICIENCY, HAVING PREVIOUSLY BEEN CITED DURING THE LAST ANNUAL SURVEY ON 01/30/09.",2015-10-01
9624,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,502,D,0,1,I2AU11,"Based on review of medical records and staff interview, the facility failed to ensure laboratory services were obtained when ordered by the physician. A urine culture and sensitivity was ordered, but not done. Resident identifier: #32. Facility census: 55. Findings include: a) Resident #32 The physician had ordered a urinalysis and urine culture and sensitivity on 12/18/09. The results could not be located in the resident's medical record. On 03/04/10 at 3:30 p.m., the director of nurse was asked to see if she could find the results of the lab work. On 03/05/10 at 9:20 a.m., the DON reported the results could not be found; it had not been done.",2015-10-01
9625,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,514,D,0,1,I2AU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to accurately and completely document the records for one (1) of fourteen (14) residents. One (1) resident had an order for [REDACTED].#45. Facility census: 55. Findings include: a) Resident # 45 Medical record review, on 03/02/10, revealed an order to check the resident's stool for [MEDICAL CONDITION] (C. diff). Further review revealed no evidence of diarrhea or any other indication the resident had symptoms of a [DIAGNOSES REDACTED] infection. This information was brought to the attention of the director of nursing (DON), who said she would contact the nurse who asked for the test. On 03/05/10 at 12:30 p.m., the DON reported she was unable to find documentation of a need for the testing for [DIAGNOSES REDACTED].",2015-10-01
9999,"WORTHINGTON NURSING AND REHABILITATION CENTER, LLC",515047,2675 36TH STREET,PARKERSBURG,WV,26104,2010-03-11,315,E,0,1,XVZI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, and staff interview, the facility failed to ensure precautionary measures were taken and causative factors were investigated when four (4) of eighteen (18) sampled residents with urinary tract infections (UTIs) cultured positive for Escherichia coli (E. coli), a bacterium associated with fecal contamination due to poor incontinence care and aseptic practices by staff. Resident #78 was incontinent of bowel and bladder and required extensive physical assistance with transfer, toilet use, and personal hygiene. This resident had a UTI on 02/27/10, and a laboratory report showed the infectious organism to be E. coli. This resident required treatment with [MEDICATION NAME] IM (intramuscular injection) every day for three (3) days. Resident #55 was incontinent of bowel and bladder and required extensive physical assistance with transfer, toilet use, and personal hygiene. This resident had a UTI on 01/04/10, and a laboratory report showed the infectious organism to be E. coli. Residents #70 and #81, who were also incontinent of bowel and bladder and required staff assistance with toileting, developed UTIs with E. coli cultured. Residents #70 and #81 also required antibiotic therapy. Residents #78, #55, #70, and #81. Facility census: 101. Findings include: a) Resident #78 Record review revealed this [AGE] year old female had [DIAGNOSES REDACTED]. Medical record review, on 03/10/10, revealed a physician's orders [REDACTED]. Review of lab reports revealed the antibiotic therapy was to treat a UTI, and the infectious organism was E. coli, a bacterium associated with fecal contamination due to poor incontinence care and aseptic practices by staff. Interview with the director of nursing (DON - Employee #42), on 03/10/10 at 11:30 a.m., confirmed the resident had a UTI with E. coli for which she received [MEDICATION NAME] injections. b) Resident #55 Record review revealed this [AGE] year old female, with [DIAGNOSES REDACTED]. Medical record review, on 03/09/10, revealed this resident had been treated with antibiotic therapy on 01/04/10 for a UTI. Review of lab reports, dated 01/04/10, revealed the infectious organism cultured in the resident's urine was E. coli, a bacterium associated with fecal contamination due to poor incontinence care and aseptic practices by staff. Review of the resident's current comprehensive care plan found the care plan failed to adequately address the problem of incontinence of bowel and bladder, with interventions developed that described the care and services for timely incontinence care and the prevention of UTIs. During an interview with the MDS nurse responsible for this resident's care plan (Employee # 13) on 03/11/10 at 12:45 p.m., Employee #13 confirmed the care plan for incontinence care and prevention of UTIs was not adequate. (See also citation at F279.) Interview with the DON, on 03/10/10, confirmed the resident had an E. coli infection and required antibiotic therapy. c) Resident #70 Record review revealed this [AGE] year old female resident, whose [DIAGNOSES REDACTED]. The physician ordered the administration of an antibiotic ([MEDICATION NAME] 500 mg) for ten (10) days beginning on 02/07/10 due to UTI. According to the assistant director of nursing (ADON) in the late afternoon of 03/10/10, when the laboratory results came back for a culture and sensitivity (C&S) and urinalysis, the infectious organism found in the resident's urine specimen was E. coli. The resident's current care plan, dated 01/25/10, revealed the interdisciplinary care team was aware of the resident having a history of recurrent UTIs; however, the interventions listed in the care plan focused on monitoring for symptoms of a UTI, and there were no interventions focused on preventing recurrence of these infections. d) Resident #81 Record review revealed this [AGE] year old female, whose [DIAGNOSES REDACTED]. She was also totally incontinent of bowel and bladder. The resident had experienced a UTI in December 2009, for which the infectious organism was identified as E. coli. In February 2010, the physician ordered a straight catheter urinalysis with culture and sensitivity; the results of the laboratory test were received and an antibiotic ([MEDICATION NAME]) was ordered for ten (10) days. Per the ADON on 03/10/10, the infectious organism was, again, E. coli. Per the resident's current care plan (dated 12/04/09 through 06/04/10), the interdisciplinary care team noted the resident had a history of [REDACTED]. .",2015-07-01
10000,"WORTHINGTON NURSING AND REHABILITATION CENTER, LLC",515047,2675 36TH STREET,PARKERSBURG,WV,26104,2010-03-11,371,F,0,1,XVZI11,". Based on observation and staff interview, the facility failed to ensure store, prepare, distribute, and/or serve food under sanitary conditions. Open containers of milk in the kitchen and in one(1) of the nutrition pantries on the nursing unit were not labeled with dates when opened, and a skillet ready for use to prepare food was not easily cleanable. These issues have the potential to affect all residents who consume foods by oral means, as all food is distributed from this central location. Facility census: 101. Findings include: a) During the initial tour of the dietary department on 03/08/10 at 1:45 p.m., observation found: 1. A large skillet was available for use by the dietary staff which contained a large amount of black build-up on the pan. This did not make the skillet easily cleanable and, therefore, it was not sanitary to use when cooking. 2. A container of white milk was found in the reach-in refrigerator without a date to indicate when it had been opened. Items are to be marked when opened, so the staff can monitor how long the item has been opened and if it is still safe for consumption. 3. The dietary manager was present for these two (2) observations, and they were brought to her attention at the time. b) During a tour of the nutrition pantries on the nursing units on 03/11/10 at 9:03 a.m., observation found a container of chocolate milk in the refrigerator on the West wing without the date to indicate when it was opened. This was brought to the attention of the assistant director of nursing at the time. .",2015-07-01
10001,"WORTHINGTON NURSING AND REHABILITATION CENTER, LLC",515047,2675 36TH STREET,PARKERSBURG,WV,26104,2010-03-11,253,E,0,1,XVZI11,". Based on observation and staff interview, facility staff did not maintain sanitary conditions in the East wing central shower room and in an individual resident toilet area. This was evident for one (1) of two (2) shower areas and for one (1) of fourteen (14) toilet areas serving sampled resident rooms. Facility census: 101 Findings include: a) Observations of the resident environment, on the morning of 03/11/10, discovered a shower chair in the East wing central shower room that was visibly soiled with feces. This was discussed with the director of nursing (DON) shortly after the observation. b) During the same observation period, individual resident rooms were inspected at which time a soiled riser seat was noted in the rest room of Room #25 located on the East wing. This was brought to the DON's attention shortly after oon on 03/11/10. .",2015-07-01
10002,"WORTHINGTON NURSING AND REHABILITATION CENTER, LLC",515047,2675 36TH STREET,PARKERSBURG,WV,26104,2010-03-11,441,D,0,1,XVZI11,". Based on observation, staff interview, and policy review, the facility failed to ensure a sanitary environment during a dressing change to help prevent the development and transmission of disease and infection. This was evident for one (1) of one (1) dressing change observations. Resident identifier: #77. Facility census: 101. Findings include: a) Resident #77 Observation of a dressing change for Resident #77, on 03/09/10 at 11:50 a.m., revealed the treatment nurse (Employee #112), when dropping the sterile 4 x 4 sponges onto a clean surface, inadvertently touched the corner edge of one (1) sponge against the plastic bin which held supplies. Although this sponge was used as a covering and not as packing and did not directly touch the wound, a clean surface should be provided for all dressing materials while preparing to perform a dressing change. Observation during the same dressing change revealed the nurse aide (Employee #6) used a gloved hand, on two (2) occasions, to wipe body fluids from the resident, then proceeded to use the same gloved hand to open the resident's bedside stand and obtain supplies (wipes). A finger of the same gloved hand was also noted to close a box of wipes before opening the stand to return it. These findings were reported to the treatment nurse, who said she was unaware the corner of a sponge had touched anything but her prepared surface. She said she would speak to Employee #6 about touching clean surfaces with unclean gloves. Interview with the infection control nurse and director of nursing revealed evidence of inservicing on proper handwashing and changing of gloves in the fall of 2009 during an annual inservice on those topics, but they would follow-up on this with spot checks and individual inservice as needed.",2015-07-01
10003,"WORTHINGTON NURSING AND REHABILITATION CENTER, LLC",515047,2675 36TH STREET,PARKERSBURG,WV,26104,2010-03-11,279,E,0,1,XVZI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of the facility's incident/accident reports, and staff interview, the facility failed to develop a comprehensive care plan that described the services to be furnished to four (4) of eighteen (18) sampled residents, to prevent elopement from the facility, address incontinence, and prevent urinary tract infections (UTIs). Resident #98 eloped from the facility on 12/27/09, at 9:10 a.m., while nursing staff was busy rendering morning care in resident rooms; staff did not hear the Wanderguard alarm. Review of the resident's comprehensive care plan (dated 02/15/10) found the problem of elopement was not adequately addressed to include specific interventions to be furnished during periods in the mornings and evening when nursing staff would be busy in resident rooms and unable to hear the Wanderguard alarms. Residents #55, #70, and #81 were incontinent of bowel and bladder and required staff assistance for transfers, toilet use, and personal hygiene. These residents developed UTIs, and the infectious organism cultured for each was Escherichia coli (E. coli), a bacterium associated with fecal contamination due to poor incontinence care and aseptic practices by staff. The residents' comprehensive care plans failed to describe the care and services to be provided for the prevention of recurrent UTIs. Facility census: 101. Findings include: a) Resident #98 Observation, during the initial tour of the facility on 03/08/10 at 1:55 p.m., found this resident, who was in a wheelchair with a lap tray, had traveled to the back door of the West wing (which opened to the parking lot), opened the door, and was attempting to get out. The Wanderguard alarm was ringing, and staff ran to assist the resident back in the door. Further observations of this resident, on 03/08/10, found the resident engaging in exit-seeking behavior which required frequent redirection by staff. Review of facility's incident / accident reports, on 03/09/10, disclosed this resident had eloped from the facility on 12/27/09 at 9:10 a.m. and was found outside in the parking lot heading toward 36th Street by a facility employee. Further review of the incident / accident report revealed that, when the employee brought the resident back into the facility, the alarm was sounding. The facility's investigation into the elopement discovered the nursing staff on the West wing was busy rendering morning care in resident rooms and did not hear the alarm sounding when the resident approached the Wanderguard system and exited the door. Review of the resident's comprehensive care plan addressing elopement (dated 02/15/10 to 05/19/10) found the care plan did not include interventions (such as planned activities or assignment of a staff member to be responsible for this resident) during periods of time when nursing staff would ordinarily be busy inside resident rooms and unable to either directly observe the resident for exit-seeking behaviors or hear the Wanderguard alarm sounding. In an interview with the minimum data set (MDS) nurse (Employee #129), who was responsible for developing this resident's care plan, Employee #129 agreed the care plan failed to address critical elements of supervision for this resident in order to prevent another elopement from the facility. b) Resident #55 Record review revealed this [AGE] year old female, with [DIAGNOSES REDACTED]. Medical record review, on 03/09/10, revealed this resident had been treated with antibiotic therapy on 01/04/10 for a UTI. Review of lab reports, dated 01/04/10, revealed the infectious organism cultured in the resident's urine was E. coli, a bacterium associated with fecal contamination due to poor incontinence care and aseptic practices by staff. Review of the resident's current comprehensive care plan found the care plan failed to adequately address the problem of incontinence of bowel and bladder, with interventions developed that described the care and services for timely incontinence care and the prevention of UTIs. During an interview with the MDS nurse responsible for this resident's care plan (Employee # 13) on 03/11/10 at 12:45 p.m., Employee #13 confirmed the care plan for the prevention of UTIs was not adequate. c) Resident #70 Record review revealed this [AGE] year old female resident, whose [DIAGNOSES REDACTED]. The physician ordered the administration of an antibiotic ([MEDICATION NAME] 500 mg) for ten (10) days beginning on 02/07/10 due to UTI. According to the assistant director of nursing (ADON) in the late afternoon of 03/10/10, when the laboratory results came back for a culture and sensitivity (C&S) and urinalysis, the infectious organism found in the resident's urine specimen was E. coli. The resident's current care plan, dated 01/25/10, revealed the interdisciplinary care team was aware of the resident having a history of recurrent UTIs; however, the interventions listed in the care plan focused on monitoring for symptoms of a UTI, and there were no interventions focused on preventing recurrence of these infections. d) Resident #81 Record review revealed this [AGE] year old female, whose [DIAGNOSES REDACTED]. She was also totally incontinent of bowel and bladder. The resident had experienced a UTI in December 2009, for which the infectious organism was identified as E. coli. In February 2010, the physician ordered a straight catheter urinalysis with culture and sensitivity; the results of the laboratory test were received and an antibiotic ([MEDICATION NAME]) was ordered for ten (10) days. Per the ADON on 03/10/10, the infectious organism was, again, E. coli. Per the resident's current care plan (dated 12/04/09 through 06/04/10), the interdisciplinary care team noted the resident had a history of [REDACTED]. .",2015-07-01
10004,"WORTHINGTON NURSING AND REHABILITATION CENTER, LLC",515047,2675 36TH STREET,PARKERSBURG,WV,26104,2010-03-11,329,D,0,1,XVZI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the drug regimen for one (1) of eighteen (18) sampled residents was free of unnecessary drugs. Resident #78 was receiving [MEDICATION NAME] for an excessive duration, in the presence of adverse consequences, and without adequate monitoring. Medical record review revealed a gradual dose reduction (GDR), as required for drugs in this category, had not been attempted at least twice within one (1) year, in an effort to discontinue its use. Additionally, there was no evidence of monitoring and/or documentation to support the benefits of the medication outweigh the risks associated with its use either by the attending physician or the psychiatric consult. Facility census: 101. Findings include: a) Resident #78 Medical record review, on 03/10/10, disclosed this [AGE] year old female resident had medical [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. According to OBRA's ""Unnecessary Drugs in the Elderly"", [MEDICATION NAME] is a sedative drug with strong [MEDICATION NAME] properties with side effects of dehydration, causing dry mouth, confusion, decreased urine output, dry skin, poor skin turgor and constipation, all of which this resident already has and is being monitored for, in addition to problems of impaired nutrition, weight loss, and dehydration. Review of the resident's current comprehensive care plan found the [MEDICATION NAME] was given for behaviors of yelling, screaming, crying, tearfulness, increased anxiety, refusal of necessary hygiene, and refusal to take medications at times. Review of physician's progress notes and a review of the progress note from the psychiatric consult, dated 01/06/10, found no documentation to support the benefits of the medication outweigh the risks associated with its use either by the attending physician or the psychiatric Review of the pharmacist's recommendations to the physician revealed the pharmacist had recommended a GDR of the [MEDICATION NAME] on 09/08/09, and no response by the physician was found documented. During an interview with the director of nursing (DON - Employee #42), on 03/10/10, at 11:30 a.m., information was requested regarding evaluation of Resident #78's [MEDICATION NAME] use. At this time, the DON presented the psychiatric consult note dated 01/06/10, which contained no evaluation of the continuing need for long term use of the [MEDICATION NAME]. .",2015-07-01
10005,"WORTHINGTON NURSING AND REHABILITATION CENTER, LLC",515047,2675 36TH STREET,PARKERSBURG,WV,26104,2010-03-11,328,D,0,1,XVZI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and record review, the facility failed to assure all residents received respiratory treatment and care as ordered by the physician. This was evident for three (3) residents in the dining room who were observed using portable oxygen while eating their meals, each of whom was wearing a nasal cannula connected to an empty oxygen tank. This had the potential to negatively affect the health and well-being of one (10 of eighteen (18) sampled residents and two (2) of six (6) randomly observed residents in the dining room. Resident identifiers: #51, #75, and #27. Facility census: 101. Findings include: a) Resident #51 Observation of Resident #51, on 03/09/10 at 12:30 p.m., found her sitting in the dining room eating lunch while wearing a nasal cannula connected to a portable oxygen tank. Observation of the oxygen tank revealed the needle was pointing all the way on the left in the red portion denoting an empty tank. This finding was reported to the administrator moments later (as she was helping to pass trays) and then relayed to a nurse (Employee #109) who said she would take care of it right away, which she did. Record review revealed physician's orders [REDACTED]. Documentation on the vital sign flow sheet indicated the most recent oxygen saturation level (O2 sat) was at 98% (with oxygen applied) on 03/08/10, but there were blank spaces where O2 sats should have been recorded (but were not) on 03/09/10 and 03/10/10. Review of the nursing notes, from 03/07/10 through 03/11/10, document the resident having used oxygen each day. During an interview with Resident #51 on 03/10/10 at 3:15 p.m., she stated she wears oxygen continuously around the clock each day, removing it only for showers; at bed-time, she wears a Bi-PAP. b) Resident #75 Observation of Resident #75, on 03/09/10 at 12:30 p.m., found her sitting in the dining room eating lunch while wearing a nasal cannula connected to a portable oxygen tank. Observation of the oxygen tank revealed the needle pointing all the way on the left in the red portion denoting an empty tank. This finding was reported to the administrator moments later and then relayed to Employee #109, who said she would take care of it right away, which she did. Record review revealed physician's orders [REDACTED]. Review of the treatment sheet revealed an order, dated 02/28/10, for oxygen at 2 liters per minute via nasal cannula for O2 sats at 78%. Further review revealed documentation on the treatment sheet of oxygen use every shift on 03/01/10, 03/03/10, 03/04/10, 03/05/10, 03/06/10, 03/07/10, 03/08/10, 03/09/10, and on 03/10/10 for the night and day shift when this sheet was copied. During an interview with Resident #75 on 03/10/10 at 3:20 p.m., she stated she uses oxygen continuously around the clock each day when she is in her room watching television, in activities or dining, and when asleep. She said she removes it only for showers. c) Resident #27 Observation of Resident #27, on 03/09/10 at 12:30 p.m., found her sitting in the dining room eating lunch while wearing a nasal cannula connected to a portable oxygen tank. Observation of the oxygen tank revealed the needle pointing all the way on the left in the red portion denoting an empty tank. This finding was reported to the administrator moments and then relayed to Employee #109 who said she would take care of it right away, which she did. Record review revealed a physician's orders [REDACTED]. [DIAGNOSES REDACTED]. Further record review revealed a treatment sheet for March 2010 with oxygen at 2 liters per minute per nasal canula, and nursing documentation, from 03/01/10 through 03/10/10, with every shift initialed for oxygen use except one (1). During interview with Resident #27's daughter on 03/11/10 at 9:30 a.m., she stated this resident wears oxygen continuously around the clock, removing it only for showers. Due to the resident sleeping at this time, an interview with her was not obtained. Interview with the nurse (Employee #15), on 03/11/10 at 9:50 a.m., revealed this resident wears oxygen all the time. .",2015-07-01
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
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
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
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
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
9400,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,156,B,0,1,85AT11,"Based on record review and staff interview, the facility failed to assure one (1) of one (1) applicable resident / responsible party was informed of the right to request a demand bill when the resident's Medicare-covered services were discontinued by the facility. This practice had the potential to affect any resident who was discontinued from Medicare-covered skilled services. Resident identifier: #60. Facility census: 97. Findings include: a) Resident #60 On 04/07/10 at 3:30 p.m., a review was conducted, with the facility's business office manager, of residents whose Medicare-covered skilled services had been discontinued by the facility. Three (3) of four (4) residents reviewed had met their rehabilitation potential and were discharged home. One (1) resident (Resident #60) was discontinued from Medicare-covered services but remained in the facility. He had not exhausted his allowable one hundred (100) Medicare days, but facility staff believed he had met his rehabilitation potential. Because of this, he should have been offered the opportunity to request a demand bill. Review of the notice provided to the resident revealed the form did not contain an option for the resident / responsible party to request a demand bill. There was a space to indicate no regarding submission of a demand bill, but no space to indicate yes requesting the facility to submit a demand bill. In an interview conducted with the social worker (Employee #103) at 4:00 p.m. on 04/07/10, Employee #103 stated she had no idea how this situation had happened but confirmed the form did not contain the required information to allow a resident / responsible party to request the facility submit a demand bill in the resident's behalf.",2015-11-01
9401,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,272,E,0,1,85AT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, observation, and staff interview, the facility failed to periodic pain assessments for one (1) of thirty-seven (37) Stage II sample residents, and failed to complete accurate assessments for three (3) of thirty-seven (37) Stage II sample residents, all of whom were erroneously coded as being on planned weight change programs. Resident identifiers: #55, #160, #111, and #94. Facility census: 97. Findings include: a) Resident #55 In an interview conducted at 3:00 p.m. on 04/06/10, Resident #55 stated he had pain in his left leg and that it often kept him awake at night. At that time, the resident was observed rubbing his left thigh. The resident's medical record, when reviewed on 04/07/10, contained a current physician's orders [REDACTED]. Based on this order, facility staff should have been aware of the possibility of leg pain and should have provided ongoing assessments for this resident's specific pain. Review of the care plan, at the same time, revealed no care plan or other mention of leg pain. In an interview at 10:45 a.m. on 04/07/10, a registered nurse (RN - Employee #136) revealed she had no knowledge of the resident experiencing left leg pain. Employee #136 reviewed the resident's pain scores (pain assessments) for April 2010 and reported there was no documentation of pain thus far in April. She confirmed that the pain score record did not specifically indicate assessment of left leg pain. Employee #136 then visited the resident in his room. At 11:00 a.m. on 04/07/10, the RN reported the resident stated to her that he has left leg pain at night and that the leg pain kept him awake at night. The resident's care plan was again reviewed, this time with Employee #136. At 5:30 p.m. on 04/07/10, Employee #136 confirmed the facility was not aware the resident was having pain and confirmed that ongoing assessments for left leg pain had not been occurring for this resident. Employee #136 stated she would assess the resident and implement appropriate interventions. The following morning, another interview was conducted with the resident, at 9:00 a.m. on 04/08/10. He stated he had been given pain medication for his leg pain last night and that it had really helped. He stated, I slept like a log. b) Residents #160, #111, and #94 1. Resident #160 Medical record review, on 04/05/10, revealed an inaccuracy in information documented on the Resident #160's most recent minimum data set (MDS) assessment. In Section K of the MDS with an assessment reference date (ARD) of 03/10/10, the assessor recorded the resident was on a planned weight change program in the last seven (7) days. Review of the registered dietitian (RD) progress notes, dated 02/24/10, identified this resident's current weight was 156#, which was within the ideal body weight range for the resident's height (150# to 170#). There was no evidence the resident required a planned weight change program. 2. Resident #111 A significant change in status MDS, with an ARD of 10/03/09, revealed the resident had no significant weight change and was not on a planned weight change program. A significant change in status MDS, with an ARD of 11/25/09, indicated the resident had a significant weight loss but was not on a planned weight change program. A Medicare 60-day / readmission MDS, with an ARD of 01/08/10, indicated the resident experienced another significant weight loss and was now on a planned weight change program. A quarterly MDS, with an ARD of 02/15/10, indicated no significant weight change had occurred and the resident was not on a planned weight change program. A review of the care plan for Resident #111 revealed that, on 11/10/09, the interdisciplinary care team identified a problem of weight loss due to a history of dysphagia with nursing interventions to encourage / assist and provide extra nourishment. This care plan was reviewed on 02/19/10, but there was no mention of the resident being on a planned weight change program, and there were no changes to the care plan in response to the assessor encoding the 01/08/10 MDS to indicate he was on a planned weight change program. A review of the RD's assessment revealed no planned weight change program for this resident. During an interview with Employee #8 at 9:00 a.m. on 04/07/10, she stated there were no facility policies or procedures for a planned weight change program and no criteria for indicating this on the MDS. Although she verified the 01/08/10 MDS indicated the resident was on such a program, she also verified there were no corresponding care plan changes or physician's orders [REDACTED]. 3. Resident #94 A review of the admission MDS, with an ARD of 12/18/09, revealed the resident was on a planned weight change program although she had not experienced a significant weight loss or gain. The quarterly MDS, with an ARD of 03/08/10, indicated that she was no longer on a planned weight change program, although she now had a Stage II pressure ulcer. The resident's current care plan did include interventions for meeting nutritional needs, but there were no differences in the care plan before or after the MDS said the resident was on a planned weight change program. There was no evidence in the record to reflect the RD had developed a planned weight change program, nor were there any physician's orders [REDACTED]. During an interview with Employee #8 at 9:00 a.m. on 04/07/10, she stated there were no facility policies or procedures for a planned weight change program and no criteria for indicating this on the MDS. She stated she did not understand that there needed to be written guidelines. 4. According to The RAI Version 2.0 User Manual, page 3-154 states: h. On Planned Weight Change Program - Resident is receiving a program of which the documented purpose and goal are to facilitate weight gain or loss (e.g., double portions; high calorie supplements; reduced calories; 10 grams fat). There was no evidence to reflect Residents #160, #111, and #94 were actually on a planned weight change program (as defined by the RAI User Manual) during the assessment reference periods noted above.",2015-11-01
9402,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,279,E,0,1,85AT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, observation, and staff interview, the facility's interdisciplinary team (IDT) failed to develop care plans for four (4) of thirty-seven (37) Stage II sample residents, which contained information necessary to provide appropriate care and services to assist each resident in attaining or maintaining his/her highest level of functioning and/or well being. Care plans were not developed for pain, weight loss, or activities, based on the assessed medical, nursing, or psychosocial needs for these four (4) residents. Resident identifiers: #55, #100, #158, and #76. Facility census: 97. Findings include: a) Resident #55 In an interview conducted at 3:00 p.m. on 04/06/10, Resident #55 stated he had pain in his left leg and that it often kept him awake at night. At that time, the resident was observed rubbing his left thigh. The resident's medical record, when reviewed on 04/07/10, contained a current physician's orders [REDACTED]. Based on this order, facility staff should have been aware of the possibility of leg pain and should have provided ongoing assessments for this resident's specific pain. Review of the care plan, at the same time, revealed no care plan or other mention of leg pain. In an interview at 10:45 a.m. on 04/07/10, a registered nurse (RN - Employee #136) revealed she had no knowledge of the resident experiencing left leg pain. Employee #136 reviewed the resident's pain scores (pain assessments) for April 2010 and reported there was no documentation of pain thus far in April. She confirmed that the pain score record did not specifically indicate assessment of left leg pain. Employee #136 then visited the resident in his room. At 11:00 a.m. on 04/07/10, the RN reported the resident stated to her that he has left leg pain at night and that the leg pain kept him awake at night. The resident's care plan was again reviewed, this time with Employee #136. At 5:30 p.m. on 04/07/10, Employee #136 confirmed the facility was not aware the resident was having pain and confirmed that ongoing assessments for left leg pain had not been occurring for this resident. Employee #136 stated she would assess the resident and implement appropriate interventions. The following morning, another interview was conducted with the resident, at 9:00 a.m. on 04/08/10. He stated he had been given pain medication for his leg pain last night and that it had really helped. He stated, I slept like a log. b) Resident #100 Medical record review, on 04/05/10, revealed a nutritional status resident assessment protocol (RAP), dated 03/24/10, which triggered for leaving twenty-five percent (25%) or more of food uneaten and for being on a therapeutic diet. Goals discussed at that time included the need to slow / minimize weight loss and minimize risk factors. Review of the resident's comprehensive plan of care revealed that, once the IDT identified her potential for weight loss, they failed to develop an individualized plan of care to attain these goals. A dietary progress note, dated 03/26/10, identified she lost 6# in one (1) month, which was a four percent (4%) weight loss and three percent (3%) since admission. She was on a cardiac diet, her meal intake was 25-50 percent, and the registered dietitian (RD) recommended the nutritional supplement Ensure 4 ounces two (2) times a day to prevent further weight loss, although the order for this was not obtained until 04/01/10. A care plan note documented that a care conference was held on 03/31/10. In this meeting, the resident complained of not liking the food. She discussed with the dietary representative her current diet order and what changes could be made to improve her intake. Review of the care plan, located in binder at the nurse station, found no revisions had been made to her care plan after this conference occurred. On 04/06/10 at 3:23 p.m., the assessment coordinator (Employee #105), when interviewed, reviewed Resident #100's care plan in the computer system and acknowledged that no plan was developed to address the resident's altered nutritional status. On 04/05/10 at 3:34 p.m., the dietary manager (Employee #8), when interviewed, reported she was aware of the care plan meeting and, since then, they had started to place gravy on the foods in order to meet her needs. c) Resident #158 During Stage I of the survey, from 03/31/10 through 04/02/10, this resident was not observed attending / participating in facility activities, either in his room or at other sites within the facility. The resident's medical record, when reviewed on 04/07/10, disclosed the initial activity / recreation evaluation had been completed for this resident on 01/04/10, shortly after admission. The evaluation described the resident's activity / recreation interests, where and when the resident preferred activities, and the degree of assistance needed by the resident to participate in activities. The resident's daily activity / recreation participation record for March 2010 was requested and received from the activity director (Employee #124). The record provided evidence the resident attended activities on occasion. When reviewed on 04/07/10, the resident's care plan made no mention of activity / recreation problems, goals, or approaches for this resident. The assistant director of nurses (ADON - Employee #32), when interviewed on 04/07/10 at 11:30 a.m., stated the resident preferred to socialize with therapy staff and visit with family / friends in his room as opposed to attending structured facility activities. When questioned as to how facility staff would be aware of the resident's activity desires / plans, the ADON reviewed and confirmed the resident's current care plan made no mention of activities / recreational needs for this resident. d) Resident #76 During Stage I of the survey, from 03/31/10 through 04/02/10, this resident was not observed attending / participating in facility activities, either in her room or at other sites within the facility. The resident's medical record, when reviewed on 04/05/10, disclosed the initial activity / recreation evaluation had been completed for this resident on 03/12/10, shortly after admission. The evaluation described the resident's activity / recreation interests, where and when the resident preferred activities, and the degree of assistance needed by the resident to participate in activities. The resident's daily activity / recreation participation record for March 2010 was requested and received from the activity director. The record provided evidence the resident attended activities on occasion. When reviewed on 04/05/10, the resident's care plan made no mention of activity / recreation problems, goals, or approaches for this resident. On 04/05/10 at 10:00 am, a registered nurse (RN - Employee #50), who held the title of patient care coordinator and who was working in the Jackson Court area of the facility, was questioned as to the plan for this resident's activity / recreational needs. This RN reviewed the resident's current care plan and confirmed the plan contained no mention of the resident's activity / recreational needs.",2015-11-01
9403,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,280,D,0,1,85AT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed, for three (3) of thirty-seven (37) Stage II sample residents, to update the plan of care to reflect current needs. Resident #153 experienced a decline in urinary continence with no update to the plan of care, Resident #158 experienced a fall with no update in the plan of care, and Resident #160 experienced a change in the status and treatment of [REDACTED]. Resident identifiers: #153, #158, and #160. Facility census: 97. Findings include: a) Resident #153 The medical record for Resident #153, when reviewed on 04/07/10, disclosed the resident was admitted to the facility on [DATE]. According to the Nursing Admission Evaluation completed on 11/23/09, as well as the Bladder Pattering and Analysis Worksheet completed on 11/24/09, the resident was continent of bladder function. An ADL (activity of daily living) Worksheet, completed during the month of January 2010, continued to note the resident as being continent of bladder function. ADL Worksheets for the months of February, March, and April 2010 disclosed the resident had declined in urinary continence to the current status of totally incontinent. The resident's current plan of care, when reviewed on 04/07/10, noted a focus area for this resident as: Occasional urinary incontinence related to hypertonicity bladder, physical limitations. This focus area was initiated on 12/08/09, and included interventions such as using absorbant products and adult briefs and providing incontinence care as needed. The care plan had been reviewed on 03/01/10, but no changes had been implemented to reflect the decreasing urinary continence as described on the ADL Worksheets for the period of time after mid-February 2010 to the present April 2010, when the resident was described as being totally incontinent of urine. A licensed practical nurse (LPN) assigned to the care of this resident on 04/08/10 (Employee #119), when question as to the urinary continence of this resident, stated the resident was almost totally incontinent and would only occasionally ask to go to the bathroom. These findings were bought to the attention of the director of nurses (DON) and assistant director of nurses (ADON) on 04/08/10 at 10:00 a.m., and the facility could provide no evidence to reflect revisions had been made the resident's care plan to address her urinary incontinence. b) Resident #158 When reviewed on 04/01/10, the care plan for Resident #158, who was admitted to the facility on [DATE], disclosed the facility, on 01/13/10, identified the resident to be at risk for falls due to use of [MEDICAL CONDITION] medications, impaired balance / poor coordination, history of falls. Further review of the resident's medical record revealed [REDACTED]. The care plan was not updated at that time to reflect additional interventions to prevent further falls. The ADON (Employee #32), when interviewed on 04/07/10 at 11:00 a.m. about the resident's fall and interventions that had been implemented following the fall to prevent further falls, stated it was believed the resident's friend had attempted to assist him to transfer at the time of the fall. This friend had been educated at that time to call for staff assistance instead of attempting to help him herself. The ADON further confirmed the resident's current care plan did not contain any of this information to alert other staff caring for the resident about the problem should it happen again. c) Resident #160 Medical record review, on 04/05/10, revealed this [AGE] year old male was admitted to the facility on [DATE] with a Stage II pressure ulcer. On 02/23/10, the wound care clinic was consulted, since the wound was not showing any progression toward healing. On 03/23/10, the wound care clinic identified the needs to keep weight off the resident's coccyx at all times by using a waffle cushion in the wheelchair, to limit the amount of time sitting in a chair, and to reposition the resident every two (2) hours when in bed. Additional review of the medical record revealed the wound care clinic made several changes in the care / treatment of [REDACTED]. On 04/07/10 at 11:24 a.m., the dressing change procedure was observed, and the nurse reported the wound care clinic had changed the treatment to wash with soap and water, pat dry, and apply antifungal ointment. On 04/06/10 at 10:00 a.m., Resident #160, when interviewed in his room while in bed, reported he believed the wound care clinic had really helped, they had made several changes, to the treatment to be completed, and he had been told the ulcer was healing up pretty good. A review of the resident's comprehensive care plan, on 04/05/10, revealed the plan addressing the resident's pressure ulcer had not been updated to reflect changes in treatment made by the wound care clinic. Current care plan interventions included: apply skin care moisturizers as needed; encourage and assist as needed to turn and reposition frequently; evaluate and record wound status per facility guidelines until healed; observe for and report any evidence of infection such as purulent drainage, swelling, localized heat, increased pain etc.; Easy Air mattress to resident bed; supplements / enhanced or fortified foods per physician orders; and physical therapy referral and treatment as ordered by physician. On 04/10/10 at 3:26 p.m., the assessment coordinator (Employee #105), when interviewed, reported the wound care nurse was responsible for assessing the wounds and revising the care plans as needed. She identified the wound care nurse was off on sick leave and was not able to be interviewed at this time. On 04/07/10 at 9:30 a.m., the DON produced a copy of the facility's policy and procedure for wound healing. Review of this policy revealed that, on page 10 related to the comprehensive plan of care: Based upon the findings of the MDS, pressure ulcer RAP and other assessments, the initial care plan is updated and comprehensive care plan is developed. When the interdisciplinary team develops or updates the patients care plan a measurable goal is determined and a target date identified. Individualized interventions are selected based upon the current clinical condition risk factors, functional status and the patients values, goals and willingness to participate with the plan of care. The care plan is reviewed and updated to reflect the patients current status and care delivery needs, as clinically indicated and per state and federal regulations. There was no evidence the facility revised Resident #160 care plan as needed when changes in treatment occurred.",2015-11-01
9404,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,309,G,0,1,85AT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, record review, and staff interview, the facility failed to provide care and services to assist each resident in attaining or maintaining the highest physical well being possible for three (3) of thirty-seven (37) Stage II sample residents. Resident #55 expressed experiencing pain in his leg that kept him awake at night, and he had an order for [REDACTED].#62 did not eat for three (3) days, and staff failed to assess for possible causes and failed to notify the physician, although the resident did not have a known terminal illness; the resident died twenty-four (24) hours after the physician was notified. Resident #153 was not appropriately assessed for fall risk and sustained two (2) falls. These actions resulted in actual harm to Resident #55 and #62. Resident identifiers: Residents #55, #62, and #153. Facility census: 97. Findings include: a) Resident #55 In an interview conducted at 3:00 p.m. on [DATE], Resident #55 stated he had pain in his left leg and that it often kept him awake at night. At that time, the resident was observed rubbing his left thigh. The resident's medical record, when reviewed on [DATE], contained a current physician's orders [REDACTED]. Based on this order, facility staff should have been aware of the possibility of leg pain and should have provided ongoing assessments for this resident's specific pain. Review of the care plan, at the same time, revealed no care plan or other mention of leg pain. In an interview at 10:45 a.m. on [DATE], a registered nurse (RN - Employee #136) revealed she had no knowledge of the resident experiencing left leg pain. Employee #136 reviewed the resident's pain scores (pain assessments) for [DATE] and reported there was no documentation of pain thus far in April. She confirmed that the pain score record did not specifically indicate assessment of left leg pain. Employee #136 then visited the resident in his room. At 11:00 a.m. on [DATE], the RN reported the resident stated to her that he has left leg pain at night and that the leg pain kept him awake at night. The resident's care plan was again reviewed, this time with Employee #136. At 5:30 p.m. on [DATE], Employee #136 confirmed the facility was not aware the resident was having pain and confirmed that ongoing assessments for left leg pain had not been occurring for this resident. Employee #136 stated she would assess the resident and implement appropriate interventions. The following morning, another interview was conducted with the resident, at 9:00 a.m. on [DATE]. He stated he had been given pain medication for his leg pain last night and that it had really helped. He stated, I slept like a log. At the time of the survey, the facility had not assessed the resident's left leg pain and had not developed and implemented a care plan to ensure the resident was as free as possible of pain. b) Resident #62 Closed record review revealed Resident #62 was admitted on [DATE] for rehabilitation related to a fractured left hip for which she had undergone internal fixation at an area hospital on [DATE]. She had been in an assisted living facility at the time of the fall and was 100-years old. The resident's discharge summary from the hospital, in the area of condition on discharge, stated she was stable. Additional medical [DIAGNOSES REDACTED]. The resident / responsible party's goal at the time of admission, according to the social work assessment of [DATE], was for the resident to be able to return to the assisted living facility where she resided prior to the fall. At the time of admission, the resident's diet was noted to be regular mechanical soft. Shortly after admission, the resident was noted to be having some difficulty with swallowing. A speech evaluation was conducted on [DATE], and the resident's diet was changed to pureed with honey-like liquids. An interdisciplinary progress note, dated [DATE], stated that resident was in thirty (30) day window for the minimum data set assessment (MDS) and she continues to work with all therapy services. She continues to show progress. The medical record contained a Living Will document completed by the resident on [DATE], stating she desired to receive no life-prolonging interventions should she be diagnosed by two (2) physicians to have a terminal condition and/or to be in a vegetative state. She had included no limitations or special directives on this declaration. Review of the resident's physician orders [REDACTED]. party on [DATE], stated the resident was not to be resuscitated in Section A. In Section B, Limited Additional Interventions were requested, which direct staff to use medical treatment, IV fluids and cardiac monitoring as needed. Transfer to hospital if indicated. Avoid intensive care. In Section C, antibiotics were requested, and in Section D, no feeding tube was requested, although IV fluids for a defined trial period were also requested. Nursing notes from the time of admission described the resident as mostly resting in bed, meds taken crushed, and voicing no complaints. Family was noted to be visiting frequently. A nursing note, on [DATE] at 7:00 p.m., stated, Resting in bed. PO (by mouth) meds taken crushed (sic) without difficulty. No complaints noted. VSS (vital signs and symptoms) per flow sheet. Foley cath patent draining yellow urine. ADL's (activities of daily living) per staff. Call bell in reach. At 9:20 a.m. on [DATE], a nursing note stated, This nurse called to notify MD that resident has refused to eat for 3 days and that this nurse held am (morning) meds (medications) due to swallowing difficulty. At 1:00 p.m. on [DATE], an addition nursing note stated the family was in to visit and explained to MPOA (medical power of attorney representative ) that resident has refused to eat for 3 days and that nurse held morning meds. The resident had not eaten for three (3) days before staff notified the physician. There was no noted response from the physician after he was notified of the resident's failure to eat for three (3) days. Although documentation stated that family was made aware and was with the resident frequently, there was no evidence that, when made aware of this failure to eat, the resident's physician or facility personnel met with the family to discuss their desire to attempt to [DIAGNOSES REDACTED]. There was no discussion about obtaining lab work or other minimally invasive diagnostic tests to ascertain why this resident - with no known terminal diagnosis - was not eating. There was no discussion related to implementation of IV fluids for a trial period, as requested on the resident's POST form. The resident died at the facility within twenty-four (24) hours of this physician's notification of her failure to eat for three (3) days. c) Resident #153 The medical record of Resident #153, when reviewed on [DATE], disclosed this [AGE] year old resident had been admitted to the facility on [DATE]. The resident's medical [DIAGNOSES REDACTED]. Further review of the record revealed a history and physical completed at the time of her last hospitalization following admission, which stated: Her dementia seems to be progressing rather quickly and she is confused to place and time. Following admission to the facility, documentation on a social work assessment and history form stated the resident was alert and oriented to person with short and long term memory impairment. An admission nursing note, dated [DATE] at 2:00 p.m., stated, Alert to self and to familiar people. Confused to time and place. A nursing note, on [DATE] at 5:00 a.m., stated, Very forgetful, and at 2:45 p.m. on [DATE], a facility nurse documented in a nursing note, Forgetful of things you have just explained to her. The resident's care plan was reviewed, and staff had recognized, on [DATE], that the resident was at risk for falls due to cognitive impairment, adjustment to new environment, use of [MEDICAL CONDITION] medications, unsteady gait. Interventions to prevent falls included checking on resident frequently, providing assist to transfer and ambulate as needed, and reinforce need to call for assistance. On [DATE] at 9:00 a.m., a nursing note described finding the resident sitting on her buttocks in front of the toilet. The resident was assessed and determined to have no injuries. The resident also attempted to leave the building on two (2) occasions on this day, at 10:20 a.m. and again at 3:30 p.m., and a nursing note stated, Resident alert, confused to time and place. At 4:30 p.m. on [DATE], a nursing note stated, CNA (certified nursing assistant) took resident to bathroom and instructed to ring when done, resident got up from toilet on own - roommate stated res.(resident) walked to w/c (wheelchair) and fell to floor on back. The resident was transferred by emergency medical services to a local hospital emergency room for evaluation and returned to the facility at 8:35 p.m. on [DATE] with an order for [REDACTED].>The director of nurses (DON) and assistant director of nurses (ADON) were interviewed related to these findings at 10:00 a.m. on [DATE]. Following review of the resident's medical record and statements related to cognitive status as described above, the DON and ADON confirmed the care plan interventions for this resident (to call for assistance) and instructions by a nursing assistant (to call for assistance when done toileting) were not appropriate for this cognitively impaired resident. The resident did not have the ability to comprehend the instructions to call for assistance.",2015-11-01
9405,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,315,D,0,1,85AT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed, for one (1) of thirty-seven (37) Stage II sample residents, to assure timely and appropriate assessment for a resident who was continent of urine when admitted to the facility and who became totally incontinent within the four (4) months following admission, in an effort to determine the possible cause and to address the incontinence to the extent possible. Resident identifier: #153. Facility census: 97. Findings include: a) Resident #153 The medical record for Resident #153, when reviewed on 04/07/10, disclosed the resident was admitted to the facility on [DATE]. According to the Nursing Admission Evaluation completed on 11/23/09, as well as the Bladder Pattering and Analysis Worksheet completed on 11/24/09, the resident was continent of bladder function. An ADL (activity of daily living) Worksheet, completed during the month of January 2010, continued to note the resident as being continent of bladder function. ADL Worksheets for the months of February, March, and April 2010 disclosed the resident had declined in urinary continence to the current status of totally incontinent. The resident's current plan of care, when reviewed on 04/07/10, noted a focus area for this resident as: Occasional urinary incontinence related to hypertonicity bladder, physical limitations. This focus area was initiated on 12/08/09, and included interventions such as using absorbant products and adult briefs and providing incontinence care as needed. The care plan had been reviewed on 03/01/10, but no changes had been implemented to reflect the decreasing urinary continence as described on the ADL Worksheets for the period of time after mid-February 2010 to the present April 2010, when the resident was described as being totally incontinent of urine. A licensed practical nurse (LPN) assigned to the care of this resident on 04/08/10 (Employee #119), when question as to the urinary continence of this resident, stated the resident was almost totally incontinent and would only occasionally ask to go to the bathroom. These findings were bought to the attention of the director of nurses (DON) and assistant director of nurses (ADON) on 04/08/10 at 10:00 a.m., and they could provide no evidence that the facility had recognized the resident's decline in urinary continence, assessed for cause, and/or implemented interventions to assist the resident to regain as much normal bladder function as possible.",2015-11-01
9406,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,319,D,0,1,85AT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed, for one (1) of thirty (30) Stage II sample residents, to accurately assess the resident's increasing emotional distress / behaviors following a [DIAGNOSES REDACTED]. Resident identifier: #162. Facility census: 97. Findings include: a) Resident #162 When reviewed on [DATE], the closed medical record of Resident #162 disclosed she was 92-years old when admitted to the facility on [DATE] from a local acute care hospital with an admission [DIAGNOSES REDACTED]. The document Medical History / Physical Examination, completed by the resident's attending physician at the time of admission, stated the resident was recently diagnosed with [REDACTED]. Review of the resident's admission minimum data set assessment (MDS), dated as completed on [DATE], disclosed in the areas of Cognitive Patterns, Section B, the resident had long and short term memory problems but was able to recall the current season, staff names and faces, and that she was in a nursing home. In the area of emotional issues, Section E, the resident was described as experiencing [MEDICAL CONDITION] and repetitive physical movements. The document also stated that, although the indicators were present, they were easily altered. The next MDS, a Medicare 14-day assessment dated as completed on [DATE], described the resident as continuing to experience [MEDICAL CONDITION], having a sad / pained / worried / facial expression, and continuing to exhibit repetitive physical movements. Additionally, the resident had become physically abusive, resisted care, and indicators of [MEDICAL CONDITION] had surfaced. A social services note, dated [DATE], stated the resident had a decline in condition and was more confused, more restless especially at night, resisting care, and hitting at staff sometimes. The resident's care plan was reviewed. Staff had assessed the resident as having altered nutritional status related to terminal diagnosis, potential for pain related to [MEDICAL CONDITION], and other physical symptoms of the terminal diagnosis. However, there was no evidence in this care plan that staff had recognized the resident had experienced an increase in emotional distress / behaviors and restlessness in the fourteen (14) days following admission, nor was the resident assessed for possible unmet psychosocial needs associated recent being informed of a terminal [DIAGNOSES REDACTED]. The resident died at the facility on [DATE]. In an interview on [DATE] at 10:00 a.m., the director of nurses (DON) and assistant director of nurses (ADON) could provide no further evidence that the resident's documented and increasing emotional distress / behaviors had been assessed for the possibility of unmet psychosocial needs and developed interventions to assist the resident emotionally during the dying process.",2015-11-01
9407,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,325,D,0,1,85AT11,"Based on record review and staff interview, the facility failed to administer nutritional supplements as care planned and/or ordered for two (2) of thirty-seven (37) Stage II sample residents meant to optimize each resident's nutritional status. Resident identifiers: #111 and #94. Facility census: 97. Findings include: a) Resident #111 A review of the medical record revealed Resident #111 had a significant weight loss in November 2009. His care plan interventions included monitoring the percentage consumed of snacks / nutritional supplements, but there was no evidence on either the treatment sheet or the activities of daily living (ADL) worksheet for April 2010 that he received and/or consumed snacks / supplements as planned. b) Resident #94 A review of the medical record revealed Resident #94 was a debilitated hospice resident who weighed 70# and had a Stage II pressure ulcer on her coccyx. The progress notes stated she was declining in all areas. According to her medical record, snacks and/or nutritional supplements were care planned and/or ordered, but there was no evidence to reflect she received and/or consumed them. The area on the ADL worksheet, where staff was to document the acceptance of evening snacks for April 2010, was incomplete, with only three (3) of seven (7) days marked. A review of the resident's treatment sheet found evidence of her having received and/or refused her nutritional supplement on thirteen (13) of twenty-one (21) occasions when it was offered. c) During an interview with a nursing assistant (Employee #46) at 9:10 a.m. on 04/08/10, she verified these were the two (2) locations staff was to record whether a resident had and/or consumed snacks and/or supplements - the ADL worksheet and the treatment sheet. She stated the nursing assistants were to document the percentage of intake on the ADL worksheet. These findings were shared with the director of nurses (DON) at 9:30 a.m. on 04/08/10. After she review the resident's record, she stated she would take care of the problem.",2015-11-01
9408,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,364,F,0,1,85AT11,"Based on confidential resident interviews, taste testing, menu review, observation, temperature measurement of test trays, and staff interview, the facility failed to assure foods were palatable and at the proper temperatures upon receipt by the residents. Additionally, the facility failed to assure menus were followed relative to planned foods, alternate foods, and use of garnishes. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 97. Findings include: a) Confidential Resident Interviews 1. Resident A On 03/29/10 at 3:29 p.m., this resident stated No when asked if the food tasted good and looked appetizing. 2. Resident B On 03/29/10 at 3:55 p.m., this resident stated No when asked if the food tasted good and looked appetizing. The resident also stated a sandwich was requested regularly because of the taste of the food. 3. Resident C On 03/29/10 at 3:13 p.m., this resident stated No when asked if the food tasted good and looked appetizing. The resident also stated, .wish they had a good cook. 4. Resident D On 03/30/10 at 10:00 a.m., this resident stated, .the milk was warm most of the time. On 03/29/10 at 3:30 p.m., this resident stated the food was often cold and the milk was always warm. 5. Resident E On 03/29/10 at 3:45 p.m., this resident said, The food is not good. You can get something else, but it's not good either. 6. Resident F During the afternoon of 03/31/10, this resident said, The food tastes bad, looks bad, some cooked too much, some not enough. 7. Resident G On 03/29/10 at 3:30 p.m., this resident stated the cold foods were always too warm. 8. Resident H On 04/05/10 at 2:36 p.m., this resident stated the food was not good and needed more seasoning. -- b) During the noon meal on 04/07/10, the green beans were tasted and did not appear to have been seasoned. Employee #62, who prepared the green beans, stated she had seasoned the green beans with garlic powder. No such flavoring was detectable upon taste testing. This was confirmed by the dietary manager (DM) at 12:40 p.m. on 04/07/10. -- c) Temperatures of foods on test trays were measured at 1:05 p.m. on 04/07/10, just after the last resident was served. The cold foods were too warm. Cucumbers in ranch dressing were 56 degrees Fahrenheit (F), a small bowl of pudding was 52 degrees F, and tomato juice was 51 degrees F. These food temperatures were measured with the DM, who confirmed the cold foods were not at palatable temperatures. -- d) The menu was not followed for the noon meal on 04/07/10: 1. Residents requiring pureed diets were supposed to be provided pureed cucumbers in Ranch dressing, but they were provided tomato juice instead. 2. The menu called for garnishes for all diet types, but none were provided. 3. Specific alternates were indicated on the menu but were not prepared. Interview with the DM, at 12:40 p.m. on 04/07/10, revealed the facility had never prepared the alternates and had been cutting them off the menus when they were posted.",2015-11-01
9409,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,371,F,0,1,85AT11,"Based on observations and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices had the potential to affect all facility residents who received nourishment from the dietary department. Facility census: 97. Findings include: a) On 04/07/10 at 11:55 a.m., observation revealed the rinse temperature of the dishwasher was 198 degrees Fahrenheit (F). According to the 2005 Food Code, the rinse temperature should not exceed a maximum of 194 degrees F., to assure proper cleaning and sanitization. This situation was brought to the attention of the dietary manager (DM) at the time of observation. The DM stated she was unaware that rinse temperatures greater than 194 degrees F were ineffective in sanitizing food service items. Additionally observations at the same time revealed a large coating of dusty debris on the walls around the dishwasher, on top of the dishwasher, and on the ceiling vent above the dishwasher. b) During observation of meal preparation and meal tray preparation at the noon meal on 04/07/10, steam table pans were observed stacked inside each other prior to air drying. Trapped moisture was observed inside each one, creating a medium for bacteria growth. Additionally, these pans, which were ready for use, contained debris which could be scraped off with a fingernail. Plate covers were stacked inside of each other prior to air drying. They also contained some type of white loose debris. c) At 11:25 a.m. on 04/07/10, a pan of cucumber salad made with Ranch dressing was observed at the serving area, ready for service. The temperature of the product was measured. It was being held for service at 50 degrees F. The temperature of pureed green beans, being held for service on the steam table, was measured at the same time. They were 120 degrees F. d) At 12:15 p.m. on 04/07/10, the tray line (with rollers) contained large amounts of greasy, dusty debris on the rollers, as well as the other surfaces. e) At 12:25 p.m. on 04/07/10, during the loading of meal trays on the food carts. Large amounts of debris, including crumbs, paper, and dried food, were observed inside the food carts. Upon inquiry, the DM stated the inside of the food carts should have been cleaned during the time the dishes were washed.",2015-11-01
9410,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,387,D,0,1,85AT12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the attending physician, for one (1) of thirteen (13) residents reviewed, completed visits to the resident every thirty (30) days for the first ninety (90) days following admission as required. Resident identifier: #68. Facility census: 105. Findings include: a) Resident #68 When reviewed on 06/15/10, the medical record for Resident #68 disclosed the resident had been admitted to the facility on [DATE]. Further review found no evidence the resident had been seen by her attending physician since that time. The facility's administrator, when interviewed on 06/15/10 at 3:15 p.m., could provide no evidence to reflect the resident had been seen by her attending physician since the time of his admission to the facility on [DATE].",2015-11-01
9411,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,431,E,0,1,85AT11,"Based on observation and staff interview, the facility failed, for one (1) of two (2) medication refrigerators, to ensure the internal temperature was maintained in a safe range of 36 to 46 degrees Fahrenheit (F). Facility census: 97. Findings include: a) At 9:23 a.m. on 04/05/10, Employee #104 observed the refrigerator and identified it was above the upper limit of the safe zone at 50 degrees F. The employee adjusted the temperature control to a colder temperature.",2015-11-01
9412,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,441,E,0,1,85AT11,"Based on observation and staff interview, the facility failed to assure the surfaces of the hand rails in the hallways on one (1) wing of the facility, and the surfaces in an employee bathroom, were maintained in such a manner that they could be adequately cleaned and disinfected to prevent the spread of infection. This had the potential to affect more than an isolated number of residents. Facility census: 97. Findings include: a) On 03/30/10 and throughout the survey, the following observations were made: 1. The bathroom located adjacent to the 300-400 nursing station, which was used by employees providing direct care to the residents on these halls, was observed by this surveyor to have cracked and missing caulking around the toilet and sink, and plastic baseboards were loose in several areas with gaps that exposed dirt and debris. 2. The handrails along the 300 hall did not have a sealed surface, as there were many chinks out of the rail surface down into the bare wood. These conditions make it impossible to thoroughly clean and sanitize these areas. During an interview with the infection control nurse (Employee #32) at 9:00 a.m. on 04/08/10, she accompanied this surveyor to the areas in question and acknowledged they were not clean and probably could not be cleaned / sanitized.",2015-11-01
9413,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,456,F,0,1,85AT11,"Based on observation and staff interview, the facility failed to assure essential equipment in the kitchen was in safe operating condition. The rinse temperature of the dishwasher was at a temperature which did not effectively sanitize food preparation and service items. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 97. Findings include: a) On 04/07/10 at 11:55 a.m., observation revealed the rinse temperature of the dish washer was 198 degrees Fahrenheit (F). According to the 2005 Food Code, the rinse temperature should not exceed a maximum of 194 degrees F, to assure proper cleaning and sanitization. This situation was brought to the attention of the dietary manager (DM), at the time of observation. The DM stated she was unaware that rinse temperatures greater than 194 degrees F were ineffective.",2015-11-01
9964,SUMMERS NURSING AND REHABILITATION CENTER LLC,515170,"JOHN COOK ROAD, PO BOX 1240",HINTON,WV,25951,2010-04-08,253,E,0,1,RRHZ11,". Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Eight (8) of eight (8) sampled residents' rooms had bathroom doors, walls, and furniture with surfaces that, due to the presence of defects, did not allow them to be easily cleanable. Resident rooms: A16, B2, B3, B4, B5, B7, B10, and B11. Facility census: 98. Findings include: a) Observations of residents' rooms, on the afternoon of 04/05/10 and throughout the day on 04/06/10, revealed bathroom doors, wardrobes, bedside stands, and walls with surface defects (e.g., long scratches, scuff marks, nicks, and mars) which did not allow them to be easily cleanable. It also gave an unsightly appearance to the rooms. This was discussed with the administrator on the late afternoon of 04/08/10, at which time he made rounds with the surveyor to view the affected rooms. .",2015-08-01
9965,SUMMERS NURSING AND REHABILITATION CENTER LLC,515170,"JOHN COOK ROAD, PO BOX 1240",HINTON,WV,25951,2010-04-08,441,E,0,1,RRHZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on the review of facility infection control data, staff interview, and medical record review, the facility failed to develop and maintain an infection control program designed to help prevent the development and transmission of disease and infection. The facility failed to identify causative organisms related to urinary tract infections. This failure would prevent the facility from assuring that residents were appropriately cohorted with like organisms to prevent cross contamination. Additionally, the failure to identify causative organisms would prevent the facility from tracking different organisms to identify trends to prevent future spread of infection. This deficient practice had the potential at affect more than an isolated number of residents. Facility census: 98. Findings include: a) A review of the facility's infection control data found a lack of evidence that the facility identified and tracked causative organisms related to urinary tract infections. The infection control data did not determine if causative organism for residents being treated for [REDACTED]. The director of nursing (DON - Employee #126), when interviewed on 04/07/10 at 2:00 p.m., was unable to provide evidence that the facility had procedures in place to track specific organisms.",2015-08-01
9966,SUMMERS NURSING AND REHABILITATION CENTER LLC,515170,"JOHN COOK ROAD, PO BOX 1240",HINTON,WV,25951,2010-04-08,280,D,0,1,RRHZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to revise each resident's interdisciplinary care plan to reflect the current status of two (2) of twenty-six (26) Stage II sample residents. Resident #36's care plan was not revised to address his repeat falls; this resident's care plan also failed to describe interventions to address his toileting needs. Resident #55's care plan did not address the need for or use of an antipsychotic medication. Facility census: 98. Findings include: a) Resident #36 1. Review of Resident #36's medical record revealed this [AGE] year old male resident readmitted to the facility on [DATE]. His most recent care plan, dated 02/08/10, noted he was ""at risk for additional falls r/t (related to) attempts to be up unassisted and history of falls. Requires the use of bed bolsters."" Further review of his record revealed that, since 02/01/10, this resident had fallen eight (8) times. An interview with an assistant director of nursing (ADON - Employee #130) verified there had been no new interventions initiated after the falls continued to occur. Employee #130 confirmed that no interventions had been attempted in the care plan and the falls were just listed by the date they occurred, with no measures to prevent further falls from occurring. There was no evidence the facility tried to protect the resident from injury when he fell (e.g., use of mats on the floor, bed in lowest position, wedge cushion, seat belt, etc.) 2. Further review of this record revealed his care plan did not provide instructions to staff regarding his toileting schedule. According to the physician's orders [REDACTED]. His most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date of 02/04/10, indicated he required the extensive physical assistance of two (2) or more staff with toilet use and was on a scheduled toileting program. However, there was no mention of this scheduled toileting program in the interdisciplinary care plan. b) Resident #55 On 04/08/10 at approximately 1:00 p.m., review of Resident #55's current care plan found no mention of the need for or use of antipsychotic medications. However, review of his physician orders [REDACTED]. Nursing notes revealed she had displayed this behavior on various occasions. The resident had received the medication for a long duration of time. No therapeutic goals and monitoring plans for the antipsychotic medication were present in the resident's care plan. The registered nursing (RN) assessment coordinator (Employee #127) agreed she had not addressed the need for or use of the antipsychotic medication with therapeutic goals, as well as plans for monitoring the effectiveness of the medication, in the resident's current care plan. .",2015-08-01
9967,SUMMERS NURSING AND REHABILITATION CENTER LLC,515170,"JOHN COOK ROAD, PO BOX 1240",HINTON,WV,25951,2010-04-08,323,D,0,1,RRHZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to assure one (1) of twenty-six (26) Stage II sample residents received adequate supervision and/or assistive devices prevent falls and injuries. Resident #36 sustained eight (8) falls in February and March 2010, and there was no evidence the facility assessed the resident for factors causing or contributing to the falls in an effort to determine why they occurred, nor did the facility implement any new interventions to prevent the falls from recurring. Resident identifier: # 36. Facility census: 98. Findings include: a) Resident #36 Multiple observations, on 04/05/10 and 04/06/10, found Resident #36 in his room lying in the bed with his eyes closed. There were no mats on the floor beside of the bed. Review of his medical record found this [AGE] year old male had experienced eight (8) falls since 02/01/10. There was no evidence in the medical record, after any of these falls occurred, of any assessment to determine why the resident had attempted to get up, nor was there any mention of interventions implemented to prevent the resident from injuring himself as a result of a fall. An assistant director of nursing (ADON - Employee #130), when interviewed on the afternoon of 04/07/10, verified Resident #36 did not have any mat beside his bed. The ADON stated they would evaluate him for this. (A subsequent observation, on 04/08/10, found a mat in the floor by the bed and the bed in the lowest position.) Employee #130 was asked to provide evidence of past unsuccessful interventions and/or devices used in the past to promote safety for this resident. She was not able to locate any information in the resident's medical record to reflect what safety measures had been tried in the past. His most recent care plan, dated 02/08/10, noted he was ""at risk for additional falls r/t (related to) attempts to be up unassisted and history of falls. Requires the use of bed bolsters."" This problem statement was initially been established on 09/02/09. The current care plan also stated, ""Last Fall: 2/2/10, 2/15/10, 2/20/10, 2/23/10, 2/24/10, 2/28/10, 3/2/10, 3/11/10."" The interventions mentioned in the care plan included the application of a restraint-free alarm to his bed and his wheelchair to make the staff aware of his need for assistance. There was no evidence the facility had assessed the resident for alternative measures to prevent the falls and/or to prevent injury to the resident as a result of a fall when it became apparent the restraint-free alarms were not effective. The resident had both fallen from the bed and slid out of the wheelchair. There were no attempts to assess or initiate the use of devices such as pads on the floor, a seat belt, a special wedge cushion, a non-slip pad for his wheelchair, a modified seat for his wheelchair, etc. During an interview with the nursing assistant providing care to the resident on 04/07/10 (Employee #9), Employee #9 identified this resident does not walk, and when these alarms on his bed and chair go off, ""It just lets you know that he has fallen in the floor."" There was no evidence the facility had assessed the effectiveness of the use of these alarms in promoting resident safety after the resident continued to fall, nor was there evidence of efforts to initiate different interventions that may have been more effective in preventing falls and injuries. .",2015-08-01
10215,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2010-04-15,325,D,0,1,WIXO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to promptly act upon knowledge of a resident's significant weight loss for one (1) of twenty-one (21) Stage II sampled residents (Resident #128), in order to maintain acceptable parameters of nutritional status. The facility failed to monitor weights in such a way that nutritional concerns could be promptly identified, the dates on which weights were obtained were not recorded, there was no evidence the physician or the family was made promptly notified of the weight loss, and there was no evidence the facility initiated any interventions to address the significant weight loss until eleven (11) days after the loss was identified. Resident identifier: #128. Facility census: 118. Findings include: a) Resident #128 Review of Resident #128's medical record revealed the weight record consisted of a form that provided, for each month, multiple spaces to record weights and the dates on which they were obtained. At the top of Resident #128's weight record, staff recorded his admission weight as 116.4 pounds (#) on 03/01/10. Also recorded in the month of March 2010 was a weight of 116.4# with no date noted as to when this weight was obtained. Upon reviewing the form, the medical records staff member (Employee #42) confirmed the resident's admission weight was written in the March 2010 column and verified this was only one (1) weight recorded on that form as of 04/13/10. The registered nurse (RN) case manager (Employee #142), when questioned as to why no further weights were recorded on this form for Resident #128 since his date of admission, informed this surveyor the resident's weights were recorded in the computer and she would have to print them off. At 10:00 a.m. on 04/13/10, Employee #142 provided a print out of all weights recorded in the computer for Resident #128. Review of the weights from the computer found the resident's admission ""base weight"" was recorded as 125#. When the resident was weighed on 03/23/10, his weight was 117#. According to this documentation, the resident lost 8.6# from 03/01/10 to 03/23/10. According to the medical record, the resident experienced an episode of decreased level of consciousness, his oxygen saturation decreased, and he developed a fever. He was transferred to the hospital and admitted with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED].) over a month period. Dietary Consult, notify POA."" This order was written while the resident was in the hospital, and there was no evidence to reflect these actions had been taken prior to that time, even though the weight loss was identified on 03/23/10. The resident was re-admitted on [DATE]. His weight on readmission was 112#. During his hospital stay, he received changes in his diet order and was placed on thickened liquids. There no evidence the facility had made the registered dietitian (RD) aware of the resident's return and the need to follow through with the dietary consult. A review of the facility's policy stated that, for residents showing a weight loss of 5# or more in one (1) month, staff was to notify the resident's responsible party and obtain an order a dietary consult. According to the policy, ""Section L on the MDS will be addressed by the care plan committee."" There was no evidence to reflect this policy had been followed when the resident's weight loss was identified on 03/23/10. During an interview with Employee #142 on 04/15/10 at 9:15 a.m., she reported this recorded weight must have been entered wrong. She stated she did not think there had been a weight loss. She was no sure where the base weight of 125# had come from. She also verified the weight of 114# recorded in the resident's comprehensive admission assessment, with an assessment reference date of 03/08/10, was incorrect. (See also citation at F278.) Employee #142 stated she did not realize these weights were incorrect until the survey. On 04/14/10, the facility's consultant RD was in the facility, and the dietary consult was completed. The RD's recommendations included giving the nutritional supplement Ensure Plus with the resident's medication pass at 9:00 a.m. and 6:00 p.m. This surveyor reviewed the resident's record again on 04/15/10 at 11:00 a.m., and there was no evidence to reflect this resident was receiving the Ensure Plus with medication pass as recommended by the RD. Employee #142 was again interviewed on 04/15/10 at 11:15 a.m., regarding the RD's recommendations. She stated they put the RD's recommendations on the physician's list and he would be in that day to review them; if he agreed with the recommendations, the Ensure Plus would be ordered. This was twenty-three (23) days after the weight loss had been identified. The director of nursing was made aware, on 04/15/10 at 1:30 p.m., that this resident's nutritional status had not been adequately assessed. She was notified that Employee #142 had stated the recorded weights were not correct, and she agreed the inconsistency of the weights would make the resident's assessment of his nutritional status inaccurate. .",2015-06-01
10216,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2010-04-15,371,F,0,1,WIXO11,". Based on observations and staff interviews, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions. Pitchers of tea were found with post-dated preparation dates, staff did not know how to use the test strips to ensure the correct amount of sanitizing solution had been dispensed into the three-compartment warewashing sink; potentially hazardous foods were stored in the refrigerator without recording a date on which they were opened or a date by which they should be used; there was no indication of when Health Shakes had been thawed; food debris was found on the mixer; the mixer bowl was uncovered with utensils stored in the bowl while a recipe book sat atop the mixer head; utensils ready for use were haphazardly stored in a bus tub; steam table pans and other items were found stored with moisture trapped inside; a dietary staff member did not wash her hands after removing the gloves she wore to handle soiled dishes and flatware and before handling clean dishes; and racks of clean items were pushed out of the dishwasher with racks of soiled dishes. These practices had the potential to affect all residents receiving items prepared in the kitchen. Facility census: 118. Findings include: a) During the initial tour of the kitchen beginning at approximately 1:35 p.m. on 04/12/10, the following sanitation infractions were observed: 1. Employee #105 (a dietary aide) was washing pots and pans in a three-compartment sink. When asked how the sanitizer in the third sink was checked, she explained the tubes connected to containers under the sink and said it was dispensed as they ran the water. When asked about test strips, she went to a small plastic dispenser affixed to the wall near the sink. She was unable to open the container to obtain a strip. Employee #83 (another dietary aide) came over and made suggestions on how to open the dispenser. She too tried and figured out how to open the plastic container to obtain a strip. When asked how much time to allow to pass before reading the strip after it had been placed in the solution in the sink, Employee #83 said after thirty (30) to forty (40) seconds. The instructions on the test strip dispenser said to read it after ten (10) seconds. The solution in the sink was tested , with the strip yielding no discernable change in color. 2. A plastic pitcher was found in the refrigerator labeled ""Sweet Tea"". The sides of the pitcher were hot to touch. The label noted the tea had been prepared on 04/14/10 and was to be used by 04/16/10. A second pitcher labeled ""Tea"" was also labeled as having been prepared on 04/14/10 and to be used by 04/16/10. These were observed on 04/12/10. 3. A 5# container of shredded chicken salad and a 5# container of cottage cheese were observed in the refrigerator. Both had been opened, but neither had been dated to indicate when they had been opened or by what date they should be used. 4. Two (2) thawed and three (3) partially frozen Great Shakes were observed in the refrigerator. There was no date to indicate when the products had been thawed or by when they should be used. 5. Quarter pans were observed placed upside down and one (1) on top of another. At least two (2) of these nested quarter pans had been stored with moisture trapped inside. The trapped moisture provides an environment conducive to the rapid and progressive growth of potentially pathogenic microorganisms. 6. Trapped moisture was also found in 1.8-quart steam table pans, 6-quart plastic containers stored on a shelf in a stainless steel cabinet, three (3) of four (4) insulated plate covers checked that were stored on a cart in the kitchen, and in coffee cups and small bowls. 7. The Univex mixer was observed. The bowl, with the attachments stored inside, sat uncovered below the head of the mixer. A large recipe book sat on top of the mixer head and created a potential for foreign substances to be introduced into the mixer bowl. The mixer also was noted to have a small flat area where the arms of the mixer attached to the stand. Several pieces of loose debris were noted on the flat area which could have fallen into the mixer bowl. 8. An array of scoops, basting brushes, and other utensils were observed stored haphazardly in a bus tub on the bottom shelf of a stainless steel cabinet. A second bus tub was in a similar condition on the other side of the cabinet. This did not allow for staff to retrieve items without creating a potential for contaminating the serving service of another utensil. 9. Employee #83 was observed washing dishes in the soiled dish room. She sprayed food off of dishes and placed them in a rack to run through the dishwasher. After loading the rack, she opened the dishwasher door and pushed a clean rack of dishes out of the dishwasher with the rack of unwashed dishes. At that point, the counter on the ""clean"" side of the dishwasher was full. She removed her rubber gloves and very briefly (less than five (5) seconds) sprayed her hands off, one (1) at a time, with the same sprayer she had been handling with the food soiled gloves. She then went and began to put away the clean dishes to make room for more racks of clean dishes. After clearing the counter, she again donned her rubber gloves and pushed a rack of clean dishes out of the dishwasher with a rack of soiled ones. The racks of soiled dishes were contaminated by dripping water and had the potential to contaminate the clean rack being pushed from the dishwasher. Additionally, when staff moved the clean racks of dishes along the counter, their hands came into contact with the side of the clean rack that had been in contact with the soiled rack of dishes. When the staff member removed her gloves, she needed to have washed her hands with soap and water without having contact with contaminated surfaces, in this instance, the sprayer. She should also have dried her hands prior to handling the clean dishes. 10. These observations were discussed with the head cook (Employee #106) in mid morning on 04/15/10. b) Observations, in the kitchen at lunch meal preparation on 04/13/10, found dietary staff used a powder thickener to thicken food items on the steam table from a container that was unlabeled and undated. This was brought to the attention of the assistant dietary manager at the time, who identified it as food thickener and verified the container was unlabeled and undated. .",2015-06-01
10217,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2010-04-15,253,E,0,1,WIXO11,"Based on observation and staff interview, the facility failed to provide housekeeping and/or maintenance services to maintain a sanitary, orderly, and comfortable interior. Eight (8) of eight (8) rooms of residents in the Stage I sample had walls and doors in poor repair. Room numbers: B200-A, B202-A, B205-B, B209-B, B210-A, B212-A, B214-A & B, and B217-A & B. Facility census: 118. Findings include: a) Observations of resident rooms, on the afternoon of 04/12/10 and throughout the day on 04/13/10, found the interior environment of the resident rooms were not in good repair as evidenced by chipped paint, gouges in the wall, scuffed marks and scrapes on doors to the bathrooms, and plaster chipped from the corners / edges of the walls, creating an interior that did not enhance quality of life for the residents occupying these rooms. The following rooms / beds were affected: B200-A, B202-A, B205-B, B209-B, B210-A, B212-A, B214-A & B, and B217-A & B. These issues were discussed with maintenance staff (Employee #53), and rounds made with him at 9:00 a.m. on 04/15/10, to show him specific issues identified as problem areas. .",2015-06-01
10218,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2010-04-15,281,D,0,1,WIXO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the medical record, observation, and staff interview, the facility failed to assure that services provided to the residents met professional standards of quality for two (2) of fifty (50) sampled residents. For Resident #128, weights were not recorded in a manner to allow the accurate assessment of the resident's nutritional status, and there was no evidence to reflect staff followed the facility's policy and procedure to assure weight loss was promptly addressed. For Resident #18, observation found eye drops were not administered as ordered by the physician. Facility census: 118. Findings include: a) Resident #128 Review of Resident #128's medical record revealed the weight record consisted of a form that provided, for each month, multiple spaces to record weights and the dates on which they were obtained. At the top of Resident #128's weight record, staff recorded his admission weight as 116.4 pounds (#) on 03/01/10. Also recorded in the month of March 2010 was a weight of 116.4# with no date noted as to when this weight was obtained. Upon reviewing the form, the medical records staff member (Employee #42) confirmed the resident's admission weight was written in the March 2010 column and verified this was only one (1) weight recorded on that form as of 04/13/10. The registered nurse (RN) case manager (Employee #142), when questioned as to why no further weights were recorded on this form for Resident #128 since his date of admission, informed this surveyor the resident's weights were recorded in the computer and she would have to print them off. At 10:00 a.m. on 04/13/10, Employee #142 provided a print out of all weights recorded in the computer for Resident #128. Review of the weights from the computer found the resident's admission ""base weight"" was recorded as 125#. When the resident was weighed on 03/23/10, his weight was 117#. According to this documentation, the resident lost 8.6# from 03/01/10 to 03/23/10. According to the medical record, the resident experienced an episode of decreased level of consciousness, his oxygen saturation decreased, and he developed a fever. He was transferred to the hospital and admitted with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED].) over a month period. Dietary Consult, notify POA."" This order was written while the resident was in the hospital, and there was no evidence to reflect these actions had been taken prior to that time, even though the weight loss was identified on 03/23/10. The resident was re-admitted on [DATE]. His weight on readmission was 112#. Upon his return to the facility, there was no evidence to reflect the notification of weight loss was given to the resident's family or a consult with the registered dietitian was arranged pursuant to the 04/05/10 order. A review of the facility's policy stated that, for residents showing a weight loss of 5# or more in one (1) month, staff was to notify the resident's responsible party and obtain an order a dietary consult. According to the policy, ""Section L on the MDS will be addressed by the care plan committee."" There was no evidence to reflect this policy had been followed when the resident's weight loss was identified on 03/23/10. During an interview with Employee #142 on 04/15/2010 at 9:15 a.m., she reported this recorded weight must have been entered wrong. She stated she did not think there had been a weight loss. She was no sure where the base weight of 125# had come from. She also verified the weight of 114# recorded in the resident's comprehensive admission assessment, with an assessment reference date of 03/08/10, was incorrect. (See also citation at F278.) Employee #142 stated she did not realize these weights were incorrect until the survey. The facility's policy was not followed regarding the interventions to be initiated in the event of a weight loss. b) Resident #18 During medication administration pass on 04/14/10 at 6:05 p.m., observation found Employee #36 prepared the resident's oral medications and placed her bottle of eye drops on a tissue on the Medication Administration Record [REDACTED]. She put the eye drops back into the drawer without having administered any. When asked about the eye drops, she agreed she had not given them. .",2015-06-01
10219,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2010-04-15,280,D,0,1,WIXO11,"**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 as needed for three (3) of twenty-one (21) residents in the Stage II sample, regarding the use of indwelling urinary catheters and hand splint devices. Resident identifiers: #104, #71, and #20. Facility census: 118. Findings include: a) Resident #104 This male resident had been in the facility with an indwelling urinary catheter inserted and was able to have it removed on 02/24/10. He was then hosptalized on [DATE], returning on 03/10/10. He returned to the facility with an order for [REDACTED]. Review of the resident's current care plan found a problem statement related to indwelling catheter dated 02/23/10, which was discontinued on 02/24/10. No new care plan was developed to address the presence of the catheter upon the resident's return from the hospital on 03/10/10. Interview with the registered nurse (RN) case manager (Employee #13), at 12:12 p.m. on 04/14/10, confirmed Resident #104's care plan had not been revised to address the use of the catheter when the resident returned from the hospital. b) Resident #71 This male resident was admitted to the facility without an indwelling urinary catheter on 05/09/08 and remained in the facility until he transferred to the hospital on [DATE]. He returned to the facility on [DATE], at which time he had an order for [REDACTED]. The resident's current care plan, dated 05/20/08 through 05/18/10, did not address the care and services for the use of a catheter during any of this time. There was a problem identified as potential for complications related to frequent urinary incontinence but nothing regarding catheter care. Employee #13, when interviewed at 12:16 p.m. on 04/14/10, acknowledged she had not revised the care plan upon Resident #71's return from the hospital to indicate the use of the indwelling catheter. c) Resident #20 This female resident had an abbreviated quarterly assessment with the assessment reference date of 02/09/10, which identified problems with range of motion on one (1) side with limitations of the arm, hand, leg, and foot. Resident #20's medical record also contained a physician order's, dated 03/12/10, to discontinue the use of hand splints. Interview with Employee #13 and a licensed practical nurse (Employee #54) found the use of the hand splints had been discontinued due to the resident refusing to wear them. The resident's current care plan (dated 08/21/07 to 05/18/10) identified a problem of limited physical mobility due to stiffness in joints, joint pain, and non-weight bearing status due to history of fracture right knee. Current interventions included the application of hand splints to to both hands. Interview with Employee #13, at 12:15 p.m. on 04/14/10, confirmed she had not revised the resident's care plan once the splints were discontinued on 03/12/10. .",2015-06-01
10220,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2010-04-15,279,D,0,1,WIXO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, resident interview, and staff interview, the facility failed to develop for each resident a comprehensive care plan that accurately described the services to be received. The interdisciplinary care plans for three (3) of twenty-one (21) Stage II sample residents did not address important resident-specific issues including the use of thickened liquids to prevent aspiration, the care needs of a resident with an indwelling urinary catheter, or the measures that were required for a resident who was on a scheduled toileting plan. Resident identifiers: #128, #39, and #51. Facility census: 118. Findings include: a) Resident #128 Review of Resident #128's comprehensive care plan revealed a plan for the potential for aspiration due to the resident's [DIAGNOSES REDACTED]. There was no intervention to assure the resident received thickened liquids. During the dinner meal on 04/12/10, observation found this resident being fed by staff, and all liquids sitting in front of him were found to have been thickened. Further review of the medical record revealed a physician's orders [REDACTED]. This intervention was not included on the care plan when it was updated on 04/09/10 to include the potential for aspiration. An interview with the registered nurse (RN) case manager (Employee #142), on 04/14/10 at 4:00 p.m., confirmed this was not included in the resident's care plan. b) Resident #39 Review of the resident's medical record found the care plan for the resident's urinary incontinence was not consistent with the comprehensive assessment. The assessment identified the resident was on a scheduled toileting plan, but no plan had been developed that was reflective of a scheduled toileting plan. The quarterly assessment with an assessment reference date (ARD) of 09/16/09, the annual assessment with an ARD of 12/16/09, and the quarterly assessment with an ARD of 03/17/10, were all coded to indicate the resident was on a scheduled toileting plan (H3a = ""Any scheduled toileting plan""). The ""Revised Long-Term Care Facility Resident Assessment Instrument User's Manual"", on page 3-125, includes: ""For residents on a scheduled toileting plan, the care plan should at least note that the resident is on a routine toileting schedule. A resident's specific toileting schedule must be in a place where it is clearly communicated, available to and easily accessible to all staff, including direct care staff. . . ."" According to the resident in an interview in late afternoon on 04/14/10, she was able to tell staff when she needed to void. According to a nursing assistant (Employee #89) in an interview on 04/15/10 at 9:46 a.m., the resident was usually continent but had needed a bit more help since she returned from the hospital. The nursing assistant said the resident just wore briefs for ""safety"". In an interview on the afternoon of 04/14/10, Employee #63 (a licensed practical nurse (LPN)) said the nursing assistants helped the resident to the bathroom. She also said the resident was usually continent and had required more help since her return from the hospital. When interviewed on 04/15/10 at 10 50 a.m., regarding whether residents were assessed for continence status upon initial admission to the facility, another LPN (Employee #54) said, ""They tell us whether they are continent or not."" She was unaware of any assessment or voiding diary being done to determine what type of incontinence management program was needed. Review of the resident's care plan found a goal of: ""Resident will not experience any urinary complications by next review date in 90 days as evidenced by no development of skin breakdown or UTI (urinary tract infection)."" The interventions were: ""Check at least q2h (every two hours) for incontinence. Wash, rinse and dry soiled areas. Change clothing prn (as needed) after incontinence episodes; Encourage adequate fluid intake of recommended range (1250 cc - 1775 cc Q 24 hrs.) Offer fluids between meals; Observed for s/sx (signs / symptoms) of UTI. . . .; Follow up with urologist as ordered, . . . ; Obtain labs as ordered . . . ; Allow for resident to perform as much of toileting activity as possible and assist when needed."" This care plan did not indicate the resident was on a scheduled toileting plan or that she was to be taken to the bathroom. The care plan also did not recognize the resident was often continent. c) Resident #51 Review of Resident #51's care plan found a problem statement (dated 06/15/09 through 06/15/10) regarding the resident's potential for dehydration related to UTI, indwelling Foley urinary catheter, and drug toxicity. The interventions associated with this problem statement did not address services to be provided for catheter use, and there was no other problem statement addressing catheter use. This female resident had been hospitalized during this time frame, and her readmission history and physical (dated 09/02/09) stated she had [MEDICAL CONDITION] with attempts made at the hospital to remove the catheter; the resident had significant residual urine, and the catheter had to be reinserted Discussion with the RN case manager (Employee #13), on 04/14/10 at 12:12 p.m., confirmed she had not addressed the care needs of maintaining the urinary catheter in the resident's current care plan. .",2015-06-01
10221,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2010-04-15,514,E,0,1,WIXO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, care plan review, and staff interview, the facility failed to maintain clinical records that were complete and accurate for two (2) of twenty-one (21) Stage II sampled residents. Resident #77's previous care plans addressing nutritional status were not available for review. Resident #128's weights were not recorded accurately in the electronic medical record. Additionally, the facility did not record the day, month, and year on which weights are obtained for residents who were being weighed monthly, which would interfere in accurately determining when a significant weight change occurred; this practice had the potential to affect more than an isolated number of residents. Resident identifiers: #77 and #128. Facility census: 118. Findings include: a) Resident #77 On 04/15/10 at approximately 1:00 p.m., medical record review for Resident #77 revealed she had a history of [REDACTED]. The nutritional status resident assessment protocol (RAP), dated 12/30/09, indicated this issue would be addressed in the resident's care plan. Further review of her medical record found documentation suggesting the resident's care plan had not addressed her nutritional status until 04/07/10. The assessment coordinator indicated the dietary manager had addressed the issue in prior care plans but had not saved copies of her work. She stated no one had ever shown the dietary manager how to save copies of her care plans and not delete them each time she updated her work. The resident's current care plan, dated 04/07/10, had addressed the problem of nutritional status, but no other documentation could support that the facility had care planned this issue prior to 04/07/10. b) Resident #128 1. Review of Resident #128's medical record revealed the weights had been inappropriately entered into the computer. The resident's admission weight were entered on the weight record as being 125.60#, and entered into the comprehensive admission assessment dated [DATE] as 114#. During an interview with the registered nurse (RN) case manager (Employee #142) on 04/15/10 at 9:15 a.m., she stated these weights must have been entered incorrectly and she did not think there had been a weight loss. She was not sure where the 125.6# weight came from and confirmed she had not previously identified the error in these weights. 2. It was also confirmed that the facility's practice was to record the month and year - but not the exact day - a weight is obtained. This was done for all of the residents in the facility who were not ordered to be weighed at a special frequency (e.g., daily or weekly). This practice would prevent the facility from accurately determining when a significant weight change for a given resident had occurred.",2015-06-01
10222,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2010-04-15,278,D,0,1,WIXO11,". Based on medical record review, resident interview, and staff interview, the facility failed to ensure the accuracy of comprehensive assessments of two (2) of thirty (30) residents on the Stage II sample. One (1) resident's assessment was not coded in accordance with the instructions in the ""Revised Long-Term Care Facility Resident Assessment Instrument User's Manual"" (RAI User's Manual), and one (1) resident's weights were not accurately reflected. Resident identifiers: #39 and #128. Facility census: 118. Findings include: a) Resident #39 The quarterly assessment with an assessment reference date (ARD) of 09/16/09, the annual assessment with an ARD of 12/16/09, and the quarterly assessment with an ARD of 03/17/10 were all coded to indicate the resident was on a scheduled toileting plan (H3a = ""Any scheduled toileting plan""). According to a nursing assistant (Employee #89) in an interview on 04/15/10 at 9:46 a.m., the resident was usually continent. The resident had needed a bit more help since she returned from the hospital. She just wore briefs in case she had an accident. The nursing assistant added that she took the resident to the bathroom in the morning, before and after meals, at bedtime, and anytime the resident asked to be taken. According to the resident in an interview in late afternoon on 04/14/10, she was able to tell staff when she needed to void. The RAI User's Manual, on page 3-125, includes: ""For residents on a scheduled toileting plan, the care plan should at least note that the resident is on a routine toileting schedule. A resident's specific toileting schedule must be in a place where it is clearly communicated, available to and easily accessible to all staff, including direct care staff. . . ."" In order for this item to have been marked on the above-referenced assessments, the scheduled toileting plan must have been specifically addressed in the resident's comprehensive care plan. Since there was no mention of a specific scheduled toileting plan on the resident's care plan, these assessments were inaccurate. (See also citation at F279.) b) Resident #128 In Section K of the resident's comprehensive admission assessment with an ARD of 03/08/10, this resident's weight was recorded as 114 pounds (#). Review of the resident's medical record found his weight on admission, on 03/01/10, was 116#. The resident's weight, when taken again on 03/23/10, was 117#. In an interview on 04/14/10 at 9:00 a.m., the registered nurse (RN) case manager on the south unit (Employee #142) acknowledged the weight recorded on the resident's admission assessment was incorrect due to a data entry error. There was no evidence in the medical record that the resident's weight was ever 114# as noted on this assessment. .",2015-06-01
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
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
10141,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-05-05,225,E,0,1,MKQ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on record review, staff interview, and policy review, the facility failed to immediately report the allegations of neglect and/or complete the five-day follow-up reports to the State survey agency as required. This was true for three (3) of thirty (30) Stage II sample residents. Resident identifiers: #61, #93, and #98. Facility census: 101. Findings include: a) Resident #61 The facility's concern log, when reviewed on 04/28/10 at 10:00 a.m., disclosed Resident #61 had reported an allegation of neglect to the facility staff on 03/18/10. There was no evidence this allegation was reported to the State survey agency as required. The administrator, when interviewed on 04/29/10 at 9:15 a.m., reviewed the facility form titled ""Record of Complaint"" and acknowledged neither an immediate report nor a five-day follow-up report had been submitted to the State survey agency as required. The social worker (Employee #51), when interviewed on 05/05/10 at 3:15 p.m., confirmed this allegation was not reported to the State survey agency as required. b) Resident #93 The facility's concern log, when reviewed on 04/28/10 at 10:00 a.m., disclosed Resident #93's son reported an allegation of neglect to the administrator on 03/24/10. There was no evidence this allegation was reported to the State survey agency as required. The administrator, when interviewed on 04/29/10 at 9:15 a.m., reviewed the facility form titled ""Record of Complaint"" and acknowledged neither an immediate report nor a five-day follow-up report had been submitted to the State survey agency as required. Employee #51, when interviewed on 05/05/10 at 3:15 p.m., also confirmed this allegation was not reported to the State survey agency as required. c) Resident #98 The facility's concern log, when reviewed on 04/28/10 at 10:00 a.m., disclosed Resident #98's medical power of attorney representative (MPOA) reported an allegation of neglect to the facility staff on 04/19/10. There was no evidence the allegation was reported to the State survey agency as required. The administrator, when interviewed on 04/29/10 at 9:15 a.m., reviewed the facility form titled ""Record of Complaint"" and acknowledged neither an immediate report nor a five-day follow-up report had been submitted to the State survey agency as required. Employee #51, when interviewed on 05/05/10 at 3:15 p.m., also confirmed this allegation was not reported to the State survey agency as required. d) The facility's policy on abuse and neglect (titled ""Suspected Abuse Investigation and Reporting"" with a revision date of 08/26/05), when reviewed on 05/05/10 at 4:00 p.m., disclosed on page 111-E-25: ""Report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation."" The facility failed to report the above allegations of neglect as required by the facility's own policy. --- Part II -- Based on review of personnel records and staff interview, the facility failed to ensure new employees were screened for findings entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. This was true for six (6) of ten (10) sampled employee personnel files reviewed. Employee identifiers: #134, #44, #39, #40, #88, and #21. Facility census: 101. Findings include: a) Sampled employees' personnel records, when reviewed on 05/03/10 at 3:00 p.m., found no evidence the facility screened Employees #134, #44, #39, #40, #88, and #21 for findings entered into the State nurse aide registry prior to their employment at the facility, as required. Interview with the medical records coordinator (Employee #99), on 05/03/10 at 4:00 p.m., confirmed the pre-employment screening against the State nurse aide registry was not completed for Employees #134, #44, #39, #40, #88, and #21. Employee #99 reported she was unaware of this requirement. .",2015-06-01
10142,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-05-05,279,E,0,1,MKQ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, resident interview, and staff interview, the facility failed to develop comprehensive care plans addressing infection control, dehydration, [MEDICAL CONDITION], depression, and indwelling catheter care for five (5) of thirty (30) Stage II sample residents. Resident #143 had infectious diarrhea and poor oral intake of fluids; no care plan had been developed to promote effective hand washing by this alert and oriented resident (to prevent the spread of infection) or to ensuring he was adequate hydrated. Resident #54 was receiving [MEDICATION NAME] every night for [MEDICAL CONDITION], and no care plan had been developed to address the [MEDICAL CONDITION] with interventions to promote sleep or determine the cause. This resident (#54) also was being monitored for [MEDICAL CONDITION] and other vision problems, had glasses available but was not wearing them, stated she could not see with them on, but no care plan had been developed to address her problems with vision. Resident #139 was receiving [MEDICATION NAME] every night for [MEDICAL CONDITION], and no care plan had been developed to address this problem. Resident #118 had an indwelling urinary catheter which was being used for wound healing, but a care plan had not been developed to address catheter care. Resident #19 was receiving multiple antidepressants, but no care plan had been developed with interventions addressing depression. Resident identifiers: #143, #54, #139, #118, and #19. Facility census: 101. Findings include: a) Resident #143 Medical record review for Resident #143 revealed this resident had a [DIAGNOSES REDACTED]. diff). According to his nursing notes, he was experiencing diarrhea daily. 1. An interview was conducted with a nursing assistant (Employee #55) at 4:35 p.m. on 05/04/10, regarding Resident # 143's toileting habits. Employee #55 stated Resident #143 was mostly continent, but he had diarrhea and was sometimes incontinent. He was also noncompliant and needed assistance, although he took himself to bathroom sometimes. He had a broken leg / knee and needed assistance with transferring. Employee #55 stated, ""After you put him on the toilet,he often cleans himself before you come back to help him."" At 4:45 p.m., Employee #55 was asked if she would have resident to wash his hands before he went to the dining room, in order for the surveyor to observe the resident's handwashing technique. Employee #55 agreed and entered this resident's room. After asking the resident if he was ready to go wash his hands for dinner, Employee #55 donned a pairs of gloves and assisted the resident in transferring to his wheelchair. He told her, ""I can wash my own hands."" Employee #55 placed Resident #143 in front of the sink. He turned the water on full blast, and the water splashed all over him and around the sink. He then stuck his hands under the stream of water and rinsed them for seven (7) seconds. He reached up with his wet hands, turned off the water, and obtained a paper towel. He never applied soap to his hands, nor did he use friction when washing his hands. Resident #143 did not effectively wash his hands to prevent the transmission of the [DIAGNOSES REDACTED] throughout the facility. Record review found no care plan had been developed to address Resident #143's non-compliance with the contact isolation precautions, including his inadequate handwashing practices. There were no instructions provided (except ""assist him to wash his hands"") to assure this resident did not spread this infectious organism to his immunocompromised roommate and throughout the entire facility, even though the facility was aware that he often provided his own handwashing and his hand hygiene practices were inadequate to prevent the spread of infection. (See also citations at F224 and F441.) 2. Resident #143's nursing assistant flow sheets revealed he had been refusing his meals, and his fluid intake was only 600 cc in twenty-four (24) hours. He was also receiving a daily diuretic medication ([MEDICATION NAME] 40 mg) and experienced repeated bouts of diarrhea related to the [DIAGNOSES REDACTED]. These issues made this resident a high risk for dehydration. The director of nursing (DON), when interviewed on 04/29/10 at 10:00 a.m., verified there was no evidence this had been included in his plan of care. b) Resident #54 1. Medical record review, on 05/03/10, disclosed this resident had been receiving [MEDICATION NAME] 12.5 mg every night for [MEDICAL CONDITION] since the last gradual dose reduction on 10/22/09. Review of the resident's comprehensive care plan, dated 02/25/10, found no care plan had been developed to address the problem of [MEDICAL CONDITION], with goals and non-pharmacologic interventions for [MEDICAL CONDITION] to promote sleep or to determine the cause of the resident's [MEDICAL CONDITION]. In an interview on 05/03/10 at 3:00 p.m., the DON confirmed no care plan had been developed for the problem of [MEDICAL CONDITION] for this resident. 2. Medical record review also disclosed this resident was being followed by a vision consultant for problems of [MEDICAL CONDITION] and other vision concerns. In an interview on 04/28/10 at 2:00 p.m., Resident #54 revealed she had glasses but did not wear them. The resident stated the glasses no longer helped her to read or see at a distance. Interviews conducted with direct care staff, on the morning of 04/29/10, found the staff had never observed this resident wearing glasses. In an interview on 05/04/10 at 10:30 a.m., the social worker (Employee #51) also reported not having seen this resident wearing glasses. The social worker had no knowledge of when the glasses - or the resident's vision acuity - were last evaluated. The social worker noted the resident has been seen by an optometrist every three (3) to four (4) months to track the progress of her [MEDICAL CONDITION] and other eye / vision problems, but she had no knowledge of the resident's glasses. Review of the resident's annual comprehensive assessment, with an assessment reference date of 11/30/09, found the problem of vision had triggered for further assessment, but the interdisciplinary team decided to not proceed with care planning for vision problems. Review of the comprehensive care plan, last updated on 02/25/10, found a plan to address the [MEDICAL CONDITION], but there was no plan to address the resident's visual acuity. c) Resident #139 Medical record review, on 04/28/10, disclosed this resident had been admitted to the facility on [DATE] and was receiving 1 mg of [MEDICATION NAME] every night for [MEDICAL CONDITION]. Review of the resident's comprehensive care plan, with a review date of 02/25/10, found no mention of the problem of [MEDICAL CONDITION] with non-pharmacologic interventions to promote sleep. During an interview on 05/04/10 at 1:30 p.m., the DON confirmed the problem of [MEDICAL CONDITION] had not been addressed on the care plan with non-pharmacologic interventions to promote sleep. d) Resident #118 Medical record review revealed Resident #118 [MEDICAL CONDITION] her upper thighs related to her own accidental coffee spill, which caused blistering of her upper thighs and the subsequent insertion of an indwelling urinary catheter to aid in wound healing. Review of the care plan, printed on 04/28/10 at 11:34 a.m., found it cited the presence of an indwelling catheter related [MEDICAL CONDITION] the resident's inner thighs under the ""problem"" area of the care plan, and the goal was to remain free of signs of infection. Approaches included medications and monitoring of side effects, monitoring vital signs during infections, noting characteristics of urine, monitoring labs, promoting fluid intake, using good handwashing before and after care, helping the resident to wash her hands. However, there was no mention of care to be provided related to the indwelling urinary catheter nor of the facility's policy for catheter care. Also, the care plan did not address psychosocial components related to how the resident felt about having the catheter, such as embarrassment or social withdrawal. During interview with the care plan coordinator (Employee #41) on 04/29/10 at 9:30 a.m., she reviewed the resident's care plan and acknowledged having missed care planning for the catheter care. She stated she always care planned with words such as ""catheter care per policy"", as the facility had policy in place for catheter care. During interview with the DON on 05/03/10, she stated the facility had 'standards of practice' approaches for catheter care and they did not list them on the care plan; rather, they tried to keep the care plans short and readable. She produced a policy on urinary catheters (revised in 2010) that listed nine (9) areas in catheter usage and care. f) Resident #19 Resident #19's medical record, when reviewed on 04/28/10 at 11:00 a.m., disclosed this resident was currently under the care of a psychiatrist for latent [MEDICAL CONDITION], dementia with behavioral disturbances, anxiety, and depression. Review of the current physician's orders [REDACTED]. Review of the resident's comprehensive care plan, dated 02/15/10, revealed the facility failed to identify the problem of depression and develop a comprehensive care plan that included the use of these antidepressants. Employee #41, when interviewed on the morning of 04/29/10, acknowledged the problem of depression and resident-specific goals and interventions were not included in the comprehensive plan of care. .",2015-06-01
10143,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-05-05,280,D,0,1,MKQ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to revise care plans as required for two (2) of thirty (30) Stage II sample residents in the areas of nutrition and use of psychoactive medications. Resident identifiers: #93 and #143. Facility census: 101. Findings include: a) Resident 93 Medical record review revealed Resident #93 began an antidepressant ([MEDICATION NAME] 30 mg daily) on 03/26/10, with to treat a [DIAGNOSES REDACTED]. Review of the resident's care plan (printed on 04/28/10 at 11:33 a.m.) revealed this resident had a problem with refusing to eat solid food. However, there was no mention in the care plan about the addition of the antidepressant as an appetite stimulant. Review of the current care plan also revealed problems of restlessness, anxiety, and melancholy mood at times, but her care plan was not revised to include the addition of antidepressant therapy to address her mood state. During an interview on 04/29/10 at 9:30 a.m., the care plan coordinator (Employee #41) acknowledged having overlooked revising the care plan for the [MEDICATION NAME], although she recalled seeing the physician's orders [REDACTED]. b) Resident #143 Review of Resident #143's medical record revealed he had experienced a significant weight loss. Although it was identified on his care plan, there was no evidence the facility revised the care plan to include a consult by the registered dietitian (RD) or her recommendations for addressing the weight loss. The dietary manager (Employee #149), when interviewed on 05/04/10 at 8:30 a.m., confirmed this resident had not been seen by the RD since his admission date of [DATE], and no RD recommendations were included in his care plan to address weight loss. (See also citation at F325.) .",2015-06-01
10144,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-05-05,309,G,0,1,MKQ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, resident interview, and staff interview, the facility failed to assess and treat pain for one (1) of thirty (30) Stage II sample residents. Resident #146 complaint of pain daily while receiving physical therapy and during repositioning with daily care, but she was not assessed for and treated with an [MEDICATION NAME] as ordered by the physician. Resident identifier: #146. Facility census: 101. Findings include: a) Resident #146 Medical record review, on 05/04/10 at 8:15 a.m., disclosed a [AGE] year old female resident who was admitted to the facility from an acute care on 04/16/10 with [DIAGNOSES REDACTED]. The initial pain assessment, dated 04/17/10, noted the resident reported having ""ache stabbing"" pain. Review of the physician orders, dated 04/16/10, reveal the physician had ordered [MEDICATION NAME] 325 mg two (2) tablets every four (4) hours for mild pain and [MEDICATION NAME] 5 mg- 500 mg one (1) tablet every four (4) hour for moderate to severe pain. Review of the Medication Administration Record [REDACTED]. The resident also received [MEDICATION NAME] two (2) tabs at 8:41 a.m. on 04/28/10. The resident was observed in bed in her room on 04/26/10, 04/27/10, 04/28/10, 04/29/10, 05/03/10, on multiple occasions between the hours of 8:00 a.m. and 6:30 p.m. The resident did not smile, spoke in a soft voice, and had a sad facial expression. The resident did not have any visitors when observed. When interviewed during one (1) of these observations, the resident reported having had a fall at home in December 2009, resulting in a fractured left ankle. The resident also reported she has had multiple admissions to acute care hospitals or long term care facilities since the fall. The registered nurse supervisor (RN - Employee #97), when interviewed on 05/03/10 at 9:00 a.m., reported the resident had not been transferred out of bed due to the resident's refusal and pain in the lower extremities. The RN reviewed the medical record and could not find documentation the resident refused care or was counseled to the health risks of not getting out of bed for extended periods of time. Review of the nurse notes, dated from 04/16/10 through 05/02/10, failed to show written evidence the resident has refused to get out of bed. The MAR indicated [REDACTED] The physical therapist assistant (PTA - Employee #150), when interviewed on 05/04/10 at 10:55 a.m., revealed the resident complained of pain to the lower extremities daily during physical therapy exercises. The PTA stated she was able to provide therapy to the residents's upper extremities daily; however, the resident did not tolerate therapy to the lower extremities due to pain. The PTA, when asked if she reported the resident's daily complaints of pain to the nurse or physician, stated, ""No."" Observation found Resident #146 in her room at 12:15 p.m. on 05/04/10. When this alert resident was asked if she was in pain, she reported she experienced pain when she was moved or having physical therapy to her lower legs. The resident rated the pain to be an ""8"" on a scale of ""1"" to ""10"", with ""10"" representing excruciating pain. The resident reported the pain occurred when her lower legs were moved during repositioning and during physical therapy. The care plan coordinator (Employee #41), when interviewed on 05/04/10 at 1:00 p.m., reported the resident's initial care conference was held today and the team did not discuss the resident's daily complaints of pain. The therapy director (Employee #151), when interviewed on 05/04/10 at 2:35 p.m., revealed Employee #150 had reported the resident had ""pain a few times"" to the therapy director; however, the therapy director stated she was unaware of the resident's ""daily complaints of pain"" and stated Employee #150 ""should have reported the complaints of pain to the nurse"". A nurse aide (Employee #42), when interviewed on 05/04/10 at 2:45 p.m., stated Resident #146 had ""daily pain"" in her lower extremities when care was provided. The nurse aide stated she had reported the pain to the nurse. The licensed practical nurse (LPN - Employee #73), when interviewed on 05/05/10 at 10:00 a.m., stated she was not informed of the resident's complaints of pain by the therapy staff or by the nurse aide. The LPN reported that, when she had assessed the resident for pain, the resident had denied pain, but the resident was resting in bed and not engaged in activity or therapy at those times. The LPN stated she was going to call the doctor to get a ""straight order for pain medication daily"". Review of the resident's pain assessment, dated 04/17/10 at 11:12 p.m., revealed the resident described her pain as ""ache stabbing"". Subsequent pain assessments, dated 04/18/10, 04/20/10, and 04/23/10, revealed the resident had pain daily, and this pain occurred ""at various times"". The pain assessments failed to rate the intensity, location, and/or activity level of the resident. The director of nurses (DON - Employee #127), when interviewed on 05/04/10 at 2:00 p.m., acknowledged the pain assessments documented in the medical record were not comprehensive and reported she was unable to provide any written evidence the resident was assessed and treated for [REDACTED]. .",2015-06-01
10145,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-05-05,312,D,0,1,MKQ811,". Based on observations, resident interview, and family interview, the facility failed to assure Resident #44 received the assistance she needed at meal times. Observation found staff did not ensure Resident #44 had her dentures in place before taking her to the dining room for meals. This occurred on two (2) different occasions. This resident had experienced a significant weight loss, and she reported she was unable to chew a lot of things without her dentures. This was true for one (1) of thirty (30) Stage II sampled residents. Resident identifier: #44. Facility census: 101. Findings include: a) Resident #44 During the evening meal on 04/26/10 at 6:00 p.m., observation found Resident #44 in the dining room. She did not have any teeth in, and she stated she could not eat without her dentures. An unidentified staff member was observed to go get them and bring them to her. She only had upper dentures. In an on 04/27/10, a family member she stated that, when she comes in to visit Resident #44, staff always forgets to put in her dentures to eat. The family member stated she has had to go to the resident's room and get her dentures. She stated Resident #44 always wore her dentures, but she now needed assistance with them because she forgets. Observation, during the evening meal on 04/27/10 at 6:15 p.m., again found Resident #44 in the dining room without her dentures. The resident, when interviewed about her dentures, said, ""I would like to have them. I cannot eat without them."" The dietary manager (Employee #149), who was observing this dinner meal, was made aware of this resident's need for her dentures. She talked to the staff, after which her dentures were then obtained and placed in her mouth. .",2015-06-01
10146,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-05-05,314,D,0,1,MKQ811,". Based on record review, observation, and staff interview, the facility failed to assure that measures were implemented as ordered by the physician to prevent the development of pressure ulcers for one (1) of thirty (30) Stage II sample residents. Staff did not apply bilateral heel protectors while in bed to reduce friction and prevent skin breakdown for Resident #53. This resident was dependent on staff for bed mobility, and she had unstageable area of eschar on her right heel. She had a heel protector on her right heel, but her left heel was observed to be directly pressing on the mattress without any intervention as ordered by the physician. This was observed on two (2) occasions on 04/28/10. Resident identifier: #53. Facility census: 101. Findings include: a) Resident #53 Observation of the application of a treatment to Resident #53's heel, on 04/28/10 at 9:20 a.m., found she had no heel protector on left heel, and this heel was pressing directly into the mattress. A heel protector was noted to be present on the right heel only. A review of the medical record revealed the resident had an order, written on 02/19/10, to have heel protectors applied to both heels. The resident care plan, dated 03/17/10, included an intervention to have heel protectors to both heels when in bed. The director of nursing (DON) was asked to accompany this surveyor at 2:00 p.m. 04/28/10, to examine the resident's feet. At that time, the resident's feet were observed to be in the same position they were in earlier that morning. Resident #54 still did not have a heel protector on her left heel at that time, four and one-half (4-1/2) hours after the initial observation. The DON obtained another heel protector for the resident at that time. .",2015-06-01
10147,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-05-05,325,G,0,1,MKQ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, observation, and resident interview, the facility failed to assure Resident #143's nutritional status was assessed by a registered dietitian (RD) or that nutritional interventions were implemented for a resident who experienced a severe weight loss of 29 pounds (#) in one (1) month. This was true for one (1) of thirty (30) Stage II sample residents. Resident identifier: #143. Facility census: 101. Findings include: a) Resident #143 1. Resident #143 was admitted to this facility from the hospital on [DATE], after falling and sustaining a fracture of his knee. He was being treated for [REDACTED]. diff), which caused him to have repeated bouts of diarrhea. His wife was already a resident at this facility, and he would come in daily to visit her prior being admitted himself. His admission weight, on 03/25/10, was 200#. The second time his weight was measured, on 04/01/10, it was 190#. He had lost 10# in one (1) week. His next weight, on 04/07/10, was 178#. On 4/15/2010, he weighed 171#. On 04/19/10, he complained abdominal pain, nausea, and anorexia and was transferred, then admitted to, the hospital. His weight, upon from the hospital on [DATE], was 171#. The minimum data set assessment, with an assessment reference date of 03/29/10, noted he was leaving greater than twenty-five percent (25%) of his meals uneaten. He was also receiving a therapeutic diet. The resident assessment protocol (RAP) for nutritional status, dated 04/05/10, contained the following recommended interventions: ""RD evaluation and Speech Therapy evaluation as needed."" 2. An interdisciplinary weight loss meeting was held on 04/09/10, at which time the interdisciplinary team (IDT) noted he had experienced an eleven percent (11%) weight loss in one (1) week. According to an IDT progress note, the physician was notified of this loss. Also noted was the resident had been receiving antibiotics for an upper respiratory tract infection, and the probable cause for the weight change was attributed to the resident having received intravenous (IV) fluids in the acute care setting prior to admission to this facility. The IDT spoke with the resident, and he was quoted as saying, ""I don't eat like I used to"" and ""I don't work like I used to."" A nurse (Employee #97) was asked to assess this resident with the surveyor at 11:00 a.m. on 05/04/10. This resident stated to the nurse, ""I do not have an appetite anymore."" The nurse ask him when this started, and he stated, ""When I fell "". There was no evidence that either of these comments was explored further to determine identify possible psychosocial factors that may have been contributing to his loss of appetite. 3. The initial care plan for this resident, established on 04/12/10, identified he had experienced a significant weight loss. Interventions to address the weight loss included: monitoring labs, monitoring bowel sheets, monitoring food intake, weighing the resident, recording his stools, recording his food intake, assisting with eating, encouraging a variety of foods, offering shakes, offering replacement foods, determining food likes and dislikes, and providing the physician-ordered diet. There were no interventions aimed at identifying why this weight loss was occurring. In addition, the care plan did not include interventions such as having the RD assess his weight loss, obtaining an order from the physician for an appetite stimulant, having the social worker further assess to see if he was experiencing depression (as the anorexia could have been linked to depression), asking this alert and oriented resident who is alert and oriented why he was refusing meals, and/or involving him in activities to stimulate his appetite. 4. The resident's dietary progress note, written by the dietary manager (Employee #149) on 04/13/10, stated the resident had a new problem - significant weight loss of eleven percent (11%) in one (1) week, and he was leaving more than twenty-five percent (25%) of his meals uneaten. 5. The next interdisciplinary weight loss meeting was held on 04/15/10. An IDT note written on this date reflected the resident had lost another 9# and acknowledged the total weight loss of 29# in one (1) month. At that time, the resident was recorded as commenting that his appetite wasn't ""what it used to be"" and stated that, on occasion, he had nausea. The physician was notified of this weight loss via fax, and action taken was to initiate sugar-free mighty shakes with meals, obtain a nutritional panel on 04/16/10, change his food consistency to mechanical soft chopped meat, and continue to offer snacks and substitutes. This note also stated ""requesting appetite stimulant"" and weigh weekly. 6. Review of the communication form, faxed to the physician on 04/15/10, found: ""Resident not eating, (arrow pointing down) 29 pounds in 1 month. Changed diet to mech (mechanical) soft chopped meat, added sugar free supplement tid (three-times-daily), getting labs in the a.m. (morning). At times he complains of stomach upset. Has no stomach meds (medications). Can we try [MEDICATION NAME]?"" The physician signed this communication form to indicate he saw it, but there was no date with the signature. The director of nursing (DON) stated the physician did not respond to the request for [MEDICATION NAME] (appetite stimulant). She was unable to find evidence to reflect that anyone followed up on this. The resident was admitted to the hospital on [DATE]. 7. Further review of the resident's dietary records found no evidence that resident, who had been admitted on [DATE], had not been evaluated by the RD as of 05/03/10, when this surveyor reviewed the resident's record. The dietary manager had made a note on 04/29/10, stating, ""Initial Re-Admission assessment from the hospital stay. Resident readmitted on [DATE]."" This note also contained a recommendation that he receive a multivitamin with iron for nutritional supplementation. This readmission assessment was completed eight (8) days after this resident returned to the nursing home; he had been out in the hospital for three (3) days. The dietary manager (Employee #149), when interviewed on 05/04/10 at 8:30 a.m., confirmed this resident had not been assessed by the RD. She stated she was ""not sure why she (the RD) has not seen him yet, but she comes on Thursday, and she will have her look at him this Thursday."" NOTE: This surveyor observed the RD had been in the facility on the previous Thursday, 04/29/10. There was no evidence she reviewed this resident's weight loss or assessed his nutritional needs at that time. 8. Further review of the medical record, on 05/04/10, revealed this resident had refused five (5) of the last nine (9) meals served and had consumed less than half of the other four (4) meals. His daily fluid intake for May 2010 had been less than 1000 cc daily, and his total daily fluid intake was very low on the following days: 05/01/10 - 840 cc; 05/02/10 - 960 cc; and 05/03/10 - 600 cc. His bowel elimination records indicated the resident had experienced bouts of diarrhea thirteen (13) times during the first three (3) days of May 2010, as well as three (3) large bowel movements. However, the nursing notes, when reviewed, contained no references to this resident's poor intake of food and fluids, nor of his continual diarrhea during the first three (3) days of May 2010. Employee #97, when questioned about the facility's procedure for identifying abnormal findings such as decreased meal intake and decreased fluid intake as recorded on the nursing assistants' activities of daily living sheets, reported night shift looked at these records then communicated the findings, but that nursing assistants should also communicate these findings to the nurse. She was asked to print a copy of the Medication Administration Record [REDACTED]. 9. A therapy screen communication request was completed on 05/04/10, after this surveyor question staff about the resident's poor intake. This request was made to upgrade the consistency of his food. This form stated the resident does not want pureed food, and the family had been bringing in other food items. There was no evidence in the record to reflect staff was aware the family was bringing food to Resident #143 or why. .",2015-06-01
10148,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-05-05,327,D,0,1,MKQ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a record review, observation, and staff interview, the facility failed to assure one (1) of thirty (30) Stage II sample residents received care and services to maintain proper hydration and health. The facility failed to adequately assess / monitor and implement interventions to ensure Resident #143, who had poor food and fluid intake, experienced a severe weight loss, and was having diarrhea, was well hydrated. Resident identifier: #143. Facility census: 101. Findings include: a) Resident #143 1. Resident #143 was admitted to this facility from the hospital on [DATE], after falling and sustaining a fracture of his knee. He was being treated for [REDACTED]. diff), which caused him to have repeated bouts of diarrhea. His wife was already a resident at this facility, and he would come in daily to visit her prior being admitted himself. His admission weight, on 03/25/10, was 200#. The second time his weight was measured, on 04/01/10, it was 190#. He had lost 10# in one (1) week. His next weight, on 04/07/10, was 178#. On 4/15/2010, he weighed 171#. On 04/19/10, he complained abdominal pain, nausea, and anorexia and was transferred, then admitted to, the hospital. His weight, upon from the hospital on [DATE], was 171#. The minimum data set assessment, with an assessment reference date of 03/29/10, noted he was leaving greater than twenty-five percent (25%) of his meals uneaten. He was also receiving a therapeutic diet. The resident assessment protocol (RAP) for nutritional status, dated 04/05/10, contained the following recommended interventions: ""RD evaluation and Speech Therapy evaluation as needed."" Documentation on the dehydration RAP noted the resident was taking a daily diuretic and was at risk for inadequate fluid intake. However, the interdisciplinary team (IDT) decided to NOT proceed with addressing dehydration on his care plan, stating, ""No special interventions needed. Average daily intake is good at 1560 cc."" 2. An IDT weight loss meeting was held on 04/09/10, at which time the IDT noted he had experienced an eleven percent (11%) weight loss in one (1) week. According to an IDT progress note, the physician was notified of this loss. Also noted was the resident had been receiving antibiotics for an upper respiratory tract infection, and the probable cause for the weight change was attributed to the resident having received intravenous (IV) fluids in the acute care setting prior to admission to this facility. The IDT spoke with the resident, and he was quoted as saying, ""I don't eat like I used to"" and ""I don't work like I used to."" 3. The initial care plan for this resident, established on 04/12/10, did not address his daily fluid intake needs. There was no care plan to address the resident's risk for dehydration or electrolyte imbalance related to his repeated bouts of diarrhea, his low daily fluid intake, his daily use of a diuretic, or his severe weight loss. There was no evidence that any interventions were initiated or changes made to the resident's care plan to address his poor intake and continued diarrhea (such as offering popsicles, gelatin, or other similar non-liquid foods) to prevent dehydration. (See also citation at F279.) 4. The resident's dietary progress note, written by the dietary manager (Employee #149) on 04/13/10, stated the resident had a new problem - significant weight loss of eleven percent (11%) in one (1) week, and he was leaving more than twenty-five percent (25%) of his meals uneaten. The dietary manager had made a note on 04/29/10, stating, ""Initial Re-Admission assessment from the hospital stay. Resident readmitted on [DATE]."" There was no evidence (as of 05/03/10) to reflect this resident had been assessed by the RD, at any time since his admission on 03/25/10, to calculate his basic daily fluid needs to ensure adequate hydration. To calculate an individual's basic daily fluid needs, one multiplies the individual's body weight in kilograms (kg) by 30 cc. Based on this formula, Resident #143, at a weight of 171#, would need approximately 2331 cc of fluid daily to maintain adequate hydration. The RD, during a nutritional assessment, would also take into consideration additional fluid needs due to conditions causing fluid loss, such as diarrhea. The dietary manager (Employee #149), when interviewed on 05/04/10 at 8:30 a.m., confirmed this resident had not been assessed by the RD. She stated she was ""not sure why she (the RD) has not seen him yet, but she comes on Thursday, and she will have her look at him this Thursday."" NOTE: This surveyor observed the RD had been in the facility on the previous Thursday, 04/29/10. There was no evidence she reviewed this resident's his fluid needs at that time. 5. Further review of the medical record, on 05/04/10, revealed this resident had refused five (5) of the last nine (9) meals served and had consumed less than half of the other four (4) meals. His daily fluid intake for May 2010 had been less than 1000 cc daily, and his total daily fluid intake was very low on the following days: 05/01/10 - 840 cc; 05/02/10 - 960 cc; and 05/03/10 - 600 cc. His bowel elimination records indicated the resident had experienced bouts of diarrhea thirteen (13) times during the first three (3) days of May 2010, as well as three (3) large bowel movements. However, the nursing notes, when reviewed, contained no references to this resident's poor intake of food and fluids, nor of his continual diarrhea during the first three (3) days of May 2010. The nurse (Employee #97), when questioned about the facility's procedure for identifying abnormal findings such as decreased meal intake and decreased fluid intake as recorded on the nursing assistants' activities of daily living sheets, reported night shift looked at these records then communicated the findings, but that nursing assistants should also communicate these findings to the nurse. The director of nursing (DON), when questioned how a resident's daily fluid needs were communicated to the staff, said they go by a standard 1500 cc per day if there is nothing written. She verified that, if a resident's daily fluid intake is poor, the nursing assistants should tell the nurse. 6. The nurse (Employee #97) was asked to assess this resident with the surveyor at 11:00 a.m. on 05/04/10. The nurse did a physical assessment for dehydration on this resident, and he did not exhibit clinical signs of dehydration. His skin turgor was good, his mouth was not dry, his lips were not cracked, etc. 7. There was no evidence (as of 05/03/10) to reflect this resident had been assessed by the RD, at any time since his admission on 03/25/10, to calculate his basic daily fluid needs to ensure adequate hydration. There was no evidence the information recorded in the ADL sheets was reviewed by the nurses. There was no evidence of any interventions to assure the direct care staff knew to provide Resident #143 with extra fluids. There was also no evidence the resident had been assessed on an on-going basis for signs or symptoms of dehydration or electrolyte imbalance, especially in view of his very low daily fluid intake and his repeated bouts of diarrhea.",2015-06-01
10149,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-05-05,329,D,0,1,MKQ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and review of OBRA's ""Unnecessary Drugs in the Elderly"", the facility failed to ensure the drug regimens of three (3) of thirty (30) Stage II sample residents were free of unnecessary drugs being used for excessive duration and/or without attempts at gradual dose reduction (GDR) to ascertain the lowest effective dose. Resident #54 received [MEDICATION NAME] for [MEDICAL CONDITION], for which no care plan had been developed with non-pharmacologic interventions to promote sleep. The consultant pharmacist recommended a trial without the [MEDICATION NAME], and the physician failed to respond appropriately. Resident #139 received a total daily dose of [MEDICATION NAME] 2 mg, which is above the 0.75 mg daily dose recommended for the elderly according to OBRA's ""Unnecessary Drugs in the Elderly"", and the dosage of this medication was increased without adequate justification by the physician. Resident #75 received Klonopin with no attempt at a GDR, or documentation that such a GDR was clinically contraindicated, as required. Resident identifiers: #54, #139, and #75. Facility census: 101. Findings include: a) Resident #54 Medical record review, on 05/03/10, disclosed this [AGE] year old female resident had been receiving [MEDICATION NAME] 12.5 mg every night for [MEDICAL CONDITION] since 10/22/09, when the last GDR was done. Review of the resident's current comprehensive care plan found no plan had been developed to address the [MEDICAL CONDITION] with non-pharmacologic interventions to promote sleep. (See also citation at F279.) Review of a pharmacy to physician communication, dated 02/04/10, found the pharmacist had recommended a trial without the medication, as the [MEDICATION NAME] had been reduced to the lowest dose possible. On 03/04/10, the physician indicated he had already responded to this request previously. Review of a previous request for a GDR, dated 10/07/09, revealed the physician had agreed to reduce the [MEDICATION NAME] from 2.5 mg every night to 12.5 mg every night. There no evidence found during the medical record review to indicate the resident had any adverse reactions resulting from the previous dose reduction in that would prohibit a trial without the drug in order to discontinue its use. b) Resident #139 Medical record review, on 04/28/10, disclosed this [AGE] year old female resident had been receiving the sedating drug [MEDICATION NAME] since admission to the facility on [DATE]. Review of physician orders [REDACTED]. Further review of physician orders [REDACTED]. Review of the physician's progress notes found no documentation made by the physician to provide a clinical rationale for increasing the [MEDICATION NAME] to 2 mg per day, which is above the recommended dose 0.75 mg daily for the elderly. During an interview with the director of nursing (DON - Employee #128) on 05/04/10 at 10:00 a.m., additional information was requested concerning the [MEDICATION NAME] dose increase; no further information was available. c) Resident #75 Medical record review revealed that, on 08/25/08, the physician prescribed to Resident #75 [MEDICATION NAME] 75 mg orally daily for depression. The dosage of this medication was decreased once, on 11/03/09, to 50 mg daily, and has remained at that dose since. Further medical record review revealed that, on 08/25/08, the physician also prescribed Klonopin 1 mg three (3) times daily for [MEDICAL CONDITIONS], which was discontinued at 10:56 a.m. on 12/01/08 and resumed at 10:57 a.m. on 12/01/08. On 07/29/09, the Klonopin was decreased to 0.5 mg twice daily [MEDICAL CONDITION] has remained at that dose since. During the first year in which a resident was admitted on a psychoactive medication other than an antipsychotic or a sedative / hypnotic, or after the facility has initiated such medication, the facility should attempt to taper the medication during at least two (2) separate quarters (with at least one (1) month between the attempts), unless clinically contraindicated. After the first year, a tapering should be attempted annually, unless clinically contraindicated. The tapering may be considered clinically contraindicated, if the resident's target symptoms returned or worsened after the most recent attempt at a tapering within the facility, and the physician has documented the clinical rationale for why any additional attempted tapering at that time would be likely to impair the resident's function. When interviewed on the afternoon of 05/03/10, the DON produced the following two (2) physician's progress notes related to the resident's psychoactive medications: [REDACTED] 1. Physician's Progress Note dated 05/26/09 - ""I guess we could try to cut her antidepressant somewhat although she is doing well. Family is not wanting any changes made recently."" 2. Physician's Progress Note dated 07/28/09 - ""I am going to try and decrease her Klonopin to 0.5 mg. BID (twice daily) and see how she tolerates."" Subsequently, the physician did a dose reduction at that time. However, the DON was unable to produce documentation to reflect the physician had attempted to taper the resident's psychoactive medications during at least two (2) separate quarters during the first year of therapy and had done an annual tapering after the first year; or, if clinically contraindicated, the written assessment by the physician or physician documentation related to a GDR recommendation from the pharmacy, or signed and dated progress note by the physician. .",2015-06-01
10150,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-05-05,431,D,0,1,MKQ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, one (1) of two (2) medication room refrigerators and one (1) of four (4) medication carts contained insulin vials that had been opened for greater than twenty-eight (28) days. This had the potential to affect an isolated number of residents. Facility census: 101. Findings include: a) On 05/04/10 at 1:30 p.m., the nurse (Employee #73) acknowledged that a vial of Lantus insulin stored in the medication room refrigerator for a resident was opened 04/01/10, and should have been discarded on 05/01/10. She discarded that vial of Lantus insulin and said she would obtain a new, unopened vial of Lantus insulin for his use. Review of physician orders [REDACTED]. b) On 05/04/10 at 1:45 p.m., the nurse (Employee #21) acknowledged that a vial of Novalog insulin on the medication cart was opened 03/16/10, and should have been discarded 04/16/10. She stated the Novalog insulin was used for the resident only for coverage when blood sugars were elevated with the four (4) time daily blood sugar checks. She discarded this vial of Novalog insulin and said she will replace it with a new, unopened vial. She also checked the Medication Administration Record [REDACTED]. c) On 05/04/10 at 4:15 p.m., the director of nursing produced a policy on medication administration and a calendar for insulin expiration dates which stated the insulin must be discarded twenty-eight (28) days from the date opened. She said she recently instructed the nurses to inventory the medication carts and medication room refrigerators to ensure there were no insulin vials opened greater than twenty-eight (28) days. .",2015-06-01
10151,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-05-05,441,F,0,1,MKQ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, medical record review, review of facility policies, procedures, and infection control logs, staff interview, a review of the manufacturer's information for OASIS cleaners, and a review of the information from the Centers for Disease Control and Prevention (CDC), the facility failed to establish and maintain an active infection control program under which it investigated, controlled, and prevented infections, and failed to implement appropriate measures based on the identified organism and the mode of transmission. One (1) of thirty (30) current residents (#143) had a highly infectious organism requiring special precautions to prevent transmission to other residents, especially to immunocompromised residents with readily available portals of entry. Resident #143 had an active infection with a highly contagious organism - Clostridium difficile (C. difficile or [DIAGNOSES REDACTED]), a spore-forming organism from which environmental contamination frequently occurs. Resident #143 was very active, attended out-of-room activities, and ate in the dining room. He received therapy, utilized the same blood pressure equipment as the other residents, used the public shower room, and sat in social settings with others. He independently propelled his own wheelchair throughout the facility, touching handrails and other common use surfaces in the process. The facility failed to assure Resident #143 (who was alert and oriented) used appropriate hand hygiene measures after toilet use while actively symptomatic, to prevent the spread of this highly infectious organism as he moved independently throughout the entire facility, putting all of the other residents at risk. There was no evidence to reflect staff members considered the surfaces outside of his room, the common areas, or nursing equipment used by this resident to be contaminated. Resident #143 shared a room with his wife, Resident #89. Resident #89 had an open portal of entry for acquiring infections (a gastrostomy tube for feeding), she was incontinent of bowel and bladder, and she was dependent upon staff for all activities of daily living (ADLs). Both Residents #143 and #89 were dependent upon staff for performance of their personal hygiene after toilet use. (Resident #143's dependence was associated with his current bout of diarrhea.) The facility failed to isolate or cohort Resident #143 in accordance with its infection control policy, placing his immunocompromised roommate (#89) at high risk for acquiring an infection, and failed to inform Resident #89's legal representative of the risks to Resident #89 associated with cohorting her with Resident #143 while he was contagious. Nursing care staff did not adhere to infection control guidelines when rendering care to Resident #143. Housekeeping staff did not sanitize Resident #143's room with a cleaning product containing sodium hypochlorite (bleach), as recommended by CDC. Review of the facility's infection control logs found they were not complete for March 2010 or April 2010; they did not indicate the presence the infectious organism for Resident #143. There was no evidence the facility had investigated, monitored, and/or assured that measures are being taken to assure there is no spread of this infection to the other residents in the facility. These actions had the potential to affect all residents in the facility. Resident identifiers: #89 and #143. Facility census: 101. Findings include: a) Resident #89 Observation of this resident's room, on 05/03/10, revealed a contact isolation sign posted on the door of this resident's room. Resident #89, a female resident who shared the room with her husband (Resident #143), was observed to be receiving a feeding by her gastrostomy tube ([DEVICE]). The surveyor noted Resident #89 was totally dependent upon staff for all ADLs and that her [DEVICE] offered an open port of entry for infectious organisms. This placed Resident #89 at high risk for contracting a contagious disease. Review of Resident #89's medical record revealed no evidence she had an active infection. Documentation revealed these residents had only moved in the room together in the last few days at the request of the husband (Resident #143). Review of Resident #143's record found he was in contact isolation for [DIAGNOSES REDACTED]. There was no documentation in Resident #89's medical record that her health care decision maker (who was not her husband) was informed of the risks associated with having these two (2) residents share the same room. --- b) Resident #143 1. Review of Resident #143's medical record revealed he was admitted to the facility on [DATE], and that he possessed the capacity to understand and make his own informed health care decisions. He was sent to the hospital on [DATE] and returned on 04/21/10. At that time, he had diarrhea and he tested positive for [DIAGNOSES REDACTED]. He was placed in contact isolation and was treated with [MEDICATION NAME] 500 mg twice a day for seven (7) days. After he finished this course of antibiotics, an order was given on 05/01/10 to obtain a stool specimen to test for the continued presence of [DIAGNOSES REDACTED]. This test came back positive on 05/03/10, and he started another course of [MEDICATION NAME] for seven (7) more days. The resident experienced diarrhea seven (7) times on 05/03/10. He remained in contact isolation at this time. -- 2. Observation found Resident #143 in the dining room area at 11:45 a.m. on 05/03/10. When interviewed, he stated he did not feel well and did not want to eat. He left the dining room independently and was then seen lying in his bed at 12:30 p.m. When interviewed again at that time, he said he just did not ""feel good today"". When questioned about his abilities to perform his own ADLs, he said, most of the time, he did things himself. He reported having had diarrhea and needing assistance cleaning up, but most of the time he did this himself. He said the diarrhea sometimes made him be incontinent of bowel before he could reach the bathroom. The resident was observed in the front lobby at 11:30 a.m. on 05/04/10. A staff member was looking for him, and when she found him, she stated, ""He runs around all the time."" Observations throughout the survey event found this resident was very active, attended out-of-room activities, and ate in the dining room. He received therapy, utilized the same blood pressure equipment as the other residents, used the public shower room, and sat in social settings with others. He also independently propelled his own wheelchair throughout the facility, touching handrails and other common surfaces in his travels. -- 3. In spite of the presence of a contact isolation sign on the door of this resident's room, the nursing assistants and the alert and oriented resident (#143) in that room did not follow contact precautions to prevent spread of the infection. - On 05/04/10 at 9:00 a.m., a very strong, foul odor was detected coming from Resident #143's room. Observation found Resident #143 coming out of the bathroom. This surveyor looked inside the bathroom and saw a raised commode seat with loose stool all over the seat. The resident, when questioned at that time about toileting, said, ""Sometimes, I can just go myself."" The bathroom, when observed again at 10:00 a.m., had been cleaned. This resident was again observed coming out of his bathroom independently at 11:00 a.m. on 05/04/10. There was no staff in the area at that time. - An interview was conducted with a nursing assistant (Employee #55) at 4:35 p.m. on 05/04/10, regarding Resident # 143's toileting habits. Employee #55 stated Resident #143 was mostly continent, but he had diarrhea and was sometimes incontinent. He was also noncompliant and needed assistance, although he took himself to bathroom sometimes. He had a broken leg / knee and needed assistance with transferring. Employee #55 stated, ""After you put him on the toilet,he often cleans himself before you come back to help him."" At 4:45 p.m., Employee #55 was asked if she would have resident to wash his hands before he went to the dining room, in order for the surveyor to observe the resident's handwashing technique. Employee #55 agreed and entered this resident's room. She leaned over the foot of his bed, placing her bare hands on the resident's bed linens and leaning on the mattress of his bed where he was lying. Employee #55 was not wearing any gloves when her bare hands came into contact with his bed linens, which were likely to be contaminated with [DIAGNOSES REDACTED]. After asking the resident if he was ready to go wash his hands for dinner, Employee #55 donned a pairs of gloves - prior to assisting Resident #143 to his wheelchair and after touching the resident's bed linens with her bare hands. She assisted the resident in transferring to his wheelchair. He told her, ""I can wash my own hands."" Employee #55 placed Resident #143 in front of the sink. He turned the water on full blast, and the water splashed all over him and around the sink. He then stuck his hands under the stream of water and rinsed them for seven (7) seconds. He reached up with his wet hands, turned off the water, and obtained a paper towel. He never applied soap to his hands, nor did he use friction when washing his hands. Resident #143 did not effectively wash his hands to prevent the transmission of the [DIAGNOSES REDACTED] throughout the facility. - Observation, on 05/04/10 at 5:30 p.m., found Resident #143 sitting in his bathroom on the toilet by himself. A nursing assistant (Employee #3), who was assigned to care for him, was asked how much assistance she provided to him for personal hygiene after toileting. She stated first he cleans himself up, and then she finishes cleaning him, because he is not totally clean. She said the occupational therapist (OT) was working with him to get him to be able to clean himself. When asked about his handwashing after having a bowel movement, she stated she gives him a disposable wipe to use on his hands after he cleans himself. (There was no mention of the use of soap and water for handwashing.) Observation found Employee #3 did not wear a gown when assisting Resident #143 with personal hygiene after toileting. This employee verified she assisted the resident with cleaning himself after he had a bowel movement. When asked why she did not wear a gown, she stated she only wears a gown if she anticipates coming in contact with stool, and she did not anticipate coming in contact with stool when caring for Resident #143. Facility policy states staff is to wear a gown if it is anticipated that he or she will come in contact with the contaminated body fluids. Given an earlier observation described that found loose stool on Resident #143's toilet seat after he used the bathroom independently, the possibility of a staff member coming into contact with stool, when assisting Resident #143 with personal hygiene after using the toilet, was great. - Record review found no care plan had been developed to address Resident #143's non-compliance with the contact isolation precautions, including his inadequate handwashing practices. There were no instructions provided (except ""assist him to wash his hands"") to assure this resident did not spread this infectious organism to his immunocompromised roommate and throughout the entire facility, even though the facility was aware that he often provided his own handwashing and his hand hygiene practices were inadequate to prevent the spread of infection. -- 4. On 05/04/10 at 2:30 p.m., a housekeeper (Employee #114) was observed coming out of Resident #143's room. When questioned about the process for cleaning a room occupied by a resident in contact isolation, Employee #114 reported the cleaning chemical she used in the bathroom was a heavy duty bathroom cleaner by ECOLAB; she also reported using OASIS 531 to clean the floor and wipe off surfaces, such as the bedside table and the side rails. She was aware this was a contact isolation room and stated she used a different rag and mop and changed her mop water after cleaning such a room, so as to not contaminate other rooms. She said she used OASIS 299 to clean the bathroom and fixtures in the bathroom. When asked if she used anything else to clean this room, she verified these were the only two (2) products she used. She was then asked to get the material safety data sheet (MSDS) for each of these products. Review of the MSDS information found neither of these products contained sodium hypochlorite. - Review of information found on the CDC's website with respect to [DIAGNOSES REDACTED] revealed: ""C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B. It is a common cause of antibiotic-associated diarrhea (AAD). ... The risk for disease increases in patients with: antibiotic exposure, gastrointestinal surgery / manipulation, long length of stay in healthcare settings, a serious underlying illness, immunocompromising conditions, and advanced age. ... [DIAGNOSES REDACTED]icile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the [DIAGNOSES REDACTED]icile spores. [DIAGNOSES REDACTED]icile spores are mainly transmitted by healthcare personnel who have touched a contaminated surface or item."" Under the heading ""What can I use to clean and disinfect surfaces and devices to help control [DIAGNOSES REDACTED]icile?"" was found: ""Surfaces should be kept clean, and body substance spills should be managed promptly as outlined in CDC's 'Guidelines for Environmental Infection Control in Health-Care Facilities.' Hospital cleaning products can be used for routine cleaning. Hypochlorite-based disinfectants have been used with some success for environmental surface disinfection in those patient-care areas where surveillance and epidemiology indicate ongoing transmission of [DIAGNOSES REDACTED]icile. ... Note: EPA-registered hospital disinfectants are recommended for general use whenever possible in patient-care areas. At present there are no EPA-registered products with specific claims for inactivating [DIAGNOSES REDACTED]icile spores, but there are a number of EPA-registered products that contain hypochlorite. If an EPA-registered proprietary hypochlorite product is used, consult the label instructions for proper and safe use conditions."" (Source: http://www.cdc.gov /ncidod/dhqp/id_CdiffFAQ_HCP.html) - According to the fact sheet provided by the facility as part of its infection control program, the CDC recommended the use of a sodium hypochlorite-based product for the disinfection of environmental surfaces exposed to [DIAGNOSES REDACTED], having identified as a special consideration that [DIAGNOSES REDACTED] is a spore-forming organism and environmental contamination frequently occurs. This fact sheet also stated the facility recommended the use of a pre-mixed EPA-registered, hospital-grade sodium hypochlorite-based disinfectant, rather than using a solution of bleach and water mixed daily. - The DON provided literature supporting the use of 10% sodium hypochlorite solution mixed fresh daily (one (1) part house hold chlorine bleach mixed with nine (9) parts tap water). She verified this was what they should have been using to clean Resident #143's room. - During an interview with the maintenance / environmental service director (Employee #44), he could not provide evidence that staff instructed on any specific method of cleaning a room of a resident with [DIAGNOSES REDACTED]. He also could not produce a specific policy and procedure for the cleaning of a room occupied by a resident in contact isolation. At 3:15 p.m., Employee #44 stated he called ECOLAB and was advised they should wipe down Resident #143's room with bleach, then mist the surfaces with the OASIS product, leave it for ten (10) minutes, then wipe it off. There was no evidence this procedure was written anywhere or that these instructions had been provided to the housekeeping staff. - The facility failed to ensure its policies and procedures were established in accordance with current standards of practice (CDC guidelines) and were being utilized to prevent spread of this infectious organism, with respect to sanitizing rooms, surfaces, and equipment used by persons infected with [DIAGNOSES REDACTED]. -- 5. Review of the facility's infection control logs found they were not complete for March 2010 or April 2010. They did not indicate Resident #143 had [DIAGNOSES REDACTED] in his stool. There was no evidence the facility had investigated, monitored, and/or implemented measures to ensure there was no spread of this highly contagious infectious organism to the other residents in the facility. - The facility's infection control compliance monitoring procedure (last revised July 2008), and the only mechanisms identified for monitor the compliance of the employees with the facility's infection control policies and procedures were self-evaluation by existing employees and observation of each new employee as follows: - Staff Self Evaluation - Each employee may be given a self evaluation form to complete every six (6) months, which will be reviewed by the infection control nurse. This self evaluation, when reviewed, contained basic questions asking staff if they performed the infection control tasks properly. (Examples: Do you decontaminate your hands before resident contact? Do you use gloves, masks, etc?) - Observation - Each new employee will be observed during orientation. The infection control nurse will then prepare a report and present it monthly or at least quarterly to the infection control committee. These methods of compliance monitoring were ineffective for ensuring the employees were following the policies regarding isolation. There was no evidence the facility monitored current employees through direct observation, to ensure they were following the infection control policies and procedures. .",2015-06-01
10152,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-05-05,490,L,0,1,MKQ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, medical record review, review of facility policies, procedures, and infection control logs, staff interview, a review of the manufacturer's information for OASIS cleaners, and a review of the information from the Centers for Disease Control and Prevention (CDC), the governing body failed to ensure the facility was administered in such a manner as to provide a safe, sanitary and comfortable environment (to help prevent the development and transmission of disease and infection) and to provide care and services to avoid physical harm to residents, by failing to develop and/or implement policies and procedures to prevent the spread of disease by one (1) of thirty (30) Stage II sample residents, who was actively symptomatic with a highly contagious infectious organism, who did not perform effective handwashing after having episodes of diarrhea, and who independently traveled throughout the facility, entering common areas and touching surfaces used by all residents. The facility's administration failed to develop and maintain an infection control program to effectively prevent the transmission of a highly contagious intestinal infection, [MEDICAL CONDITION] (C. difficile or [DIAGNOSES REDACTED]), by Resident #143. There were no specific policies for the cleaning of rooms, surfaces, and/or equipment used by this resident infected, and there was no evidence of inservicing to ensure the staff was aware of this resident's infection and the proper techniques to be employed to prevent transmission of the infectious organism throughout the entire building. There was no evidence to reflect the administration provided oversight to the infection control program to ensure infection control policies and procedures were reflective of current standards of practice (in accordance with recommended CDC guidelines) and that staff implemented those policies and procedures as written. These practices placed all residents in the facility in immediate jeopardy for acquiring a [DIAGNOSES REDACTED] infection. (See citation at F224 for specific information related to the immediate jeopardy.) Facility census: 101. Findings include: a) Based on observations, medical record review, review of facility policies, procedures, and infection control logs, staff interview, a review of the manufacturer's information for OASIS cleaners, and a review of the information from the Centers for Disease Control and Prevention (CDC), the facility failed to provide care and services to avoid physical harm to residents, by failing to develop and/or implement policies and procedures to prevent the spread of disease by one (1) of thirty (30) Stage II sample residents, who was actively symptomatic with a highly contagious infectious organism. Resident #143 had an active infection with a highly contagious organism - [MEDICAL CONDITION] (C. difficile or [DIAGNOSES REDACTED]) - a spore-forming organism from which environmental contamination frequently occurs. -- Review of information found on the CDC's website with respect to [DIAGNOSES REDACTED] revealed: ""C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B. It is a common cause of antibiotic-associated diarrhea (AAD). ... The risk for disease increases in patients with: antibiotic exposure, gastrointestinal surgery /manipulation, long length of stay in healthcare settings, a serious underlying illness, immunocompromising conditions, and advanced age. ... [DIAGNOSES REDACTED]icile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the [DIAGNOSES REDACTED]icile spores. [DIAGNOSES REDACTED]icile spores are mainly transmitted by healthcare personnel who have touched a contaminated surface or item."" Under the heading ""What can I use to clean and disinfect surfaces and devices to help control [DIAGNOSES REDACTED]icile?"" was found: ""Surfaces should be kept clean, and body substance spills should be managed promptly as outlined in CDC's 'Guidelines for Environmental Infection Control in Health-Care Facilities.' Hospital cleaning products can be used for routine cleaning. Hypochlorite-based disinfectants have been used with some success for environmental surface disinfection in those patient-care areas where surveillance and epidemiology indicate ongoing transmission of [DIAGNOSES REDACTED]icile. ... Note: EPA-registered hospital disinfectants are recommended for general use whenever possible in patient-care areas. At present there are no EPA-registered products with specific claims for inactivating [DIAGNOSES REDACTED]icile spores, but there are a number of EPA-registered products that contain hypochlorite. If an EPA-registered proprietary hypochlorite product is used, consult the label instructions for proper and safe use conditions."" (Source: /ncidod/dhqp/id_CdiffFAQ_HCP.html>) -- Resident #143 shared a room with his wife, Resident #89. Resident #89 had an open portal of entry for acquiring infections (a gastrostomy tube for feeding), she was incontinent of bowel and bladder, and she was dependent upon staff for all activities of daily living (ADLs). Both Residents #143 and #89 were dependent upon staff for performance of their personal hygiene after toilet use. (Resident #143's dependence was associated with his current bouts of diarrhea.) The facility failed to isolate or cohort Resident #143 in accordance with its infection control policy, placing his immunocompromised roommate (#89) at high risk for acquiring an infection, and failed to inform Resident #89's legal representative of the risks to Resident #89 associated with cohorting her with Resident #143 while he was contagious. Resident #143 was also very active, attended out-of-room activities, and ate in the dining room. He received therapy, utilized the same blood pressure equipment as the other residents, used the public shower room, and sat in social settings with others. He independently propelled his own wheelchair throughout the facility, touching handrails and other common use surfaces in the process. The facility failed to assure Resident #143 (who was alert and oriented) used appropriate hand hygiene measures after toilet use while actively symptomatic, to prevent the spread of this highly infectious organism as he moved independently throughout the entire facility, putting all of the other residents at risk. There was no evidence to reflect staff members considered the surfaces outside of his room, the common areas, or nursing equipment used by this resident to be contaminated. Nursing care staff did not adhere to infection control guidelines when rendering care to Resident #143. Housekeeping staff did not sanitize Resident #143's room with a cleaning product containing sodium hypochlorite (bleach), as recommended by CDC. Review of the facility's infection control logs found they were not complete for March 2010 or April 2010; they did not indicate the presence the infectious organism for Resident #143. There was no evidence the facility had investigated, monitored, and/or assured that measures are being taken to assure there is no spread of this infection to the other residents in the facility. The above actions placed all residents of this facility in immediate jeopardy for acquiring an infection by this highly contagious organism. On 05/04/10 at approximately 5:45 p.m., the facility's administrator and director of nursing (DON) were notified of the immediate jeopardy situation. (See also citations at F224 and F441.) -- b) According to the fact sheet provided by the facility as part of its infection control program, the CDC recommended the use of a sodium hypochlorite-based product for the disinfection of environmental surfaces exposed to [DIAGNOSES REDACTED], having identified as a special consideration that [DIAGNOSES REDACTED] is a spore-forming organism and environmental contamination frequently occurs. This fact sheet also stated the facility recommended the use of a pre-mixed EPA-registered, hospital-grade sodium hypochlorite-based disinfectant, rather than using a solution of bleach and water mixed daily. The DON provided literature supporting the use of 10% sodium hypochlorite solution mixed fresh daily (one (1) part house hold chlorine bleach mixed with nine (9) parts tap water). She verified this was what they should have been using to clean Resident #143's room. During an interview with the maintenance / environmental service director (Employee #44), he could not provide evidence that staff instructed on any specific method of cleaning a room of a resident with [DIAGNOSES REDACTED]. He also could not produce a specific policy and procedure for the cleaning of a room occupied by a resident in contact isolation. At 3:15 p.m., Employee #44 stated he called ECOLAB and was advised they should wipe down Resident #143's room with bleach, then mist the surfaces with the OASIS product, leave it for ten (10) minutes, then wipe it off. The administration failed to ensure the facility's policies and procedures were established in accordance with current standards of practice (CDC guidelines) and were being utilized to prevent spread of this infectious organism, with respect to sanitizing rooms, surfaces, and equipment used by persons infected with [DIAGNOSES REDACTED]. -- c) Review of the facility's infection control logs found they were not complete for March 2010 or April 2010. They did not indicate Resident #143 had [DIAGNOSES REDACTED] in his stool. Nursing personnel did not employ appropriate infection control measures when rendering assistance with personal hygiene after Resident #143 had a bowel movement, nor did nursing personnel recognize and take appropriate precautions when coming into contact with his bed linens, which should have been viewed as potentially contaminated. Nursing personnel did not ensure Resident #143 effectively sanitized his hands after he performed his own personal hygiene after having a bowel movement, to ensure [DIAGNOSES REDACTED] was not spread to surfaces he touched throughout the facility. The facility's infection control compliance monitoring procedure (last revised July 2008), and the only mechanisms identified for monitor the compliance of the employees with the facility's infection control policies and procedures were self-evaluation by existing employees and observation of each new employee as follows: - Staff Self Evaluation - Each employee may be given a self evaluation form to complete every six (6) months, which will be reviewed by the infection control nurse. This self evaluation, when reviewed, contained basic questions asking staff if they performed the infection control tasks properly. (Examples: Do you decontaminate your hands before resident contact? Do you use gloves, masks, etc?) - Observation - Each new employee will be observed during orientation. The infection control nurse will then prepare a report and present it monthly or at least quarterly to the infection control committee. These methods of compliance monitoring were ineffective for ensuring the employees were following the policies regarding isolation. There was no evidence the facility monitored current employees through direct observation, to ensure they were following the infection control policies and procedures. The administration failed to ensure the facility's infection control program investigated, monitored, and/or implemented measures to ensure there was no spread of this highly contagious infectious organism to the other residents in the facility. .",2015-06-01
10153,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-05-05,224,L,0,1,MKQ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, medical record review, review of facility policies, procedures, and infection control logs, staff interview, a review of the manufacturer's information for OASIS cleaners, and a review of the information from the Centers for Disease Control and Prevention (CDC), the facility failed to provide care and services to avoid physical harm to residents, by failing to develop and/or implement policies and procedures to prevent the spread of disease by one (1) of thirty (30) Stage II sample residents, who was actively symptomatic with a highly contagious infectious organism. Resident #143 had an active infection with a highly contagious organism - [MEDICAL CONDITION] (C. difficile or [DIAGNOSES REDACTED]) - a spore-forming organism from which environmental contamination frequently occurs. Resident #143 shared a room with his wife, Resident #89. Resident #89 had an open portal of entry for acquiring infections (a gastrostomy tube for feeding), she was incontinent of bowel and bladder, and she was dependent upon staff for all activities of daily living (ADLs). Both Residents #143 and #89 were dependent upon staff for performance of their personal hygiene after toilet use. (Resident #143's dependence was associated with his current bouts of diarrhea resulting in bowel incontinence.) The facility failed to isolate or cohort Resident #143 in accordance with its infection control policy, placing his immunocompromised roommate (#89) at high risk for acquiring an infection, and failed to inform Resident #89's legal representative of the risks to Resident #89 associated with cohorting her with Resident #143 while he was contagious. Resident #143 was also very active, attended out-of-room activities, and ate in the dining room. He received therapy in the common use therapy room, utilized the same blood pressure equipment as the other residents, used the public shower room, and sat in social settings with others. He independently propelled his own wheelchair throughout the facility, touching handrails and other common use surfaces in the process. The facility failed to assure Resident #143 (who was alert and oriented) used appropriate hand hygiene measures after toilet use while actively symptomatic, to prevent the spread of this highly infectious organism as he moved independently throughout the entire facility, putting all of the other residents at risk. There was no evidence to reflect staff members considered the surfaces outside of his room, the common areas, or nursing equipment used by this resident to be contaminated. Nursing care staff did not adhere to infection control guidelines when rendering care to Resident #143. Housekeeping staff did not sanitize Resident #143's room with a cleaning product containing sodium hypochlorite (bleach), as recommended by CDC. Review of the facility's infection control logs found they were not complete for March 2010 or April 2010; they did not indicate the presence the infectious organism for Resident #143. There was no evidence the facility had investigated, monitored, and/or assured that measures are being taken to assure there is no spread of this infection to the other residents in the facility. The above actions placed all residents of this facility in immediate jeopardy for acquiring an infection by this highly contagious organism. On 05/04/10 at approximately 5:45 p.m., the facility's administrator and director of nursing (DON) were notified of the immediate jeopardy situation. The administrator provided a corrective action plan for removing the immediate jeopardy, including relocating the immunocompromised resident (#89) to another room; providing teaching to Resident #143 and his family member about the infectious organism and the need for appropriate hand hygiene; inservicing staff on appropriate infection control measures to be implemented, including the use of personal protective equipment; disinfecting all resident rooms and common areas with a bleached-based product; and inservicing all housekeeping staff on the proper procedure (and chemicals to be used) for disinfecting the rooms of residents with this infectious organism. The resident with the infection (Resident #143) agreed to stay in his room until his symptoms resolved. The DON developed an infection tracking form for trending patterns, and the infections for March, April, and May 2010 were researched to assure there were no other risks for transmission to a possible compromised roommate. After observing the facility's actions, assuring Resident #89 was safely moved into another room, and assuring the cleaning tasks were completed, the survey team verified all planned actions were implemented to remove the immediate jeopardy at 8:45 p.m. on 05/04/10, and there was no further deficient practice in this requirement. Resident identifiers: #89 and #143. Facility census: 101. Findings include: a) Resident #89 Observation of this resident's room, on 05/03/10, revealed a contact isolation sign posted on the door of this resident's room. Resident #89, a female resident who shared the room with her husband (Resident #143), was observed to be receiving a feeding by her gastrostomy tube ([DEVICE]). The surveyor noted Resident #89 was totally dependent upon staff for all ADLs and that her [DEVICE] offered an open port of entry for infectious organisms. This placed Resident #89 at high risk for contracting a contagious disease. Review of Resident #89's medical record revealed no evidence she had an active infection. Documentation revealed these residents had only moved in the room together in the last few days at the request of the husband (Resident #143). Review of Resident #143's record found he was in contact isolation for [DIAGNOSES REDACTED]. There was no documentation in Resident #89's medical record that her health care decision maker (who was not her husband) was informed of the risks associated with having these two (2) residents share the same room. --- b) Resident #143 1. Review of Resident #143's medical record revealed he was admitted to the facility on [DATE], and that he possessed the capacity to understand and make his own informed health care decisions. He was sent to the hospital on [DATE] and returned on 04/21/10. At that time, he had diarrhea and he tested positive for [DIAGNOSES REDACTED]. He was placed in contact isolation and was treated with [MEDICATION NAME] 500 mg twice a day for seven (7) days. After he finished this course of antibiotics, an order was given on 05/01/10 to obtain a stool specimen to test for the continued presence of [DIAGNOSES REDACTED]. This test came back positive on 05/03/10, and he started another course of [MEDICATION NAME] for seven (7) more days. The resident experienced diarrhea seven (7) times on 05/03/10. He remained in contact isolation at this time. -- 2. Observation found Resident #143 in the dining room area at 11:45 a.m. on 05/03/10. When interviewed, he stated he did not feel well and did not want to eat. He left the dining room independently and was then seen lying in his bed at 12:30 p.m. When interviewed again at that time, he said he just did not ""feel good today"". When questioned about his abilities to perform his own ADLs, he said, most of the time, he did things himself. He reported having had diarrhea and needing assistance cleaning up, but most of the time he did this himself. He said the diarrhea sometimes made him be incontinent of bowel before he could reach the bathroom. The resident was observed in the front lobby at 11:30 a.m. on 05/04/10. A staff member was looking for him, and when she found him, she stated, ""He runs around all the time."" Observations throughout the survey event found this resident was very active, attended out-of-room activities, and ate in the dining room. He received therapy, utilized the same blood pressure equipment as the other residents, used the public shower room, and sat in social settings with others. He also independently propelled his own wheelchair throughout the facility, touching handrails and other common surfaces in his travels. -- 3. In spite of the presence of a contact isolation sign on the door of this resident's room, the nursing assistants and the alert and oriented resident (#143) in that room did not follow contact precautions to prevent spread of the infection. - On 05/04/10 at 9:00 a.m., a very strong, foul odor was detected coming from Resident #143's room. Observation found Resident #143 coming out of the bathroom. This surveyor looked inside the bathroom and saw a raised commode seat with loose stool all over the seat. The resident, when questioned at that time about toileting, said, ""Sometimes, I can just go myself."" The bathroom, when observed again at 10:00 a.m., had been cleaned. This resident was again observed coming out of his bathroom independently at 11:00 a.m. on 05/04/10. There was no staff in the area at that time. - An interview was conducted with a nursing assistant (Employee #55) at 4:35 p.m. on 05/04/10, regarding Resident #143's toileting habits. Employee #55 stated Resident #143 was mostly continent, but he had diarrhea and was sometimes incontinent. He was also noncompliant and needed assistance, although he took himself to bathroom sometimes. He had a broken leg / knee and needed assistance with transferring. Employee #55 stated, ""After you put him on the toilet, he often cleans himself before you come back to help him."" At 4:45 p.m., Employee #55 was asked if she would have resident to wash his hands before he went to the dining room, in order for the surveyor to observe the resident's handwashing technique. Employee #55 agreed and entered this resident's room. She leaned over the foot of his bed, placing her bare hands on the resident's bed linens and leaning on the mattress of his bed where he was lying. Employee #55 was not wearing any gloves when her bare hands came into contact with his bed linens, which were likely to be contaminated with [DIAGNOSES REDACTED]. (See also citation at F441.) After asking the resident if he was ready to go wash his hands for dinner, Employee #55 donned a pairs of gloves - prior to assisting Resident #143 to his wheelchair and after touching the resident's bed linens with her bare hands. She assisted the resident in transferring to his wheelchair. He told her, ""I can wash my own hands."" Employee #55 placed Resident #143 in front of the sink. He turned the water on full blast, and the water splashed all over him and around the sink. He then stuck his hands under the stream of water and rinsed them for seven (7) seconds. He reached up with his wet hands, turned off the water, and obtained a paper towel. He never applied soap to his hands, nor did he use friction when washing his hands. Resident #143 did not effectively wash his hands to prevent the transmission of the [DIAGNOSES REDACTED] throughout the facility. - Observation, on 05/04/10 at 5:30 p.m., found Resident #143 sitting in his bathroom on the toilet by himself. A nursing assistant (Employee #3), who was assigned to care for him, was asked how much assistance she provided to him for personal hygiene after toileting. She stated first he cleans himself up, and then she finishes cleaning him, because he is not totally clean. She said the occupational therapist (OT) was working with him to get him to be able to clean himself. When asked about his handwashing after having a bowel movement, she stated she gives him a disposable wipe to use on his hands after he cleans himself. (There was no mention of the use of soap and water for handwashing.) Observation found Employee #3 did not wear a gown when assisting Resident #143 with personal hygiene after toileting. This employee verified she assisted the resident with cleaning himself after he had a bowel movement. When asked why she did not wear a gown, she stated she only wears a gown if she anticipates coming in contact with stool, and she did not anticipate coming in contact with stool when caring for Resident #143. Facility policy states staff is to wear a gown if it is anticipated that he or she will come in contact with the contaminated body fluids. Given an earlier observation described that found loose stool on Resident #143's toilet seat after he used the bathroom independently, the possibility of a staff member coming into contact with stool, when assisting Resident #143 with personal hygiene after using the toilet, was great. (See also citation at F441.) - Record review found no care plan had been developed to address Resident #143's non-compliance with the contact isolation precautions, including his inadequate handwashing practices. There were no instructions provided (except ""assist him to wash his hands"") to assure this resident did not spread this infectious organism to his immunocompromised roommate and throughout the entire facility, even though the facility was aware that he often provided his own handwashing and his hand hygiene practices were inadequate to prevent the spread of infection. (See also citation at F279.) -- 4. On 05/04/10 at 2:30 p.m., a housekeeper (Employee #114) was observed coming out of Resident #143's room. When questioned about the process for cleaning a room occupied by a resident in contact isolation, Employee #114 reported the cleaning chemical she used in the bathroom was a heavy duty bathroom cleaner by ECOLAB; she also reported using OASIS 531 to clean the floor and wipe off surfaces, such as the bedside table and the side rails. She was aware this was a contact isolation room and stated she used a different rag and mop and changed her mop water after cleaning such a room, so as to not contaminate other rooms. She said she used OASIS 299 to clean the bathroom and fixtures in the bathroom. When asked if she used anything else to clean this room, she verified these were the only two (2) products she used. She was then asked to get the material safety data sheet (MSDS) for each of these products. Review of the MSDS information found neither of these products contained sodium hypochlorite. - Review of information found on the CDC's website with respect to [DIAGNOSES REDACTED] revealed: ""C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B. It is a common cause of antibiotic-associated diarrhea (AAD). ... The risk for disease increases in patients with: antibiotic exposure, gastrointestinal surgery /manipulation, long length of stay in healthcare settings, a serious underlying illness, immunocompromising conditions, and advanced age. ... [DIAGNOSES REDACTED]icile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the [DIAGNOSES REDACTED]icile spores. [DIAGNOSES REDACTED]icile spores are mainly transmitted by healthcare personnel who have touched a contaminated surface or item."" Under the heading ""What can I use to clean and disinfect surfaces and devices to help control [DIAGNOSES REDACTED]icile?"" was found: ""Surfaces should be kept clean, and body substance spills should be managed promptly as outlined in CDC's 'Guidelines for Environmental Infection Control in Health-Care Facilities.' Hospital cleaning products can be used for routine cleaning. Hypochlorite-based disinfectants have been used with some success for environmental surface disinfection in those patient-care areas where surveillance and epidemiology indicate ongoing transmission of [DIAGNOSES REDACTED]icile. ... Note: EPA-registered hospital disinfectants are recommended for general use whenever possible in patient-care areas. At present there are no EPA-registered products with specific claims for inactivating [DIAGNOSES REDACTED]icile spores, but there are a number of EPA-registered products that contain hypochlorite. If an EPA-registered proprietary hypochlorite product is used, consult the label instructions for proper and safe use conditions."" (Source: http://www.cdc.gov /ncidod/dhqp/id_CdiffFAQ_HCP.html) - According to the fact sheet provided by the facility as part of its infection control program, the CDC recommended the use of a sodium hypochlorite-based product for the disinfection of environmental surfaces exposed to [DIAGNOSES REDACTED], having identified as a special consideration that [DIAGNOSES REDACTED] is a spore-forming organism and environmental contamination frequently occurs. This fact sheet also stated the facility recommended the use of a pre-mixed EPA-registered, hospital-grade sodium hypochlorite-based disinfectant, rather than using a solution of bleach and water mixed daily. - The DON provided literature supporting the use of 10% sodium hypochlorite solution mixed fresh daily (one (1) part house hold chlorine bleach mixed with nine (9) parts tap water). She verified this was what they should have been using to clean Resident #143's room. - During an interview with the maintenance / environmental service director (Employee #44), he could not provide evidence that staff instructed on any specific method of cleaning a room of a resident with [DIAGNOSES REDACTED]. He also could not produce a specific policy and procedure for the cleaning of a room occupied by a resident in contact isolation. At 3:15 p.m., Employee #44 stated he called ECOLAB and was advised they should wipe down Resident #143's room with bleach, then mist the surfaces with the OASIS product, leave it for ten (10) minutes, then wipe it off. There was no evidence this procedure was written anywhere or that these instructions had been provided to the housekeeping staff. -- 5. Review of the facility's infection control logs found they were not complete for March 2010 or April 2010. They did not indicate Resident #143 had [DIAGNOSES REDACTED] in his stool. There was no evidence the facility had investigated, monitored, and/or implemented measures to ensure there was no spread of this highly contagious infectious organism to the other residents in the facility. 5. Review of the facility's infection control logs found they were not complete for March 2010 or April 2010. They did not indicate Resident #143 had [DIAGNOSES REDACTED] in his stool. There was no evidence the facility had investigated, monitored, and/or implemented measures to ensure there was no spread of this highly contagious infectious organism to the other residents in the facility. - The facility's infection control compliance monitoring procedure (last revised July 2008), and the only mechanisms identified for monitor the compliance of the employees with the facility's infection control policies and procedures were self-evaluation by existing employees and observation of each new employee as follows: - Staff Self Evaluation - Each employee may be given a self evaluation form to complete every six (6) months, which will be reviewed by the infection control nurse. This self evaluation, when reviewed, contained basic questions asking staff if they performed the infection control tasks properly. (Examples: Do you decontaminate your hands before resident contact? Do you use gloves, masks, etc?) - Observation - Each new employee will be observed during orientation. The infection control nurse will then prepare a report and present it monthly or at least quarterly to the infection control committee. These methods of compliance monitoring were ineffective for ensuring the employees were following the policies regarding isolation. There was no evidence the facility monitored current employees through direct observation, to ensure they were following the infection control policies and procedures. (See also citation at F441.) -- 6. The above actions placed all residents of this facility in immediate jeopardy for acquiring an infection by this highly contagious organism. On 05/04/10 at approximately 5:45 p.m., the facility's administrator and the DON were notified of the immediate jeopardy situation. The administrator provided a corrective action plan for removing the immediate jeopardy, including relocating the immunocompromised resident (#89) to another room; providing teaching to Resident #143 and his family member about the infectious organism and the need for appropriate hand hygiene; inservicing staff on appropriate infection control measures to be implemented, including the use of personal protective equipment; disinfecting all resident rooms and common areas with a bleached-based product; and inservicing all housekeeping staff on the proper procedure (and chemicals to be used) for disinfecting the rooms of residents with this infectious organism. Resident #143 agreed to stay in his room until his symptoms resolved. After observing the facility's actions and assuring that Resident #89 was safely moved into another room, and the cleaning tasks were completed, the survey team verified all planned actions were implemented to remove the immediate jeopardy at 8:45 p.m. on 05/04/10, and there was no further deficient practice in this requirement. .",2015-06-01
10154,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-05-05,492,C,0,1,MKQ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of dietary employees' food handler certificates and staff interview, the facility failed to assure all of dietary employees had current food handler certificates as required by their County health department. One (1) of thirteen (13) dietary employees reviewed did not have a current certificate. This practice had the potential to affect all residents receiving on an oral diet. Employee identifier: #47. Facility census: 101. Findings include: a) Employee #47 Review of the dietary employees' food handler certificates, on [DATE], found Employee #47's food handler certificate had expired in [DATE]. The dietary manager (Employee #149), when interviewed regarding this finding, stated she was aware this employee's food handler certificate had expired. She stated she would ensure this employee attended the County health department's next available class. Employee #149 confirmed that Employee #47 worked on full-time on a regular basis. She stated they ""must have missed her"". This employee repeated the food handlers class during the survey on [DATE], and she was issued a current certificate at that time. .",2015-06-01
10155,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-05-05,520,L,0,1,MKQ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, medical record review, review of facility policies, procedures, and infection control logs, staff interview, a review of the manufacturer's information for OASIS cleaners, and a review of the information from the Centers for Disease Control and Prevention (CDC), the facility's quality and assessment assurance (QAA) committee failed to identify and implement measures to correct quality deficiencies - of which it should have known - to address a system failure with respect to the facility's infection control program. The facility failed to develop and maintain an infection control program to effectively prevent the transmission of a highly contagious intestinal infection, [MEDICAL CONDITION] (C. difficile or [DIAGNOSES REDACTED]) by Resident #143. There were no specific policies for the cleaning of rooms, surfaces, and/or equipment used by Resident #143, and there was no evidence of inservicing to ensure the staff was aware of this resident's infection and the proper techniques to be employed to prevent transmission of the infectious organism throughout the entire building. There was no evidence to reflect the facility ensured its infection control policies and procedures were reflective of current standards of practice (in accordance with recommended CDC guidelines) and that staff implemented those policies and procedures as written. These practices placed all residents in the facility in immediate jeopardy for acquiring a [DIAGNOSES REDACTED] infection. (See citation at F224 for specific information related to the immediate jeopardy.) According to the director of nursing (DON), the facility's QAA committee reviewed the infection control nurse's reports of active infections monthly. Resident #143's [DIAGNOSES REDACTED] infection was not on the March 2010 or April 2010 infection control logs. Although the facility was aware Resident #143 had returned from the hospital with [DIAGNOSES REDACTED] and was being actively treated for [REDACTED]. Facility census: 101. Findings include: a) Based on observations, medical record review, review of facility policies, procedures, and infection control logs, staff interview, a review of the manufacturer's information for OASIS cleaners, and a review of the information from the Centers for Disease Control and Prevention (CDC), the facility failed to provide care and services to avoid physical harm to residents, by failing to develop and/or implement policies and procedures to prevent the spread of disease by one (1) of thirty (30) Stage II sample residents, who was actively symptomatic with a highly contagious infectious organism. Resident #143 had an active infection with a highly contagious organism - [MEDICAL CONDITION] (C. difficile or [DIAGNOSES REDACTED]) - a spore-forming organism from which environmental contamination frequently occurs. -- Review of information found on the CDC's website with respect to [DIAGNOSES REDACTED] revealed: ""C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B. It is a common cause of antibiotic-associated diarrhea (AAD). ... The risk for disease increases in patients with: antibiotic exposure, gastrointestinal surgery /manipulation, long length of stay in healthcare settings, a serious underlying illness, immunocompromising conditions, and advanced age. ... [DIAGNOSES REDACTED]icile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the [DIAGNOSES REDACTED]icile spores. [DIAGNOSES REDACTED]icile spores are mainly transmitted by healthcare personnel who have touched a contaminated surface or item."" Under the heading ""What can I use to clean and disinfect surfaces and devices to help control [DIAGNOSES REDACTED]icile?"" was found:""Surfaces should be kept clean, and body substance spills should be managed promptly as outlined in CDC's 'Guidelines for Environmental Infection Control in Health-Care Facilities'. Hospital cleaning products can be used for routine cleaning. Hypochlorite-based disinfectants have been used with some success for environmental surface disinfection in those patient-care areas where surveillance and epidemiology indicate ongoing transmission of [DIAGNOSES REDACTED]icile. ... Note: EPA-registered hospital disinfectants are recommended for general use whenever possible in patient-care areas. At present there are no EPA-registered products with specific claims for inactivating [DIAGNOSES REDACTED]icile spores, but there are a number of EPA-registered products that contain hypochlorite. If an EPA-registered proprietary hypochlorite product is used, consult the label instructions for proper and safe use conditions."" (Source: /ncidod/dhqp/id_CdiffFAQ_HCP.html>) -- Resident #143 shared a room with his wife, Resident #89. Resident #89 had an open portal of entry for acquiring infections (a gastrostomy tube for feeding), she was incontinent of bowel and bladder, and she was dependent upon staff for all activities of daily living (ADLs). Both Residents #143 and #89 were dependent upon staff for performance of their personal hygiene after toilet use. (Resident #143's dependence was associated with his current bouts of diarrhea.) The facility failed to isolate or cohort Resident #143 in accordance with its infection control policy, placing his immunocompromised roommate (#89) at high risk for acquiring an infection, and failed to inform Resident #89's legal representative of the risks to Resident #89 associated with cohorting her with Resident #143 while he was contagious. Resident #143 was also very active, attended out-of-room activities, and ate in the dining room. He received therapy, utilized the same blood pressure equipment as the other residents, used the public shower room, and sat in social settings with others. He independently propelled his own wheelchair throughout the facility, touching handrails and other common use surfaces in the process. The facility failed to assure Resident #143 (who was alert and oriented) used appropriate hand hygiene measures after toilet use while actively symptomatic, to prevent the spread of this highly infectious organism as he moved independently throughout the entire facility, putting all of the other residents at risk. There was no evidence to reflect staff members considered the surfaces outside of his room, the common areas, or nursing equipment used by this resident to be contaminated. Nursing care staff did not adhere to infection control guidelines when rendering care to Resident #143. Housekeeping staff did not sanitize Resident #143's room with a cleaning product containing sodium hypochlorite (bleach), as recommended by CDC. Review of the facility's infection control logs found they were not complete for March 2010 or April 2010; they did not indicate the presence the infectious organism for Resident #143. There was no evidence the facility had investigated, monitored, and/or assured that measures are being taken to assure there is no spread of this infection to the other residents in the facility. The above actions placed all residents of this facility in immediate jeopardy for acquiring an infection by this highly contagious organism. On 05/04/10 at approximately 5:45 p.m., the facility's administrator and director of nursing (DON) were notified of the immediate jeopardy situation. (See also citations at F224 and F441.) -- b) According to the fact sheet provided by the facility as part of its infection control program, the CDC recommended the use of a sodium hypochlorite-based product for the disinfection of environmental surfaces exposed to [DIAGNOSES REDACTED], having identified as a special consideration that [DIAGNOSES REDACTED] is a spore-forming organism and environmental contamination frequently occurs. This fact sheet also stated the facility recommended the use of a pre-mixed EPA-registered, hospital-grade sodium hypochlorite-based disinfectant, rather than using a solution of bleach and water mixed daily. The DON provided literature supporting the use of 10% sodium hypochlorite solution mixed fresh daily (one (1) part house hold chlorine bleach mixed with nine (9) parts tap water). She verified this was what they should have been using to clean Resident #143's room. During an interview with the maintenance / environmental service director (Employee #44), he could not provide evidence that staff instructed on any specific method of cleaning a room of a resident with [DIAGNOSES REDACTED]. He also could not produce a specific policy and procedure for the cleaning of a room occupied by a resident in contact isolation. At 3:15 p.m., Employee #44 stated he called ECOLAB and was advised they should wipe down Resident #143's room with bleach, then mist the surfaces with the OASIS product, leave it for ten (10) minutes, then wipe it off. The facility's policies and procedures were not established in accordance with current standards of practice (CDC guidelines) and were not being utilized to prevent spread of this infectious organism, with respect to sanitizing rooms, surfaces, and equipment used by persons infected with [DIAGNOSES REDACTED]. -- c) Review of the facility's infection control logs found they were not complete for March 2010 or April 2010. They did not indicate Resident #143 had [DIAGNOSES REDACTED] in his stool. Nursing personnel did not employ appropriate infection control measures when rendering assistance with personal hygiene after Resident #143 had a bowel movement, nor did nursing personnel recognize and take appropriate precautions when coming into contact with his bed linens, which should have been viewed as potentially contaminated. Nursing personnel did not ensure Resident #143 effectively sanitized his hands after he performed his own personal hygiene after having a bowel movement, to ensure [DIAGNOSES REDACTED] was not spread to surfaces he touched throughout the facility. The facility's infection control compliance monitoring procedure (last revised July 2008), and the only mechanisms identified for monitor the compliance of the employees with the facility's infection control policies and procedures were self-evaluation by existing employees and observation of each new employee as follows: - Staff Self Evaluation - Each employee may be given a self evaluation form to complete every six (6) months, which will be reviewed by the infection control nurse. This self evaluation, when reviewed, contained basic questions asking staff if they performed the infection control tasks properly. (Examples: Do you decontaminate your hands before resident contact? Do you use gloves, masks, etc?) - Observation - Each new employee will be observed during orientation. The infection control nurse will then prepare a report and present it monthly or at least quarterly to the infection control committee. These methods of compliance monitoring were ineffective for ensuring the employees were following the policies regarding isolation. There was no evidence the facility monitored current employees through direct observation, to ensure they were following the infection control policies and procedures. The facility's infection control program failed to effectively investigate, monitor, and/or implement measures to ensure there was no spread of this highly contagious infectious organism to the other residents in the facility. -- d) During an interview with the DON on 05/05/10 at 3:00 p.m., the facility ' s quality assurance program was discussed. According to the DON, the infection control nurse brings a report to the QAA committee meeting every month and everyone discusses what they were monitoring. It was identified that Resident #143 had recently come from the hospital with [DIAGNOSES REDACTED], and the facility had not identified the need for implementing any special measures to ensure [DIAGNOSES REDACTED] was not spread by Resident #143 throughout the entire facility.",2015-06-01
10301,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,329,D,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for two (2) of twenty-one (21) Stage II sample residents, to assure their drug regimen was free of unnecessary drugs including drugs without adequate monitoring. One (1) resident was receiving an antipsychotic medication for behaviors with no evidence those behaviors continued to be present. One (1) resident was receiving a medication for lowering cholesterol levels without evidence of recommended lab studies to assure their safety. Resident identifiers: #34 and #31. Facility census: 34. Findings include: a) Resident #34 When reviewed on 05/05/10, the resident's medical record disclosed he was receiving [MEDICATION NAME] 50 mg two (2) times daily for agitation. The resident had been receiving the medication since 07/29/09. When reviewed for behaviors associated with the agitation, documentation suggested the resident became agitated when staff attempted to persuade him to shower. The record disclosed nurses' notes on only two (2) occasions, 02/10/10 and 03/02/10, both associated with attempts to bath resident. The resident's behavior monitoring sheets for February 2010 through April 2010 disclosed agitated behaviors on three (3) occasions in March 2010. The resident's care plan, when reviewed, disclosed the following problem statement identified by staff on 05/12/09: ""Behavior problem related to verbally abusive behavior as evidenced by verbally abusive."" On 02/03/10, the care plan problem stated, ""D/C (discontinue) no behavior issues for some time now."" A pharmacy recommendation, dated 12/23/09, requested the resident's attending physician attempt a gradual dose reduction of the medication. The physician stated ""no change"" and did not decrease the medication. The physician declined an additional request for a gradual dose reduction attempt on 04/15/10, with no explanation given. These findings were brought to the attention of the vice president of nursing services (Employee #32) and the unit's director of nurses (Employee #31) at 11:50 a.m. on 05/13/10. Employee #31 stated the resident did have behaviors and there had been unsuccessful attempts to reduce the medication dosage in the past. At the time of exit from the facility on 05/12/10 at 5:00 p.m., staff had provided no evidence of attempts to decrease this resident's medication. b) Resident #31 Medical record review revealed this resident was receiving [MEDICATION NAME]. According to the manufacturer's recommendations, liver function should be monitored for residents who use this medication. This resident was not monitored for liver function. .",2015-05-01
10302,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,274,D,0,1,MM9U11,". Based on medical record review and staff interview, the facility failed to complete a comprehensive assessment when a significant change in status occurred for one (1) of twenty-one (21) Stage II sample residents. This resident had significant declines in both mood state and self-performance of bathing, but a significant change in status assessment was not completed. Resident identifier: #53. Facility census: 34. Findings include: a) Resident #53 Review of this resident's medical record, and interview with the social worker (Employee #30) on 05/12/10 at 10:20 a.m., revealed this resident had experienced declines in mood indicators and activities of daily living (ADL) self-performance since admission on 12/12/09. Comparison of the resident's comprehensive admission assessment (with an assessment reference date (ARD) of 12/22/09) and her first abbreviated quarterly assessment (with an ARD of 03/24/10) revealed the following: - Resident #53 only had one (1) indicator of depression, anxiety, and/or sad mood present on admission (coded at Item E.1.m.). However, on her quarterly assessment completed three (3) months later, the assessor noted the presence of six (6) indicators of depression, anxiety, and/or sad mood (coded at Items E1.a., E1.c, E1.d, E1.h, E1.i, and E1.n.). - In Section G, physical functioning and structural problems, the resident exhibited a significant decline in self-performance of bathing from ""2"" (physical help limited to transfer only) on admission to ""4"" (total dependence) three (3) months later. This significant decline in status was not identified when the quarterly assessment was reviewed and signed by the interdisciplinary team on 03/25/10. No comprehensive assessment was completed in recognition of this significant change in status as of 05/12/10. On 05/12/10 at 10:40 a.m., this information was brought to the attention of the assessment coordinator (Employee #25). At that time, Employee #25 confirmed the changes and confirmed that a comprehensive assessment had not been completed as required - within fourteen (14) days after the facility determined, or should have determined, that a significant change in the resident's physical or mental condition had occurred. .",2015-05-01
10303,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,431,B,0,1,MM9U11,". Based on observation and staff interview, the facility failed to assure the safe storage of drugs and biologicals, by retaining a vial of immunization past the manufacturer's expiration date and storing it in a refrigeration rather than in the freezer as recommended. This practice had the potential to affect any resident with orders for this medication. Facility census: 34. Findings include: a) On 05/11/10 at 9:20 a.m., observation of the facility's medication storage room, including the medication storage refrigerator used to store all medications requiring refrigeration for facility residents, found a boxed ampul with a label reading ""Varicella Virus Vaccine"". The labeled box also stated the medication should be stored at an average temperature of 5 degrees Fahrenheit (F), and the noted expiration date of the medication was 19 March 2010. The refrigerator temperature at that time was 46 degrees F. Two (2) licensed practical nurses (LPNs - Employees #21 and #22) were present at the time ,and although neither of the nurses had any idea why the medication was there or who it was for, they both confirmed the medication was beyond the expiration date and was not stored as recommended on the label. .",2015-05-01
10304,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,492,C,0,1,MM9U11,". Based on record review and staff interview, the facility failed to provide the opportunity to request a demand bill for residents who were discontinued from Medicare-covered skilled services, as required to comply with 42CFR489.21(b). This practice affected all residents who were discontinued from Medicare-covered skilled services. Facility census: 34. Findings include: a) Review of the information provided residents who were discontinued from Medicare-covered skilled services, with the social worker (SW - Employee #30) on 05/11/10, revealed the facility was not providing the residents or their responsible parties an opportunity to request a demand bill when skilled services were discontinued. At that time, the SW provided copies of the letters sent, which did not include the information required to request a demand bill. He was unaware of any other forms required, and the facility had not been providing these notices to applicable Medicare residents. Therefore, no resident was offered the opportunity to request a demand bill. .",2015-05-01
10305,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,364,E,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to assure pureed foods were attractive when served. The pureed food items flattened out and ran together on the plates. In addition, garnishes were not provided residents who were ordered pureed diets. This practice affected each of the eight (8) residents who had a physician's orders [REDACTED]. Findings include: a) On 05/11/10 at 12:05 p.m., observation was made of food service in the kitchen. Pureed beef, pureed noodles, and pureed green beans were served the residents requiring pureed diets. All these products were thin and without form. They flattened and ran together on the plates, creating an unattractive and unappetizing presentation. At the time of the observation, the thin pureed foods were brought to the attention of Employee #90, the dietary manager (DM). The DM confirmed the pureed foods should have a shape / form and the pureed foods served at the meal did not, making the meal unattractive. Additionally, garnishes (to add interest and contrast to the meal) were used at this meal for residents who were not ordered pureed foods; however, garnishes were not provided residents who required pureed foods. .",2015-05-01
10306,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,371,F,0,1,MM9U11,". 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 had 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: 34. Findings include: a) On 05/11/10 at 11:50 a.m., soup bowls and water pitchers were observed stacked inside each other. They contained moisture, creating a medium for bacterial growth. At this time, the situation was brought to the attention of the dietary manager (DM). The DM confirmed the bowls and pitchers should have been air dried prior to stacking inside each other b) Observation, at 11:50 a.m. on 05/11/10, also revealed the inside finish was worn off several plastic soup bowls. Once the finish is gone, these food service items cannot be effectively sanitized. .",2015-05-01
10307,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,309,D,0,1,MM9U11,"**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 physical well-being for two (2) of twenty-one (21) Stage II sample residents. One (1) resident had no follow-up assessments or monitoring after two (2) falls, and another resident's ill-fitting socks were causing indentations in the resident's lower legs. Resident identifiers: #31 and #12. Facility census: 34. Findings include: a) Resident #31 Medical record review, on 05/12/10, revealed this resident fell on [DATE], and was taken to the emergency room (ER) for evaluation. The next note, also on 03/08/10, described the resident being brought back from the ER and the resident's current condition. There were no nursing notes, between 03/08/10 and 03/15/10, seven (7) days later. The note on 03/15/10 did not mention the fall. There was no evidence the facility did any type of follow-up assessment or monitoring of the resident after the fall on 03/08/10. This resident fell again on 04/29/10 at 1930 (7:30 p.m.) and was taken to the ER. According to the medical record, the resident returned to the facility at 2200 (8:36 p.m.). There were no nursing notes regarding the fall and no evidence of any assessment or monitoring for the next three (3) days, until 05/02/10 at 1240 (12:40 p.m.). Interview with the vice president of patient care services (Employee #32), at 9:45 a.m. on 05/13/10, revealed nursing staff were supposed to complete follow-up assessments after any fall. Employee #32 reviewed the medical record and was unable to find any assessments following the fall on 03/08/10. Additionally, Employee #32 confirmed there should have been follow-ups between 04/29/10 and 05/02/10. -- b) Resident #12 At 2:00 p.m. on 05/12/10, during an interview with this resident, observation revealed the elastic tops of both of the resident's socks were making indentations in her legs just above her ankles. Review of the resident's medical record and care plan revealed nothing relative to assuring the resident's socks were not too tight on her legs. This was of particular concern, because the resident had [DIAGNOSES REDACTED]. .",2015-05-01
10308,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,411,D,0,1,MM9U11,". Based on observation, resident interview, and staff interview, the facility failed to obtain needed dental services for one (1) of twenty-one (21) Stage II sample residents. The facility had identified the resident's teeth were in poor condition and that she needed dental care; however, this service had not been obtained or pursued by the facility. Resident identifier: #31. Facility census: 34. Findings include: a) Resident #31 During an interview with this resident on 05/04/10 at 3:30 p.m., she stated she often had toothaches. Upon inquiry, the resident stated she had not mentioned the toothaches to facility staff, nor had she been seen by a dentist. Broken and carious teeth were observed as the resident spoke. At one (1) point, the resident opened her mouth to display the condition of her teeth. Observation revealed her teeth were in extremely poor condition. On 05/12/10, the resident's initial care plan (dated 02/15/10) and the first review of the care plan (dated 04/22/10) were reviewed. The care plans identified broken and carious teeth as one (1) of the resident's problems. There was an intervention, originally dated 02/15/10, for social services to ""Coordinate arrangements for dental care..."" As of 05/12/10, there was no evidence this had occurred. At 10:40 a.m. on 05/12/10, this information was brought to the attention of the care plan / assessment nurse (Employee #25). At that time, Employee #25 confirmed the condition of the resident's teeth and stated dental services had not been arranged, because the resident was only receiving Medicare services when she was admitted . Employee #25 stated the facility was waiting until the resident became Medicaid-eligible and planned to arrange dental services at that time. Upon inquiry, Employee #25 checked the resident's records and reported the resident became Medicaid-eligible on 03/06/10. As of 05/12/10, arrangements for dental care for this resident had not been initiated. Employee #25 confirmed the dental care should have already been implemented for the resident. .",2015-05-01
10309,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,282,D,0,1,MM9U11,". Based on medical record review, resident interview, observation, and staff interview, the facility failed to implement a care plan for one (1) of twenty-one (21) Stage II sample residents. This resident had a care plan related to broken teeth and dental caries which was not implemented by the facility. Resident identifier: #31. Facility census: 34. Findings include: a) Resident #31 During an interview with this resident on 05/04/10 at 3:30 p.m., she stated she often had toothaches. Upon inquiry, the resident stated she had not mentioned the toothaches to facility staff, nor had she been seen by a dentist. Broken and carious teeth were observed as the resident spoke. At one (1) point, the resident opened her mouth to display the condition of her teeth. Observation revealed her teeth were in extremely poor condition. On 05/12/10, the resident's initial care plan (dated 02/15/10) and the first review of the care plan (dated 04/22/10) were reviewed. The care plans identified broken and carious teeth as one (1) of the resident's problems. There was an intervention, originally dated 02/15/10, for social services to ""Coordinate arrangements for dental care..."" As of 05/12/10, there was no evidence this had occurred. At 10:40 a.m. on 05/12/10, this information was brought to the attention of the care plan / assessment nurse (Employee #25). At that time, Employee #25 confirmed the condition of the resident's teeth and stated dental services had not been arranged, because the resident was only receiving Medicare services when she was admitted . Employee #25 stated the facility was waiting until the resident became Medicaid-eligible and planned to arrange dental services at that time. Upon inquiry, Employee #25 checked the resident's records and reported the resident became Medicaid-eligible on 03/06/10. As of 05/12/10, arrangements for dental care for this resident had not been initiated. Employee #25 confirmed the dental care should have already been implemented for the resident. .",2015-05-01
10310,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,311,E,0,1,MM9U11,". Based on observations and staff interview, the facility failed to assure six (6) of thirty-four (34) residents, identified through random observations, were provided services to assure maintenance or improvement of their ability to feed themselves. Resident identifiers: #67, #14, #2, #29, #53, and #13. Facility census: 34. Findings include: a) Residents #14, #13, #2, and #67 Observation of the evening meal was conducted beginning at 5:45 p.m. on 05/03/10. Ten (10) residents ate in their rooms that evening. These four (4) residents needed prompting and encouragement to eat their meals. No staff members were observed monitoring the hallways to provide necessary prompting and encouragement to these residents, who were not eating. The only time a staff member was observed on the hallway was at 6:17 p.m., when one (1) nursing assistant went to see if the residents were finished with their meals. 1. Resident #14 - At 6:00 p.m., this resident was asleep with her uneaten meal in front of her. She had eaten nothing. 2. Resident #13 - At 6:00 p.m., this resident was asleep with her meal in front of her. She had eaten approximately 25% of her meal. 3. Resident #2 - At 6:00 p.m., this resident was asleep with her meal in front of her. She had eaten approximately 25% of her meal. 4. Resident #67 - At 6:05 p.m., this resident had stopped eating and was just sitting quietly in her room. The meal was still in front of her. She had eaten approximately 10% of her meal. -- b) Resident #67 In addition to the evening meal observation on 05/03/10, this resident was observed during the evening meal at 6:00 p.m. on 05/12/10. The resident was asleep with her uneaten meal in front of her. At 6:05 p.m., the director of nursing (DON) was asked to observe this situation, and she did. At that time, the DON confirmed the resident required prompting and encouragement at meals. -- c) Observations were made in the dining room at the evening meal on 05/03/10 and at the noon meal on 05/04/10. Several residents were seated at tables which were so high, the residents had to raise their arms in an unnatural position to reach their food. -- d) Resident #53 This resident laid her head on the table, in front of her meal, while eating in the dining room at 1:15 p.m. on 05/05/10. Twice she sat up, looked at her meal, then laid her head back on the table and fell asleep again, with her meal in front of her. She had consumed approximately 25%. Every now and again, the resident awoke and took a drink of milk, then laid her head down and fell back to sleep. No one offered her prompting or encouragement to stay awake and eat her meal. -- e) Resident #29 This resident was seated at the same table as Resident #53, while eating in the dining room, at 1:15 p.m. on 05/05/10. She was just sitting with her plate of uneaten food in front of her. No one offered her prompting or encouragement to eat her meal. .",2015-05-01
10311,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,281,E,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed to assure that services provided met current professional standards of quality, by administering the medication [MEDICATION NAME], to four (4) of ten (10) residents observed during medication administration, outside of the recommendations for use by the manufacturer of the medication. Resident identifiers: #3, #8, #6, and #15. Facility census: 34. Findings include: a) Residents #3 and #8 During medication administration by a licensed practical nurse (LPN - Employee #22) on 05/11/10 at 9:00 a.m. and 10:17 a.m. respectively, Residents #3 and #8 were observed receiving their medications. At that time, both residents received [MEDICATION NAME], a [MEDICAL CONDITION] replacement medication. The LPN, when questioned, confirmed the residents had just finished their breakfast. Review of the Internet website www.drugs.com disclosed the following statement: ""Take [MEDICATION NAME] as a single dose, preferably on an empty stomach, one-half to one hour before breakfast. The drug is absorbed better on an empty stomach."" b) Residents #6 and #15 During medication administration by Employee #22 on 05/12/10 at 9:00 a.m., Residents #6 and #15 were observed receiving their medication. At that time, both residents received [MEDICATION NAME], a [MEDICAL CONDITION] replacement medication. The LPN, when questioned, confirmed the residents had just finished their breakfast. Review of the Internet website www.drugs.com disclosed the following statement: ""Take [MEDICATION NAME] as a single dose, preferably on an empty stomach, one-half to one hour before breakfast. The drug is absorbed better on an empty stomach."" When interviewed on 05/12/10 at 11:00 a.m., another LPN (Employee #28) stated she had spoken to the unit's consulting pharmacist concerning this information the previous evening, and the pharmacist agreed with this information and stated she had planned to submit that recommendation on her next visit to the unit. .",2015-05-01
10312,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,272,D,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, record review, and resident interview, the facility failed, for three (3) of twenty-one (21) Stage II sample residents, to complete initial and/or periodic comprehensive assessments of each resident's functional capacity, to include assessments of skin condition, bladder continence, and nutritional status. Resident identifiers: #9, #31, and #53. Facility census: 34. Findings include: a) Resident #9 When interviewed on 05/03/10 at 3:45 p.m. about the status of Resident #9's skin integrity, Employee #18 (a licensed practical nurse - LPN) stated the resident had an open area on each heel and he ""came from hospital with them."" When reviewed on 05/12/10, the resident's medical record disclosed this [AGE] year old had been admitted to the facility from a local hospital on [DATE], following repair of a [MEDICAL CONDITION] that he had incurred at home. The resident's nursing admission assessment made no mention of skin breakdown other than describing the area of the surgical wound on the resident's left hip. Nursing notes and physician orders [REDACTED]. A nurse's note, dated 02/03/10 at 12:20 p.m., stated, ""Resident complained of heels hurting this am (morning). Heel up (sic) off bed. Both heels black area. Told charge nurse."" Orders were received, and treatment was started to the heels at that time. An additional nurse's note, dated 03/01/10, stated a physician questioned the resident and his wife related to the areas on his heels, and both the resident and his wife agreed that his heels had been sore since he was at home, prior to his hospitalization for the [MEDICAL CONDITION]. When interviewed on 05/12/10 at 4:07 p.m., the facility's care plan and assessment nurse (Employee #25) confirmed the skin integrity of the resident's heels, according to the resident and family, had been somehow compromised at the time of admission to the ECU. This employee stated the ECU protocol for skin assessments was for an assessment to be completed on the resident at the time of admission and then monthly thereafter by the nurse, unless there was a recognized skin issue; then, a weekly skin assessment (wound assessment) was completed. This nurse further confirmed that no assessment of the resident's heels had been completed until the resident complained of pain on 02/03/10. The resident's MDS documents, when reviewed, disclosed that both the admission MDS (with an assessment reference date (ARD) of 01/17/10) and the Medicare 14-Day MDS (with an ARD of 01/24/10) made no mention, in Section M, of the resident having any skin breakdown. The resident's next MDS (with an ARD of 02/09/10) described the resident, in Section M, as having four (4) Stage IV pressure ulcers. -- b) Resident # 31 Medical record review, on 05/12/10, revealed this resident was incontinent of bladder when admitted on [DATE]. A six-page bladder incontinence assessment form was found in the medical record; however, it had not been completed. This form also contained the protocols for assessing residents with urinary incontinence. At 2:00 p.m. on 05/12/10, the director of nursing (DON - Employee #31) and the vice president of patient care services (Employee #32) were asked if they would locate a completed bladder incontinence assessment for this resident. Each reviewed the medical record and checked other sources, then confirmed no such assessment had been completed. At 11:00 a.m. on 05/13/10, the resident was interviewed regarding her incontinence. At that time, the resident stated she could feel the urge to urinate and would like to be continent of urine if at all possible. -- c) Resident #53 Review of this resident's medical record, on 05/12/10, revealed a weight of 101.4 pounds (#) on 03/02/10, and a weight of 94.6# on 04/02/10. There was no evidence the resident was reweighed to confirm or dispute this six and seven-tenths percent (6.7%) weight loss in one (1) month. If the weight loss were accurate as recorded, the facility should have immediately acted on this significant weight loss. There was no evidence the weight loss had been further assessed or addressed. Interview with Employee #32, at 2:05 p.m. on 05/12/10, revealed nursing staff should have reweighed the resident when there was such a variance in weight. When asked how staff would know this should be done, Employee #32 stated, ""They just know to do so, but they did not."" When a request was made for a policy and procedure regarding weights, Employee #32 stated no such policy existed. .",2015-05-01
10313,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,279,E,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, observation, and resident interview, the facility failed, for seven (7) of twenty-one (21) Stage II sample residents, to develop a comprehensive plan of care that accurately described the services to be furnished to each resident to assist in attaining or maintaining the highest practicable physical, mental and/or psychosocial well being. Two (2) residents had no care plan related to the use of an indwelling Foley urinary catheter, one (1) resident had no care plan related to urinary incontinence, one (1) resident had no care plan for pressure ulcers, one (1) resident had no care plan for the restoration of bladder function, one (1) resident had no care plan for the need for a nutritional assessment, and one (1) resident had a care plan with inappropriate / unexplainable interventions. Resident identifiers: #32, #18, #33, #9, #31, #2, and #53. Facility census: 34. Findings include: a) Resident #32 When reviewed on 05/12/10, the resident's medical record disclosed the resident had been admitted to the Extended Care Unit (ECU) on 12/21/09, following hospitalization for a broken pelvis. At the time of admission to the ECU from acute care, the resident had in place an indwelling Foley urinary catheter. The catheter was removed, according to nurse's notes on 01/12/10. An interview with a licensed practical nurse (LPN - Employee #28), on 05/12/10 at 9:52 a.m., disclosed that facility protocol was typically to remove catheters within twenty-four (24) hours of admission unless there was a [DIAGNOSES REDACTED]. The LPN further stated this resident had a broken pelvis and personally requested that the catheter remain in place. On 01/12/10, the resident agreed to have it removed. The medical record contained no physician's order for the removal of the catheter, no evidence of any attempt by staff to assess the resident's ability to regain continence, and no evidence of any attempt at bladder re-training prior to the removal of the catheter. The resident's minimum data set (MDS) assessments for the previous several months were reviewed. An admission MDS, with an assessment reference date of 10/18/09, stated in Section H that the resident was continent of bowel and bladder (both coded ""0"") with no devices or appliance (such as an indwelling catheter) present. A second admission MDS (with an ARD of 01/05/10) was identical as the above mentioned, although nurse's notes and staff interview stated the resident did have an indwelling catheter present between the dates of 12/21/09 and 01/12/10. A quarterly MDS (with an ARD of 04/05/10) stated the resident was continent of bowel (coded ""0"") and mostly incontinent of bladder (coded ""4""). Although the MDSs inaccurately denied the presence of the indwelling catheter on any assessment, these findings would indicate the resident had been continent of urine prior to her hospitalization and placement of the indwelling catheter and that urinary continence may possibly have been attainable following the removal of the catheter. The resident's current care plan, when reviewed, contained no mention of urinary incontinence. The care plan / assessment nurse (Employee #25) confirmed, when interviewed on 05/12/10, that the resident's care plan did not reflect necessary services in the area of urinary incontinence or a plan to assist the resident in restoring as much normal bladder function as possible. -- b) Resident #18 During an interview related to the use of an indwelling catheter for this resident on 05/04/10, Employee #28 stated the catheter was used periodically for wound healing then removed. The LPN further stated the resident was transferred with a mechanical lift and did not like to go back to bed after she gets up, thus causing re-current breakdown in her skin integrity. Medical record review, on 05/10/10, describe the presence of a Stage I pressure ulcer at this time. A physician's telephone order,dated 03/22/10, stated, ""Insert F/C (Foley catheter) to aid in healing decub to buttock, re-evaluate in 7 days."" On 05/10/10 at 1:45 p.m., observation found the resident in the activity room with the catheter drainage bag suspended under her wheelchair enclosed in a protective cloth bag to conceal it. The resident's most current care plan, when reviewed, disclosed a problem identified by staff on 11/16/09 and reviewed on 02/10/10, stating this resident had ""actual pressure ulcer or altered skin integrity related to urinary incontinence, poor mobility as evidenced by recurring Stage II to coccyx."" The care plan made no mention of the use of an indwelling catheter. Employee #28, when interviewed on 05/10/10, confirmed the resident's care plan had not been updated at the time of the insertion of the indwelling catheter to reflect the resident's current status and necessary services. -- c) Resident #33 When interviewed on 05/04/10 related to the presence of an indwelling Foley urinary catheter for this resident, Employee #28 stated this resident had a Foley catheter due to severe [MEDICAL CONDITION] of the lower legs. The resident was stated to be voiding down her legs, making the skin condition worse. When reviewed on 05/12/10, the resident's medical record revealed the resident was admitted to the ECU on 03/18/10. She had been hosptalized on [DATE], when, according to hospital reports, she presented to the emergency department with pain in her right leg. Her provisional [DIAGNOSES REDACTED]. The resident was re-hosptalized on [DATE] and remained hospitalized until 04/26/10, at which time, according to a nursing readmission assessment on this day, the resident returned to the ECU with an indwelling Foley urinary catheter to assist with wound healing. The resident, when observed on numerous occasions during the course of the survey between 05/03/10 and 05/13/10, was noted to have a Foley catheter drainage bag which was suspended on the bottom of her wheelchair and enclosed in a protective cloth bag. The resident's care plan, when reviewed, disclosed a problem identified by staff for this resident on 04/04/10 as follows: ""Potential for complications related to urinary incontinence. Incontinent at times (sic). Also doesn't like to sit on toilet, she tries to stand over toilet and urine runs down legs."" The care plan made no mention of the resident's indwelling catheter or needs associated with its use. Employee #28 confirmed, when interviewed on 05/12/10, this resident's care plan did not address the care needs associated with her indwelling catheter. -- d) Resident #9 When interviewed on 05/03/10 at 3:45 p.m. about the status of Resident #9's skin integrity, Employee #18 (a licensed practical nurse - LPN) stated the resident had an open area on each heel and he ""came from hospital with them."" When reviewed on 05/12/10, the resident's medical record disclosed this [AGE] year old had been admitted to the facility from a local hospital on [DATE], following repair of a [MEDICAL CONDITION] that he had incurred at home. The resident's nursing admission assessment made no mention of skin breakdown other than describing the area of the surgical wound on the resident's left hip. Nursing notes and physician orders were reviewed in their entirety for this resident. A nurse's note, dated 02/03/10 at 12:20 p.m., stated, ""Resident complained of heels hurting this am (morning). Heel up (sic) off bed. Both heels black area. Told charge nurse."" Orders were received, and treatment was started to the heels at that time. An additional nurse's note, dated 03/01/10, stated a physician questioned the resident and his wife related to the areas on his heels, and both the resident and his wife agreed that his heels had been sore since he was at home, prior to his hospitalization for the [MEDICAL CONDITION]. When interviewed on 05/12/10 at 4:07 p.m., the facility's care plan and assessment nurse (Employee #25) confirmed the skin integrity of the resident's heels, according to the resident and family, had been somehow compromised at the time of admission to the ECU. This employee stated the ECU protocol for skin assessments was for an assessment to be completed on the resident at the time of admission and then monthly thereafter by the nurse, unless there was a recognized skin issue; then, a weekly skin assessment (wound assessment) was completed. This nurse further confirmed that no assessment of the resident's heels had been completed until the resident complained of pain on 02/03/10. The resident's MDS documents, when reviewed, disclosed that both the admission MDS (with an assessment reference date (ARD) of 01/17/10) and the Medicare 14-Day MDS (with an ARD of 01/24/10) made no mention, in Section M, of the resident having any skin breakdown. The resident's next MDS (with an ARD of 02/09/10) described the resident, in Section M, as having four (4) Stage IV pressure ulcers. The resident's ""wound assessment and progress review"" document stated, on 05/09/10, the resident had a Stage II pressure ulcer on his left heel that was identified on 02/03/10. The resident's plan of care, when reviewed 05/12/10, made no mention of the resident's pressure ulcers, only the potential for skin breakdown related to incontinence and immobility. Employee #25, when interviewed on 05/12/10 at 3:00 p.m., confirmed the resident's care plan did not address the presence of pressure ulcer(s) or the care needs / services associated with skin breakdown. -- e) Resident #31 Medical record review, on 05/12/10, revealed this resident was incontinent of bladder when admitted on [DATE]. Review of the resident's care plan revealed no plan regarding an attempt at restoring normal bladder function. The resident's care plan regarding bladder incontinence, originating on 02/15/10 and updated on 04/22/10, was: ""Will be clean and dry with use of incontinence products and prompt incontinence care through review date."" The interventions were to check for incontinence and change clothing after incontinence, etc. There were no care plans to assist the resident in regaining bladder continence. This was confirmed by Employee #28 when interviewed at 1:00 p.m. on 05/12/10. At 11:00 a.m. on 05/13/10, the resident was interviewed regarding her incontinence. At that time, the resident stated she could feel the urge to urinate and would like to be continent if at all possible. -- f) Resident #2 Medical record review, on 05/12/10, revealed this resident was underweight and had experienced additional weight loss. Review of the resident's care plan revealed a goal for the resident to maintain a stable weight. One (1) of the interventions for this goal was: ""Provide and serve supplements as ordered."" The resident was to be provided the nutritional supplement Ensure with each meal and for her 2:00 p.m. and 8:00 p.m. snacks. At 1:00 p.m. on 05/12/10, Employee #28 was asked to provide evidence the Ensure was offered and how much Ensure the resident was consuming. Employee #28 stated it was not documented in her medical record, because the resident's son provided the Ensure. The facility had a care plan to provide Ensure but had no means of assuring the Ensure was offered according to the care plan and/or if the supplement was consumed by the resident as planned. -- g) Resident #12 During an interview with this resident at 9:30 a.m. on 05/04/10, she stated her feet ""constantly hurt and burn"". In addition, the resident stated her legs always hurt. Medical record review, on 05/12/10, revealed this resident had a care plan regarding pain, dated 12/02/09 and updated on 03/03/10. One (1) of the interventions was for nursing staff to ""Provide alternative comfort measures. i.e. heat / cold applications, massage..."" There were no specific directives for the implementation of these comfort measures. (Directives were essential, because the resident had [DIAGNOSES REDACTED]. Based on these diagnoses, some methods of implementation of heat / cold applications and/or massage would be contraindicated for this resident.) Additionally, interview with the resident, at 2:15 p.m. on 05/12/10, revealed nursing staff was not providing hot / cold applications or massage according to the care plan. -- h) Resident #53 Review of this resident's medical record, and interview with the social worker (Employee #30) on 05/12/10 at 10:20 a.m., revealed this resident had experienced declines in mood indicators and activities of daily living (ADL) self-performance since admission on 12/12/09. Review of the resident's current care plan, dated 03/25/10, revealed no changes in the planned interventions for mood, communication, activity involvement, or ADLs since the initial care plan dated 01/01/10, even though staff confirmed the resident had experienced these declines. The interventions for each of these areas were not working for this resident; therefore, different interventions should have been established when the care plan was reviewed on 03/25/10. .",2015-05-01
10314,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,428,E,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure that irregularities noted by the consulting pharmacist for two (2) residents reviewed were reported to a resident's attending physician, and failed to assure that reported irregularities for three (3) residents were acted upon by their attending physician within a reasonable time period. This practice affected five (5) of twenty-one (21) Stage II sample residents. Resident identifiers: #14, #32, #34, #31, and #53. Facility census was 34. Findings include: a) Resident #14 When reviewed on 05/11/10 at 4:00 p.m., the resident's medical record disclosed a ""Chronological Record of Drug Regimen Review"" form dated 03/24/10. The consultant registered pharmacist (RPH) made recommendation to the resident's attending physician and the unit's director of nurses (DON) relevant to an irregularity in the resident's drug regimen. This recommendation could not be found on the medical record. Facility staff was asked to locate the recommendation for surveyor review. On 05/12/10 at 11:55 a.m., a licensed practical nurse (LPN - Employee #28) confirmed the recommendation was not available and there was no evidence it had ever been reported to the DON or attending physician as stated. This employee contacted the RPH, and the report was faxed to the unit for review by the DON and attending physician at that time. -- b) Resident #32 When reviewed on 05/11/10, the resident's medical record disclosed a ""Pharmacy to Physician communication"" document dated 01/26/10, which recommended the physician consider changing a medication, Prilosec (used in the treatment of [REDACTED]. The resident had the medical [DIAGNOSES REDACTED]. This recommendation stated that Prilosec may decrease the effectiveness of another medication, Plavix (a medication used to help prevent harmful blood clots from forming, which given to people who have had a recent heart attack or stroke). Further review revealed the physician did not act upon this recommendation until 04/16/10, when an order was issued to discontinue the Prilosec and to begin Zantac (a medication used to treat heartburn, ulcers, GERD, erosive esophagitis, and other conditions). This finding was confirmed by Employee #28 at 11:30 a.m. on 05/12/10. -- c) Resident #34 When reviewed on 05/11/10, the resident's medical record disclosed a ""Pharmacy to Physician Communication"" document dated 01/26/10, which recommended the physician consider changing the dosage of the medication Zantac. The recommendation stated that related to the resident's CrCl (creatinine clearance), the resident's dosage should be decreased by one-half (1/2) of the current dose he was receiving. (The creatinine clearance test compares the level of creatinine in urine with the creatinine level in the blood. Creatinine is a breakdown product of creatine, which is an important part of muscle. The test helps provide information on kidney function.) The same recommendation was relayed via the communication form to the resident's attending physician on 03/24/10. The physician acted upon the RPH's recommendation by decreasing the dose as recommended on 04/15/10, nearly three (3) months following the original recommendation. -- d) Resident #53 Medical record review, on 05/12/10, revealed the RPH identified an irregularity on 01/26/09. On 05/12/10, a request was made of Employee #28 to locate the written RPH consultant report regarding the irregularity. When Employee #28 was unable to locate the report, she called the RPH. Employee #28 reported the RPH stated to her a written report was not provided, because the RPH directly informed the medication nurse who was passing medications. The RPH stated the change was immediately done. Later that day (05/12/10), the RPH provided a statement regarding the irregularity, which was a need to separate, by two (2) hours, the administration of Cipro (which the resident was ordered at 9:00 a.m. and 9:00 p.m.) with the administration of an iron supplement (at 9:00 a.m.) and a calcium supplement (at 9:00 a.m. and 9:00 p.m.), to prevent absorption problems. Review of the resident's medication administration records (MARs) revealed the irregularity was not corrected and the resident continued to receive the medications together until the course of antibiotics was completed on 01/30/10. -- e) Resident #31 This resident was receiving Zocor. Review of the resident's medical records revealed the facility had not obtained liver function values. The RPH had not identified and reported this irregularity. .",2015-05-01
10315,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,315,G,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview, and staff interview, the facility failed, for two (2) of twenty-one (21) Stage II sample residents who were continent of urine when they entered the facility and became incontinent, to assure timely and appropriate assessment in an effort to possibly regain urinary continence. This resulted in actual harm, as both residents stated a desire to regain normal bladder function and no attempts were made by the facility to assist them with this goal. Resident identifiers: #32 and #31. Facility census: 34. Findings include: a) Resident #32 When reviewed on 05/12/10, the resident's medical record disclosed the resident had been admitted to the Extended Care Unit (ECU) on 12/21/09, following hospitalization for a broken pelvis. At the time of admission to the ECU from acute care, the resident had in place an indwelling Foley urinary catheter. The catheter was removed, according to nurse's notes on 01/12/10. An interview with a licensed practical nurse (LPN - Employee #28), on 05/12/10 at 9:52 a.m., disclosed that facility protocol was typically to remove catheters within twenty-four (24) hours of admission unless there was a [DIAGNOSES REDACTED]. The LPN further stated this resident had a broken pelvis and personally requested that the catheter remain in place. On 01/12/10, the resident agreed to have it removed. The medical record contained no physician's order for the removal of the catheter, no evidence of any attempt by staff to assess the resident's ability to regain continence, and no evidence of any attempt at bladder re-training prior to the removal of the catheter. The resident's minimum data set (MDS) assessments for the previous several months were reviewed. An admission MDS, with an assessment reference date of 10/18/09, stated in Section H that the resident was continent of bowel and bladder (both coded ""0"") with no devices or appliance (such as an indwelling catheter) present. A second admission MDS (with an ARD of 01/05/10) was identical as the above mentioned, although nurse's notes and staff interview stated the resident did have an indwelling catheter present between the dates of 12/21/09 and 01/12/10. A quarterly MDS (with an ARD of 04/05/10) stated the resident was continent of bowel (coded ""0"") and mostly incontinent of bladder (coded ""4""). Although the MDSs inaccurately denied the presence of the indwelling catheter on any assessment, these findings would indicate the resident had been continent of urine prior to her hospitalization and placement of the indwelling catheter and that urinary continence may possibly have been attainable following the removal of the catheter. When interviewed on 05/13/10 at 9:45 am, the resident stated she feels the urge and tries to control it as much as possible. She stated she has ""always had the desire to control it somehow. One thing for sure, I try to avoid the stuff that causes you to urinate. A person that has problems with urine control, they should not drink liquid before they go to bed, especially coffee."" The resident's current care plan, when reviewed, contained no mention of urinary incontinence. The care plan / assessment nurse (Employee #25) confirmed, when interviewed on 05/12/10, that the resident's care plan did not reflect necessary services in the area of urinary incontinence or a plan to assist the resident in restoring as much normal bladder function as possible. b) Resident # 31 Medical record review, on 05/12/10, revealed this resident was incontinent of bladder when admitted on [DATE]. Review of the resident's care plan revealed no plan regarding an attempt at restoring normal bladder function. The resident's care plan regarding bladder incontinence, originating on 02/15/10 and updated on 04/22/10, was: ""Will be clean and dry with use of incontinence products and prompt incontinence care through review date."" The interventions were to check for incontinence and change clothing after incontinence, etc. There were no care plans to assist the resident in regaining bladder continence. This was confirmed by Employee #28 when interviewed at 1:00 p.m. on 05/12/10. At 11:00 a.m. on 05/13/10, the resident was interviewed regarding her incontinence. At that time, the resident stated she could feel the urge to urinate and would like to be continent if at all possible. .",2015-05-01
10316,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,278,D,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident interview, and observation, the facility failed to assure the minimum data set (MDS) assessment accurately reflected the physical status of two (2) of twenty-one (21) Stage II sample residents. Resident identifier: #31 and #33. Facility census: 34. Findings include: a) Resident #31 During an interview with this resident on 05/04/10 at 3:30 p.m., observation made as the resident spoke found broken and carious teeth. The resident described her teeth as being in ""pretty bad shape"" and opened her mouth to display the condition of her teeth. Observation revealed her teeth were in extremely poor condition. The resident's initial minimum data set (MDS), with an assessment reference date (ARD) of 02/07/10, was reviewed. Section L, relative to oral / dental status, did not accurately identify the condition of the resident's teeth. L.1.d ""Broken loose, carious teeth"" was not marked on the MDS, even though this condition had to have existed upon the resident's admission on 01/26/10. -- b) Resident #33 When interviewed on 05/04/10 related to the presence of an indwelling Foley urinary catheter for this resident, Employee #28 (a licensed practical nurse and the medical record coordinator) stated this resident had a Foley catheter due to severe [MEDICAL CONDITION] of the lower legs. The resident was stated to be voiding down her legs, making the skin condition worse. When reviewed on 05/12/10, the resident's medical record revealed the resident was admitted to the Extended Care Unit (ECU) of the facility on 03/18/10. She had been hosptalized on [DATE], when, according to hospital reports, she presented to the emergency department with pain in her right leg. Her provisional [DIAGNOSES REDACTED]. The resident was re-hosptalized on [DATE] and remained hospitalized until 04/26/10, at which time, according to a nursing readmission assessment on this day, the resident returned to the ECU with an indwelling Foley urinary catheter to assist with wound healing. The resident, when observed on numerous occasions during the course of the survey between 05/03/10 and 05/13/10, was noted to have a Foley catheter drainage bag which was suspended on the bottom of her wheelchair and enclosed in a protective cloth bag. Record review revealed the resident's most recent minimum data set assessment (MDS) was a Medicare 5-Day assessment with an assessment reference date (ARD) of 05/02/10. In Section H, the assessor coded the resident as ""3"" in area bladder incontinence, indicating the resident was frequently incontinent of urine. In Section H3, the assessor did not check the item to that would indicated the presence of an indwelling urinary catheter. Employee #28, when asked about the accuracy of this assessment on 05/12/10 at 3:09 p.m., confirmed the resident had had an indwelling Foley urinary catheter in place since readmission to the facility on [DATE] and the MDS was incorrect. .",2015-05-01
10317,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,363,E,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, menu review, recipe review, and staff interview, the facility failed to assure menus were followed for 1200 and 1500 calorie diets, and failed to assure there were menu plans for 2 gram sodium, cardiac, and renal diets. This practice affected fourteen (14) of thirty-three (33) residents who received nourishment from the dietary department. Facility census: 34. Findings include: a) Observation of meal service, on 05/11/10 at 12:05 p.m., revealed all residents were served a 3 ounce portion of meat. Review of the menu plan for this meal revealed the three (3) residents requiring 1200 and 1500 calorie diets were supposed to be served a 2 ounce portion of meat at this meal. At 12:30 p.m., this was brought to the attention of the dietary manager (DM - Employee #90), who confirmed the menu called for 2 ounces, yet 3 ounces were served to these residents. b) Medical record review revealed there were seven (7) residents with a physician's orders [REDACTED]. Review of the menu plan, for the noon meal on 05/11/10, revealed there were no specific menu plans for 2 gram sodium, cardiac, and renal diets. The menu did not indicate which food items were to be salt-free and/or fat-free for these diets. When this was brought to the attention of the DM, the DM stated the specific directives for these diets were on the recipes. The recipes for this meal were reviewed with the DM. There were no special directives for 2 gram sodium, cardiac, or renal diets on the recipes. .",2015-05-01
10318,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2010-05-13,323,G,0,1,MM9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed, for one (1) of twenty-one (21) Stage II sample residents, to provide a resident environment as free of accident hazards as possible, by failing to ensure staff consistently secured and alarmed an exit door leading from the unit to a stairwell. This practice resulted in actual harm for Resident #30 when she exited the door unnoticed and fell down eight (8) steps in her wheelchair, sustaining an acromioclavicular joint separation (separated shoulder). Resident identifier: #30. Facility census: 34. Findings include: a) Resident #30 Review of the facility's incident / accident reports, on 05/11/10, revealed a report stating that, on 03/23/10 at 11:00 a.m., Resident #30 was found in a stairwell off the Extended Care Unit (ECU) at the bottom of eight (8) stairs. Further review of the document disclosed that, following investigation, it was determined a staff member had failed to utilize the proper method of securing the door and re-setting the door alarm after another resident had activated the alarm the day before. This information was confirmed in an interview with vice president of patient care services (Employee #32) on the morning of 05/13/10. The resident's medical record, when reviewed on 05/12/10, disclosed this [AGE] year old female was known to the facility to wander and to be at risk for falling. According to the resident's care plan, which was reviewed on 05/12/10, staff was aware the resident was a high risk for falls related to a history of falls. Interventions to assure the resident was free from falls included measures such as providing activities that minimize the potential for falls while providing diversion and distraction and applying a bed alarm and an EZ release seat belt while in wheelchair. The resident also wore a WanderGuard alarming device / bracelet, but this door was not equipped with the WanderGuard system. Review of the resident's minimum data set (MDS) assessments disclosed an MDS with an assessment reference date of 02/24/10. In Section E (Mood and Behavior), the assessor noted the resident exhibited wandering one (1) to three (3) days in the seven-day assessment reference period. The resident was noted in Section B (Cognitive Skills) to be moderately impaired in cognitive skills for daily decision-making, and in Section G (Physical Functioning), the resident was noted to range from needing extensive assistance to being totally dependent for completing most activities of daily living. When the resident was discovered following the fall, nurses' notes stated she was ""lying on face / left side with wheelchair on back. Had to release EZ release seat belt to get w/c (wheelchair) off resident."" The resident was secured to a back board and transferred to the emergency room (ER). The resident underwent [REDACTED]. There was acromioclavicular joint separation (separated shoulder), the resident returned to the ECU with a sling on the left arm, and the resident's pain medication was increased. .",2015-05-01
9735,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2010-05-19,157,D,0,1,QP8711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, medical record review, and staff interview, the facility failed to notify the medical power of attorney representative (MPOA) of one (1) of twenty-nine (29) Stage II residents of a change in condition requiring scheduled diagnostic testing. Resident identifier: #5. Facility census: 53. Findings include: a) Resident #5 On 05/12/10 at approximately 3:00 p.m., medical record review revealed Resident #5 lacked the capacity to make informed health care decisions for herself due to her inability to process information. The resident had executed a West Virginia medical power of attorney document dated 03/25/02, designating her daughter as the representative to act on her behalf, giving, withholding or withdrawing consent to health care decisions in the event the resident could not do so herself. The document further stated that, if the chosen representative would became unable, unwilling or disqualified to serve, the resident's son would become the successor representative. The medical record did not indicate the daughter had became unwilling, unable or disqualified to serve as her mother's MPOA. The medical record's record of admission (face sheet) indicated the daughter was the resident's MPOA; her name and telephone number were listed as the primary contact. On 05/12/10 at approximately 5:00 p.m., a telephone call to the resident's MPOA revealed she had not received notification of the procedures her mother had scheduled on 05/11/10. She indicated she did know about Resident #5's scheduled medical appointment on 04/29/10; however, she denied being told the exact procedures the resident needed to have performed. A nursing note, dated 04/29/10 at 5:45 p.m., stated, Rtd. (returned) to facility from Dr. (name) office - to return May 11/10 - dtr (daughter) (name) notified. The daughter stated she knew Resident #5 would return to the physician's office on 05/11/10, but the facility did not tell her what procedures the physician wanted to perform on that date. A review of the consultation report from the urologist revealed findings and recommendations for treatment. The consulting urologist had dated the form 04/29/10. The facility physician had reviewed the orders on 05/03/10. The licensed practical nurse had transcribed the order onto a physician's telephone orders form on 05/03/10. The transcribed order indicated the resident would receive a cystoscopy, EMG, pelvic exam, HgbA1c check (a blood test that reflects one's average blood glucose levels for a two (2) to three (3) month period), folic acid, vitamin B12, and [MEDICATION NAME]. The physician's telephone order had a place at the bottom where the nurse could check if the family had received notification of the change in treatment; this section was left blank. The director of nursing indicated, on 05/12/10 at approximately 4:00 p.m., that the nurse should have completed this section for verification that the MPOA had received notification of the tests to be performed.",2015-10-01
9736,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2010-05-19,241,E,0,1,QP8711,"Based on observation, staff interview, and review of medical records, the facility failed to ensure each resident was treated in a manner that promoted a dignified existence for the individual. Random observations of the evening dining experience during Stage I noted residents were brought to the restorative dining room well in advance of their meals being served; once meal service began, three (3) of the seven (7) residents in this dining room had to sit and watch as the others ate, before they were assisted with their meals. Observations of the noon meal during Stage II again found the residents in the restorative dining area had to wait for a lengthy period before their meals were served. One (1) resident was brought into the main dining room and placed at a table where two (2) other residents were eating; this resident was not served for fourteen (14) minutes. During observations of treatments during Stage II, the nurse labeled the dressing for two (2) residents after the dressings had been applied to their bodies. Additionally, a staff member was heard asking a resident questions of a personal nature in a public area. Eight (8) residents dining in the restorative dining room, and Residents #30, #37, #75, and #45 were affected. Facility census: 53. Findings include: a) Restorative dining at dinner time on 05/10/10 On 05/10/10 at 6:00 p.m., observation found residents were already in the restorative dining room. At 6:15 p.m., Resident #33 told a nursing assistant (Employee #34) she was hungry. At 6:35 p.m., the first resident in the restorative dining room was served. At 6:36 p.m., Employee #34 brought two (2) Styrofoam cups of coffee and a glass containing a supplement. At 6:30 p.m. and 6:41 p.m., Employee #34, who was seated behind the horseshoe table at which Resident #33 was seated, asked Resident #33 if she was hungry, to which the resident replied, Yeah, both times. Each time, the nursing assistant handed the resident her coffee, as her meal had not yet been served to her. At 6:44 p.m., four (4) of the seven (7) residents in the restorative dining room had been served. The other three (3) residents could only sit and watch as the others ate or were being fed. By this time (6:44 p.m.), Resident #33 had become increasingly difficult to keep at the table. She was moving her wheelchair about with increasing frequency, and Employee #34 asked another employee, who was passing through the area, to return the resident to the table on more than one (1) occasion. At 6:45 p.m., the fifth resident was served her meal by the director of nursing (Employee #2). At 6:50 p.m., the sixth resident was served his meal. At 6:52 p.m., Resident #33 was served her meal - more than fifty-two (52) minutes after arriving in the dining room and after having said she was hungry three (3) times in response to questions posed by staff. -- b) Restorative dining at lunch time on 05/18/10 At lunch time on 05/18/10 at 11:45 a.m., observation found eight (8) residents seated in the small dining room awaiting lunch. Staff was in the adjacent main dining area, but none was observed in the small dining room for at least ten (1) minutes. The residents had beverages on the tables in front of them, but not all of the residents could access the beverages either by virtue of debility and/or positioning. The first resident in the restorative dining room was not served until 12:30 p.m., more than forty-five (45) minutes after she had been brought to the dining room. -- c) Resident #30 Resident #54 and another female resident were seated at a table in the main dining room at lunch time on 05/18/10. Both had been served and were eating their meals by 12:10 p.m., when Resident #30 was brought into the dining room and seated at their table. Resident #30 sat at the table for fourteen (14) minutes before she was served her lunch. By that time, the other two (2) residents at the table were nearly finished. -- d) Resident #75 On 05/17/10 at 2:30 p.m., Employee #20, a licensed practical nurse (LPN), was observed providing dressing changes to the two (2) small wounds on the resident's right foot and another one (1) on his left foot. After applying the dressings to each area, she would remove a Sharpie marker from her pocket and date and initial the dressing. -- e) Resident #37 On 05/18/10 at 11:20 a.m., Employee #20, an LPN, was observed performing a dressing change to the resident's gastrostomy tube site. After she had applied the dressing, she labeled the dressing with a Sharpie marker. On 05/18/10 at approximately 2:00 p.m., the issue of labeling dressings after they were applied (a dignity issue) was discussed with Employee #20. She said she did not know why she had labeled them after application - she usually labeled them before she put them on the resident. -- f) Resident #46 During observations of the resident environment on 05/19/10 at approximately 10:45 a.m., the director of nursing (DON) was overheard to loudly ask Resident #46 personal and private questions in a seating area adjacent to the nursing station. Observation found other residents and staff members present and within hearing distance when this occurred.",2015-10-01
9737,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2010-05-19,246,D,0,1,QP8711,"Based on observations during Stage II, the facility failed to provide each resident with a reasonable accommodation of needs. A resident was noted to be seated in a wheelchair that did not allow for support of the resident's feet, creating a potential for impediment of circulation due to pressure on the back of the resident's legs and a potential to further affect the muscles and tendons of the legs and feet. Resident identifier: #2. Facility census: 53. Findings include: a) Resident #2 On 05/18/10 at 7:30 a.m., this resident was observed sitting in his wheelchair in the hall near the dining room. As a nursing assistant (Employee #41) passed by, the resident asked to be repositioned in his wheelchair. (The resident's hips had slid forward in the chair, and he needed them repositioned toward the back of the seat of the chair.) After Employee #41 repositioned the resident, observation found the resident's feet did not touch the floor, nor was there any type of support for his feet. This resulted in the resident's feet dangling a few inches above the floor. At approximately 9:15 a.m., Employee #20 (a licensed practical nurse) was asked whether the resident used his feet or hands to maneuver his wheelchair. She said he sometimes used both. A few minutes later, the resident was observed with Employee #18. At that time, he was sitting in the activities room in his wheelchair. She agreed he did not have support for his feet. She said sometimes the resident would get his feet going and move his chair, sometimes he would use his hand, and at times he would use them both. She said staff often had to pull the resident back in his wheelchair. At approximately 9:30 a.m., Employee #77 (an occupational therapist) was asked to look at the resident with respect to the wheelchair, as his feet were unsupported and this had the potential to affect circulation as well as his ability to maintain his position in the chair. Shortly after, Employee #77 had the resident in the therapy room with Employee #57 trying to adjust the resident's wheelchair, but he was still unable to touch the floor with his feet. Employee #77 said they would need to order a smaller chair for the resident.",2015-10-01
9738,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2010-05-19,250,D,0,1,QP8711,"Based on record review, staff interview, resident interview, and review of the National Social Workers Standards for Clinical Social Work, the facility failed to ensure the social services department maintained documentation to describe the social services being provided to two (2) of twenty-nine (29) Stage II sampled residents. There was no documentation regarding what interventions were implemented when a resident reported missing funds, and there was no documentation regarding a discussion pertaining to surrogate decision-making. Resident identifiers: #40 and #61. Facility census: 53. Findings include: a) Resident #40 In an interview on 05/11/10, Resident #40 reported she had lost $140.00, but the facility had only reimbursed her $100.00. Discussion with the social worker (Employee #54), on 05/17/10 at 3:40 p.m., revealed she could not find any documentation to show this concern had been reported, investigated, and/or resolved. The social worker referred the surveyor to the business office, where the business office staff was able to locate a note stating the nurse on duty at the time (Employee #4, a registered nurse) had reimbursed the resident $100.00 out of her own funds and was then repaid by the facility. Employee #4 stated in her note that Resident #40's family acknowledged they were sure the resident had $100.00, but they could not confirm she actually had any amount over that. They allegedly reported that, if there was additional money, the resident may have had staff go out to buy her something or that a granddaughter had stopped by, and the resident may have given her money. The note in the business office was the only documentation found by the staff regarding this report of missing funds. A member of the corporate staff was notified of this issue on the morning of 05/18/10; at 10:45 a.m., the corporate staff member reported there was no additional information / documentation found. -- b) Resident #61 A review of the medical record for this resident revealed there was a medical power of attorney document designating two (2) family members as co-representatives to serve simultaneously when making medical decisions for the resident. The surveyor asked Employee #54 about the joint MPOA designation during a discussion on the mid-afternoon of 05/17/10. She related she had a written note from one (1) of the family members stating he did not wish to handle decisions any more and wanted to let the other family member take charge, after there had been some conflict between the two (2) on what care should be provided. This note could not be found, and there were no progress notes regarding this entered into the social services section of the resident's medical record. Employee #54 further stated, later in the afternoon on the same day, that she had contacted the family member who wished to relinquish decision-making responsibility for the resident, and he was to stop by the next day to write another note. This second note was not provided to the surveyor for review by the time of exit at 3:30 p.m. on 05/19/10. c) Per the National Social Workers Standards for Clinical Social Work, on page 18, documentation of services provided to or on behalf of the client shall be recorded in the client's file or record of services. Documentation regarding the social services provided for these two (2) residents was not available.",2015-10-01
9739,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2010-05-19,279,D,0,1,QP8711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, resident interview, and observations, the facility failed to develop a comprehensive care plan to address a problem identified by the comprehensive assessment of one (1) of twenty-nine (29) Stage II sample residents, who was identified as having vision problems. Resident identifier: #58. Facility census: 53. Findings include: a) Resident #58 This resident was selected for further investigation of vision in the Stage II survey sample. Review of her medical record found she had been admitted to the facility on [DATE]. Her admission information included a notation it had been 5+ years since her last eye exam. The resident's annual minimum data set assessment, with an assessment reference date of 12/08/09, triggered the resident assessment protocol (RAP) for vision. The RAP note regarding vision, dated 12/15/09, stated: Contributing factors include [DIAGNOSES REDACTED]. (Resident #58) would not participate in a visual exam due to decreased cognition. However, (Resident #58) makes eye contact during conversations. Her eyes follow objects in her visual field. She will often stop people who pass by and talk with them. (Resident #58) does not wear glasses. According to family, her vision is not expected to improve. Impaired vision will be mentioned in her care plan. Her most recent falls risk assessments noted her vision was poor with or without glasses. In a note on 12/18/09, the registered dietitian recorded the resident said she was blind and unable to see food. Review of the resident's medical record found she had had appointments with an ophthalmologist on 01/21/10, 02/19/10, and 03/29/10. [MEDICATION NAME] cream and refresh liquagel had been ordered for Blepharitis OU (both eyes) and [DIAGNOSES REDACTED] OU. She had a return appointment scheduled for 06/22/10. On 05/13/10 at 11:40 a.m., observation found Resident #58 lying on her bed in her room. When asked whether she wore glasses, she said no but she wished she did. She was able to see the presence of staff from 8 to 10 feet away, and this was confirmed by a nursing assistant (Employee #44). When asked if she had seen the eye doctor, she said she had; when asked what he had said, she said, Oh, wait another month. (She does have an appointment for follow-up of the blepharitis and [DIAGNOSES REDACTED].) Review of the resident's care plan did not find any plan related to her vision, although the RAP note had included, Impaired vision will be mentioned in her care plan. Additionally, although the resident had problems with blepharitis and [DIAGNOSES REDACTED], there was no related care plan established to address these concerns.",2015-10-01
9740,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2010-05-19,281,D,0,1,QP8711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on observation, staff interview, and review of facility policy, the facility failed to assure a licensed nurse checked for placement of a gastrostomy tube ([DEVICE]) prior to administering a water flush via the [DEVICE] for one (1) of one (1) observations. Resident identifier: #37. Facility census: 53. Findings include: a) Resident #37 During observation of the medication administration pass on 05/18/10 at 12:25 p.m., Employee #15 (a licensed practical nurse - LPN) inserted a 60 cc syringe into the end of the resident's [DEVICE]. Without checking for appropriate placement via auscultation or aspiration, she then instilled 220 cc of water. In an interview following this observation, Employee #15 stated she did check for placement for [DEVICE]s at other places she had worked, but she could not do it here using a bulb syringe. She stated she was unaware if this facility had other equipment available for performing this check. The director of nursing (DON) provided the facility's policy entitled, Administering Medications though an Enteral Tube. Review of the policy found the following, 7. For nasogastric, esophagostomy, or gastrostomy tubes, check placement and gastric contents:. The DON stated the nurse should have checked for placement of the [DEVICE] prior to instilling the water. --- Part II -- Based on observation and medical record review, the facility failed to assure a licensed nurse administered the correct medications for one (1) of ten (10) residents observed on the medication pass. Resident identifier: #47. Facility census: 53. Findings include: a) Resident #47 1. During observation of the medical administration pass on 05/11/10 at 7:30 a.m., Employee #18 (an LPN) placed one (1) drop of Artifical Tears into each of Resident #47's eyes. Review of the medical record found the physician ordered two (2) drops to be placed in each of the resident's eyes. 2. Employee #18 administered one (1) tablet of [MEDICATION NAME] to Resident #47 during the medication administration pass conducted at 7:30 a.m. on 05/11/10. Review of the medical record found the resident was to receive [MEDICATION NAME] plus Vitamin D.",2015-10-01
9741,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2010-05-19,310,D,0,1,QP8711,"Based random dining observations during Stage I, the facility failed to ensure a resident's ability to eat did not diminish. One (1) resident repeatedly rolled her wheelchair away from the table requiring staff to return her to the table. Additionally, she would roll her chair back from the table and have to lean forward to receive a bite of food when fed by a staff member. Another resident was observed feeding himself; instead of encouraging him to feed himself independently, a staff member sat beside him and provided him bites of food between the bites he was feeding himself. Resident identifiers: #33 and #8. Facility census: 53. Findings include: a) Resident #33 During dining observations of the evening meal on 05/10/10, this resident was seated at a horseshoe-shaped table in the restorative dining room. She repeatedly rolled her wheelchair away from the table. Employee #34, a nursing assistant, was positioned behind the horseshoe table and could not easily get out to bring the resident back to the table. The employee often had to wait until another staff member would pass through the dining room to have the resident returned to the table. Even when the resident sat facing her food, she would push her chair back away from the table. When the staff member would give the resident a bit of food, the resident would have to lean forward with her head extended past her knees to accept the bite of food. The resident could hold finger foods or a cup and feed herself or drink, but the nursing assistant could not give these items to the resident at times, due to the resident moving her wheelchair away from the table. b) Resident #8 On 05/10/10 at dinner time in the restorative dining room, the resident was seated at a horseshoe table. After his meal was served, he began to slowly feed himself. Employee #34 sat beside the resident and began giving him bites of food. When employee did not provide a bite of food, the resident would begin to feed himself again. The resident's quarterly minimum data set assessment, with an assessment reference date of 02/03/10, identified the resident as requiring supervision for eating. His care plan indicated he was able to feed himself, but at times he needed assistance or might be totally dependent. On this occasion, the resident was feeding himself before and after the staff member intervened.",2015-10-01
9742,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2010-05-19,312,D,0,1,QP8711,"Based on observation and staff interview, the facility failed to provide necessary care and services to maintain good nutrition. Resident #45 was not assisted with her dinner meal in a timely manner. One (1) of twenty-nine (29) Stage II sample residents was affected. Resident identifier: #45. Facility census: 53. Findings include: a) Resident #45 On 05/11/10 at 6:00 p.m., observation found Resident #45 lying in bed with both eyes closed. The resident's dinner meal tray was uncovered and in front of her on the bedside table. At approximately 6:30 p.m., Resident #45 remained in her room in bed with her dinner tray untouched. She appeared sleeping, and no one had assisted her with eating her meal. On 05/11/10 at 6:45 p.m., Resident #45 had still not received assistance with her dinner meal. An interview with the director of nursing (DON - Employee #2), at this time, revealed the resident usually feeds herself but, sometimes, she becomes too tired to feed herself by the evening meal and must be assisted. After this interview, the resident did receive assistance from staff with her meal.",2015-10-01
9743,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2010-05-19,353,F,0,1,QP8711,"Based on observations, review of the copy of the licensed nurse schedule provided by the facility, and staff interviews, the facility failed to deploy sufficient direct care staff to ensure dependent residents were served and assisted with meals in a timely manner. Additionally, the schedule for licensed nursing staff did not denote a designation of which licensed nurse would be in charge on each tour of duty. This had the potential to affect all residents residing in the facility. Facility census: 53. Findings include: a) During random observations of the evening meal beginning at 6:00 p.m. on 05/10/10, Employee #34 (a nursing assistant) was attending the seven (7) residents in the restorative dining area. The first resident in the restorative dining room was not served until 6:35 p.m. Between 6:20 p.m. and 6:45 p.m., Employee #34 asked other staff members, as they passed through the dining room, if they could help in the restorative dining room, saying, We need help in here. Resident #33 turned her wheelchair away from the table and toward a wall on occasion. This occurred with increasing frequency as she awaited her meal. It was 6:52 p.m. before this resident was served her dinner. At 7:00 p.m., Resident #33 knocked her cup of coffee onto Employee #34's scrub pants. The employee asked for someone to watch Resident #33 and went to take care of the spill. At 7:10 p.m., Employee #20 took Resident #33 from the dining room. No one had made any further attempts to feed the resident or to get her to drink her beverages. -- b) Charge nurse on each tour of duty 1. Review of the copy of the licensed nursing staff schedule provided by the facility found there was no designation of which nurse was to be the charge nurse on each tour of duty. 2. On 05/18/10 at 3:20 p.m., Employee #19, a licensed practical nurse (LPN), when asked who was the charge nurse on evening shift, replied, It's usually the one who has been here the longest. 3. On 05/18/10 at 3:40 p.m., Employee #4, a registered nurse (RN) who was also designated as the infection control / staff development nurse, was asked about the designation of a charge nurse on each shift. She, too, said it was usually the nurse who had been working at the facility the longest, but she added there were exceptions. She looked at the copy of the schedule and agreed one could not tell who was the charge nurse by looking at the schedule.",2015-10-01
9744,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2010-05-19,364,E,0,1,QP8711,"Based on confidential resident interview, staff interview, and test tray results, the facility failed to serve foods at the proper temperature for palatability. The hot breakfast foods served to residents on the West hallway were cold. This practice affected more than an isolated number of residents. Facility census: 53. Findings include: a) While doing interviews during the Stage I portion of the survey on 05/10/10, a confidential resident interview revealed that hot foods were served cold at times and that hot breakfast items were always cold. b) On the morning of 05/11/10, surveyors arrived at 8:06 a.m., in time to evaluate the last tray being delivered to residents on the West hall. The surveyor requested a hot tray for the resident who was to receive the last tray at 8:15 a.m., and dietary staff provided a thermometer to measure the temperatures of foods on the original tray. The temperatures were found to be as follows: - Pureed eggs - 90 degrees Fahrenheit (F) - Pureed sausage - 92 degrees F - Pureed bread - 100 degrees F - Hot cereal - 104 degrees F The certified dietary manager (Employee #67), who was present at the time these temperatures were taken, verified they were below the acceptable levels. c) According to State law (64 CSR 13): 8.15.d. Food. A nursing home shall provide each resident with: . 8.15.d.2. Food that is palatable, attractive, and at the proper temperature; 8.15.d.2.A. At the time of receipt by the resident, foods shall be at a temperature of no less than 120 degrees F for hot foods and at no more than 50 degrees F for cold foods; .",2015-10-01
9745,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2010-05-19,371,F,0,1,QP8711,"Based on observation and staff interview, the facility failed to store food items in refrigerators and failed to maintain equipment in a manner that ensured sanitary conditions. These practices have the potential to affect all residents who consume foods by oral means, as all food is served from this central location. Facility census: 53. Findings include: a) During the initial tour of the dietary department on 05/10/10 at 3:50 p.m., the following items were noted: 1. Whole fresh eggs were observed being stored on an upper shelf of the walk-in refrigerator. Were these raw eggs to break, the contents would run down on to items stored on lower shelves, causing cross contamination. 2. The reach-in refrigerator held a plastic container of chicken salad which had no date to indicate when it was opened. This practice would not allow dietary staff to monitor how long the product had been opened and if it was still safe for consumption. 3. The reach-in refrigerator unit had a torn gasket along the bottom of the door which did not allow the unit to maintain a proper seal and keep the food at the proper temperature. 4. The drip pan of the cook stove top held food debris and was in need of cleaning. Some of the debris was dried and caked on the sheet and did not appear fresh (as if it had been from the previous meal). The certified dietary manager (Employee #67) was present and making rounds with the surveyor when these issues were observed. -- b) During environmental review on 05/18/10 at 12:50 p.m., observation found the freezer section of the refrigerator located in the nursing nourishment pantry did not contain a thermometer. This practice would not allow staff to monitor and ensure that frozen items in the unit were maintained at the correct temperature. This was verified with a member of corporate staff at 3:35 p.m. on 05/18/10.",2015-10-01
9746,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2010-05-19,428,D,0,1,QP8711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to ensure the attending physician acted upon recommendations by the registered pharmacist regarding a gradual dose reduction for an antipsychotic medication. This was evident for one (1) of twenty-nine (29) Stage II sample residents. Resident identifier: #61. Facility census: 53. Findings include: a) Resident #61 A review of Resident #61's medical record revealed a recommendation by the registered pharmacist dated 03/31/10. A form entitled Note to Attending Physician / Prescriber stated, The resident currently takes the following antipsychotic Geodon 20 mg BID (twice daily). Consider an attempt at gradual dose reduction (GDR) for the above mentioned medication. If a GDR is contraindicated please provide documentation. Please refer to the attached CMS guidelines on antipsychotics for information on GDR, frequency and contraindications. Under the Physician / Prescriber Response section of the form, the physician replied with an X for Other with the following statement: Followed by Dr.(name of psychiatrist). This response was dated 04/20/10. Discussion with the licensed practical nurse (LPN - Employee #15), on 05/18/10 at 9:40 a.m., revealed staff was not able to find any documentation from the psychiatrist identified by the attending physician. Staff returned later in the afternoon and reported they had attempted to reach the psychiatrist and were unable to get any information regarding the resident, as the psychiatrist would not be back in the office until later in the week. Later in the afternoon, staff reported contact was made with the attending physician, who gave an order to decrease the Geodon from 20 mg BID to Geodon 20 mg QD (once daily) for the [DIAGNOSES REDACTED]. This was shared with a member of the corporate staff on 05/18/10, and no further information was provided by survey exit at 3:30 p.m. on 05/19/10.",2015-10-01
9747,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2010-05-19,441,E,0,1,QP8711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview, the facility failed to assure licensed nurses administered medications in a safe, sanitary manner to help prevent the development and transmission of infection for five (5) of ten (10) residents observed during medication administration passes and treatment applications. Resident identifiers: #47, #49, #52, #75, and #37. Facility census: 53. Findings include: a) Resident #47 Employee #18, a licensed practical nurse (LPN), was observed during the administration of eye drops at 7:30 a.m. on 05/11/10. The nurse placed gloves onto the bedside table after removing them from her uniform pocket. She then placed tissues onto the bedside table. Without first washing her hands, the nurse donned the contaminated gloves and placed drops into Resident #47's eyes. She then wiped the resident's eyes with the contaminated tissues. Review of the facility policy provided by the director of nursing (DON) at 12:00 p.m. on 05/12/10, entitled Eye Drops / Ointments, found the following language: 1. Hands washed / sanitized before and after administration;. b) Resident #49 Employee #16, an LPN, was observed during the administration of [MEDICATION NAME] with [MEDICATION NAME] eye drops at 8:00 a.m. on 05/11/10. The nurse did not wash or sanitize her hands prior to attempting the instill the drops. She was observed to place her gloves and tissues onto the resident's nightstand. The nurse donned the contaminated gloves and repeatedly attempted to open the resident's left eye by tugging downward on the resident's lower eye lid. This practice placed the resident at risk of development of an eye infection. c) Resident #52 Employee #16 was observed to administer an [MEDICATION NAME] inhaler to Resident #52 at 8:40 a.m. on 05/11/10. The resident was noted to place her lips over the mouthpiece of the inhaler and breath inward. As the nurse was replacing the [MEDICATION NAME] inhaler into the medication cart, it was noted that Resident #75's name was written on it in black marker. When this was pointed out the the nurse, she stated, That's not good, is it? d) Resident #75 On 05/17/10 at 2:30 p.m., Employee #20, an LPN, was observed providing dressing changes to the two (2) small wounds on the resident's right foot and another one (1) on his left foot. While preparing to perform the treatments, the nurse obtained gloves she would need. She handled the fingers of the gloves prior to washing her hands. Additionally, the gloves were placed directly on the resident's overbed table. Although the gloves were not sterile, they would be considered clean. By handling the gloves by the finger portion and by placing them on the overbed table, a potential for contamination was created. e) Resident #37 On 05/18/10 at 11:20 a.m., Employee #20 was observed performing a dressing change to the resident's gastrostomy tube site. The nurse retrieved gloves from a box, then placed them directly on the top of the treatment cart while she retrieved other needed supplies from the cart. She then carried the gloves in a ball in her hand into the room, where she placed them directly on an overbed table. This created a potential for contamination of the gloves and a potential for introduction of non-resident microorganisms to the resident's stoma site.",2015-10-01
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
9626,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-05-20,225,D,0,1,SWBO11,"Based on a review of personnel files and staff interview, the facility failed to thoroughly screen one (1) of ten (10) sampled employees were for findings of abuse or neglect, by failing to make an inquiry to the WV Nurse Aide Registry before the individual began work at the facility. Employee identifier: #27. Facility census: 111. Findings include: a) Employee #27 A review of the personnel file for Employee #27, on 05/20/10 at 11:40 a.m., revealed she was hired as a registered nurse (RN) on 03/18/10, but there was no indication this employee was screened through the WV Nurse Aide Registry for past findings of resident abuse / neglect. When interviewed on 05/20/10 at 11:50 a.m., the facility's human resources director (Employee #141) confirmed there was no evidence to reflect the required registry check was performed prior to the employment of Employee #27.",2015-10-01
9627,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-05-20,278,D,0,1,SWBO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and clinical record review, the facility failed to accurately document the cogntive, physical, and/or mental functioning status of three (3) of thirty-three (33) Stage II sample residents. Resident identifiers: #78, #147, and #7. Facility census: 111. Findings include: a) Resident #78 Resident #78 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Multiple observations of Resident #78, from 05/11/10 through 05/18/10, revealed the resident self-propelled by wheelchair throughout the facility hallways. Interview with Resident #78, on 05/11/10 at 9:45 a.m., revealed the resident did not respond to verbal interaction with words and sentences that were understood. Review of the clinical record revealed a significant change in status minimum data set (MDS), dated [DATE], indicated Resident #78 was severely impaired for daily decision making, rarely / never made self understood, sometimes understands others, and exhibited wandering behaviors one (1) to three (3) days in the last seven (7) days and this behavior was not easily altered. Review of the quarterly MDS, dated [DATE], indicated the resident was severely impaired for daily decision making, was rarely / never understood and rarely / never understands others, and exhibited daily wandering behaviors that were not easily altered. Review of the quarterly MDS, dated [DATE], indicated the resident was moderately impaired for cognitive skills for daily decision making, was sometimes understood and sometimes understands others, and exhibited wandering behavior one (1) to three (3) days in the last seven (7) days and this behavior was not easily altered. During an interview on 05/18/10 at 3:30 p.m., the director of care delivery (Employee #22) reported Resident #78 had severe cognitive impairment, was rarely understood, rarely understood others, and wandered daily. During an interview on 05/18/10 at 3:35 p.m., the MDS coordinator (Employee #164) reviewed the quarterly MDS dated [DATE] and reported the entries did not reflect Resident #78's cognitive and wandering status, noting the data entries were coded by the activities director (Employee #90) and the social worker (Employee #118). During an interview on 05/18/10 at 3:40 p.m., Employee #90 reviewed the quarterly MDS dated [DATE] and reported the entries for Section C4 and C6 were errors in data entry and would be corrected. The employee further indicated the resident was not able to form words and sentences that were understood. During an interview on 05/18/10 at 3:40 p.m., Employee #118 reviewed the quarterly MDS dated [DATE] and indicated the entries for Sections B4 and E4 were errors in data entry. The employee further indicated the resident was severely cognitively impaired for daily decision making and exhibited daily wandering behavior that was not easily altered. When asked, the employee stated the cognitive assessment was determined by observation and interaction with the resident. After interviews with the above staff, the quarterly MDS dated [DATE] was corrected on 05/18/10. The reason for the corrections was data entry error. The corrections indicated the resident was severely impaired for daily decision making, was rarely understood and rarely understands others, and exhibited daily wandering behavior that was not easily altered. b) Resident #147 A review of the significant change in status MDS, dated [DATE], found the assessor indicated, in Section N2, this resident spent no time in activities. The MDS also indicated the resident preferred her own room for activities and was awake in the morning and afternoon. The resident was observed on tour at 2:30 p.m. on 05/11/10, watching TV in her room. Observation on 05/13/10 at 4:00 p.m. found her with her rosary and prayer book while seated in her room in a geri-chair. On 05/14/10, the resident was observed at 10:00 a.m., in her room getting a nebulizer treatment while seated in a geri-chair, and at 11:00 a.m., the resident was seated in the geri-chair with her rosary and prayer book. On 05/18/10 at 9:00 a.m., observation again found her in her room seated in a geri chair with rosary in her hands. An interview was conducted with the activities director (Employee #90) on 05/18/10 at 11:15 a.m., while reviewing the resident's activities participation records for March 2010 through May 2010. During this interview, Employee #90 reported the resident received daily family visits (which provided a strong base of emotional support), used her rosary and prayer book, and received visits from a local priest; however, none of these was documented in the participation records. She agreed Section N2 of the MDS was incorrectly coded. b) Resident #7 A comparison of the resident's Medicare 5-Day MDS (dated 02/01/10) and Medicare 14-Day MDS (dated 02/13/10) found significant differences in the items coded in Section E for mood indicators. The Medicare 5-Day MDS indicated the resident had exhibited no sad, pained, worried expressions in the thirty (3) day period preceding the assessment reference date (ARD) of 02/01/10. However, the assessor noted on the Medicare 14-Day MDS the resident had exhibited sad, pained, worried, expressions up to five (5) days a week within the last thirty (30) days preceding the ARD of 02/13/10. Section E2 of the Medicare 14-Day MDS was also coded 2 to indicate one (1) or more indicators for sad or anxious mood were present and not easily altered by attempts to cheer up, console, or reassure the resident over last seven (7) days. Continued review of prior and subsequent MDS assessments, dated 12/24/09, 12/17/10, and 03/24/10, found no evidence of mood indicators or persistence coded any sections in E1 or E2. When interviewed regarding the apparent change in mood state that transpired between 02/01/10 and 02/13/10, the director of nursing (DON - Employee #161) said she could not recall any reason why the resident was assessed that way. Additional information was requested at this time. On 05/18/10 at 10:55 a.m., the social worker reported that the decision was made for the resident to stay at the facility about this time, and the resident became somewhat disappointed. She reported the nursing notes documented health care changes for the resident during this time, and she used these and direct observation as the basis for her assessment of the resident's mood indicators in Section E of the MDS. Review of the nursing notes, for 12/02/09 through 02/18/10, failed to find evidence the resident was exhibiting any change in her mood status; although health care changes were documented, the resident's mood indicators were not reflected in the nursing notes or the nurse practioner notes for this period of time.",2015-10-01
9628,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-05-20,279,D,0,1,SWBO11,"Based on observation, medical record review, and staff interview, the facility failed to develop a care plan, for one (1) of thirty-three (33) Stage II sample residents, that was individualized and identified interventions specific to the resident. Resident #147's care plan contained a goal to attend group activities, but it did not identify that the resident preferred independent in-room activities, including activities of a spiritual nature, and frequent family visitation. Facility census: 111. Findings include: a) Resident #147 A review of the resident's most recent comprehensive assessment, coded for a significant change in status and with an assessment reference date (ARD) of 03/12/10, revealed in Section N2 this resident spent no time in activities. The assessment also indicated the resident preferred her own room for activities and was awake in the morning and afternoon. The resident was observed on tour at 2:30 p.m. on 05/11/10, watching TV in her room. Observation on 05/13/10 at 4:00 p.m. found her with her rosary and prayer book while seated in her room in a geri-chair. On 05/14/10, the resident was observed at 10:00 a.m., in her room getting a nebulizer treatment while seated in a geri-chair, and at 11:00 a.m., the resident was seated in the geri-chair with her rosary and prayer book. On 05/18/10 at 9:00 a.m., observation again found her in her room seated in a geri chair with rosary in her hands. An interview was conducted with the activities director (Employee #90) on 05/18/10 at 11:15 a.m., while reviewing the resident's activities participation records for March 2010 through May 2010. During this interview, the activities director reported the resident received daily family visits (which provided a strong base of emotional support), used her rosary and prayer book, and received visits from a local priest; however, none of these was documented in the participation records. The participation records did indicate the resident attended groups occasionally, attended music / singing activities passively, had visitors daily, and watched television almost daily. The resident's current activities care plan, dated 11/03/09, stated, Some of (Resident #147's) interests are bingo, church, current events, entertainment, music, reading, watching TV, and special events. Goals were: Resident will participate in independent leisure activities such and reading and watching TV and Resident will participate in 2 activities / week that promote socialization with peers consistent with likes and interests such as bingo, music, current events, entertainment and special events. The focus of the care plan did not identify frequent visitors or her rosary and prayer book as interests or strengths for this resident, and the interventions were no specific or important to this resident. The activities director agreed these interests were important to the resident and should have been included when the care plan was developed.",2015-10-01
9629,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-05-20,280,D,0,1,SWBO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon resident interview, staff interview, and medical record review, the facility failed to review and revise the resident's care plan following a planned surgery that resulted in the onset of new pain concerns. This was found for one (1) of thirty-three (33) Stage II sample residents. Resident identifier: #139. Facility census: 111. Findings include: a) Resident #139 Resident #139, an [AGE] year old female who had been in the facility since 02/16/10, was interviewed at 1:30 p.m. on 05/12/10. She reported she had just undergone planned [MEDICATION NAME] surgery the day before, on 05/11/10, and she was having pain as a result of the surgery. She stated that staff was intervening, and she was sure it will get better. When interviewed again on 05/17/10 at 4:11 p.m., Resident #139 related that her pain was getting better. She stated the doctor had given her something stronger for the pain from surgery, that staff was giving it to her when she needed it, and although it sometimes still hurt, it was getting better. A review of Resident #139's medical record, on 05/18/10 at 9:00 a.m., revealed a physician's orders [REDACTED]. There was also documentation to show that nurses were monitoring and responding to episodes of pain when reported by the resident. The resident's hard copy care plan in the care plan book showed no evidence of any updates since 02/25/10. When interviewed at 11:30 a.m. on 05/18/10, the minimum data set (MDS) assessment coordinator (Employee #164) was asked if any revisions had been made to the care plan of Resident #139 since her surgery on 05/11/10; she replied that any revisions to the care plan would be found on the hard copy in the care plan book at the nurses' station. She concurred the resident had recent surgery and that she would be expected to have pain as a result. On 05/18/10 at 11:57 p.m., the director of care delivery (Employee #119) presented a revision to the care plan of Resident #139 to reflect the issue of pain related to recent hemorrhoid surgery. The care plan item was dated 05/18/10.",2015-10-01
9630,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-05-20,281,D,0,1,SWBO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to ensure one (1) of ten (10) sampled residents, observed during medication administration, received [MEDICATION NAME] (a diuretic) in the dosage ordered by the physician. Resident identifier: #29. Facility census: 111. Findings include: a) Resident #29 A review of Resident #29's medical record revealed a physician's orders [REDACTED]. During observation of the medication pass at 9:10 a.m. on 05/13/10, the licensed practical nurse supervisor (Employee #121) administered a 40 mg tablet of [MEDICATION NAME] to Resident #29 along with the rest of her medications. After reviewing the physician's orders [REDACTED]. After doing so in the presence of the surveyor, the nurse acknowledged she had only administered 40 mg of [MEDICATION NAME] to the resident. She stated a new order was written on 04/27/10 that increased the [MEDICATION NAME] from the previous 40 mg dosage, and she had just misread the dosage.",2015-10-01
9631,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-05-20,323,E,0,1,SWBO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on observations, clinical record reviews, and resident and staff interviews, the facility failed to maintain an environment free of burn hazards for twelve (12) of one hundred-eleven (111) residents in the facility (#78, #138, #210, #211, #212, #213, #214, #215, #216, #217, #218, and #219) identified by staff as being cognitively impaired, self-mobilizing and exhibited wandering behaviors. Findings include: Resident #78 Resident #78 was admitted to the facility 11/29/06 with [DIAGNOSES REDACTED]. Review of the clinical record revealed a significant change assessment, dated 10/23/2009, that indicated Resident #78 had severely impaired cognitive skills for daily decision making, long and short term memory problems, rarely made self understood and sometimes understands, exhibited wandering behaviors not easily altered, required extensive assistance for transfer with one staff person and a wheelchair was the primary means of locomotion. The quarterly assessment dated [DATE] indicated that the resident was severely impaired for daily decision making, is rarely understood and rarely understands, exhibited daily wandering behavior that was not easily altered, required extensive assistance of 2 staff persons for transfer, and independent with set-up for locomotion. The quarterly assessment with a correction date of 5/18/10 indicated that the resident was severely impaired for daily decision making, is rarely understood and rarely understands, exhibited daily wandering behavior that was not easily altered, required extensive assistance of 2 staff persons for transfer, and independent with set-up for locomotion. An observation on 5/11/10 at 9:54 a.m. revealed that Resident #78 was sitting in a wheelchair, in the hallway near Room 215. At the time of the observation, the resident was repeatedly touching a wall heater grate, pulling her hand away quickly each time and verbalizing in unclear speech that was not understood. Observation of the wall heater grate revealed that it was positioned between and at the level of the hand railings. There was a brownish discoloration on the lower half of the grate and a metal stem, without a knob, protruded from the heater grate. When touched by the surveyor, the heater grate was too hot to maintain finger/skin contact. When asked about the resident touching the heater grate, Employee #38 approached the resident and pushed the resident down hall in the wheelchair, after telling the resident that the heater was too hot to touch. On 5/11/10 at 9:56 a.m., Employee #58 exited Room 215 into the hallway near the wall heater. During an interview, the employee stated that she could see where it (the heater) gets pretty warm and she was afraid that someone could get burned. On 5/11/10 at 10:01 a.m., the survey team checked all six of the other wall heaters accessible to the residents in the facility, including those located at the end of hallway 100, 300 (with brownish discoloration on grate), and 400 in the resident care areas, the wall heater in the Dining Room located near the front hallway and the heaters in the front hallway. All other wall heaters were found to be turned off and cool to touch. During this process, Resident #78 was observed touching a heater grate in the hallway near the front windows. When checked by the survey team, that heater was cool to touch and did not have a metal stem protruding from the heater grate. On 5/11/10 at 10:16 a.m., the survey team returned to the heater located near Room 215. At 10:18 a.m., Employee #57 and Employee #123 were observed walking down the hallway toward the wall heater and at the same time, Resident #78 was observed self-propelling by wheelchair from her room (Room 213) towards the wall heater near Room 215, a distance of approximately 10 feet. The resident again began touching the heater grate and turned the metal stem protruding from the heater. Attempts by Employee #57 to redirect Resident #78 and to examine the resident's hands were resisted. The resident raised her hand at one point and no evidence of a burn was observed on the resident's hand by the surveyor. The wall heater was examined by the surveyor and was found to be warm to the touch and the stem was easily turned using the fingers. Further interviews with Employees #38, #58 and #123 did not reveal how or by whom the heater near Room 215 was turned off. On 5/11/10 at 10:45 a.m., Employee #123 stated that the breakers were all off and the heaters would no longer function, therefore the heaters could not be turned on. On 5/11/10 at 11:06 a.m., Employee #123 reported to the survey team that he talked with his boss and disabled the wall heaters by disconnecting the heaters from the breaker. Heaters that recess into the ceiling were ordered and a copy of the estimate and order sheet was presented to the survey team. He also stated that the hallways were warmed by forced air heat in the mean time. On 5/14/10 at 10:00 during an interview, Employee #123 stated that the wall heaters had been capable of heating up to 150 degrees and the brownish discoloration on the heater grates may be due to the paint not being heat resistant. He also stated that he has worked at the facility for [AGE] years and does not know when or why the knobs were removed from the stems on the heaters. He indicated that he did not recall any incidence or event related to the missing knobs. When asked about the monthly safety maintenance rounds, Employee #123 stated that the heaters are checked on rounds and a sticker is placed on the heaters that are checked. Review of the Air Condition/Heat Units monthly logs from 1/6/10 through 5/12/10 revealed that the room units were checked. When asked about the wall heaters in the hallway, he stated that the wall heaters are checked on rounds but a sticker is not placed on them since the grate would have to be removed each time. On 5/14/10 at 10:36 a.m., a review of the Incident Reports from 3/1/09 to present, did not reveal any incidence of burns reported. On 5/14/10 at 10:38 a.m., all six wall heaters in the resident hallways, the Dining Room and the front hallway by the windows were re-checked found to be cool to touch and stems were removed. The facility was requested and provided a list of cognitively impaired residents that exhibited wandering behaviors. Review of the list indicated that the wall heaters placed Resident #78 and 11 other cognitively impaired, wandering and self-mobile residents at risk for a burn hazard (Residents #138, #210, #211, #212, #213, #214, #215, #216, #217, #218, and #219). Part II -- Based on clinical record review, observations, and family and staff interviews, the facility failed to maintain resident care equipment free of accident hazards for one (1) of thirty-three (33) Stage II sample residents (#66). Resident #66's scoop chair had sharp metal edges which presented a potential skin hazard to the resident. Facility census: 111. Findings include: Resident #66 Resident #66 was admitted on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record revealed a quarterly assessment dated [DATE] indicating the resident had severe cognitive impairment, had long and short term memory problems, had periods of restlessness, was rarely understood and rarely understands, had repetitive physical movements, had mood indicators present and not easily distracted, and the resident was totally dependent for bed mobility and transfer with the assistance of two staff. The assessment also revealed that the resident was provided the interventions of protective skin treatments with pressure relieving devices in the chair and bed. Review of the annual assessment dated [DATE] revealed that the resident had severe cognitive impairment, had long and short-term memory problems, had periods of restlessness, was rarely understood and rarely understands, had repetitive physical movements, was totally dependent for bed mobility and transfer with the assistance of two staff. The assessment also revealed that the resident was provided the interventions of protective skin treatments with pressure relieving devices in the chair and bed. Review of the Physical Restraints assessment dated [DATE] indicated that the resident is confused, combative at times and resistant to care and is total care for activities of daily living (ADL). The resident is restless and throws her legs out over the sling back chair, which was discontinued on 3/18/10 and the resident was placed in a geri-chair. Subsequently, she was constantly moving around in the geri-chair and bumping her legs on the geri-chair arms and frame. After discussion with the staff, the resident was placed in a scoop chair and was to be monitored for comfort. She is unable to walk and can not get out of the scoop chair, so it is not a restraint. Review of the physician's orders [REDACTED]. Observation of Resident #66 in her room on 5/12/10 @ 2:15 p.m. revealed that the resident was sitting in a mesh, sling like, scoop chair that was equipped with metal bars extending out in front of the chair on both sides. The metal tube bars were approximately 3 inches high, pointing upward, and had exposed sharp edges. The resident was observed to have a scabbed over abrasion and healed superficial scratches on her left lower anterior leg. At the time of the observation, the resident had both legs positioned over the metal bar on the right side of the chair. Interview with Employee #63 at the time of the observation revealed that the the metal bars had been wrapped at one time and could be a hazard. She stated that the resident was changed from a geri-chair to a scoop chair because she was injuring her legs by slinging them around in the geri-chair. Interview with the family of Resident #66 was also conducted at the time of the observation and they indicated that the resident was flinging her legs around in the geri-chair, causing scratches on her legs and she did better in the scoop chair. On 5/12/10 @ 2:25 p.m., Employee #146 was interviewed regarding the scoop chair having metal bars with sharp edges protruding from the front of the chair, in the area of the lower legs. She stated that Therapy did not assess the resident for the use of the chair, that nursing placed the resident in the chair at the request of the resident's family. She also indicated that the metal pieces needed padding, were a potential hazard and that the resident may need a different chair. When asked about the purpose of the metal bars, she stated that the metal bars were for attaching the foot rests but the resident did not use the foot rests. Employee #146 replaced the chair immediately with a different type of scoop chair. On 5/12/10 at 2:30 p.m. Employee #22 was interviewed and indicated that she was aware of what the bars on the chair looked like and that they did pose a hazard to the resident. Review of the Scoop Chair Care Plan revised on 4/21/10, revealed a goal of no injury requiring transfer to hospital due to fall. Interventions included getting resident up in a scoop chair, monitor skin with care activities for signs of pressure areas, and provide education to resident/family about the risks /benefits of the device. Review of a skin audit sheet dated 5/6/10 indicated that the resident had a scab on her left anterior lower leg, currently remains with scab and healing. Review of the Resident's incident/accident reports did not reveal an incident related to the scoop chair. On 5/17/10 at 10:30 a.m., when asked who assessed Resident #66 for the scoop chair, Employee #79 stated I do not know that nursing assessed for the scoop chair. The normal process is Therapy would be consulted for the assessment for the scoop chair. The employee presented documentation that a Physical Therapy and Occupational Therapy consult was ordered without a reason indicated and had the notation notified March 2, 2010. On 5/17/10 at 11:20 a.m. Employee #22 reviewed the clinical record with the surveyor and identified that the resident returned from the hospital on [DATE] and was placed in a sling back wheel chair. On 3/18/10 the resident was placed in the geri-chair for comfort. On 4/21/10 the geri-chair was a problem since the resident was flinging around and sustained a skin tear and placed in scoop chair per family request. She further stated that therapy does not assess residents for chairs in every instance. On 5/18/10 at 9:15 a.m., Employee #161, when asked if a chair with sharp edged metal bars was appropriate for a resident with a history of flinging her legs, stated that it was not. She also stated that as a team the nurses can assess the need for a chair and that Therapy is consulted for a resident that requires evaluation for positioning. She further stated that the family wanted the resident in the chair and chairs can be obtained from Maintenance or Therapy. There was no evidence presented that the facility identified Resident #66's Scoop Chair with the sharp edges on the metal as a potential skin hazard until the inquiry by the surveyor.",2015-10-01
9632,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-05-20,329,D,0,1,SWBO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility did not ensure the medication regimens of two (2) of thirty-three (33) Stage II sample residents were free of unnecessary drugs. Resident #138 was ordered [MEDICATION NAME] (Klonopin) to be given as needed (PRN) and routinely at different doses twice a day, and the only behavior indicated for its use was wandering. Resident #147 is receiving [MEDICATION NAME] on a PRN basis without adequate indications for its use and without monitoring effectiveness when used. Facility census: 111. Findings include: a) Resident #138 A review of Resident #138's medical record revealed three (3) physician's orders [REDACTED]. - The resident was admitted to the facility on [DATE], and a review of the admission orders [REDACTED]. - On 02/28/10, the resident was ordered [MEDICATION NAME] 0.5 mg every six (6) hours PRN for agitation; this was decreased to 0.25 mg related to a family concern that the resident was sleeping too much. - On 03/10/10, an order was received for [MEDICATION NAME] 0.25 mg everyday at noon. On 03/10/10, an order was received for [MEDICATION NAME] 0.50 mg at bedtime. On 03/15/10 at 3:00 a.m., a nursing note recorded, Trying to take covers off roommate to get her out of bed. Brought to nurse's station for a while. Medicated for agitation after an hour. She went back to bed and slept the rest of the shift. On 03/16/10 at 3:20 a.m., a nursing note recorded, (Symbol for zero) behaviors (sic) asleep at long intervals. Klonopin given per order at 12:00 p.m. (sic) no behaviors noted. A nursing note, on 05/14/10, recorded, Resident has made multiple attempts to exit, has had door open before stopped by staff. Given PRN [MEDICATION NAME] per order and placed on 1:1 (one-on-one) staffing until settles down. Mood pleasant. Nursing notes on 02/03/10 revealed the family was concerned about the resident sleeping too much, and the nursing home administrator (who was also a registered nurse) had requested a decrease in the Klonopin from 0.50 mg to 0.25 mg as needed. Nursing notes also indicated the resident was having falls. A nursing note, dated 03/11/10, indicated the resident slipped and fell from the bed. On 04/01/10, a nursing note indicated the resident fell in doorway of room. Resident #138's minimum data set assessment (MDS) for admission (dated 07/09/09) and the quarterly MDS (dated 04/14/10) both indicated the resident was independent for ambulation and the only behavior listed was wandering. An interview with a licensed practical nurse (LPN) supervisor (Employee #121), on 05/18/10 at 2:25 p.m., revealed Resident #138 was sometimes restless and wandered but was usually in a good mood. The resident had a fall on 05/14/10 and seemed to be very unsteady when ambulating. Employee #121 stated the resident had other falls when ambulating related to being unsteady. A psychiatrist evaluated Resident #138 on 01/12/10, and listed confusion and questionable depression on the consult report. A recommendation was made to decrease the Klonopin to 0.25 mg a day for seven (7) days then stop the medication. A review of the medication administration records (MARs) for March and April 2010 found Resident #138 received a PRN dose of Klonopin at 0.25 mg on 03/08/10 at 6:00 p.m. for increased agitation attempting to exit seek. On 03/09/10 at 4:00 p.m., a PRN dose of Klonopin was administered for exit seeking. On 03/15/10 at 1:00 a.m., a PRN dose was administered for taking a blanket off of another resident. On 04/24/10, a PRN dose was administered for exit seeking. No non-pharmacologic interventions to address the wandering were attempted by the nursing staff before administering a PRN dose of the Klonopin. Observation, on 05/18/10 at 1:30 p.m., found Resident #138 sitting in the activity room with other residents. The residents were playing the Wii game on the television. Resident #138 was observed sitting in a chair slumped to the right side and had her eyes closed. Another observation, on 05/18/10 at 3:00 p.m., found Resident #138 walking on the hallway with an unsteady gait. b) Resident #147 Record review revealed Resident #147 was ordered PRN [MEDICATION NAME] 03/01/10, after returning from the hospital. Since admission, the resident had taken the drugs at least monthly. An interview with the director of care delivery (Employee #22) and the administrator, on 05/14/10 at 4:00 p.m., found the resident came back from the hospital on [DATE] with orders for these medications. According to these employees, when PRN medications are used, the reason for and response to the medication were to be documented in the nursing notes, as well as any non-pharmacologic interventions attempted prior to the use of the medication, and behavior sheets were only used to monitor the side effects of the medications and did not track resident behaviors. An interview with the resident's family nurse practioner, a registered nurse (RN) supervisor (Employee #65), the medical records clerk (Employee #3), on 05/19/10 at 1:45 p.m., found Resident #147 was out to the hospital from 02/12/10 until 03/01/10, and came back on both medications. The 03/11/10 resident assessment protocol (RAP) for [MEDICAL CONDITION] drugs indicated the resident had a hard time sleeping and had been on a ventilator, and the [MEDICATION NAME] requested by the family. Documentation for the RAP found the resident's condition was poor with a very poor prognosis. The resident became anxious in the evenings, was in isolation, and wanted someone to sit with her during that period of time. The RAP indicated that [MEDICAL CONDITION] drug use would be addressed in the care plan. Review of the resident's current care plan found it did not address the use of [MEDICAL CONDITION] medications. The MARs for March, April, and May 2010 included an order for [REDACTED]. A review of the MARs and nursing notes failed to find any evidence the resident was exhibiting behaviors necessitating the administration of PRN [MEDICATION NAME] on these dates or documentation to reflect whether it was effective for the resident.",2015-10-01
9633,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-05-20,365,E,0,1,SWBO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of menus and current diet orders, and staff interview, the facility failed to ensure residents with orders for pureed diets received pureed biscuits prepared for the evening meal on 05/17/10. This had the potential to affect all nineteen (19) residents identified by the assistant dietary manager as having an order for [REDACTED]. Findings include: a) Observations of the kitchen, during meal service for the evening meal from 4:30 p.m. through 5:15 p.m. on 05/17/10, found pureed biscuits were omitted during the preparation of meal trays for residents with orders for pureed diets. A review of the expanded menu for the evening meal on 05/17/10 confirmed pureed diets were to receive pureed biscuits. After the tray for Resident #109 was prepared, this observation was discussed with the cook (Employee #155). On 05/17/10 at 4:45 p.m., the cook (Employee #155) said she forgot to make the pureed biscuits, as they get a prepackaged mix from the food supplier and it did not come in. Further discussion found this had the potential to affect all nineteen (19) residents with orders for pureed diets. An interview with the assistant to the dietary manager (Employee #132), at 10:15 a.m. on 05/18/10, revealed she knew about the lack of biscuits for residents who were ordered pureed diets and reported there were other ways to make pureed bread products (besides using the prepackaged mix that did not come in), so that an acceptable substitute could have been provided for the residents.",2015-10-01
9634,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-05-20,371,E,0,1,SWBO11,"Based on observations, staff interview, and a review of the facility's policy Labeling Food and Date Marketing (dated 04/07/06), the facility failed to ensure foods were stored under sanitary conditions. Opened packages of french fries and chicken were in the refrigerator, and they were not dated when opened to facilitate recognition of the need to discard potentially unsafe food. This had the potential to affect any residents who might eat french fries and chicken. Facility census: 111. Findings include: a) Observations of the walk-in refrigerator, made in the company of the dietary manager (Employee #45) on 05/11/10 at 9:39 a.m., a bag of opened french fries and three (3) bags of chicken that had been removed from the original container. Neither of these items had been labeled and dated when opened. Review of the facility's policy Labeling Food and Date Marking found, . It is recommended that all items placed in refrigeration units be labeled with the name of the item, the date the item is placed in the refrigerator and date it is to be used.",2015-10-01
9635,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2010-05-20,492,B,0,1,SWBO11,"Based on a review of personnel files and staff interview, the facility failed to assure four (4) of five (5) sampled nursing assistants were provided with the West Virginia State Rule 69CSR6-8.1 regarding the WV Nurse Aide Registry as required by State law. Employee identifiers: #37, #172, #173, and #99. Facility census: 111. Findings include: a) Employees #37, #172, #173, and #99 A review of the personnel files for Employees #37, #172, #173, and #99, on 05/20/10 at 11:20 a.m., revealed they were hired as nursing assistants, but there was no evidence to reflect they were provided with a copy of the West Virginia State Rule 69CSR6-8.1 regarding the WV Nurse Aide Registry, as required by State law. When interviewed on 05/20/10 at 11:50 a.m., the human resources director (Employee #141) confirmed there was no evidence that the required information was provided to these four (4) nursing assistants. According to 69CSR6-8. 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.",2015-10-01
9782,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-06-01,156,C,0,1,2XEX11,". Based upon review of the notices of non-coverage for Medicare skilled services (denial notices) and staff interview, the facility failed to specify the service being denied and/or the reason for the denial in the letter provided by the facility to the resident and/or responsible party, when informing them of services that would no longer be covered under Medicare, for six (6) of (6) sampled notices. Resident identifiers: #97, #34, #16, #66, #161, and #96. Facility census: 57. Findings include: a) Residents #97, #34, #16, #66, #161, and #96 A review of the Notice of Medicare Non-Coverage letters, on 05/31/10, revealed that the only description of services paid for by Medicare that were no longer being covered, for Residents #97, #34, #16, #66, #161, and #96, was skilled nursing services, and none of the six (6) residents' denial notices provided any reason for the denial of Medicare coverage as required. During a discussion with the facility's administrator (Employee #63) on 05/31/10 at 2:00 p.m., she acknowledged the required information was not included. .",2015-09-01
9783,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-06-01,164,E,0,1,2XEX11,". Based on observation and staff interview, the facility failed to ensure resident privacy was maintained during the evening meal on 05/24/10. The physician's assistant was observed examining and discussing medical issues with residents and family members openly in the dining room during the meal with other residents AND their family members present and within hearing distance. This occurred for one (1) of thirty three (33) Stage II sample residents and three (3) randomly observed residents. Resident identifiers: #154, #170, #171, and #172. Facility census: 57. Findings include: a) Residents #154, #170, #171, and #172 During the evening meal on 05/24/10, observation found the certified physician's assistant (PA-C) in the dining room talking to residents and their family members. There were other residents and family members present in the dining room who were able to hear the PA-C discuss the residents' medical conditions. The PA-C also examined two (2) of the residents while they were eating their meals (Resident #150 and #171), using a stethoscope and listening to their chests. During an interview on 05/27/10 at 10:00 a.m., the administrator acknowledged these residents should be removed from the dining room to a private area for discussion of their medical conditions and examination by the PA-C. .",2015-09-01
9784,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-06-01,203,D,0,1,2XEX12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, facility policy review, and review of information submitted to the State survey agency following the survey team's exit conference, the facility failed, for one (1) of five (5) residents whose closed records were reviewed, to provide a written notice of transfer or discharge (to include the reasons for the move and a notice of the right to appeal this action to the State) to the resident's legal representative at least thirty (30) days before the resident was transferred or discharged . Resident identifier: #57. Facility census: 54. Findings include: a) Resident #57 1. On 08/03/10 at 3:00 p.m., review of Resident #57's medical record revealed this [AGE] year old female was admitted to the nursing facility from a local hospital on [DATE], and she was discharged to a legally unlicensed care home on 07/29/10. The resident's closed record contained no evidence that a written notice of transfer or discharge was provided by the facility to the resident's legal representative at least thirty (30) days before the resident was moved, to include the reasons for the transfer / discharge and a notice of the right to appeal this action to the State. - 2. In an interview on 08/04/10 at 10:45 a.m., the facility's social worker (Employee #59) reported there was no discharge planning meeting held or discharge notice given to the resident's legal representative, but they did discuss discharge during the resident's last care plan meeting. Review of the care plan meeting notes with the social worker, at this time, found no mention of any discharge plan. The social worker reported the physical therapist expressed that Resident #57 had reached a plateau. The social worker reported she then contacted the resident's legal representative, who set everything up for the discharge herself. The social worker did contact the unlicensed care home to ensure they had a mechanical (Hoyer) lift available for use at the facility and twenty-four (24) hour care. - 3. In a telephone interview on 08/04/10 at 11:10 a.m., Resident #57's legal representative reported she did not receive anything in writing from the facility, but that the social worker called and informed her that Resident #57 had reached a plateau in therapy and needed to be discharged . The legal representative stated the resident's intended discharge date was projected to be in August, but no set date was mentioned, and upon admission she knew there were no long term care beds available at the nursing facility. The legal representative was not sure why the discharge date was moved up and she wished Resident #57 could have stayed at the nursing facility longer, since she was only able to take a few steps with the assistance of two (2) people, one (1) on each side of her. - 4. Review of the facility policy titled 2.11 Discharge and Transfer (revision date 04/01/03), on 08/05/09 at 9:00 a.m., found: 1. The social service department is responsible for coordinating transfers and discharges. 2. All customers will receive a Notice of Transfer or discharge whenever a voluntary or involuntary transfer / discharge occurs. This includes customers being transferred to the hospital of discharges from a certified bed to a non-certified bed. 2.1. The charge nurse will provide the Notice of Transfer or Discharge in the absence of the social worker. 3. If the discharge is involuntary, 30 days advance notice in writing of the proposed transfer or discharge must be given to the customer, family member, or legal representative (if known). A copy of the notice is placed in the clinical record and a copy forwarded to the local district Ombudsmen council. 4. The notice must include the appeal procedure. - 5. On 08/09/10 at 12:03 p.m., the State survey agency forwarded to this surveyor information received from the facility following the survey team's exit. These materials contained no evidence to reflect the facility had provided a written notice at least thirty (30) days before the resident's transfer / discharge from the facility, to include the reasons for the move. Other items that should also have been included in such a written notice were: the effective date of transfer or discharge; the location to which the resident was being transferred or discharged ; a statement that the resident has the right to appeal the action to the State; the name, address and telephone number of the State long term care ombudsman; for nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. .",2015-09-01
9785,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-06-01,204,D,0,1,2XEX12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, and review of information provided by the facility to the State survey agency after the survey team's exit, the facility failed, for one (1) of five (5) residents whose closed records were reviewed, to take steps within its control to ensure a safe and orderly discharge of Resident #57 from the nursing facility to a legally unlicensed care home. Resident identifier: #57. Facility census: 54. Findings include: a) Resident #57 1. On 08/03/10 at 3:00 p.m., review of Resident #57's medical record revealed this [AGE] year old female was admitted to the nursing facility from a local hospital on [DATE], and she was discharged to a legally unlicensed care home on 07/29/10. Review of Resident #57's admission record (face sheet) revealed her [DIAGNOSES REDACTED]. According to her hospital discharge summary, dictated and transcribed on 07/06/10, she was admitted to the hospital on [DATE]. Her discharge [DIAGNOSES REDACTED]. On page 2 of the discharge summary, the physician noted, .Because of her moderate dementia and alcohol dependence she was given [MEDICATION NAME] to prevent withdrawal. Also on page 2 was stated, Physical Therapy notes that patient does require a walker and assistance for ambulation and has easy fatigue and endurance. They do emphasize that she is not safe of independent gait and transfers at this time. (This last sentence was written in bold font and was underlined.) On page 3 under Discharge Disposition and Special Discharge Instructions was: 5. Activity is ambulation with assist and a walker. A progress note by the certified physician's assistant (PA-C), dated 07/16/10, noted under A/P (assessment and plan): 5. Alcohol dependence: Abstain from future use . - 2. According to her comprehensive admission assessment, with an assessment reference date (ARD) of 07/13/10, she had problems with both long and short term memory, she was not oriented to person, place, or season, her cognitive skills for daily decision making were moderately impaired, she required the extensive physical assistance of one (1) person for bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, and bathing, and she was frequently incontinent of both bowel and bladder. During this assessment reference period, the resident did not walk, and her primary mode of locomotion was via a wheelchair. She received the services of speech, occupational, and physical therapy five (5) days a week during this assessment period, and a trunk restraint was used daily. According to a Medicare 14-day full assessment, with an ARD of 07/17/10, she had problems with both long and short term memory, she was not oriented to person, place, or season, her cognitive skills for daily decision making were moderately impaired, she required the extensive physical assistance of one (1) person for locomotion, dressing, and personal hygiene, and she required the extensive physical assistance of two (2) persons for bed mobility, transfer, and toilet use. During this assessment reference period, the resident did not walk. She received the services of speech, occupational, and physical therapy five (5) days a week during this assessment period, and a trunk restraint was used daily. - 3. Documentation by the physical therapist revealed Resident #57 received physical therapy from 07/07/10 through 07/27/10. Under the heading Summary of Care was noted: Summary of Progress:: pt. (sic) not progressing well, difficulty with cooperation and partiicipation (sic) secondary to dementia and decreased insight and safety, decreased intake as well as making participation difficult. family (sic) not in for training or education. recommend (sic) assist and continued PT if able to maximize functional mobility and assisted mobility. Under the heading Discharge Recommendations was noted: Discharge Setting: Other (personal care home); Recommended services upon discharge: Home Health Services, A (assistance) with all mobility; Equipment recommended upon discharge: w/c (wheelchair). Documentation by the occupational therapist revealed she received occupational therapy from 07/07/10 through 07/28/10. Under the heading Summary of Care was noted: Summary of Progress:: Pt. demo(nstrated) limited progress toward goals due to cognitive level and lack of participation in therapy. Pt. at times will refuse or become beligerant (sic) with therapist. Family and SW (social worker) decided to transfer patient to a personal care home closer to family. Discharge skilled OT treatment. Under the heading Discharge Recommendations was noted: Discharge Setting: Other (personal care home); Recommended services upon discharge: 24/7 care; Equipment recommended upon discharge: pt. could benefit from w/c and FWW (front-wheeled walker). Review of the speech therapy progress notes, for 07/20/10, revealed under the heading Current Status: Precautions: puree (diet); nectar-thick fluids; fall risk; easily agitated per hospital records; sundowners. Under the heading Encounter Summary was noted: . SLP (speech language pathologist) suggested that PCH (personal care home) staff come to facility next week to observe pt in tx (treatment) and determine if she will be appropriate for their setting. Pt's POA (power of attorney) to set this up for next week. Review of the facility's Rehab UM Meeting notes for Resident #57 on 07/21/10 revealed, . D/C (discharge) plan? Lap buddy. Transfers with mod A (moderate assistance) for safety. AMb (sic) (ambulate) - 30ft with Mod A and RW (roller walker).; MBSS (modified [MEDICATION NAME] swallow study) on 7/22 at noon. PO (oral) intake is extremely poor; drinks better on nectar (thickened liquids). Review of the facility's Rehab UM Meeting notes for Resident #57 on 07/27/10 revealed, . D/C plan? Lap buddy. Transfers with max A (maximum assistance) for safety. Pt now not ambulating.; Question pt with UTI (urinary tract infection). Pt with decreased performance. Handwritten in the block containing Resident #57's name was: DC tom (discharge tomorrow) pm. Review of the resident's telephone orders found an order dated 07/27/10 for: Home Health w/ (with) PT & OT. Review of the social service notes revealed Resident #57 was discharged from the nursing facility at 6:00 p.m. on 07/29/10. Review of facility records found no evidence to reflect there had been any discussion between the social worker and the resident's legal representative regarding the appropriateness of discharging Resident #57 from a skilled nursing facility to a legally unlicensed care home in the community, in view of the resident's assessed needs with respect to her level of dependence on staff with activities of daily living, her dysphagia, and her need for monitoring related to her recently diagnosed urinary tract infection. - 4. In an interview on 08/04/10 at 10:45 a.m., the facility's social worker (Employee #59) reported there was no discharge planning meeting held or discharge notice given to the resident's legal representative, but they did discuss discharge during the resident's last care plan meeting. Review of the care plan meeting notes with the social worker, at this time, found no mention of any discharge plan. The social worker reported the physical therapist expressed that Resident #57 had reached a plateau. The social worker reported she then contacted the resident's legal representative, who set everything up for the discharge herself. The social worker did contact the unlicensed care home to ensure they had a mechanical (Hoyer) lift available for use at the facility and twenty-four (24) hour care. The social worker confirmed that no follow-up appointment with a physician had been made, she did not communicate to staff at the unlicensed home that the resident had a history of [REDACTED]. - 5. In a telephone interview on 08/04/10 at 11:10 a.m., Resident #57's legal representative reported she did not receive anything in writing from the facility, but that the social worker called and informed her that Resident #57 had reached a plateau in therapy and needed to be discharged . The legal representative stated the resident's intended discharge date was projected to be in August, but no set date was mentioned, and upon admission she knew there were no long term care beds available at the nursing facility. The legal representative was not sure why the discharge date was moved up and she wished Resident #57 could have stayed at the nursing facility longer, since she was only able to take a few steps with the assistance of two (2) people, one (1) on each side of her. She also reported that Resident #57's transition from the nursing facility to the unlicensed care home was rough. According to the legal representative, Resident #57 had resided in an assisted living facility in Ohio prior to being admitted to the hospital on [DATE]; while there, staff gave Resident #57 alcoholic beverages to drink, and during a visit there, the legal representative found both the resident and her caregiver were intoxicated. During a visit at the unlicensed care home (after her discharge from the nursing facility on 07/29/10), the legal representative found that staff at the unlicensed care home was giving Resident #57 alcoholic beverages; the legal representative quickly intervened but noted the nursing facility failed to inform staff at the unlicensed care home of the need for Resident #57 to abstain from alcohol. Additional information obtained from Resident #57's legal representative during this telephone interview included: - No information had been communicated to the staff at the unlicensed home regarding how to safely assist Resident #57 out of the legal representative's personal vehicle (from a sitting to a standing position), and she reported the mechanical lift at the facility was broken. - No information was communicated to the staff at the unlicensed home of the need to obtain follow-up services from a physician related to the resident's urinary tract infection. The legal representative reported having to take Resident #57 to an Urgent Care provider after her discharge from the facility, because the resident's urine was dark-colored and foul-smelling, and she could not get an appointment with a primary care physician until 08/30/10. - No physical therapy or occupational therapy services had yet been provided to Resident #57 since her admission to the unlicensed care home. - 6. On 08/09/10, the surveyor received additional information that had been submitted by the facility to the State survey agency after the survey team's exit. Review of these materials, including the resident's discharge transition plan dated 07/29/10, revealed the following: You can get around (at discharge): With a little help. Devices used: wheelchair (There was no mention of a front-wheeled or roller walker.) Get up/down from a seated position (at discharge): W/ at great deal of help (There was no mention of the need for the use of any devices when transferring, such as a walker or a mechanical lift.) Your dietary recommendations are: Regular Diet (There was no mention pureed foods or thickened liquids.) On page 3, under the heading of Your physician follow-ups, nothing was written to direct either the resident's family or the receiving facility's staff to contact any physician. (There was no mention of the need to monitor the resident for signs / symptoms of a UTI.) On page 5 of this document, under the heading Your health services provider follow-ups were checked Physical Therapy, Home Medical Equipment / Supplies, and Pharmacy Provider. None of the services under Home Care Services was checked, nor was Occupational Therapy checked under Therapy Services, as had been ordered by the physician on 07/27/10. Under Home Medical Equipment / Supplies, someone had scratched through information regarding the provider of a wheelchair, but there was no information to indicate a walker had been ordered. There was no mention anywhere on the document of the need to monitor the resident for falling, in view of the fact that she had used a lap buddy when at the nursing facility and had been identified as being at risk for falls by all of the rehabilitative therapy services. No information was communicated in the discharge transition plan regarding any special feeding techniques or alterations needed in the consistencies of foods and fluids to address her dysphagia, the transition plan incorrectly identified her diet as being of regular consistency, and there was no evidence that staff from the unlicensed home had come to the nursing facility to observe the resident during speech therapy to determine if she will be appropriate for their setting, as recommended by the SLP. The facility failed to take steps within its control to ensure a safe and orderly discharge of Resident #57 from the nursing facility to a legally unlicensed care home. .",2015-09-01
9786,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-06-01,250,D,0,1,2XEX12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, facility policy review, and review of information submitted by the facility to the State survey agency following the survey team's exit conference, the facility failed to provide medically-related social services by failing to develop and implement a discharge plan to ensure a safe and orderly discharge from the facility. This was found for one (1) of five (5) residents whose closed records were reviewed. Resident identifier: #57. Facility census: 54. Findings include: a) Resident #57 1. On 08/03/10 at 3:00 p.m., review of Resident #57's medical record revealed this [AGE] year old female was admitted to the nursing facility from a local hospital on [DATE], and she was discharged to a legally unlicensed care home on 07/29/10. Review of Resident #57's admission record (face sheet) revealed her [DIAGNOSES REDACTED]. According to her hospital discharge summary, dictated and transcribed on 07/06/10, she was admitted to the hospital on [DATE]. Her discharge [DIAGNOSES REDACTED]. On page 2 of the discharge summary, the physician noted, .Because of her moderate dementia and alcohol dependence she was given Valium to prevent withdrawal. Also on page 2 was stated, Physical Therapy notes that patient does require a walker and assistance for ambulation and has easy fatigue and endurance. They do emphasize that she is not safe of independent gait and transfers at this time. (This last sentence was written in bold font and was underlined.) On page 3 under Discharge Disposition and Special Discharge Instructions was: 5. Activity is ambulation with assist and a walker. A progress note by the certified physician's assistant (PA-C), dated 07/16/10, noted under A/P (assessment and plan): 5. Alcohol dependence: Abstain from future use . - 2. According to her comprehensive admission assessment, with an assessment reference date (ARD) of 07/13/10, she had problems with both long and short term memory, she was not oriented to person, place, or season, her cognitive skills for daily decision making were moderately impaired, she required the extensive physical assistance of one (1) person for bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, and bathing, and she was frequently incontinent of both bowel and bladder. During this assessment reference period, the resident did not walk, and her primary mode of locomotion was via a wheelchair. She received the services of speech, occupational, and physical therapy five (5) days a week during this assessment period, and a trunk restraint was used daily. According to a Medicare 14-day full assessment, with an ARD of 07/17/10, she had problems with both long and short term memory, she was not oriented to person, place, or season, her cognitive skills for daily decision making were moderately impaired, she required the extensive physical assistance of one (1) person for locomotion, dressing, and personal hygiene, and she required the extensive physical assistance of two (2) persons for bed mobility, transfer, and toilet use. During this assessment reference period, the resident did not walk. She received the services of speech, occupational, and physical therapy five (5) days a week during this assessment period, and a trunk restraint was used daily. - 3. Documentation by the physical therapist revealed Resident #57 received physical therapy from 07/07/10 through 07/27/10. Under the heading Summary of Care was noted: Summary of Progress:: pt. (sic) not progressing well, difficulty with cooperation and partiicipation (sic) secondary to dementia and decreased insight and safety, decreased intake as well as making participation difficult. family (sic) not in for training or education. recommend (sic) assist and continued PT if able to maximize functional mobility and assisted mobility. Under the heading Discharge Recommendations was noted: Discharge Setting: Other (personal care home); Recommended services upon discharge: Home Health Services, A (assistance) with all mobility; Equipment recommended upon discharge: w/c (wheelchair). Documentation by the occupational therapist revealed she received occupational therapy from 07/07/10 through 07/28/10. Under the heading Summary of Care was noted: Summary of Progress:: Pt. demo(nstrated) limited progress toward goals due to cognitive level and lack of participation in therapy. Pt. at times will refuse or become beligerant (sic) with therapist. Family and SW (social worker) decided to transfer patient to a personal care home closer to family. Discharge skilled OT treatment. Under the heading Discharge Recommendations was noted: Discharge Setting: Other (personal care home); Recommended services upon discharge: 24/7 care; Equipment recommended upon discharge: pt. could benefit from w/c and FWW (front-wheeled walker). Review of the speech therapy progress notes, for 07/20/10, revealed under the heading Current Status: Precautions: puree (diet); nectar-thick fluids; fall risk; easily agitated per hospital records; sundowners. Under the heading Encounter Summary was noted: . SLP (speech language pathologist) suggested that PCH (personal care home) staff come to facility next week to observe pt in tx (treatment) and determine if she will be appropriate for their setting. Pt's POA (power of attorney) to set this up for next week. Review of the resident's telephone orders found an order dated 07/27/10 for: Home Health w/ (with) PT & OT. Review of the social service notes revealed Resident #57 was discharged from the nursing facility at 6:00 p.m. on 07/29/10. Review of facility records found no evidence to reflect there had been any discussion between the social worker and the resident's legal representative regarding the appropriateness of discharging Resident #57 from a skilled nursing facility to a legally unlicensed care home in the community, in view of the resident's assessed needs with respect to her level of dependence on staff with activities of daily living, her dysphagia, and her need for monitoring related to her recently diagnosed urinary tract infection. - 4. In an interview on 08/04/10 at 10:45 a.m., the facility's social worker (Employee #59) reported there was no discharge planning meeting held or discharge notice given to the resident's legal representative, but they did discuss discharge during the resident's last care plan meeting. Review of the care plan meeting notes with the social worker, at this time, found no mention of any discharge plan. The social worker reported the physical therapist expressed that Resident #57 had reached a plateau. The social worker reported she then contacted the resident's legal representative, who set everything up for the discharge herself. The social worker did contact the unlicensed care home to ensure they had a mechanical (Hoyer) lift available for use at the facility and twenty-four (24) hour care. The social worker confirmed that no follow-up appointment with a physician had been made, she did not communicate to staff at the unlicensed home that the resident had a history of [REDACTED]. - 5. In a telephone interview on 08/04/10 at 11:10 a.m., Resident #57's legal representative reported she did not receive anything in writing from the facility, but that the social worker called and informed her that Resident #57 had reached a plateau in therapy and needed to be discharged . The legal representative stated the resident's intended discharge date was projected to be in August, but no set date was mentioned, and upon admission she knew there were no long term care beds available at the nursing facility. The legal representative was not sure why the discharge date was moved up and she wished Resident #57 could have stayed at the nursing facility longer, since she was only able to take a few steps with the assistance of two (2) people, one (1) on each side of her. She also reported that Resident #57's transition from the nursing facility to the unlicensed care home was rough. According to the legal representative, Resident #57 had resided in an assisted living facility in Ohio prior to being admitted to the hospital on [DATE]; while there, staff gave Resident #57 alcoholic beverages to drink, and during a visit there, the legal representative found both the resident and her caregiver were intoxicated. During a visit at the unlicensed care home (after her discharge from the nursing facility on 07/29/10), the legal representative found that staff at the unlicensed care home was giving Resident #57 alcoholic beverages; the legal representative quickly intervened but noted the nursing facility failed to inform staff at the unlicensed care home of the need for Resident #57 to abstain from alcohol. Additional information obtained from Resident #57's legal representative during this telephone interview included: - No information had been communicated to the staff at the unlicensed home regarding how to safely assist Resident #57 out of the legal representative's personal vehicle (from a sitting to a standing position), and she reported the mechanical lift at the facility was broken. - No information was communicated to the staff at the unlicensed home of the need to obtain follow-up services from a physician related to the resident's urinary tract infection. The legal representative reported having to take Resident #57 to an Urgent Care provider after her discharge from the facility, because the resident's urine was dark-colored and foul-smelling, and she could not get an appointment with a primary care physician until 08/30/10. - No physical therapy or occupational therapy services had yet been provided to Resident #57 since her admission to the unlicensed care home. -- b) During an interview with the nursing facility's administrator (Employee #53) on 08/04/10 at 12:03 p.m., she stated that discharge planning was primarily the responsibility of the facility's social worker. She confirmed that no reason for the transfer / discharge of Resident #57 was documented, that no written notice prior to transfer was documented, and that no arrangements were made for appropriate transportation, follow-up physician appointment, and ordered adaptive equipment. She agreed there was no evidence to reflect appropriate medical history had been communicated to the receiving facility. She stated the social worker was hired about six (6) months ago, had no previous long term care experience, and, although she had received orientation, she was in need of education on long term care requirements and services. -- c) A review of facility policy and procedures for discharge and transfer, conducted on 08/05/10 at 8:00 a.m., found the following: - Under the section Policy is stated: Customers and/or legal representatives will be provided proper notice in accordance with state and federal regulations should a transfer or discharge be initiated by a Genesis ElderCare Center. - Under the section Process is stated as #1: The social services department is responsible for coordinating transfers and discharges. -- d) A review of facility policy and procedures for discharge planning, conducted on 08/05/10 at 8:20 a.m., found under the section Policy: Upon admission, all customers will be asked about their discharge goals and assessed for discharge potential. For customers anticipating a short stay, discharge/transition planning will begin upon admission and be completed as part of the Interdisciplinary Care Plan process. Under the section Purpose is stated: To ensure the most appropriate discharge/transition plan for all customers and, To provide comprehensive discharge information for all customers, family members, and post-discharge care providers. -- e) On 08/09/10, the surveyor received additional information that had been submitted by the facility to the State survey agency after the survey team's exit. Among these materials were found Rehab UM Meeting notes and a discharge transition plan. - Review of the facility's Rehab UM Meeting notes for Resident #57 on 07/21/10 revealed, . D/C (discharge) plan? Lap buddy. Transfers with mod A (moderate assistance) for safety. AMb (sic) (ambulate) - 30ft with Mod A and RW (roller walker).; MBSS (modified barium swallow study) on 7/22 at noon. PO (oral) intake is extremely poor; drinks better on nectar (thickened liquids). - Review of the facility's Rehab UM Meeting notes for Resident #57 on 07/27/10 revealed, . D/C plan? Lap buddy. Transfers with max A (maximum assistance) for safety. Pt now not ambulating.; Question pt with UTI (urinary tract infection). Pt with decreased performance. Handwritten in the block containing Resident #57's name was: DC tom (discharge tomorrow) pm. Review of the resident's discharge transition plan, dated 07/29/10, revealed the following: - You can get around (at discharge): With a little help. Devices used: wheelchair (There was no mention of a front-wheeled or roller walker.) - Get up/down from a seated position (at discharge): W/ at great deal of help (There was no mention of the need for the use of any devices when transferring, such as a walker or a mechanical lift.) - Your dietary recommendations are: Regular Diet (There was no mention pureed foods or thickened liquids.) - On page 3, under the heading of Your physician follow-ups, nothing was written to direct either the resident's family or the receiving facility's staff to contact any physician. (There was no mention of the need to monitor the resident for signs / symptoms of a UTI.) - On page 5 of this document, under the heading Your health services provider follow-ups were checked Physical Therapy, Home Medical Equipment / Supplies, and Pharmacy Provider. None of the services under Home Care Services was checked, nor was Occupational Therapy checked under Therapy Services, as had been ordered by the physician on 07/27/10. Under Home Medical Equipment / Supplies, someone had scratched through information regarding the provider of a wheelchair, but there was no information to indicate a walker had been ordered. There was no mention anywhere on the document of the need to monitor the resident for falling, in view of the fact that she had used a lap buddy when at the nursing facility and had been identified as being at risk for falls by all of the rehabilitative therapy services. No information was communicated in the discharge transition plan regarding any special feeding techniques or alterations needed in the consistencies of foods and fluids to address her dysphagia, the transition plan incorrectly identified her diet as being of regular consistency, and there was no evidence that staff from the unlicensed home had come to the nursing facility to observe the resident during speech therapy to determine if she will be appropriate for their setting, as recommended by the SLP. .",2015-09-01
9787,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-06-01,278,D,0,1,2XEX11,". Based on closed record review and staff interview, the facility failed recognize a significant weight loss and accurately record this on the resident assessment instrument for one (1) of thirty-three (33) Stage II sample residents. Resident identifier: #51. Facility census: 57. Findings include: a) Resident #51 A review of the clinical record revealed Resident #51 weighed 180 pounds (#) on admission on 03/09/10 and 167# on 04/14/10. This was a 7.7% weight loss in one (1) month, which is a significant weight loss. The dietary manager (DM) had entered the resident's weights accurately into the comprehensive admission minimum data set (MDS) on 03/15/10, the Medicare 30-Day MDS on 03/29/10, and the Medicare 60-Day MDS on 04/28/10, but the DM failed to indicate that a significant weight loss had occurred. In an interview with the MDS nurse at 10:30 a.m. on 05/27/10, she acknowledged she was responsible for the MDS and the resulting resident assessment protocols (RAPs), but she reported the information on nutritional status (found in Section K) was entered by the DM. During an interview with the DM at 10:45 a.m. on 05/27/10, he acknowledged he completed the dietary sections of the MDS assessment and had no explanation for not indicating on the Medicare 60-Day MDS that a significant weight loss had occurred. The initial dietary assessment by the registered dietitian, on 03/09/10, stated the resident needed high-caloric intake to promote wound healing. There was no follow-up dietary assessment done when the significant weight loss occurred, nor was the resident's care plan reviewed or revised to address this weight loss. .",2015-09-01
9788,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-06-01,279,D,0,1,2XEX11,"**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, for one (1) of thirty-three (33) Stage II sample residents who was receiving outpatient [MEDICAL TREATMENT], had an individualized care plan specific to the resident's needs. Resident identifier: #37. Facility census: 57. Findings include: a) Resident #37 1. Interview with Resident #37, on 05/25/10 at 11:00 a.m., found he was receiving outpatient [MEDICAL TREATMENT] and usually left early in the morning to go to the [MEDICAL TREATMENT] center. The resident reported he took a snack with him and sometimes ate it at [MEDICAL TREATMENT]. He did not eat breakfast on the days he went to [MEDICAL TREATMENT]. The resident also reported he came back to the facility for lunch. He attended [MEDICAL TREATMENT] three (3) times weekly. He said he was weighed by the facility before he left and when he returned, and staff also checked his blood pressure before he went to [MEDICAL TREATMENT]. Review of Resident #37's current care plan, dated 05/02/10, found the facility would request pre- and post-[MEDICAL TREATMENT] weights from the [MEDICAL TREATMENT] center and would send a communication book to the [MEDICAL TREATMENT] center and review the contents of the book upon return. Other interventions noted in the care plan included monitoring of his blood pressure, but the intervention did not specify when his blood pressure was to be monitored (before and/or after [MEDICAL TREATMENT]). 2. Review of the physician's orders [REDACTED]. Review of the dietary report indicated the resident was on a no added salt diet. Review of the care plan for nutritional risk, dated 05/04/10, found the resident was to receive diet as ordered and staff was to honor food preferences within meal plan. An interview with the dietary manager, on 06/01/10 at 9:30 a.m., found the resident's regular diet was altered by identifying - as allergies [REDACTED]. This information was not included in the care plan for the resident. .",2015-09-01
9789,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-06-01,280,D,0,1,2XEX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to revise the care plan of one (1) of thirty-three (33) Stage II sampled residents, to include newly identified safety needs / interventions after a series of falls. Resident identifier: #154. Facility census: 57. Findings include: a) Resident #154 A review of the clinical record for Resident #154 revealed he was admitted on [DATE], with [DIAGNOSES REDACTED]. He was ambulatory with a walker and independent with transfers. A care plan initiated on admission (dated 03/09/10, prior to the date of admission) indicated the resident was at risk for falls due to cognitive loss and lack of safety awareness. The interventions were generic and included items not applicable to this resident. For example: Provide verbal cues., Place call light within reach., and Remind resident to use call light. were given as interventions, when the resident was described as having advanced [MEDICAL CONDITION] with poor communication skills and an ability to understand and/or retain information / directions. On 04/30/10, 05/03/10, and 05/09/10, Resident #154 sustained three (3) falls with minor injuries. The Resident Fall Investigation Forms and the physical therapy evaluation indicated the resident independently transferred, was ambulatory with the use of a walker, and/or used a wheelchair for locomotion. He was unsteady on his feet, had balance problems, exhibited right-sided weakness, and was always described as confused. (These signs / symptoms were verified during an interview with the nurse (Employee #55) at 2:30 p.m. on 05/31/10.) There were no entries on any of the investigation forms indicating that any new interventions / preventive measures were added to the care plan. There was another fall on 05/25/10, resulting in a trip to the emergency room related to a hematoma to the forehead and pelvic pain. Again, there was no indication on the investigation form of the need to review / revise to the resident's care plan. A review of the nurse aide assignment sheet, on 06/01/10, revealed instructions for the care of Resident #154, to include: WANDERGUARD - Set up to dress. Supervision to groom with cues to shave. Supervision with FWW (front wheeled walker) has right neglect. W/C (wheelchair) as needed. Needs assist and supervision with ambulation. Encourage use of walker with ambulation for safety. The care plan was reviewed and revised on 05/21/10, but there were no new interventions added, although several old interventions had been discontinued deletions. There was no mention of walker or wheelchair use by the resident, no mention of the resident being unsteady or of having right-sided weakness, no mention of the use of a Wanderguard, and no mention of the need for assistance / supervision for safety with ambulation. None of the interventions identified on the nurse aide assignment sheet were on the resident's care plan. During an interview with the assistant director of nurses (ADON - Employee #67) at 10:10 a.m. on 06/01/10, she acknowledged, after reviewing the record, the interventions identified on the nurse aide assignment sheet should also have been added to the resident's care plan. .",2015-09-01
9790,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-06-01,281,D,0,1,2XEX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to ensure each resident received medications in the correct dosage amount as ordered by the physician, for one (1) of ten (10) residents observed during medication pass. Resident identifier: #42. Facility census: 57. Findings include: a) Resident #42 During the observation of the passing of medications at 9:13 a.m. on 05/25/10, a registered nurse (RN - Employee #7) administered 2 Tablespoons (20 ml) of [MEDICATION NAME] to this resident and verbally repeated the order to the surveyor. A review of the physician's orders [REDACTED]. [REDACTED]. This finding was reviewed with Employee #7, who reviewed the MAR and acknowledged her error. .",2015-09-01
9791,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-06-01,284,D,0,1,2XEX12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, facility policy review, and review of information submitted by the facility to the State survey agency following the survey team's exit conference, the facility failed, for one (1) of five (5) residents whose closed records were reviewed, to develop a post-discharge plan of care that accurately and completely identified and communicated to the resident's family and receiving facility the care and services the resident would require in order to ensure a safe and orderly discharge. The discharge transition plan developed by the nursing facility for Resident #57 failed to communicate significant information about the resident's medical history (including a recent history of alcohol dependence) and current health status, failed to identify the need for home health services and occupational therapy as ordered by the physician, and failed to accurately communicate the need for such things as diet modifications and special equipment. Facility census: 54. Findings include: a) Resident #57 1. On 08/03/10 at 3:00 p.m., review of Resident #57's medical record revealed this [AGE] year old female was admitted to the nursing facility from a local hospital on [DATE], and she was discharged to a legally unlicensed care home on 07/29/10. Review of Resident #57's admission record (face sheet) revealed her [DIAGNOSES REDACTED]. According to her hospital discharge summary, dictated and transcribed on 07/06/10, she was admitted to the hospital on [DATE]. Her discharge [DIAGNOSES REDACTED]. On page 2 of the discharge summary, the physician noted, .Because of her moderate dementia and alcohol dependence she was given [MEDICATION NAME] to prevent withdrawal. Also on page 2 was stated, Physical Therapy notes that patient does require a walker and assistance for ambulation and has easy fatigue and endurance. They do emphasize that she is not safe of independent gait and transfers at this time. (This last sentence was written in bold font and was underlined.) On page 3 under Discharge Disposition and Special Discharge Instructions was: 5. Activity is ambulation with assist and a walker. A progress note by the certified physician's assistant (PA-C), dated 07/16/10, noted under A/P (assessment and plan): 5. Alcohol dependence: Abstain from future use . - 2. According to her comprehensive admission assessment, with an assessment reference date (ARD) of 07/13/10, she had problems with both long and short term memory, she was not oriented to person, place, or season, her cognitive skills for daily decision making were moderately impaired, she required the extensive physical assistance of one (1) person for bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, and bathing, and she was frequently incontinent of both bowel and bladder. During this assessment reference period, the resident did not walk, and her primary mode of locomotion was via a wheelchair. She received the services of speech, occupational, and physical therapy five (5) days a week during this assessment period, and a trunk restraint was used daily. According to a Medicare 14-day full assessment, with an ARD of 07/17/10, she had problems with both long and short term memory, she was not oriented to person, place, or season, her cognitive skills for daily decision making were moderately impaired, she required the extensive physical assistance of one (1) person for locomotion, dressing, and personal hygiene, and she required the extensive physical assistance of two (2) persons for bed mobility, transfer, and toilet use. During this assessment reference period, the resident did not walk. She received the services of speech, occupational, and physical therapy five (5) days a week during this assessment period, and a trunk restraint was used daily. - 3. Documentation by the physical therapist revealed Resident #57 received physical therapy from 07/07/10 through 07/27/10. Under the heading Summary of Care was noted: Summary of Progress:: pt. (sic) not progressing well, difficulty with cooperation and partiicipation (sic) secondary to dementia and decreased insight and safety, decreased intake as well as making participation difficult. family (sic) not in for training or education. recommend (sic) assist and continued PT if able to maximize functional mobility and assisted mobility. Under the heading Discharge Recommendations was noted: Discharge Setting: Other (personal care home); Recommended services upon discharge: Home Health Services, A (assistance) with all mobility; Equipment recommended upon discharge: w/c (wheelchair). Documentation by the occupational therapist revealed she received occupational therapy from 07/07/10 through 07/28/10. Under the heading Summary of Care was noted: Summary of Progress:: Pt. demo(nstrated) limited progress toward goals due to cognitive level and lack of participation in therapy. Pt. at times will refuse or become beligerant (sic) with therapist. Family and SW (social worker) decided to transfer patient to a personal care home closer to family. Discharge skilled OT treatment. Under the heading Discharge Recommendations was noted: Discharge Setting: Other (personal care home); Recommended services upon discharge: 24/7 care; Equipment recommended upon discharge: pt. could benefit from w/c and FWW (front-wheeled walker). Review of the speech therapy progress notes, for 07/20/10, revealed under the heading Current Status: Precautions: puree (diet); nectar-thick fluids; fall risk; easily agitated per hospital records; sundowners. Under the heading Encounter Summary was noted: . SLP (speech language pathologist) suggested that PCH (personal care home) staff come to facility next week to observe pt in tx (treatment) and determine if she will be appropriate for their setting. Pt's POA (power of attorney) to set this up for next week. Review of the resident's telephone orders found an order dated 07/27/10 for: Home Health w/ (with) PT & OT. Review of the social service notes revealed Resident #57 was discharged from the nursing facility at 6:00 p.m. on 07/29/10. Review of facility records found no evidence to reflect there had been any discussion between the social worker and the resident's legal representative regarding the appropriateness of discharging Resident #57 from a skilled nursing facility to a legally unlicensed care home in the community, in view of the resident's assessed needs with respect to her level of dependence on staff with activities of daily living, her dysphagia, and her need for monitoring related to her recently diagnosed urinary tract infection. - 4. In an interview on 08/04/10 at 10:45 a.m., the facility's social worker (Employee #59) reported there was no discharge planning meeting held or discharge notice given to the resident's legal representative, but they did discuss discharge during the resident's last care plan meeting. Review of the care plan meeting notes with the social worker, at this time, found no mention of any discharge plan. The social worker reported the physical therapist expressed that Resident #57 had reached a plateau. The social worker reported she then contacted the resident's legal representative, who set everything up for the discharge herself. The social worker did contact the unlicensed care home to ensure they had a mechanical (Hoyer) lift available for use at the facility and twenty-four (24) hour care. The social worker confirmed that no follow-up appointment with a physician had been made, she did not communicate to staff at the unlicensed home that the resident had a history of [REDACTED]. - 5. In a telephone interview on 08/04/10 at 11:10 a.m., Resident #57's legal representative reported she did not receive anything in writing from the facility, but that the social worker called and informed her that Resident #57 had reached a plateau in therapy and needed to be discharged . The legal representative stated the resident's intended discharge date was projected to be in August, but no set date was mentioned, and upon admission she knew there were no long term care beds available at the nursing facility. The legal representative was not sure why the discharge date was moved up and she wished Resident #57 could have stayed at the nursing facility longer, since she was only able to take a few steps with the assistance of two (2) people, one (1) on each side of her. She also reported that Resident #57's transition from the nursing facility to the unlicensed care home was rough. According to the legal representative, Resident #57 had resided in an assisted living facility in Ohio prior to being admitted to the hospital on [DATE]; while there, staff gave Resident #57 alcoholic beverages to drink, and during a visit there, the legal representative found both the resident and her caregiver were intoxicated. During a visit at the unlicensed care home (after her discharge from the nursing facility on 07/29/10), the legal representative found that staff at the unlicensed care home was giving Resident #57 alcoholic beverages; the legal representative quickly intervened but noted the nursing facility failed to inform staff at the unlicensed care home of the need for Resident #57 to abstain from alcohol. Additional information obtained from Resident #57's legal representative during this telephone interview included: - No information had been communicated to the staff at the unlicensed home regarding how to safely assist Resident #57 out of the legal representative's personal vehicle (from a sitting to a standing position), and she reported the mechanical lift at the facility was broken. - No information was communicated to the staff at the unlicensed home of the need to obtain follow-up services from a physician related to the resident's urinary tract infection. The legal representative reported having to take Resident #57 to an Urgent Care provider after her discharge from the facility, because the resident's urine was dark-colored and foul-smelling, and she could not get an appointment with a primary care physician until 08/30/10. - No physical therapy or occupational therapy services had yet been provided to Resident #57 since her admission to the unlicensed care home. -- b) During an interview with the nursing facility's administrator (Employee #53) on 08/04/10 at 12:03 p.m., she stated that discharge planning was primarily the responsibility of the facility's social worker. She confirmed that no reason for the transfer / discharge of Resident #57 was documented, that no written notice prior to transfer was documented, and that no arrangements were made for appropriate transportation, follow-up physician appointment, and ordered adaptive equipment. She agreed there was no evidence to reflect appropriate medical history had been communicated to the receiving facility. She stated the social worker was hired about six (6) months ago, had no previous long term care experience, and, although she had received orientation, she was in need of education on long term care requirements and services. -- c) A review of facility policy and procedures for discharge and transfer, conducted on 08/05/10 at 8:00 a.m., found the following: - Under the section Policy is stated: Customers and/or legal representatives will be provided proper notice in accordance with state and federal regulations should a transfer or discharge be initiated by a Genesis ElderCare Center. - Under the section Process is stated as #1: The social services department is responsible for coordinating transfers and discharges. -- d) A review of facility policy and procedures for discharge planning, conducted on 08/05/10 at 8:20 a.m., found under the section Policy: Upon admission, all customers will be asked about their discharge goals and assessed for discharge potential. For customers anticipating a short stay, discharge/transition planning will begin upon admission and be completed as part of the Interdisciplinary Care Plan process. Under the section Purpose is stated: To ensure the most appropriate discharge/transition plan for all customers and, To provide comprehensive discharge information for all customers, family members, and post-discharge care providers. -- e) On 08/09/10, the surveyor received additional information that had been submitted by the facility to the State survey agency after the survey team's exit. Among these materials were found Rehab UM Meeting notes and a discharge transition plan. - Review of the facility's Rehab UM Meeting notes for Resident #57 on 07/21/10 revealed, . D/C (discharge) plan? Lap buddy. Transfers with mod A (moderate assistance) for safety. AMb (sic) (ambulate) - 30ft with Mod A and RW (roller walker).; MBSS (modified [MEDICATION NAME] swallow study) on 7/22 at noon. PO (oral) intake is extremely poor; drinks better on nectar (thickened liquids). - Review of the facility's Rehab UM Meeting notes for Resident #57 on 07/27/10 revealed, . D/C plan? Lap buddy. Transfers with max A (maximum assistance) for safety. Pt now not ambulating.; Question pt with UTI (urinary tract infection). Pt with decreased performance. Handwritten in the block containing Resident #57's name was: DC tom (discharge tomorrow) pm. Review of the resident's discharge transition plan, dated 07/29/10, revealed the following: - You can get around (at discharge): With a little help. Devices used: wheelchair (There was no mention of a front-wheeled or roller walker.) - Get up/down from a seated position (at discharge): W/ at great deal of help (There was no mention of the need for the use of any devices when transferring, such as a walker or a mechanical lift.) - Your dietary recommendations are: Regular Diet (There was no mention pureed foods or thickened liquids.) - On page 3, under the heading of Your physician follow-ups, nothing was written to direct either the resident's family or the receiving facility's staff to contact any physician. (There was no mention of the need to monitor the resident for signs / symptoms of a UTI.) - On page 5 of this document, under the heading Your health services provider follow-ups were checked Physical Therapy, Home Medical Equipment / Supplies, and Pharmacy Provider. None of the services under Home Care Services was checked, nor was Occupational Therapy checked under Therapy Services, as had been ordered by the physician on 07/27/10. Under Home Medical Equipment / Supplies, someone had scratched through information regarding the provider of a wheelchair, but there was no information to indicate a walker had been ordered. There was no mention anywhere on the document of the need to monitor the resident for falling, in view of the fact that she had used a lap buddy when at the nursing facility and had been identified as being at risk for falls by all of the rehabilitative therapy services. No information was communicated in the discharge transition plan regarding any special feeding techniques or alterations needed in the consistencies of foods and fluids to address her dysphagia, the transition plan incorrectly identified her diet as being of regular consistency, and there was no evidence that staff from the unlicensed home had come to the nursing facility to observe the resident during speech therapy to determine if she will be appropriate for their setting, as recommended by the SLP. .",2015-09-01
9792,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-06-01,285,D,0,1,2XEX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to screen applicants, prior to admission, for mental illness and/or mental [MEDICAL CONDITION] requiring specialized services as required, for one (1) of thirty-three (33) Stage II sample residents. Resident identifier: #89. Facility census: 57. Findings include: a) Resident #89 A review of Resident #89's closed clinical record revealed this was admitted to the facility on [DATE], but the Level II determination of mental health status was not completed until 04/06/10. At the time of admission, a determination was made by the West Virginia Medical Institute (contracted by the State Medicaid agency) that a Level II evaluation for specialized services to treat a [DIAGNOSES REDACTED]. During an interview with the social worker at 11:10 a.m. on 05/25/10, she acknowledged, after reviewing her records, that Resident #89 had been admitted prior to completion of the Level II evaluation. .",2015-09-01
9793,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-06-01,309,D,0,1,2XEX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, medical record review, and staff interview, the facility failed to provide, to one (1) of thirty-three (33) Stage II sample residents who was receiving outpatient [MEDICAL TREATMENT], care and services specific to this resident's assessed needs to attain or maintain the resident's highest practicable physical well-being. Resident identifier: #37. Facility census: 57. Findings include: a) Resident #37 1. Interview with Resident #37, on 05/25/10 at 11:00 a.m., found he was receiving outpatient [MEDICAL TREATMENT] and usually left early in the morning to go to the [MEDICAL TREATMENT] center. The resident reported he took a snack with him and sometimes ate it at [MEDICAL TREATMENT]. He did not eat breakfast on the days he went to [MEDICAL TREATMENT]. The resident also reported he came back to the facility for lunch. He attended [MEDICAL TREATMENT] three (3) times weekly. He said he was weighed by the facility before he left and when he returned, and staff also checked his blood pressure before he went to [MEDICAL TREATMENT]. 2. Review of the physician's orders [REDACTED]. An interview with the assistant director of nursing (ADON - Employee #67), on 06/01/10 at 1:00 p.m., found the only reference to the resident requiring [MEDICAL TREATMENT] was the discharge summary from the hospital dated 04/20/10, but a physician's orders [REDACTED]. [REDACTED]. 3. Review of Resident #37's current care plan, dated 05/02/10, found the facility would request pre- and post-[MEDICAL TREATMENT] weights from the [MEDICAL TREATMENT] center and would send a communication book to the [MEDICAL TREATMENT] center and review the contents of the book upon return. Other interventions noted in the care plan included monitoring of his blood pressure, but the intervention did not specify when his blood pressure was to be monitored (before and/or after [MEDICAL TREATMENT]). Review of the [MEDICAL TREATMENT] communication book found staff at the [MEDICAL TREATMENT] center did not communicate with staff at the nursing facility about the resident following each [MEDICAL TREATMENT] treatment. Documentation found on some of the communication sheets upon return from the [MEDICAL TREATMENT] center contained a signature at the bottom, but the entry(ies) above the signature was (were) often made by one (1) of the nurses at the nursing facility or by the resident's nurse practioner and not by staff at the [MEDICAL TREATMENT] center. 4. Review of the physician's orders [REDACTED]. Review of the dietary report indicated the resident was on a no added salt diet. Review of the care plan for nutritional risk, dated 05/04/10, found the resident was to receive diet as ordered and staff was to honor food preferences within meal plan. An interview with the dietary manager, on 06/01/10 at 9:30 a.m., found the resident's regular diet was altered by identifying - as allergies [REDACTED]. This information was not included in the care plan for the resident. .",2015-09-01
9794,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-06-01,315,D,0,1,2XEX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure a resident, who was initially admitted to the facility without an indwelling catheter, was not catheterized unless the resident's clinical condition demonstrated the catheter was medically necessary. This occurred for one (1) of thirty-three (33) Stage II sample residents. Resident identifier #155. Facility census: 57. Findings include: a) Resident #155 Record review revealed Resident #155's initial admission to the facility occurred on 03/12/10. The resident's past medical history included [DIAGNOSES REDACTED]. The resident's discharge diagnoses, from the hospital on [DATE], included large left middle cerebral artery stroke and status [REDACTED]. Review of the resident's comprehensive admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 03/19/10, found, in Section H, the assessor encoded 4 for both bladder and bowel elimination, indicating total incontinence. No appliances or programs were documented. The resident assessment protocol (RAP) summary triggered for urinary incontinence. Documentation on the urinary incontinence RAP stated, Resident is incontinent of urine. Care plan will be directed towards preventing complications of incontinence via incontinence care. Will proceed with careplanning incontinence status. On 3/23/10, the facility completed a Urinary Incontinence Management Program Evaluation Admission Assessment; the facility's actions, per this assessment, were to monitor the care plan for effectiveness of interventions and to continue to manage the resident's incontinence with protective absorbent products. The care plan also contained these same interventions. The resident discharged to the hospital on [DATE] and returned to the facility on [DATE]. The resident's readmission orders [REDACTED]. At this time, the resident had an order for [REDACTED]. Review of the Medicare 5-Day MDS, with an ARD of 4/23/10, found the assessor encoded 0 in Section H for bladder elimination, indicating the resident was now continent of bladder, which includes use of in dwelling urinary catheter or ostomy device that does not leak urine or stool. The resident was also identified as having an indwelling catheter. Review of the physician's progress notes and the nursing notes found no medical justification for the continued use of the indwelling urinary catheter upon the resident's return to the facility on [DATE]. There was also no evidence to reflect efforts by the facility to further assess the resident for possible reversible causes of the [MEDICAL CONDITION], to include attempts to remove the catheter and measure the post-void residual of urine. An interview with the director of nursing (DON - Employee #58) and the assistant director of nursing (ADON - Employee #67) was completed at 9:00 a.m. on 06/01/10. When this surveyor inquired regarding the use of an indwelling urinary catheter without adequate indications for its use, the DON and ADON stated the catheter was placed while the resident was in the hospital for [MEDICAL CONDITION]. A request was made at that time for information to support the continued presence of [MEDICAL CONDITION] following the resident's discharge from the hospital. Upon exit on 06/01/10 at 3:00 p.m., no additional information was provided by the facility. .",2015-09-01
9795,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-06-01,325,D,0,1,2XEX12,"**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 fifteen (15) sampled residents, to ensure the resident received appropriate treatment and services to maintain acceptable parameters of nutritional status, by failing to ensure all direct care staff was aware of interventions identified by the rehabilitative therapy staff to reduce distractions during meal times and promote good oral 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. In an interview on 08/03/10 at 2:16 p.m., a CNA (Employee #10) reported that Resident #3 eats in the dining room and acknowledged that she (Employee #10) assists this and other residents in the dining room during the lunch meal. Employee #10 identified that, sometimes, Resident #3 eats independently and sometimes she does not; when she does not feed herself, staff provides verbal cues. When asked, Employee #10 stated there was no certain position the resident needs to be in during meals. The last two (2) to three (3) times she has assisted the resident with eating, the resident played with the butter and sugar packets. - 6. In an interview on the afternoon of 08/03/10, the SLP (Employee #67) reported having provided education to staff on 06/15/10 regarding how to assist Resident #3 during meals, noting the inservice sheet was in her office. She returned shortly with the inservice sheet. Review of this inservice sheet found only seven (7) CNAs were educated concerning mealtime techniques to be used with Resident #3. Employee #10 was not among those who received this training. Also at this time, the dietary manager (Employee #54) was in the conference room and was not aware of the interventions suggested by either ST or OT. The assistant director of nurse (ADON - Employee #58), who was also the facility's nurse educator, was in the room, and she was not aware of the inservice provided to CNAs regarding Resident #3. The ADON reviewed the inservice sheet and noted there were no signatures of licensed nurses or dietary staff. The following day (08/04/10), the ADON reported she had been on vacation during the time this staff education was provided. - 7. 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. .",2015-09-01
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
10223,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,313,D,0,1,5XSR11,"**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 one (1) of twenty-nine (29) Stage II sample residents received appropriate care and services to address his vision needs. The resident's glasses were missing, and there was no evidence to reflect the facility attempted to locate the missing glasses or obtain a replacement pair of glasses for him. Resident identifier: #46. Facility census: 48. Findings include: a) Resident #46 Review of Resident #46's medical record, on 05/27/10 at approximately 12:00 p.m., revealed an admission nursing assessment dated [DATE], which indicated Resident #46 wore eyeglasses. Further medical record review revealed a physician's orders [REDACTED]. Review of the resident's care plan, conducted on 05/27/10, found the facility identified the resident was at risk of falling. Interventions to promote the resident's safety included keeping his glasses clean and within his reach. In an interview on 05/27/10 at approximately 3:30 p.m., Resident #46 reported he did have glasses, and the glasses did help him see better, but he did not know where they were. In an interview on 05/27/10 at approximately 4:00 p.m., the director of nurses (DON - Employee #25) and the social worker (Employee #152) reported having no knowledge that the resident wore glasses and expressed having no idea where his glasses were. Staff did acknowledge that a pair of brown-framed glasses was on one (1) of the medication carts, but they did not know if these belong to Resident #46. Observation of Resident #46's room, on 06/04/10 at approximately 10:00 a.m., found a pair of brown-framed glasses lying on the resident's overbed table. When interviewed, Resident #46 did not know if they belonged to him. Interview shortly thereafter, with a licensed practical nurse (LPN - Employee #50) who had given the resident his medications, revealed the LPN had never seen these glasses before and she did not know where they had come from. The registered nurse (Employee #36) who completed the admission nursing assessment acknowledged knowing the resident arrived at the facility with glasses, but she had never noticed he had not wore them for several months. There were no intervention in place to assist this resident with his vision needs. .",2015-06-01
10224,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,280,D,0,1,5XSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure the interdisciplinary team (IDT) reviewed and revised each resident's care plan when a change occurred in the resident's condition and care or treatment needs for one (1) of twenty-nine (29) Stage II sample residents. Resident #52 was confined to a single occupancy room for isolation with no revisions made to his care plan to address his special care needs while in isolation. Resident identifier: #52. Facility census: 48. Findings include: a) Resident #52 1. Record review revealed Resident #52 had been in the hospital in April and returned to the nursing facility on 05/17/10. At the time of his return, he required isolation precautions related to an infectious organism in his stool ([MEDICAL CONDITION] or [DIAGNOSES REDACTED]). His current care plan, dated 04/12/10 through 07/14/10, was not revised to indicate that he was in isolation for [DIAGNOSES REDACTED], nor did it describe the precautions to be taken to prevent the spread of this infection. 2. Review of Resident #52's current care plan, dated 04/12/10 through 07/14/10, revealed the interdisciplinary care team identified a problem with his nutritional status, which was to be addressed by having the resident attend food-related activities. However, because this resident was confined to his room due to this infection, he was not permitted to leave his room to attend these food-related activities. There was no evidence his care plan was revised when he was placed in isolation, to address his inability to attend out-of-room activities of any kind. This was discussed with the administrator on the afternoon of 06/03/10. No further information was provided to surveyors regarding this concern prior to exit on 06/04/10. .",2015-06-01
10225,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,323,K,0,1,5XSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on observation, staff interview, staff-assisted checks of facility water temperatures, interview with the life safety code (LSC) surveyor, review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), and record review, the facility failed to provide a resident environment as free of accident hazards as is possible. The facility failed to assure water temperatures at hand sinks and showers accessible to residents remained in a safe temperature range to prevent injuries. Water temperatures in the resident environment were measured, using the facility's thermometer in the presence of facility staff, to be as high as 136 degrees Fahrenheit (F). According to Table 1 in the Guidance to Surveyors for this requirement found in Appendix PP of the CMS State Operations Manual, a third degree burn can occur after an exposure of only fifteen (15) seconds to a water temperature of 133 degrees F and after an exposure of only five (5) seconds to a water temperature of 140 degrees F. The excessive hot water temperatures found in the resident environment placed more than an isolated number of residents in immediate jeopardy of harm or death due to the potential for scalding / burn injuries, especially those residents with cognitive impairment and/or decreased sensitivity to pain and/or extreme temperatures. The administrator was informed of the immediate jeopardy determination at 11:00 a.m. on 05/27/10. An interview with the life safety surveyor at 11:35 a.m. on 05/27/10 found that the facility could provide no evidence that hot water temperatures were monitored to prevent accidental scalding or burns to facility residents. The administrator was informed, at 1:18 p.m. on 05/27/10, the circumstances leading to the immediate jeopardy were found to have been removed, when the facility was able to sustain a maximum hot water temperature of less than 110 degrees F as verified by surveyor observation and testing. After removal of the immediate jeopardy, a deficient practice remained with the potential for causing more than minimal harm to more than an isolated number of residents related to a failure by the facility to have in place a system for routinely monitoring water temperatures in the resident environment. Facility census: 48. Findings include: a) On 05/27/10 at 10:13 a.m., a maintenance employee (Employee #104) assisted the surveyor with measuring water temperatures in the resident environment utilizing facility equipment. A check of the hand sink located in the restroom (accessible to residents) located adjacent to the resident dining room found the hot water measured 136 degrees F. The hand sink in resident room 126 (occupied) registered 133 degrees F. The hand sink in resident room (occupied) 127 registered 132 degrees F. The hot water temperature from the shower nozzle in the resident shower room registered 123 degrees F. Employee #104 stated, during the assessment of water temperatures, the hot water supply line came down through the ceiling directly above the resident areas that had been checked and continued throughout the facility. He stated the hot water temperatures would be consistent throughout the facility. -- According to information in the Guidance to Surveyors for this requirement found in Appendix PP of the CMS State Operations Manual: Table 1. Time and Temperature Relationship to Serious Burns Water Temp - Time Required for a 3rd Degree Burn to Occur 155 degrees F - 1 sec 148 degrees F - 2 sec 140 degrees F - 5 sec 133 degrees F - 15 sec 127 degrees F - 1 min 124 degrees F - 3 min 120 degrees F - 5 min 100 degrees F - Safe 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. -- The program manager was subsequently informed of the excessive hot water temperatures in these resident areas. The determination that these findings placed the residents in immediately jeopardy, due to the high risk for sustaining third degrees burns after only brief periods of exposure to hot water, was conveyed to the administrator at 11:00 a.m. on 05/27/10. -- An interview with the LSC surveyor, at 11:35 a.m. on 05/27/10, found the facility could provide no evidence that hot water temperatures were routinely monitored to prevent accidental scalding or burns of the residents. -- The administrator submitted a plan for hot water temperatures to be taken and recorded on a daily basis with interventions in place should hot water temperatures register above 110 degrees F. -- Subsequent water temperature checks, completed at 1:18 p.m. on 05/27/10, found hot water temperatures were now consistently below 110 degrees F. The administrator was informed at that time that the residents were no longer in immediate jeopardy of injury or death from excessive hot water temperatures. --- Part II -- Based on observation, record review, and staff interview, the facility failed to provide adequate supervision and/or assistive devices appropriate to each resident's individual assessed needs, to prevent avoidable accidents with injuries. Resident #53 was admitted to the facility on [DATE]. On 04/17/10, staff applied four (4) half side rails to Resident #53's bed, with full-length side rail pads over each set of half rails on either side of Resident #53's mattress. On 04/20/10, Resident #53 was found on the floor after having climbed over the side rails. Subsequently, Resident #53 was noted to attempt on multiple occasions to exit the bed and/or throw his legs over the side rails. The facility failed to re-evaluate the use of these devices after staff should have identified they presented a safety hazard to Resident #53. Facility census: 48. Findings include: a) Resident #53 Observation, at 8:00 a.m. on 06/03/10, found Resident #53 in bed with two (2) half rails up on each side of his bed. He also utilized full-length pads that covered both sets of half rails on either side of his mattress running from the head to the foot of the bed. His bed was in the lowest position possible, but this was not a ""low bed"" near the floor. There were no safety mats on the floor on either side of the bed. -- Record review revealed this resident was admitted to the facility on [DATE]. A bed safety assessment, completed on the day of admission, indicated the need for two (2) upper half rails for bed mobility. On the following day (04/17/10), a pre-restraint assessment stated, ""A telephone consent was obtained from the responsible party for 4 half rails with 2 long pads since this was considered a restraint."" There was no evidence to reflect the facility had considered the risks and benefits associated with the use of these devices (including the risk for injury or death) for a resident who attempts to exit the bed by climbing over the side rails. Documentation on this 04/17/10 assessment identified no members of the interdisciplinary team (IDT) were present at that time the assessment was completed, because it was Saturday. There was no evidence that the IDT reviewed this issue when they returned on Monday. A nursing note, dated 04/20/10, stated, ""Resident found in floor in room had crawled over bed rails, no injuries noted. ..."" Staff identified that the bed alarm also in use at that time was not working properly, but the IDT did not address the issue of the resident climbing over the side rails. -- Review of the resident's care plan, dated 04/29/10, found the side rails were listed as an intervention to prevent falls. The care plan did not identify the use of these sets of half rails with full-length pads as a physical restraint. There was no evidence to reflect the IDT had discussed, or addressed in his care plan, the issue of this resident having climbed over the side rails on 04/20/10 (several days before the care plan meeting was held), nor was there evidence to reflect efforts by the IDT to identify the reason(s) why the resident was attempting to exit the bed. There was also no plan for the systematic and gradual reduction of the use of these devices (which functioned as physical restraints) as required. (See citation at F221.) -- Further review of Resident #53's medical record found he continued to attempt to exit his bed over the side rails. A nursing note, dated 05/30/10, indicated the resident had frequent episodes of staying awake on the 11:00 p.m. to 7:00 a.m. shift. This note also indicated the resident was attempting to climb out of bed, noting that he would pull himself close to the side rails when he was in bed and put his legs over the side rails. -- During an interview with the assessment nurse (Employee #16) at 3:00 p.m. on 06/03/10, she reported Resident #53 had used side rails since his admission. She stated he was due for a re-evaluation, and they would look at them (the side rails) again, because he was walking better now. When questioned at that time about other safety interventions to prevent falls from bed or to lessen injuries related to falls (e.g., a bed lower to floor level, a different type of mattress, pads on the floor beside the bed, etc.), she could not provide evidence that alternatives to the side rails had been attempted. She was aware of the resident climbing over the bed rails, but she reported he had climbed over the rails and fallen only one (1) time. She confirmed that, after that fall, the care plan was not revised. -- On 06/04/10, Employee #16 produced evidence of a re-assessment for the use of side rails. This documentation identified that the family was notified and agreed with the recommendation to use only the upper half rails and to put Resident #53 on an exercise plan. .",2015-06-01
10226,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,221,D,0,1,5XSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to assure residents were free from physical restraints imposed for the convenience of staff and not to treat a medical condition for one (1) of twenty-nine (29) Stage II sample residents. Resident #53 was admitted to the facility on [DATE]. On 04/17/10, staff applied four (4) half side rails to Resident #53's bed, with full-length side rail pads over each set of half rails on either side of Resident #53's mattress. On 04/20/10, Resident #53 was found on the floor after having climbed over the side rails. Subsequently, Resident #53 was noted to attempt on multiple occasions to exit the bed and/or throw his legs over the side rails. The facility failed to identify the use of these sets of half side rails with full-length pads as a physical restraint, failed to develop a plan for the systematic and gradual reduction of the use of these devices as a physical restraint (to ensure the resident's safety), and failed to re-evaluate the use of these devices once they presented a safety hazard to Resident #53. Facility census: 48. Findings include: a) Resident #53 Observation, at 8:00 a.m. on 06/03/10, found Resident #53 in bed with two (2) half rails up on each side of his bed. He also utilized full-length pads that covered both sets of half rails on either side of his mattress running from the head to the foot of the bed. His bed was in the lowest position possible, but this was not a ""low bed"" near the floor. There were no safety mats on the floor on either side of the bed. -- Record review revealed this resident was admitted to the facility on [DATE]. A bed safety assessment, completed on the day of admission, indicated the need for two (2) upper half rails for bed mobility. On the following day (04/17/10), a pre-restraint assessment stated, ""A telephone consent was obtained from the responsible party for 4 half rails with 2 long pads since this was considered a restraint."" There was no evidence to reflect the facility had considered the risks and benefits associated with the use of these devices (including the risk for injury or death) for a resident who attempts to exit the bed by climbing over the side rails. Documentation on the pre-restraint assessment identified no members of the interdisciplinary team (IDT) were present at that time the assessment was completed, because it was Saturday. There was no evidence that the IDT reviewed this issue when they returned on Monday. A nursing note, dated 04/20/10, stated, ""Resident found in floor in room had crawled over bed rails, no injuries noted. ..."" Staff identified that the bed alarm also in use at that time was not working properly, but the IDT did not address the issue of the resident climbing over the side rails. -- Review of the resident's care plan, dated 04/29/10, found the side rails were listed as an intervention to prevent falls. The care plan did not identify the use of these sets of half rails with full-length pads as a physical restraint. There was no evidence to reflect the IDT had discussed, or addressed in his care plan, the issue of this resident having climbed over the side rails on 04/20/10 (several days before the care plan meeting was held), nor was there evidence to reflect efforts by the IDT to identify the reason(s) why the resident was attempting to exit the bed. There was also no plan for the systematic and gradual reduction of the use of these devices (which functioned as physical restraints) as required. -- Further review of Resident #53's medical record found he continued to attempt to exit his bed over the side rails. A nursing note, dated 05/30/10, indicated the resident had frequent episodes of staying awake on night shift (11:00 p.m. to 7:00 a.m.). This note also indicated the resident was attempting to climb out of bed, noting that he would pull himself close to the side rails when he was in bed and put his legs over the side rails. -- During an interview with the assessment nurse (Employee #16) at 3:00 p.m. on 06/03/10, she reported Resident #53 had used side rails since his admission. She stated he was due for a re-evaluation, and they would look at them (the side rails) again, because he was walking better now. When questioned at that time about other safety interventions to prevent falls from bed or to lessen injuries related to falls (e.g., a bed lower to floor level, a different type of mattress, pads on the floor beside the bed, etc.), she could not provide evidence that alternatives to the side rails had been attempted. When asked about the use of low beds close to the floor, she stated they had tried these in the past, but the families did not like them. She was aware of the resident climbing over the bed rails, but she reported he had only climbed over the rails and fallen one (1) time. -- On 06/04/10, Employee #16 produced evidence of a re-assessment for the use of side rails. This documentation identified that the family was notified and agreed with the recommendation to use only the upper half rails and to put Resident #53 on an exercise plan. .",2015-06-01
10227,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,241,E,0,1,5XSR11,". Based on observation, staff interview, and review of the facility's infection control policy, the facility failed to provide care for residents in a manner and in an environment that enhanced each resident's dignity. Plastic clothing protectors were used on residents during meal times; at first glance, they had the appearance of small plastic garbage bags. Three (3) residents in isolation (#52, #45, and #49) were served meals on Styrofoam dishware, although there was no indication of the need for using disposables based on the nature of their infectious processes, and one (1) resident, who was not in isolation, was provided disposable utensils and Styrofoam dishes in her room. The wrong menu was posted in the dining room. Additionally, two (2) residents in the dining room were not served their trays at the same time as the other residents and were left to watch the others while they ate. This has the potential to affect more than an isolated number of residents. Facility census: 48. Findings include: a) Plastic clothing protectors During the evening meal on 05/24/10, residents were noted to have plastic clothing protectors in place. At first glance, it was thought the plastic clothing protectors were small plastic garbage bags. Discussion with the administrator, on the afternoon of 06/03/10, revealed the facility had used cloth clothing protectors, but they stained easily and the facility could not keep a supply of them readily available, so the facility discontinued their use. These thin plastic clothing protectors did not enhance the residents' dignity during meal times. -- b) Residents #52, #45, and #49 Observation of tray distribution, during lunch on 06/03/10, revealed the meals for Residents #52, #45, and #49 were served meals on Styrofoam dishware due to isolation precautions from infections. Observation also noted Resident #52's trash can contained Styrofoam dishware which had been used at breakfast. According to the facility's infection control policy, there were no infections that required the use of Styrofoam dishware. The types of infections the residents had would not have required the use of these products. Being served on these type of utensils did not enhance these residents' dining experience. -- c) Resident #32 Observation, on 05/25/10 at 4:15 p.m., found this resident was served dinner on Styrofoam dinnerware and was provided plastic utensils. The resident was residing in the isolation room, but she was not on any type of isolation. During an interview on 05/26/10 at 9:30 a.m., the director of nursing (DON) said, ""The kitchen thinks, since she is in the isolation room, she has an infection, but she doesn't. She has a surgical wound."" Nursing personnel failed to inform dietary this resident was not in isolation and did not require disposable dinnerware and utensils. -- d) Wrong menu posted Observation, during the evening meal in the dining room on 05/24/10, found the currently posted menu did not contain the items that were being served for that meal. A later discussion with the dietary manager (Employee #54), at lunchtime on 05/26/10, revealed the correct menu should have been for Cycle 2. A later observation found the correct menu was posted. On 06/02/10, the surveyor again spot checked the menu in the dining room and found Cycle 2 was still posted when it should now have been the Cycle 3 menu. This did not allow the residents to be aware of what the menu should be for the day and what they would be receiving for their meal. This was discussed with the administrator on the afternoon of 06/03/10. -- e) Residents #45 and #48 During the dinner meal observation on 05/24/10, Residents #45 and #48 were observed sitting in the dining room with other residents. The other residents were served their dinner meals at approximately 5:10 p.m.,. while these two individuals continued to wait for approximately ten (10) minutes before their meals arrived at 5:20 p.m. The nurse aide (Employee #43) who assisted with the passing out of the meals indicated this practice of residents having to wait for their food and watch others eat in front of them occurred frequently. She denied knowing why the practice continued to occur. .",2015-06-01
10228,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,364,F,0,1,5XSR11,". Based on observation and staff interview, the facility failed to serve food at the appropriate temperature for palatability. This practice has the potential to affect all residents consuming food prepared from this central location. Facility census: 48. Findings include: a) Meal observations, on the evening of 05/24/10, found three (3) residents had trays sitting in their rooms with the food covered, but none of the plates were seated in any type of device that would keep hot foods heated. These trays remained in place in the rooms from 5:14 p.m. until 5:58 p.m. - a periods of forty-four (44) minutes. This surveyor then proceeded to the kitchen, retrieved a thermometer, and requested new tray for one (1) of the three (3) affected residents (#34). At the time the thermometer was requested from the kitchen, the dietary manager (Employee #57) stated the thermometer was probably not accurate and then proceeded to attempt to calibrate the device. At 6:08 p.m., the surveyor measured the temperatures of the food items on Resident #34's original meal tray and found the following: - Pureed chicken (a hot product) - 60 degrees Fahrenheit (F) - Pureed potato salad (a cold product) - 62 degrees F - Puree 3-bean salad (a cold product) - 64 degrees F (At the time of receipt by the resident, State law requires foods be at a temperature of no less than 120 degrees F for hot foods and at no more than 50 degrees F for cold foods.) These issues were presented to the administrator on the afternoon of 06/03/10. No other information was provided by the facility prior to exit on 06/04/10. .",2015-06-01
10229,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,371,F,0,1,5XSR11,". Based on observation and staff interview, the facility failed to ensure foods were stored in a manner which maintained sanitary conditions. Food items found in the refrigerator were without labels and dates, equipment was in need of cleaning, and there was no thermometer inside of one (1) walk-in refrigerator to ensure the refrigerated food was being stored at the correct temperature. These practices have the potential to affect all residents who consume foods served from this central location. Facility census: 48. Findings include: a) During the initial tour with the dietary manager (Employee #54) on the mid-morning of 05/24/10, the following deficient practices were observed in the kitchen area: 1. The walk-in refrigerator near the dietary manager's office in the dry food storage room did not contain an internal thermometer so dietary staff could accurately monitor whether the unit was maintaining its temperature to keep food items within the safe storage temperature range. 2. Observation found dust and debris on the surface of a ledge behind the stove / range area. 3. In the reach-in refrigerator in the kitchen area, observation found a tray with small bowls of various items which were not labeled nor dated so as to identify the item and the length of time that had past since they had been prepared. .",2015-06-01
10230,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,490,K,0,1,5XSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, policy review, resident and staff interviews, and review of guidelines published by the Centers for Disease Control and Prevention (CDC), the governing body failed to ensure the facility was administered in an efficient and effective manner as evidence by the presence of system failures in the areas of accident hazards, infection control, and activity programming, 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 due to excessive hot water temperatures in resident-accessible areas which had the potential to result in third [MEDICAL CONDITION] exposure of fifteen (15) seconds or less; 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; resulted in actual harm to one (1) resident who suffered confusion related to her relocation and psychological harm and mental distress due to the facility's failure to develop and implement an effective infection control program and a failure to provide for her need for social interaction during her period of involuntary seclusion; and presented the potential for more than minimal harm to all residents related to the facility's failure to ensure a qualified activity director was involved in the development and implementation of an ongoing program of activities based on the assessed needs and interests of individual residents. These actions resulted in findings of immediate jeopardy, actual harm, 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 changes to facility systems. Facility census: 48. Findings include: a) Excessive hot water temperatures Based on observation, staff interview, staff-assisted checks of facility water temperatures, interview with the life safety code (LSC) surveyor, review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), and record review, the facility failed to provide a resident environment as free of accident hazards as is possible. The facility failed to assure water temperatures at hand sinks and showers accessible to residents remained in a safe temperature range to prevent injuries. Water temperatures in the resident environment were measured, using the facility's thermometer in the presence of facility staff, to be as high as 136 degrees Fahrenheit (F). According to Table 1 in the Guidance to Surveyors for this requirement found in Appendix PP of the CMS State Operations Manual, a third degree burn can occur after an exposure of only fifteen (15) seconds to a water temperature of 133 degrees F and after an exposure of only five (5) seconds to a water temperature of 140 degrees F. The excessive hot water temperatures found in the resident environment placed more than an isolated number of residents in immediate jeopardy of harm or death due to the potential for scalding / burn injuries, especially those residents with cognitive impairment and/or decreased sensitivity to pain and/or extreme temperatures. The administrator was informed of the immediate jeopardy determination at 11:00 a.m. on 05/27/10. An interview with the LSC surveyor, at 11:35 a.m. on 05/27/10, found the facility could provide no evidence that hot water temperatures were routinely monitored to prevent accidental scalding /[MEDICAL CONDITION] facility residents. Had the facility developed and implemented a plan to routinely monitor water temperatures in resident-accessible areas, the facility would have been able to identify this quality deficiency and take correction in advance of this survey. The administrator was informed, at 1:18 p.m. on 05/27/10, the circumstances leading to the immediate jeopardy were found to have been removed, when the facility was able to sustain a maximum hot water temperature of less than 110 degrees F as verified by surveyor observation and testing. After removal of the immediate jeopardy, a deficient practice remained with the potential for causing more than minimal harm to more than an isolated number of residents related to a failure by the facility to have in place a system for routinely monitoring water temperatures in the resident environment. (See citation at F323 for additional details.) -- b) Infection control Based on observations, a review of the facility's infection control policy and procedure manual, staff interview, and review of guidelines published by the CDC, the facility failed to establish and implement an infection control program effective in providing a safe, sanitary resident environment and effective in preventing the development and transmission of disease and infection. The facility did not establish policies and procedures consistent with current professional standards of practice for infection control, failed to implement transmission-based precautions based on the identified infectious organism and the mode of transmission, and failed to ensure staff was donning appropriate personal protective equipment when caring for residents in contact precautions, effectively sanitizing rooms occupied by residents with [MEDICAL CONDITION] (C. difficile or [DIAGNOSES REDACTED] - a highly contagious spore-forming organism from which environmental contamination frequently occurs), and properly disposing of contaminated linen removed from an isolation room. These quality deficiencies should have been identified by the facility's QAA Committee when the contents of the facility's infection control policy and procedure manual were reviewed in January 2010, as the CDC's revised guidelines for transmission-based isolation precautions were issued in 2007. An interview with the quality improvement designee for the hospital (Employee #116), on 06/03/10 at 3:00 p.m., revealed she allowed staff on the hospital's nursing facility unit to operate their QAA activities independently of the hospital. Employee #116 identified the director of nursing for that unit (Employee #25) as being responsible for identifying quality deficiencies to be addressed, gathering pertinent information, and forming / implementing an action plan. This was then reported to the hospital-wide quality improvement committee. As of this time, no quality improvement activities had been developed or implemented with respect to [DIAGNOSES REDACTED], and no policies and/or procedures had been reviewed or developed to ensure staff on the nursing facility unit knew how to care for residents with this infectious organism. These practices have the potential to affect all residents in the facility. (See citation at F441 for additional details.) -- c) Involuntary seclusion Based on observation, medical record review, staff interview, review of the facility's infection control policies, resident interview, and review of the CDC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, the facility failed to assure one (1) of twenty-nine (29) Stage II sample residents was not placed in involuntary seclusion against her will due to the inappropriate application of isolation procedures. Resident #45 was required to remain alone in a single occupancy isolation room with the door closed with no planned in-room activities or other interventions to prevent the resident from being socially isolated from other residents who were important to her (to include a male resident whom she stated must be ""worrying his brains out"", because he did not know where she was). As a result, Resident #45 suffered confusion related to her relocation and psychological harm and mental distress during this period of involuntary seclusion due to the facility's failure to provide for her need for social interaction. Review of CDC's 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, on page 34, Section I.D.2.a. for long term care facilities (LTCFs), found the following language: ""LTCFs are different from other healthcare settings in that elderly patients at increased risk for infection are brought together in one setting and remain in the facility for extended periods of time; for most residents, it is their home... it has been recommended that psychosocial needs be balanced with infection control needs in the LTCF setting..."". Had the facility revised its infection control policies and procedures to reflect current professional standards of practice of isolation precautions as established by CDC and implemented those policies and procedures accordingly, Resident #45 would not have experienced this social isolation. (See citations at F223, F248, F249, F279, and F441 for additional details.) -- d) Activity director Based on a review of the key personnel worksheet, review of personnel files, review of the activity program documentation, observation, resident interview, and staff interview, the facility failed to involve the activity director in the assessment, development, implementation and/or revision of an individualized activity program for individual residents. The individual identified by the facility as being the activity director of record was only a consultant who visited the facility on a monthly basis to review the activity calendar and residents' activity plans. There was no evidence to reflect this individual's involvement in assessing the activity needs and interests of individual residents, developing and/or revising programs based on the assessed needs and interests for each resident, and/or implementing a schedule of activities for individuals and groups. The individual identified by the facility as being responsible for implementing the facility's activity program on a day-to-day basis (who had completed a State-approved activity director training course but was not the activity director of record) was Employee #1. There was no evidence Employee #1 assessed / recorded each resident's activity interests and needs, developed an individualized program of ongoing activities designed to appeal to each resident's interests and to enhance each resident's highest practicable level of physical, mental, and psychosocial well-being, and/or revised each resident's program of activities when changes occurred in the resident's overall plan of care (such as when a resident was confined to her room due to an infectious process). Additionally, on occasion, Employee #1 was not available to implement activities programming due to being pulled to work as a nursing assistant when a staffing shortage occurred. This practice had the potential to affect all residents in the facility. (See citations at F249 and F248 for additional details.) .",2015-06-01
10231,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,520,K,0,1,5XSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, policy review, resident and staff interviews, and review of guidelines published by the Centers for Disease Control and Prevention (CDC), 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 accident hazards, infection control, and activity programming, 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 due to excessive hot water temperatures in resident-accessible areas which had the potential to result in third [MEDICAL CONDITION] exposure of fifteen (15) seconds or less; 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; resulted in actual harm to one (1) resident who suffered confusion related to her relocation and psychological harm and mental distress due to the facility's failure to develop and implement an effective infection control program and to provide for her need for social interaction during her period of involuntary seclusion; and presented the potential for more than minimal harm to all residents related to the facility's failure to ensure a qualified activity director was involved in the development and implementation of an ongoing program of activities based on the assessed needs and interests of individual residents. These actions resulted in findings of immediate jeopardy, actual harm, and substandard quality of care. Facility census: 48. Findings include: a) Excessive hot water temperatures Based on observation, staff interview, staff-assisted checks of facility water temperatures, interview with the life safety code (LSC) surveyor, review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), and record review, the facility failed to provide a resident environment as free of accident hazards as is possible. The facility failed to assure water temperatures at hand sinks and showers accessible to residents remained in a safe temperature range to prevent injuries. Water temperatures in the resident environment were measured, using the facility's thermometer in the presence of facility staff, to be as high as 136 degrees Fahrenheit (F). According to Table 1 in the Guidance to Surveyors for this requirement found in Appendix PP of the CMS State Operations Manual, a third degree burn can occur after an exposure of only fifteen (15) seconds to a water temperature of 133 degrees F and after an exposure of only five (5) seconds to a water temperature of 140 degrees F. The excessive hot water temperatures found in the resident environment placed more than an isolated number of residents in immediate jeopardy of harm or death due to the potential for scalding / burn injuries, especially those residents with cognitive impairment and/or decreased sensitivity to pain and/or extreme temperatures. The administrator was informed of the immediate jeopardy determination at 11:00 a.m. on 05/27/10. An interview with the LSC surveyor, at 11:35 a.m. on 05/27/10, found the facility could provide no evidence that hot water temperatures were routinely monitored to prevent accidental scalding /[MEDICAL CONDITION] facility residents. Had the facility developed and implemented a plan to routinely monitor water temperatures in resident-accessible areas, the facility would have been able to identify this quality deficiency and take correction in advance of this survey. The administrator was informed, at 1:18 p.m. on 05/27/10, the circumstances leading to the immediate jeopardy were found to have been removed, when the facility was able to sustain a maximum hot water temperature of less than 110 degrees F as verified by surveyor observation and testing. After removal of the immediate jeopardy, a deficient practice remained with the potential for causing more than minimal harm to more than an isolated number of residents related to a failure by the facility to have in place a system for routinely monitoring water temperatures in the resident environment. (See citation at F323 for additional details.) -- b) Infection control Based on observations, a review of the facility's infection control policy and procedure manual, staff interview, and review of guidelines published by the CDC, the facility failed to establish and implement an infection control program effective in providing a safe, sanitary resident environment and effective in preventing the development and transmission of disease and infection. The facility did not establish policies and procedures consistent with current professional standards of practice for infection control, failed to implement transmission-based precautions based on the identified infectious organism and the mode of transmission, and failed to ensure staff was donning appropriate personal protective equipment when caring for residents in contact precautions, effectively sanitizing rooms occupied by residents with [MEDICAL CONDITION] (C. difficile or [DIAGNOSES REDACTED] - a highly contagious spore-forming organism from which environmental contamination frequently occurs), and properly disposing of contaminated linen removed from an isolation room. These quality deficiencies should have been identified by the facility's QAA Committee when the contents of the facility's infection control policy and procedure manual were reviewed in January 2010, as the CDC's revised guidelines for transmission-based isolation precautions were issued in 2007. An interview with the quality improvement designee for the hospital (Employee #116), on 06/03/10 at 3:00 p.m., revealed she allowed staff on the hospital's nursing facility unit to operate their QAA activities independently of the hospital. Employee #116 identified the director of nursing for that unit (Employee #25) as being responsible for identifying quality deficiencies to be addressed, gathering pertinent information, and forming / implementing an action plan. This was then reported to the hospital-wide quality improvement committee. As of this time, no quality improvement activities had been developed or implemented with respect to [DIAGNOSES REDACTED], and no policies and/or procedures had been reviewed or developed to ensure staff on the nursing facility unit knew how to care for residents with this infectious organism. These practices have the potential to affect all residents in the facility. (See citation at F441 for additional details.) -- c) Involuntary seclusion Based on observation, medical record review, staff interview, review of the facility's infection control policies, resident interview, and review of the CDC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, the facility failed to assure one (1) of twenty-nine (29) Stage II sample residents was not placed in involuntary seclusion against her will due to the inappropriate application of isolation procedures. Resident #45 was required to remain alone in a single occupancy isolation room with the door closed with no planned in-room activities or other interventions to prevent the resident from being socially isolated from other residents who were important to her (to include a male resident whom she stated must be ""worrying his brains out"", because he did not know where she was). As a result, Resident #45 suffered confusion related to her relocation and psychological harm and mental distress during this period of involuntary seclusion due to the facility's failure to provide for her need for social interaction. Review of CDC's 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, on page 34, Section I.D.2.a. for long term care facilities (LTCFs), found the following language: ""LTCFs are different from other healthcare settings in that elderly patients at increased risk for infection are brought together in one setting and remain in the facility for extended periods of time; for most residents, it is their home... it has been recommended that psychosocial needs be balanced with infection control needs in the LTCF setting..."". Had the facility revised its infection control policies and procedures to reflect current professional standards of practice of isolation precautions as established by CDC and implemented those policies and procedures accordingly, Resident #45 would not have experienced this social isolation. (See citations at F223, F248, F249, F279, and F441 for additional details.) -- d) Activity director Based on a review of the key personnel worksheet, review of personnel files, review of the activity program documentation, observation, resident interview, and staff interview, the facility failed to involve the activity director in the assessment, development, implementation and/or revision of an individualized activity program for individual residents. The individual identified by the facility as being the activity director of record was only a consultant who visited the facility on a monthly basis to review the activity calendar and residents' activity plans. There was no evidence to reflect this individual's involvement in assessing the activity needs and interests of individual residents, developing and/or revising programs based on the assessed needs and interests for each resident, and/or implementing a schedule of activities for individuals and groups. The individual identified by the facility as being responsible for implementing the facility's activity program on a day-to-day basis (who had completed a State-approved activity director training course but was not the activity director of record) was Employee #1. There was no evidence Employee #1 assessed / recorded each resident's activity interests and needs, developed an individualized program of ongoing activities designed to appeal to each resident's interests and to enhance each resident's highest practicable level of physical, mental, and psychosocial well-being, and/or revised each resident's program of activities when changes occurred in the resident's overall plan of care (such as when a resident was confined to her room due to an infectious process). Additionally, on occasion, Employee #1 was not available to implement activities programming due to being pulled to work as a nursing assistant when a staffing shortage occurred. This practice had the potential to affect all residents in the facility. (See citations at F249 and F248 for additional details.)",2015-06-01
10232,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,463,E,0,1,5XSR11,". Based on observation, staff interview, and review of 2006 Guidelines for Design and Construction of Health Care Facilities, the facility failed to ensure each resident's toilet room was equipped with a pull cord which would activate the call system if a resident were lying on the floor following a fall. This deficient practice had the potential to affect more than an isolated number of residents currently residing in the facility. Facility census: 48. Findings include: a) Random observations, conducted on 05/25/10, found the nurse call system in the toilet facilities of each of the following resident rooms was equipped with a pull chain measuring only approximately 4 inches in length located adjacent to the toilet: 102, 103, 112, 114, 118, 122, 124, and 125. The bottoms of these chains were 36 inches from the floor and would not have been accessible by a resident who had fallen to the floor. Review of Section 10.3.6.3 of the 2006 Guidelines for Design and Construction of Health Care Facilities found the following language, ""Emergency call system. An emergency call system shall be provided at each resident toilet, bath, sitz bath, and shower room. (1) This system shall be accessible to a resident lying on the floor. Inclusion of a pull cord or portable radio frequency pushbutton will satisfy this standard."" The above observations were shared with the director of nursing (DON) on the afternoon of 05/26/10. On the afternoon of 05/27/10, interview with a maintenance employee (Employee #104) revealed he had installed pull cord extensions in the above noted bathrooms. .",2015-06-01
10233,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,516,F,0,1,5XSR11,". Based on observation and staff interview, the facility failed to assure resident-identifiable clinical information was safeguarded against unauthorized use. Staff members were noted to enter resident-specific clinical information on a computer equipped with a large screen which could be read by any passerby from the resident hallway adjacent to the nursing station. This deficient practice had the potential to affect all residents currently residing in the facility. Facility census: 48. Findings include: a) Observations made throughout this annual resurvey found nursing staff and other disciplines entered resident-specific clinical information on a computer located at the nursing station. Further observation found that any individual standing at the counter of the nursing station could clearly read everything the staff person was entering on the computer via the large screen attached to the computer. The director of nursing (DON) was informed that failing to have a filtering screen or other device attached to the large computer screen allowed anyone to read private information concerning residents on the afternoon of 05/27/10. Once this was brought to the attention of the DON on 05/27/10, further observations over the course of the resurvey found the facility failed to implement any measures to protect against unauthorized access of resident-specific information as of the exit from the facility at 1:30 p.m. on 06/03/10. .",2015-06-01
10234,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,441,F,0,1,5XSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, a review of the facility's infection control policy and procedure manual, staff interview, resident interview, and review of guidelines published by the Centers for Disease Control and Prevention (CDC), the facility failed to establish and implement an infection control program effective in providing a safe, sanitary resident environment and effective in preventing the development and transmission of disease and infection. The facility failed to establish policies and procedures consistent with current professional standards of practice for infection control in long-term care facilities, failed to implement transmission-based precautions based on the identified infectious organism and the mode of transmission, and failed to ensure staff was donning appropriate personal protective equipment when caring for residents in contact precautions, effectively sanitizing rooms occupied by residents with Clostridium difficile (C. difficile or [DIAGNOSES REDACTED] - a highly contagious spore-forming organism from which environmental contamination frequently occurs), and properly disposing of contaminated linen removed from an isolation room. These practices have the potential to affect all residents in the facility. Facility census: 48. Findings include: a) Observation and record review, over the course of the survey event from 05/24/10 through 06/04/10, found Resident #52 was in contact precautions for [DIAGNOSES REDACTED], Resident #49 was in contact precautions for Methicillin-resistant Staphylococcus aureus (MRSA) in a wound on her ankle, and Resident #45 was in droplet precautions for MRSA in her sputum. These residents were isolated to single occupancy rooms with the doors closed and were not permitted to come out to common areas used by the other residents. The facility's policy and procedures regarding infection control were requested to assure they were being followed for these residents. -- 1. Review of the facility's infection control (IC) policy and procedure (P&P) manual found, in a P&P titled ""Synopsis of Types of Precautions and Patients Requiring Precautions"" (with a review date of ""1/10""), reference to various types of precautions to be used by staff based on specific types of infectious organisms, including standard precautions, airborne precautions, droplet precaution, and contact precautions. Elsewhere in the IC manual was found a P&P titled ""Standard Precautions for the Care of All Patients"" (with a review date of ""1/10"") and another P&P titled ""Standard Blood & Body Fluid Precautions Applicable to All Hospital Patients"" (with a review date of ""1/10""), which included discussion of what personal protective equipment (PPE) to use when caring for residents. However, there was no P&P detailing any additional actions to be taken when caring for residents for which the physician ordered contact precautions. According to CDC's 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, on page 70: ""III.B.1. Contact Precautions - Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment ... Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. ... Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination..."" -- 2. The IC manual did not contain any P&P addressing special directives related to the care of residents with [DIAGNOSES REDACTED] (a highly contagious spore-forming bacterium), to include the use of a sodium hypochlorite-based product for the disinfection of environmental surfaces exposed to [DIAGNOSES REDACTED], as recommended by CDC. During an interview with the infection control nurse (Employee #118) on 06/02/10 at 3:00 p.m., Employee #118 confirmed the nursing facility had no specific P&P addressing [DIAGNOSES REDACTED]. She verified staff used the same IC P&Ps in both the hospital and the nursing facility. She reported she was not aware housekeeping staff was not utilizing a bleach-based product to clean environmental surfaces in the nursing facility. She acknowledged she was aware things were missing from the IC manual and that they needed to revise it. She stated she had developed a P&P for [DIAGNOSES REDACTED], but it had not yet been approved for implementation. -- Random observations, throughout the course of the survey event from 05/24/10 through 06/04/10, found nursing staff were not donning PPE in accordance with CDC guidelines when entering the room occupied by Resident #52 who had [DIAGNOSES REDACTED] in his stool. The resident was in an isolation room with a handwashing sink area outside the main room. Staff was observed to wash their hands and don gloves before entering his room. After providing his care, staff exited his room, removed the gloves, and washed their hands again. However, staff did not don isolation gowns when entering and while remaining in the room. According to CDC's 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, on page 51: ""II.E.2. Isolation gowns - Isolation gowns are used as specified by Standard and Transmission-Based Precautions, to protect the HCW's (healthcare worker's) arms and exposed body areas and prevent contamination of clothing with blood, body fluids, and other potentially infectious material. ... The wearing of isolation gowns and other protective apparel is mandated by the OSHA Bloodborne Pathogens Standard. ... (W)hen Contact Precautions are used (i.e., to prevent transmission of an infectious agent that is not interrupted by Standard Precautions alone and that is associated with environmental contamination), donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated environmental surfaces. ... Isolation gowns are always worn in combination with gloves, and with other PPE when indicated. ..."" -- In an interview with the housekeeping supervisor (Employee #81) on the afternoon of 06/01/10, she stated the housekeeping staff should be wiping down with bleach the environmental surfaces of rooms occupied by residents with [DIAGNOSES REDACTED]. She verified she did not have this procedure in writing but reiterated that her staff had been instructed to do this. In an interview with a housekeeper (Employee #69) on the afternoon of 06/01/10, she reported she was not allowed to use bleach to clean resident rooms, because there was a member of the nursing staff who could not be around it. This information was confirmed through interviews with nurses who were present during the interview with Employee #69. Discussion with a registered nurse (RN - Employee #16) and members of the housekeeping staff (Employees #69, #78, and #81), on the mid-morning of 06/03/10, revealed they were uncertain about the proper procedure for cleaning the room of a resident with [DIAGNOSES REDACTED]. The housekeeping supervisor (Employee #81) showed the surveyor a bottle of cleaning agent that did not contain any amount of bleach in it. The housekeepers confirmed this was the product they used to clean surfaces in Resident #52's room. Employee #81 stated they knew to use bleach, but they could not use it on the nursing facility unit, because a member of the nursing staff had a reaction when around bleach products. Review of information found on the CDC's website with respect to [DIAGNOSES REDACTED] revealed: ""C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B. It is a common cause of antibiotic-associated diarrhea (AAD). ... The risk for disease increases in patients with: antibiotic exposure, gastrointestinal surgery / manipulation, long length of stay in healthcare settings, a serious underlying illness, immunocompromising conditions, and advanced age. ... [DIAGNOSES REDACTED]icile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the [DIAGNOSES REDACTED]icile spores. [DIAGNOSES REDACTED]icile spores are mainly transmitted by healthcare personnel who have touched a contaminated surface or item."" Under the heading ""What can I use to clean and disinfect surfaces and devices to help control [DIAGNOSES REDACTED]icile?"" was found: ""Surfaces should be kept clean, and body substance spills should be managed promptly as outlined in CDC's 'Guidelines for Environmental Infection Control in Health-Care Facilities.' Hospital cleaning products can be used for routine cleaning. Hypochlorite-based disinfectants have been used with some success for environmental surface disinfection in those patient-care areas where surveillance and epidemiology indicate ongoing transmission of [DIAGNOSES REDACTED]icile. ... Note: EPA-registered hospital disinfectants are recommended for general use whenever possible in patient-care areas. At present there are no EPA-registered products with specific claims for inactivating [DIAGNOSES REDACTED]icile spores, but there are a number of EPA-registered products that contain hypochlorite. If an EPA-registered proprietary hypochlorite product is used, consult the label instructions for proper and safe use conditions."" (Source: http://www.cdc.gov /ncidod/dhqp/id_CdiffFAQ_HCP.html) -- At 8:45 a.m. on 06/02/10, the surveyor opened the door to Resident #52's room and noticed he had spilled water on the floor. As he was independently ambulatory about his room, the surveyor notified the housekeeper (Employee #80) of the need to clean up the spill to prevent a possible accident. Employee #80 obtained a clean towel, washed his hands, and put on gloves before entering the room. After wiping up the spill, he came out of the room past the handwashing sink into the hallway with the wet towel and asked nursing staff what he should do with it. A member of the nursing staff obtained a plastic bag for him to place it in separately from other items. Employee #80 unaware of the proper procedure to dispose of contaminated linen from an isolation room. -- An interview with the quality improvement designee for the hospital (Employee #116), on 06/03/10 at 3:00 p.m., revealed she allowed staff on the hospital's nursing facility unit to operate their QAA activities independently of the hospital. Employee #116 identified the director of nursing for that unit (Employee #25) as being responsible for identifying quality deficiencies to be addressed, gathering pertinent information, and forming / implementing an action plan. This was then reported to the hospital-wide quality improvement committee. As of this time, no quality improvement activities had been developed or implemented with respect to [DIAGNOSES REDACTED], and no policies and/or procedures had been reviewed or developed to ensure staff on the nursing facility unit knew how to care for residents with this infectious organism. The above issues were discussed with the facility's administrator on the late afternoon of 06/03/10. -- 3. Resident #45 Observations, conducted from 05/24/10 through 05/27/10, noted Resident #45 to be out of her room ambulating in the hallways, participating in activities, and dining with other residents. On the return visit the following week, beginning on 06/01/10, observation found Resident #45 had been moved to a single occupancy isolation room with the door closed and was not observed to leave her room throughout the day. Review of Resident #45's medical record found a physician's orders [REDACTED]. Review of the resident's current care plan, effective through 08/25/10, found the following, ""Has a special friendship / relationship with a male resident. Thinks of him as her boyfriend."" Review of the planned interventions included, ""Provide activities that res (resident) and friend can attend together, such as parties, movies, singings, outings... Provide private space for physical relations if both residents desire."" Review of an activities progress note, dated, 02/01/10, found the following, ""Resident enjoys all activities, loves to talk to staff and residents. She does her own AM (morning) care. Is able to feed, and dress self. She enjoys singing, and all socials. Will go out on field trips. Loves to talk about her family, mother, father, brothers. Enjoys walking around drinking her coffee. She is out of her room most of the day. She is a joy. Will continue with her care plans. Will keep her encouraged."" Review of the May 2010 activity attendance record for Resident #45 found she participated in church services, current events, Bingo, group exercise, ice cream socials, trivia time, etc., until she was placed in isolation on 05/27/10. Other than two (2) in-room activities (which were documented after inquiry by surveyor on 06/01/10), her activity participation was marked with an ""I"", indicating she was in ""isolation"". A nursing note, dated 05/27/10 at 2:25 p.m., documented that the resident continued in respiratory isolation per order. ""Client (resident) continues to be reoriented, confusion noted in regards to isolation room. Client continues to attempt to leave. Staff continues to redirect back to room..."". An interview with the individual responsible for the day-to-day planning and organization of the activities department (Employee #1) was conducted at 4:14 p.m. on 06/01/10. She was asked what planned activities had been developed to address Resident #45's activity needs while she was alone and confined in the isolation room. Employee #1 stated she had not initiated a plan of activities related to the resident being confined to her room. When asked if she had visited the resident at all that day to provide in-room activities, Employee #1 stated she had not. Employee #1 reported the resident wanted to come out, stating, ""I let her know that she can't come out. Her boyfriend (Resident #20) thinks she's dead. (Resident #45) likes to do anything and everything we do, parties, snacks, music, church, and bluegrass the other night. She don't (sic) like it; she don't (sic) like to be in her room. She likes to be with (Resident #20). She does not like being away from him at all."" Observations of the medication administration pass were conducted with a licensed practical nurse (LPN - Employee #44) at 10:00 a.m. on 06/02/10. Resident #45 stated to the nurse that she wanted to go home, that there wasn't anything wrong with her chest. Employee #44 related that the resident referred to her room (prior to isolation room) as ""home"". The resident was interviewed following Employee #44's departure. When asked how she liked her new room, she stated that there wasn't anything to do and there wasn't even a clock in her room. Observation confirmed there was no clock nor any activity items (such as magazines, books, etc.) in her room. The resident stated her boyfriend must be ""worrying his brains out"", because he did not know where she was. -- Review of the facility's infection control policy and procedures titled ""Protocol for Patients with MRSA Infection or Colonization"" found: ""1. All patients with positive MRSA cultures will be placed in contact isolation immediately upon discovery of the infection or colonization."" The policy was devoid of procedures for implementing ""contact isolation"", as noted above. -- Review of CDC's 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, on page 34, Section I.D.2.a. for long term care facilities (LTCFs), found the following language: ""LTCFs are different from other healthcare settings in that elderly patients at increased risk for infection are brought together in one setting and remain in the facility for extended periods of time; for most residents, it is their home... it has been recommended that psychosocial needs be balanced with infection control needs in the LTCF setting..."". The facility's IC P&P manual for isolation precautions were not consistent with current standards of professional practice for long-term care facilities established by CDC, which ""recommended that psychosocial needs be balanced with infection control needs"". .",2015-06-01
10235,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,492,C,0,1,5XSR11,". Based on a review of the consultant pharmacy permit and staff interview, as well as a review of Title 15 Legislative Rule West Virginia Board of Pharmacy Series I Rules and Regulations of the Board of Pharmacy, the facility failed to comply with 15CSR1-23.2.a., which requires a pharmacist providing consultation services to file an application with the Board of Pharmacy for each institution for which consultation services are provided. This practice had the potential to affect all residents in the facility. Facility census: 48. Findings include: a) On 05/25/10, the administrator of the facility provided a copy of the consultant pharmacist's application for license renewal. This application for renewal had the dates of 07/01/10 to 06/30/11. However, these dates were marked out with black ink, and the dates of 07/01/09 to 06/30/10 were replaced. The administrator produced this signed application on 05/25/10, one (1) day after the resurvey began. The consultant pharmacist had not applied for his 2009-2010 consultant pharmacist's license for this facility until 05/25/10. Review of Title 15 Legislative Rule, West Virginia Board of Pharmacy Series 1 Rules and Regulations of the Board of Pharmacy (15CSR1-23.2.a.) found, ""The consultant pharmacist shall file an application with the Board for each institution, place or person to whom consulting services are provided."" On 06/03/10 at approximately 2:00 p.m., the administrator confirmed the consultant pharmacist should have completed his renewal application in a timely manner, and the administrator agreed the facility did not have a pharmacist who held a current license to provide consultative services as required by State law. .",2015-06-01
10236,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,248,G,0,1,5XSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of documentation by activity staff, medical record review, observation, resident interview, and staff interview, the facility failed to develop and implement an ongoing program of activities tailored to meet the individual needs and interests of each resident, failed to assess / record each resident's interests (including a history of hobbies / things the resident enjoyed doing for leisure) for use as a basis for developing an individualized program of activities, and failed to recognize and address the activity needs of residents confined to their rooms due to isolation. These practices affected five (5) of twenty-nine (29) Stage II sample residents and resulted in actual harm to Resident #45, who was required to remain alone in an isolation room with the door closed with no planned in-room activities or other interventions to prevent the resident from being socially isolated from other residents who were important to her; Resident #45 suffered psychological harm and mental distress during this period of involuntary seclusion due to the facility's failure to provide for her known needs for socialization. Resident identifiers: #45, #49, #52, #4, and #16. Facility census: 48. Findings include: a) Resident #45 Observations, conducted from 05/24/10 through 05/27/10, noted Resident #45 to be out of her room ambulating in the hallways, participating in activities, and dining with other residents. On the return visit the following week, beginning on 06/01/10, observation found Resident #45 had been moved to an isolation room and was not observed to leave her room throughout the day. Review of Resident #45's medical record found a physician's orders [REDACTED]. -- Review of her most current resident assessment instrument, an abbreviated quarterly assessment with an assessment reference date of 04/28/10, revealed this [AGE] year old female was alert and oriented to season, location of her own room, staff names / faces, and to the fact that she was in a nursing facility. The assessor noted the resident had problems with her short-term memory but no problems with her long-term memory, and that her cognitive skills for daily decision-making were moderately impaired. Her [DIAGNOSES REDACTED]. She was independent with the self-performance of all activities of daily living and required staff supervision only with locomotion when off the unit. She had no indicators of [MEDICAL CONDITION] and no indicators of depression, anxiety, or sad mood. -- Review of the resident's current care plan, effective through 08/25/10, found the following, ""Has a special friendship / relationship with a male resident. Thinks of him as her boyfriend."" Review of the planned interventions included, ""Provide activities that res (resident) and friend can attend together, such as parties, movies, singings, outings.... Provide private space for physical relations if both residents desire."" Review of an activities progress note, dated, 02/01/10, found the following, ""Resident enjoys all activities, loves to talk to staff and residents. She does her own AM (morning) care. Is able to feed, and dress self. She enjoys singing, and all socials. Will go out on field trips. Loves to talk about her family, mother, father, brothers. Enjoys walking around drinking her coffee. She is out of her room most of the day. She is a joy. Will continue with her care plans. Will keep her encouraged."" -- Review of the May 2010 activity attendance record for Resident #45 found she participated in church services, current events, Bingo, group exercise, ice cream socials, trivia time, etc., until she was placed in isolation on 05/27/10. Other than two (2) in-room activities (which were documented after inquiry by surveyor on 06/01/10), her activity participation was marked with an ""I"", indicating she was in ""isolation"". -- A nursing note, dated 05/27/10 at 2:25 p.m., documented that the resident continued in respiratory isolation per order. ""Client (resident) continues to be reoriented, confusion noted in regards to isolation room. Client continues to attempt to leave. Staff continues to redirect back to room..."". -- An interview with the individual responsible for the day-to-day planning and organization of the activities department (Employee #1) was conducted at 4:14 p.m. on 06/01/10. She was asked what planned activities had been developed to address Resident #45's activity needs while she was alone and confined in the isolation room. Employee #1 stated she had not yet initiated a care plan for activities related to the resident being confined to her room. (See also citation at F279.) When asked if she had visited the resident at all that day to provide in-room activities, Employee #1 stated she had not. Employee #1 reported the resident wanted to come out, stating, ""I let her know that she can't come out. Her boyfriend (Resident #20) thinks she's dead. (Resident #45) likes to do anything and everything we do, parties, snacks, music, church, and bluegrass the other night. She don't (sic) like it; she don't (sic) like to be in her room. She likes to be with (Resident #20). She does not like being away from him at all."" -- Observations of the medication administration pass were conducted with a licensed practical nurse (LPN - Employee #44) at 10:00 a.m. on 06/02/10. Resident #45 stated to the nurse that she wanted to go home, that there wasn't anything wrong with her chest. Employee #44 related that the resident referred to her room (prior to isolation room) as ""home"". The resident was interviewed following Employee #44's departure. When asked how she liked her new room, she stated there wasn't anything to do and there wasn't even a clock in her room. Observation confirmed there was no clock nor any activity items (such as magazines, books, etc.) in her room. The resident stated her boyfriend must be ""worrying his brains out"", because he did not know where she was. -- Resident #45 was required to remain alone in a single occupancy isolation room with the door closed and with no planned in-room activities or interventions to prevent the resident from being socially isolated from other residents who were important to her. Resident #45 experienced psychological harm and mental distress due to the facility's failure to provide for her known needs for socialization during this period of involuntary seclusion. (See also citation at F223 related to involuntary seclusion.) --- b) Resident #49 Review of Resident #49's medical record found she was placed in contact isolation and confined to her room on the morning of 05/29/10, related to [MEDICAL CONDITION]-infected wound on her right ankle. Observation of the resident's ankle found it was covered with a dressing with no evidence of drainage or seepage; the infectious organism was fully contained in the dressing, with no evidence to suggest the need for her to be confined to her room. Review of a care plan note, dated 04/06/10, found the following: ""Likes to attend most activities. She likes talking to staff and, the other residents. She attends socials, church, and some of the games such as horseshoes and bean bag toss."" Review of the resident's current care plan, dated 01/10 with a goal date of 08/12/10, found no goals or interventions addressing her activity needs while she was being confined to her room. (See also citation at F279.) Resident #49 was required to remain alone in a single occupancy isolation room with no planned in-room activities or interventions to prevent the resident from being socially isolated. --- c) Resident #52 Review of Resident #52's current care plan, dated 04/12/10 through 07/14/10, revealed the interdisciplinary care team identified a problem with his nutritional status, which was to be addressed by having the resident attend food-related activities. However, because this resident was confined to his room due to an infection ([MEDICAL CONDITION]), he was not permitted to leave his room to attend these food-related activities. There was no evidence his care plan was revised when he was placed in isolation, to address his inability to attend out-of-room activities of any kind. (See also citation at F280.) This was discussed with the administrator on the afternoon of 06/03/10. No further information was provided to surveyors regarding this concern prior to exit on 06/04/10. --- d) Resident #4 A review of the activity information provided by the office assistant III (Employee #47) for Resident #4 did not include an assessment of this resident's past interests / hobbies. This resident had lived at the facility for several years and had little family involvement. The resident was able to communicate and relate things she enjoyed doing; however, the activity director or designee did not collect and/or record this information for use in developing an individualized activity plan for her. The resident's daily activity attendance record for May 2010 indicated she participated in events such as going to the beauty shop and going ""out shopping"". However, this facility did not take its residents out shopping; instead, staff went to the store and purchased items for the residents. This record also listed as an activity ""feeding pets""; however, at no time did this resident ever go outside to feed a pet, nor did the facility have any indoor pets. Resident #4's daily activity attendance record for May 2010 contained the same activities as were listed on the monthly activity calendar. No individual activities unique for this resident were noted. Further review of other residents' daily activity attendance records revealed also they reiterated, verbatim, the events listed on the monthly activity calendar with no evidence to reflect individualized activity programming had been provided to any resident. The last activity progress note recorded in this resident's medical record was dated ""12/16"" (with no year identified). This note indicated she attended some out-of-room activities and enjoyed watching television in her room. Observation found she did engage in this independent in-room activity throughout the survey. A licensed practical nurse (LPN - Employee #2) indicated this resident enjoyed watching ""soap operas"". However, the activity staff had not identified this personal preference through an assessment of her interests. Observation found the resident did seem to enjoy in-room television, but no evidence was found during record review to reflect the activity staff had explored with her what specific programs she particularly enjoyed. --- e) Resident #16 Medical record review, on 06/03/10, revealed this resident had a [DIAGNOSES REDACTED]. She was non-verbal and unable to communicate. At 12:00 p.m. on 06/03/10, the resident was observed in her room with a nurse. When the nurse spoke or touched the resident, the resident smiled and laughed. According to the nurse, the resident always responded in this manner when spoken to and touched. Review of the resident's assessments and care plans revealed no plans to provide activities for this resident to include talking with her and touching her. There was no evidence the facility identified this resident's interests and needs in an effort to develop an ongoing individualized program of activities to enhance this resident's highest level of mental and psychosocial well-being. (See also citations at F272 and F279.) --- See also citation at F249. .",2015-06-01
10237,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,272,D,0,1,5XSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to conduct a comprehensive assessment which identified activity needs for one (1) of twenty-nine (29) Stage II sample residents. There was no evidence the facility utilized resident observations, communication with nursing personnel, or family members to obtain an accurate assessment of the resident's activity needs. Resident identifier: #16. Facility census: 48. Findings include: a) Resident #16 Medical record review, on 06/03/10, revealed this resident had a [DIAGNOSES REDACTED]. She was non-verbal and unable to communicate. At 12:00 p.m. on 06/03/10, the resident was observed in her room with a nurse. When the nurse spoke or touched the resident, the resident smiled and laughed. According to the nurse, the resident always responded in this manner when spoken to and touched. Record review revealed the resident had a brother who was active in the resident's care. The resident was cared for in the home for many years prior to requiring nursing home care. There was no evidence the facility interviewed the brother regarding the resident's preferences and needs. review of the resident's medical record revealed [REDACTED]. This note did not indicate any type of initial or ongoing assessments of the resident's activity needs. Review of the resident's assessments and care plans revealed no plans to provide activities for this resident to include talking with her and touching her. There was no evidence the facility identified this resident's interests and needs in an effort to develop an ongoing individualized program of activities to enhance this resident's highest level of mental and psychosocial well-being. There was no evidence the facility utilized resident observations, communication with nursing personnel, or family members to assure an accurate assessment of the resident's activity needs. On 06/03/10 at 11:30 a.m., interviews were conducted with a licensed practical nurse (LPN - Employee #17, the activity assistant (Employee #29), and an office assistant (OA - Employee #47) regarding whether there was additional activity assessment information for this resident. At 11:50 a.m. on 06/03/10, the LPN and the OA reported no additional information was available. .",2015-06-01
10238,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,279,E,0,1,5XSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to develop a comprehensive care plan for each resident that included measurable objectives to meet the resident's assessed needs and that described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. This affected four (4) of twenty-nine (29) Stage II sample residents. Resident #53 experienced falls from both his chair and bed. While his care plan identified he was at risk for falls, the care plan did not acknowledge that he actually was falling. The goals associated with this fall risk care plan did not pertain to fall prevention; instead, the goals were related to his cleanliness, dressing, and vision. Staff applied a pair of half side rails covered with a full-length pad on each side of Resident #53's bed to prevent him from falling from the bed. Within days of the initiating the use of these devices, Resident #53 climbed over the side rails and fell to the floor; after this fall, staff noted multiple occasions when Resident #53 threw his legs over the side rails and/or attempted to exit the bed over the rails. The facility failed to develop a care plan in recognition of the fact that these devices were physical restraints and failed to develop a gradual and systematic plan to reduce the use of these restraints. The care plans for Residents #45, #49, and #16 did not address the activity needs of these residents. Residents #45 and #49 were confined to their rooms due to isolation, and no plan was developed to address their social and recreational needs during this period of confinement. Resident #16 was nonverbal and noncommunicative; the activity care plan was not developed based on a comprehensive assessment of the resident, nor did it contain measurable goals / objectives. Resident identifiers: #53, #45, #49, and #16. Facility census: 48. Findings include: a) Resident #53 1. Review of Resident #53's current care plan, dated 04/29/10, found the following plan related to falls: - Problem: ""Dependent on staff for ADL's (activity of daily living) due to cognitive and physical deficits r/t (related to) DX (diagnosis): of dow[DIAGNOSES REDACTED], recent hospitalization with pneumonia, impaired vision r/t bilateral [MEDICAL CONDITION], able to identify objects - Risk for falls."" - Goals: ""Resident will remain clean, odor free and appropriately dressed during the next review period. Resident will experience no visual decline during the next review period."" - Interventions: ""Shower and shampoo and shave 3 x a wk (week) with bed bath on days not showered. Oral Care q (every) shift and PRN (as needed). Must wear shirt and pants (jogging or pajama) at all times. Clip and clean nails q week. SR (side rails) x 4 with full SR pads to prevent falls. Bed and Chair alarms at all times. Transfer and ambulation assist x 1 - 2 staff. May be up in G/C (geri-chair) daily within view of staff. Ambulate with assist x 1-2 staff 50 - 60 ft daily increasing distance as tolerated. ROM (range of motion) to extr (extremities) BID (twice a day) with care. Keep bed at lowest position with bed wheels locked. Shoes and socks with non skid soles. Keep pathway free of debris and liquids. Reevaluate need for SR x 4 by the end of the next review. Resident will not fall / injuries during the next review."" A review of the nursing notes found this resident had fallen multiple times, sliding out of his chair. He also climbed out of his bed over the side rail on 04/20/10. The care plan, written on 04/29/10, did not address these actual falls - only the risk for falls, and there was no goal established related to falls; the goals for this problem were related to the resident's cleanliness, dressing, and vision. The interventions for this plan included grooming interventions (shower, shave, clip nails) that were not related to fall risk. The interventions also contained the statement: ""Resident will not fall / injuries during the next review."" This may have been intended as a goal, but it was written as an intervention. During an interview with the assessment nurse (Employee #16) on 06/03/10 at 3:00 p.m., she confirmed Resident #53's current care plan did not contain a goal for falls. She later stated there was a goal, but it was in the wrong column. She was aware of the resident climbing over the bed rails, but she reported he had climbed over the rails and fallen only one (1) time. She also confirmed that, after that fall, the care plan was not revised. 2. Review of the resident's care plan, dated 04/29/10, found the side rails were listed as an intervention to prevent falls. The care plan did not identify the use of these sets of half rails with full-length pads as a physical restraint. There was no evidence to reflect the interdisciplinary team (IDT) had discussed, or addressed in his care plan, the issue of this resident having climbed over the side rails on 04/20/10 (several days before the care plan meeting was held), nor was there evidence to reflect efforts by the IDT to identify the reason(s) why the resident was attempting to exit the bed. There was also no plan for the systematic and gradual reduction of the use of these devices (which functioned as physical restraints) as required. During an interview with the assessment nurse (Employee #16) at 3:00 p.m. on 06/03/10, she reported Resident #53 had used side rails since his admission. She stated he was due for a re-evaluation, and they would look at them (the side rails) again, because he was walking better now. When questioned at that time about other safety interventions to prevent falls from bed or to lessen injuries related to falls (e.g., a bed lower to floor level, a different type of mattress, pads on the floor beside the bed, etc.), she could not provide evidence that alternatives to the side rails had been attempted. On 06/04/10, Employee #16 produced evidence of a re-assessment for the use of side rails. This documentation identified that the family was notified and agreed with the recommendation to use only the upper half rails and to put Resident #53 on an exercise plan. --- b) Resident #45 Review of the medical record found Resident #45 was placed in contact isolation for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in her sputum and was confined to a single occupancy room with the door closed beginning on 05/27/10. An interview with the individual responsible for the day-to-day planning and organization of the activities department (Employee #1) was conducted at 4:14 p.m. on 06/01/10. She was asked what planned activities had been developed to address Resident #45's activity needs while she was alone and confined in the isolation room. Employee #1 confirmed she had not yet initiated a care plan for activities related to the resident being confined to her room. --- c) Resident #49 Review of Resident #49's medical record found she was placed in contact isolation and confined to her room on the morning of 05/29/10, related to [MEDICAL CONDITION]-infected wound on her right ankle. Review of a care plan note, dated 04/06/10, found the following: ""Likes to attend most activities. She likes talking to staff and, the other residents. She attends socials, church, and some of the games such as horseshoes and bean bag toss."" Review of the resident's current care plan, dated 01/10 with a goal date of 08/12/10, found no goals or interventions addressing her activity needs while she was being confined to her room. --- d) Resident #16 Medical record review, on 06/03/10, revealed this resident had a [DIAGNOSES REDACTED]. She was non-verbal and unable to communicate. At 12:00 p.m. on 06/03/10, the resident was observed in her room with a nurse. When the nurse spoke or touched the resident, the resident smiled and laughed. According to the nurse, the resident always responded in this manner when spoken to and touched. Review of the resident's current care plan, on 06/03/10, revealed no evidence the activity care plan was based on a comprehensive assessment of the resident's activity needs and preferences. The only reference to activities in the resident's current care plan, originally dated 09/30/07 and updated to include an estimated date of 06/29/10, was: ""Needs to improve activity attendance."" The only intervention for this ""problem"" was for activity department staff to provide three (3) in-room activities weekly; however, there were no specific activities described. The activity care plan did not include any recognition that the resident responded to being spoken to or touched. There was no evidence of collaboration with nursing staff who knew the resident's reactions to them when the resident was spoken to or touched. The care plan did not build on this aspect of the resident's needs. Additionally, the stated goal (""Needs to improve activity attendance"") was not measurable. Due to this, it was not possible for facility staff to measure improvement, or lack of improvement, toward attaining the goal. .",2015-06-01
10239,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,225,D,0,1,5XSR11,". Based on a review of incident / accident reports, review of abuse / neglect files, and staff interview, the facility failed to assure incidents of neglect were immediately reported to the appropriate State agencies. The facility conducted an internal investigation into an allegation of neglect involving a licensed practical nurse (LPN); based on that investigation, the allegation of neglect was substantiated by the facility. Subsequently, the facility failed to report this LPN to either the State survey and certification agency, the State licensing board of LPNs, or the ombudsman program; instead, this event was incorrectly reported to the State nurse aide registry. This failure to report to State agencies as required occurred for one (1) of five (5) reviewed cases of abuse / neglect. Resident identifier: #53. Facility census: 48. Findings include: a) Resident #53 Review of the facility's incident / accident reports found Resident #53 had crawled over his bed rails and was found in the floor on 04/20/10. His bed alarm was not on at that time. The facility's internal investigation into this fall revealed the resident's bed had been changed out by an LPN earlier in the shift, but the LPN failed to ensure the bed alarm on his new bed was working properly. The facility concluded neglect occurred when the LPN failed to ensure the bed alarm on the bed used by Resident #53 was working properly after switching the beds. This event was reported to the State nurse aide registry and to adult protective services (APS) on 04/20/10. This was not, however, reported to the LPN licensing board, to the State survey and certification agency, or the ombudsman program as required. During an interview on 06/01/10 at 2:00 p.m., the social service director confirmed this event was not reported to all applicable State agencies as required. .",2015-06-01
10240,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,223,G,0,1,5XSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, staff interview, review of the facility's infection control policies, resident interview, and review of the Centers for Disease Control and Prevention (CDC) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, the facility failed to assure one (1) of twenty-nine (29) Stage II sample residents was not placed in involuntary seclusion against her will due to the inappropriate application of isolation procedures. The facility's infection control policies and procedures for isolation precautions were not consistent with current standards of professional practice for long-term care facilities established by CDC, which ""recommended that psychosocial needs be balanced with infection control needs"". Resident #45 was required to remain alone in an isolation room with the door closed with no planned in-room activities or other interventions to prevent the resident from being socially isolated from other residents who were important to her (to include a male resident whom she stated must be ""worrying his brains out"", because he did not know where she was). As a result, Resident #45 suffered confusion related to her relocation and psychological harm and mental distress during this period of involuntary seclusion due to the facility's failure to provide for her need for social interaction. Resident identifier: #45. Facility census: 48. Findings include: a) Resident #45 Observations, conducted from 05/24/10 through 05/27/10, noted Resident #45 to be out of her room ambulating in the hallways, participating in activities, and dining with other residents. On the return visit the following week, beginning on 06/01/10, observation found Resident #45 had been moved to a single occupancy isolation room with the door closed and was not observed to leave her room throughout the day. Review of Resident #45's medical record found a physician's orders [REDACTED]. -- Review of her most current resident assessment instrument, an abbreviated quarterly assessment with an assessment reference date of 04/28/10, revealed this [AGE] year old female was alert and oriented to season, location of her own room, staff names / faces, and to the fact that she was in a nursing facility. The assessor noted the resident had problems with her short-term memory but no problems with her long-term memory, and that her cognitive skills for daily decision-making were moderately impaired. Her [DIAGNOSES REDACTED]. She was independent with the self-performance of all activities of daily living and required staff supervision only with locomotion when off the unit. She had no indicators of [MEDICAL CONDITION] and no indicators of depression, anxiety, or sad mood. -- Review of the resident's current care plan, effective through 08/25/10, found the following, ""Has a special friendship / relationship with a male resident. Thinks of him as her boyfriend."" Review of the planned interventions included, ""Provide activities that res (resident) and friend can attend together, such as parties, movies, singings, outings... Provide private space for physical relations if both residents desire."" Review of an activities progress note, dated, 02/01/10, found the following, ""Resident enjoys all activities, loves to talk to staff and residents. She does her own AM (morning) care. Is able to feed, and dress self. She enjoys singing, and all socials. Will go out on field trips. Loves to talk about her family, mother, father, brothers. Enjoys walking around drinking her coffee. She is out of her room most of the day. She is a joy. Will continue with her care plans. Will keep her encouraged."" -- Review of the May 2010 activity attendance record for Resident #45 found she participated in church services, current events, Bingo, group exercise, ice cream socials, trivia time, etc., until she was placed in isolation on 05/27/10. Other than two (2) in-room activities (which were documented after inquiry by surveyor on 06/01/10), her activity participation was marked with an ""I"", indicating she was in ""isolation"". A nursing note, dated 05/27/10 at 2:25 p.m., documented that the resident continued in respiratory isolation per order. ""Client (resident) continues to be reoriented, confusion noted in regards to isolation room. Client continues to attempt to leave. Staff continues to redirect back to room..."". -- An interview with the individual responsible for the day-to-day planning and organization of the activities department (Employee #1) was conducted at 4:14 p.m. on 06/01/10. She was asked what planned activities had been developed to address Resident #45's activity needs while she was alone and confined in the isolation room. Employee #1 stated she had not initiated a plan of activities related to the resident being confined to her room. When asked if she had visited the resident at all that day to provide in-room activities, Employee #1 stated she had not. Employee #1 reported the resident wanted to come out, stating, ""I let her know that she can't come out. Her boyfriend (Resident #20) thinks she's dead. (Resident #45) likes to do anything and everything we do, parties, snacks, music, church, and bluegrass the other night. She don't (sic) like it; she don't (sic) like to be in her room. She likes to be with (Resident #20). She does not like being away from him at all."" -- Observations of the medication administration pass were conducted with a licensed practical nurse (LPN - Employee #44) at 10:00 a.m. on 06/02/10. Resident #45 stated to the nurse that she wanted to go home, that there wasn't anything wrong with her chest. Employee #44 related that the resident referred to her room (prior to isolation room) as ""home"". The resident was interviewed following Employee #44's departure. When asked how she liked her new room, she stated that there wasn't anything to do and there wasn't even a clock in her room. Observation confirmed there was no clock nor any activity items (such as magazines, books, etc.) in her room. The resident stated her boyfriend must be ""worrying his brains out"", because he did not know where she was. (Note that 06/02/10 was Day 7 of this resident's isolation.) -- An interview with the assessment nurse (Employee #36) was conducted at 4:30 p.m. on 06/01/10. Upon review of Resident #45's current care plan, Employee #36 agreed that it had not been updated to reflect interventions related to the resident being confined to her room due to [MEDICAL CONDITION] infection. Employee #36 stated it was her understanding that Resident #45 was not allowed out of her room. -- Review of the facility's infection control policy and procedures titled ""Protocol for Patients [MEDICAL CONDITION] Infection or Colonization"" found: ""1. All patients with [MEDICAL CONDITION] cultures will be placed in contact isolation immediately upon discovery of the infection or colonization."" The policy was devoid of procedures for implementing ""contact isolation"". (See citation at F441.) -- Review of CDC's 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, on page 34, Section I.D.2.a. for long term care facilities (LTCFs), found the following language: ""LTCFs are different from other healthcare settings in that elderly patients at increased risk for infection are brought together in one setting and remain in the facility for extended periods of time; for most residents, it is their home... it has been recommended that psychosocial needs be balanced with infection control needs in the LTCF setting..."". Resident #45 was required to remain alone in a single occupancy isolation room with the door closed with no planned in-room activities or interventions to prevent the resident from being socially isolated from other residents who were important to her, which caused her psychosocial and emotional distress. Relocation of Resident #45 to this isolation room resulted in confusion with attempts to leave the isolation room. -- Following inquiries concerning the stringent infection control practices of the facility and the lack of a care plan in accordance with accepted standards of practice for LTCFs to address contact isolation, the facility developed, on 06/02/10, a care plan which included allowing the resident to attend out-of-the-room activities. -- A nursing note, written at 3:52 p.m. on 06/02/10, documented that the resident was taken outside for gathering in Sunshine Park with mask on for approximately thirty-five (35) minutes with no attempts to remove the mask. .",2015-06-01
10241,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,249,F,0,1,5XSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the key personnel worksheet, review of personnel files, review of the activity program documentation, observation, resident interview, and staff interview, the facility failed to involve the activity director in the assessment, development, implementation and/or revision of an individualized activity program for individual residents. The individual identified by the facility as being the activity director of record was only a consultant who visited the facility on a monthly basis to review the activity calendar and residents' activity plans. There was no evidence to reflect this individual's involvement in assessing the activity needs and interests of individual residents, developing and/or revising programs based on the assessed needs and interests for each resident, and/or implementing a schedule of activities for individuals and groups. The individual identified by the facility as being responsible for implementing the facility's activity program on a day-to-day basis (who had completed a State-approved activity director training course but was not the activity director of record) was Employee #1. There was no evidence Employee #1 assessed / recorded each resident's activity interests and needs, developed an individualized program of ongoing activities designed to appeal to each resident's interests and to enhance each resident's highest practicable level of physical, mental, and psychosocial well-being, and/or revised each resident's program of activities when changes occurred in the resident's overall plan of care (such as when a resident was confined to her room due to an infectious process). Additionally, on occasion, Employee #1 was not available to implement activities programming due to being pulled to work as a nursing assistant when a staffing shortage occurred. This practice had the potential to affect all residents in the facility. Resident identifiers: #45, #49, #52, #4, and #16. Facility census: 48. Findings include: a) On 05/26/10 at approximately 1:00 p.m., a review of key personnel information revealed the individual designated by the facility's management as its ""activity director"" of record was actually a consultant who came to the facility on a monthly basis to review the activity calendar and activity care plans. This individual was not involved in conducting assessments of residents' activity interests or needs or the development of initial activity care plan, nor was this person involved in the day-to-day implementation of the activities programming. When asked who was responsible for carrying out these responsibilities on a day-to-day basis, the facility identified Employee #1. Review of Employee #1's personnel file, on 05/26/10 at approximately 1:15 p.m., found this individual was a nursing assistant who had successfully completed a State-approved 45-hour activity director training course on 09/20/02. Review of Employee #1's job description found the nature of her work included: ""Under general supervision, performs paraprofessional work at the full-performance level assisting professional staff in the care, treatment, habilitation and rehabilitation of mentally and/or physically challenged at state-operated facility's or in community setting. Acts as a lead worker or charge assistant in assigning, scheduling and reviewing the work of Health Service Workers. Develops, writes, implements and evaluates basic therapeutic treatment programs...."" According to the facility's administrator in an interview on 05/26/10 at approximately 2:00 p.m., Employee #1 was responsible for carrying out the daily activity programming at the facility; however, on 05/25/10, Employee #1 had worked as a nursing assistant (rather than conducting activity programming) due to a shortage of nursing assistants on that particular day. The administrator provided a copy of a purchasing agreement between the facility and the consultant group that employed the individual identified as the facility's activity director. This agreement, dated 05/15/09, stated, ""The proposal is for Activities Consultation for the fiscal year 2009-10 to be provided on a monthly basis. Consultation includes regulatory oversight, program review, and staff development. The proposed cost is for 12 monthly visits at a cost of $200 per visit or for a total cost of $2400.00 for the year."" Employee #1 was on vacation during the last four (4) days of this resurvey, and her assistant (Employee #29 - whose primary duties were as a housekeeper) did not appear to have a great deal of knowledge of the day-to-day operation of the activity department. -- A review of the activity consultant's reports for the months of March, April and May 2010 found each contained a generalized statement with no discussion of any resident-specific issues or any new ideas / approaches for working with the types of debilitated residents present at this facility. The consultation report dated 04/30/10 included, ""The activities calendar was reviewed and discussed. Calendar includes a nice variety of daily, evening and weekend activities. May calendar includes special activities for National Nursing Home Week. ..."" Review of the May 2010 month's activity calendar found very little variety was offered to the residents on a day-to-day or week-to-week basis. Exclusive of additional activities offered only during the week of National Nursing Home Week from 05/09/10 through 05/15/10, the schedule of events was as follows: Sundays - 10:00 a.m. - Sunday school or church service 2:00 p.m. - ""Heart and Soul"", church service, or President's trivia quiz 4:00 p.m. - ""One-on-one"" (three times monthly) or ""Memory Sharing"" (twice monthly) 6:00 p.m. - ""In-room act (activity)"" Mondays - 9:00 a.m. - ""Greetings"" and/or ""One-on-one"" (twice monthly) 10:00 a.m. - ""Group or Individual Exercise"" 2:00 p.m. - ""Current events"" (three times monthly), Bingo (once monthly), or horseshoes (once monthly) 4:00 p.m. - ""One-on-one"" (four times monthly) or ""Coloring time"" (once monthly) 6:00 p.m. - ""Bible reading w/ (with) Judge Stephens"" Tuesdays - 9:00 a.m. - ""Beauty & Barber Shop"" 10:00 a.m. - ""Manicures"" 2:00 p.m. - ""Ice cream social"" (or birthday party once monthly) 4:00 p.m. - ""One-on-one"" 6:00 p.m. - ""Martha Rose"" or ""St. James Baptist Singers"" Wednesdays - 10:00 a.m. - ""Care Plans w/ Residents"" 2:00 p.m. - ""Red Hat"", ""Ice cream floats"", ""Gray Cappers"", or ""Bingo"" 4:00 p.m. - ""One-on-one"" (or Resident Council Meeting once monthly) 6:00 p.m. - ""In-room act"" Thursdays - 9:00 a.m. - ""Greetings & One-on-one"" 2:00 p.m. - ""Memory Sharing"" (twice monthly), ""Bean bag toss"" (once monthly), or ""Ice cream social"" (once monthly) 4:00 p.m. - ""One-on-one"" 6:00 a.m. - ""In-room act"" (twice monthly) or ""FUMS"" (once monthly) 7:00 p.m. - ""Triplett Family"" (once monthly) Fridays - 9:00 a.m. - ""Beauty & Barber Shop"" 10:00 a.m. - ""Manicures"" (three times monthly) 2:00 p.m. - ""Freddie Lewis"" 4:00 p.m. - ""One-on-one"" 6:00 p.m. - ""In-room act"" (two times monthly) or ""Joseph Baptist Church"" (once monthly) Saturdays - 9:00 a.m. - ""Greetings & One-on-one"" (twice monthly) 10:00 a.m. - ""Group or Individual Exercise"" (three times monthly) 1:00 p.m. - ""Church w/ Cindi"" 2:00 p.m. - ""Bingo"" 4:00 p.m. - ""One-on-one"" Of the one hundred twenty-nine (129) events found on the May 2010 activity calendar, ""One-on-one"" was offered twenty-nine (29) times; this activity did not promote interactions between residents. Church services, Sunday school, Bible reading, and church singing groups were scheduled at least nineteen (19) times. ""Beauty & Barber Shop"" and ""Manicures"" together were offered fifteen (15) times. ""In-room act"" (the most frequently scheduled evening activity) was offered thirteen (13) times; this activity was primarily self-directed and did not involve staff-to-resident interactions. ""Care plans (with) residents"" was identified as an activity four (4) times. No outings were offered. The calendar also noted, ""Shopping day will be on Fridays unless something changes. Have your list ready for pick up!"" This ""shopping"" did not involve taking residents out of the facility to a store; instead, residents gave their shopping lists to staff, and a staff member would make the purchases and bring them back to the residents. -- Observations, over the course of the eight (8) day on-site resurvey, found very few resident-centered group activities that engaged and/or stimulated the participants, and residents with special activity needs and interests were not provided individualized activity programing to meet their needs. 1. Resident #45 Observations, conducted from 05/24/10 through 05/27/10, noted Resident #45 to be out of her room ambulating in the hallways, participating in activities, and dining with other residents. On the return visit the following week, beginning on 06/01/10, observation found Resident #45 had been moved to an isolation room and was not observed to leave her room throughout the day. Review of Resident #45's medical record found a physician's orders [REDACTED]. Review of the resident's current care plan, effective through 08/25/10, found the following, ""Has a special friendship / relationship with a male resident. Thinks of him as her boyfriend."" Review of the planned interventions included, ""Provide activities that res (resident) and friend can attend together, such as parties, movies, singings, outings.... Provide private space for physical relations if both residents desire."" Review of an activities progress note, dated, 02/01/10, found the following, ""Resident enjoys all activities, loves to talk to staff and residents. She does her own AM (morning) care. Is able to feed, and dress self. She enjoys singing, and all socials. Will go out on field trips. Loves to talk about her family, mother, father, brothers. Enjoys walking around drinking her coffee. She is out of her room most of the day. She is a joy. Will continue with her care plans. Will keep her encouraged."" Review of the May 2010 activity attendance record for Resident #45 found she participated in church services, current events, Bingo, group exercise, ice cream socials, trivia time, etc., until she was placed in isolation on 05/27/10. Other than two (2) in-room activities (which were documented after inquiry by surveyor on 06/01/10), her activity participation was marked with an ""I"", indicating she was in ""isolation"". A nursing note, dated 05/27/10 at 2:25 p.m., documented that the resident continued in respiratory isolation per order. ""Client (resident) continues to be reoriented, confusion noted in regards to isolation room. Client continues to attempt to leave. Staff continues to redirect back to room..."". An interview with the individual responsible for the day-to-day planning and organization of the activities department (Employee #1) was conducted at 4:14 p.m. on 06/01/10. She was asked what planned activities had been developed to address Resident #45's activity needs while she was alone and confined in the isolation room. Employee #1 stated she had not initiated a plan of activities related to the resident being confined to her room. When asked if she had visited the resident at all that day to provide in-room activities, Employee #1 stated she had not. Employee #1 reported the resident wanted to come out, stating, ""I let her know that she can't come out. Her boyfriend (Resident #20) thinks she's dead. (Resident #45) likes to do anything and everything we do, parties, snacks, music, church, and bluegrass the other night. She don't (sic) like it; she don't (sic) like to be in her room. She likes to be with (Resident #20). She does not like being away from him at all."" Observations of the medication administration pass were conducted with a licensed practical nurse (LPN - Employee #44) at 10:00 a.m. on 06/02/10. Resident #45 stated to the nurse that she wanted to go home, that there wasn't anything wrong with her chest. Employee #44 related that the resident referred to her room (prior to isolation room) as ""home"". The resident was interviewed following Employee #44's departure. When asked how she liked her new room, she stated that there wasn't anything to do and there wasn't even a clock in her room. Observation confirmed there was no clock nor any activity items (such as magazines, books, etc.) in her room. The resident stated her boyfriend must be ""worrying his brains out"", because he did not know where she was. Resident #45 was required to remain alone in a single occupancy isolation room with no planned in-room activities or interventions to prevent the resident from being socially isolated from other residents who were important to her, which caused her distress. 2. Resident #49 Review of Resident #49's medical record found she was placed in contact isolation and confined to her room on the morning of 05/29/10, related to [MEDICAL CONDITION]-infected wound on her right ankle. Observation of the resident's ankle found it was covered with a dressing with no evidence of drainage or seepage; the infectious organism was fully contained in the dressing, with no evidence to suggest the need for her to be confined to her room. Review of a care plan note, dated 04/06/10, found the following: ""Likes to attend most activities. She likes talking to staff and, the other residents. She attends socials, church, and some of the games such as horseshoes and bean bag toss."" Review of the resident's current care plan, dated 01/10 with a goal date of 08/12/10, found no goals or interventions addressing her activity needs while she was being confined to her room. Resident #49 was required to remain alone in isolation with no planned in-room activities or other interventions to prevent the resident from being socially isolated. 3. Resident #52 Review of Resident #52's current care plan, dated 04/12/10 through 07/14/10, revealed the interdisciplinary care team identified a problem with his nutritional status, which was to be addressed by having the resident attend food-related activities. However, because this resident was confined to his room due to an infection ([MEDICAL CONDITION]), he was not permitted to leave his room to attend these food-related activities. There was no evidence his care plan was revised when he was placed in isolation, to address his inability to attend out-of-room activities of any kind. (See also citation at F280.) This was discussed with the administrator on the afternoon of 06/03/10. No further information was provided to surveyors regarding this concern prior to exit on 06/04/10. 4. Resident #16 Medical record review, on 06/03/10, revealed this resident had a [DIAGNOSES REDACTED]. She was non-verbal and unable to communicate. At 12:00 p.m. on 06/03/10, the resident was observed in her room with a nurse. When the nurse spoke or touched the resident, the resident smiled and laughed. According to the nurse, the resident always responded in this manner when spoken to and touched. Review of the resident's assessments and care plans revealed no plans to provide activities for this resident to include talking with her and touching her. There was no evidence the facility identified this resident's interests and needs in an effort to develop an ongoing individualized program of activities to enhance this resident's highest level of mental and psychosocial well-being. 5. Resident #4 A review of the activity information provided by the office assistant III (Employee #47) for Resident #4 did not include an assessment of this resident's past interests / hobbies. This resident had lived at the facility for several years and had little family involvement. The resident was able to communicate and relate things she enjoyed doing; however, the activity director or designee did not collect and/or record this information for use in developing an individualized activity plan for her. The activity attendance record for May 2010 indicated Resident #4 participated in events such as going to the beauty shop and going ""out shopping"". However, this facility did not take its residents out shopping; instead, staff went to the store and purchased items for the residents. This record also listed as an activity ""feeding pets""; however, at no time did this resident ever go outside to feed a pet, nor did the facility have any indoor pets. Resident #4's daily activity attendance record for May 2010 contained the same activities as were listed on the monthly activity calendar. No individual activities unique for this resident were noted. Further review of other sampled residents' daily activity attendance records revealed they also reiterated, verbatim, the events listed on the monthly activity calendar with no evidence to reflect individualized activity programming had been provided to any resident. -- See also citation at F248. .",2015-06-01
10242,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,250,E,0,1,5XSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, staff interview, and resident interview, the facility failed to provide medically related social services to for four (4) of twenty-nine (29) residents in the Stage II sample. The facility failed to assure the needs of three (3) residents (who were confined to their rooms) were met, by failing to identify how the strict isolation was affecting each resident and failing to provide support in view of each resident's individual needs and preferences, customary routines, concerns, and choices. Residents #45, #49, and #52 were confined to, and required to remain in, single-occupancy rooms with no outside contact with other residents or planned activities. Additionally, the facility failed to assist Resident #46 when she was unable to locate her glasses. Resident identifiers: #45, #49, #52, and #46. Facility census: 48. Findings include: a) Residents #45, #49, and #52 Observations, medical record review, and resident and staff interviews found these three (3) residents were confined to, and prohibited from leaving, their rooms due to isolation procedures in conflict with accepted standards of practice. (See also citations at F223 and F441.) 1. Resident #45 Record review revealed Resident #45 tested positive for Methicillin-resistant staphylococcus aureus (MRSA) in her sputum on 05/27/10. She was moved from her usual room and placed into a single occupancy isolation room with the door closed. The resident had not been allowed to leave this room to interact with other residents and participate in activities from 05/27/10 through 06/02/10. An interview with the individual responsible for the day-to-day planning and organization of the activities department (Employee #1) was conducted at 4:14 p.m. on 06/01/10. She was asked what planned activities had been developed to address Resident #45's activity needs while she was alone and confined in the isolation room. Employee #1 stated she had not initiated a plan of activities related to the resident being confined to her room. When asked if she had visited the resident at all that day to provide in-room activities, Employee #1 stated she had not. (See also citations at F248 and F249.) Employee #1 reported the resident wanted to come out, stating, ""I let her know that she can't come out. Her boyfriend (Resident #20) thinks she's dead. (Resident #45) likes to do anything and everything we do, parties, snacks, music, church, and bluegrass the other night. She don't (sic) like it; she don't (sic) like to be in her room. She likes to be with (Resident #20). She does not like being away from him at all."" Observations of the medication administration pass were conducted with a licensed practical nurse (LPN - Employee #44) at 10:00 a.m. on 06/02/10. Resident #45 stated to the nurse that she wanted to go home, that there wasn't anything wrong with her chest. Employee #44 related that the resident referred to her room (prior to isolation room) as ""home"". The resident was interviewed following Employee #44's departure. When asked how she liked her new room, she stated there wasn't anything to do and there wasn't even a clock in her room. Observation confirmed there was no clock nor any activity items (such as magazines, books, etc.) in her room. The resident stated her boyfriend must be ""worrying his brains out"", because he did not know where she was. An interview with the social services director (SSD) Employee #152, on 06/02/10 at approximately 10:30 a.m., revealed she was unaware that Resident #45 had no clock in her room or any self-directed activities in which to engage during her confinement. She stated she was hesitant to enter the room due to being pregnant. 2. Residents #49 and #52 Observation and record review revealed Resident #49 was in isolation for MRSA in a wound and Resident #52 was in isolation for Clostridium difficile (C. diff) in his stool. The facility was unable to provide evidence that medically-related social services had been provided in an effort to identify and address the social isolation suffered by these residents as a result of being prohibited from leaving their single-occupancy rooms. -- b) Resident #46 Review of Resident #46's medical record, on 05/27/10 at approximately 12:00 p.m., revealed an admission nursing assessment dated [DATE], which indicated Resident #46 wore eyeglasses. Further medical record review revealed a physician's orders [REDACTED]. Review of the resident's care plan, conducted on 05/27/10, found the facility identified the resident was at risk of falling. Interventions to promote the resident's safety included keeping his glasses clean and within his reach. In an interview on 05/27/10 at approximately 3:30 p.m., Resident #46 reported he did have glasses, and the glasses did help him see better, but he did not know where they were. In an interview on 05/27/10 at approximately 4:00 p.m., the director of nurses (DON - Employee #25) and the social worker (Employee #152) reported having no knowledge that the resident wore glasses and expressed having no idea where his glasses were. Staff did acknowledge that a pair of brown-framed glasses was on one (1) of the medication carts, but they did not know if these belong to Resident #46. Observation of Resident #46's room, on 06/04/10 at approximately 10:00 a.m., found a pair of brown-framed glasses lying on the resident's overbed table. When interviewed, Resident #46 did not know if they belonged to him. Interview shortly thereafter, with a licensed practical nurse (LPN - Employee #50) who had given the resident his medications, revealed the LPN had never seen these glasses before and she did not know where they had come from. The registered nurse (Employee #36) who completed the admission nursing assessment acknowledged knowing the resident arrived at the facility with glasses, but she had never noticed he had not wore them for several months. A review of the social service section of the medical record revealed no interventions related to locating or acquiring new glasses for Resident #46. The social worker did not acknowledge even knowing the resident ever wore glasses. (See also citation at F313.) .",2015-06-01
10243,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,159,D,0,1,5XSR11,". Based on family interview, staff interview, and medical record review, the facility had failed to ensure residents and/or their legally authorized representatives received quarterly statements informing them of the balance in their personal funds accounts, for one (1) of twenty-nine (29) Stage II sample residents. Resident identifier: #48. Facility census: 48. Findings include: a) Resident #48 During a telephone interview on 05/25/10 at approximately 7:00 p.m., Resident #48's daughter-in-law, who was her responsible party, reported she did not receive quarterly statements from the facility informing her of the balance in the resident's personal funds account. In an interview on 06/01/10 at approximately 3:00 p.m., the account collections technician III (Employee #156) reported she did not mail out quarterly statements to the responsible parties, nor did she give them out to residents who were capable of handling their own finance. She reported the facility's social worker (Employee #152) was responsible for these activities. In an interview on 6/02/10 at 11:08 a.m., the facility's social worker (Employee #152) reported Employee #156 comes over to the facility on a quarterly basis and reviews with her the residents' personal funds statements. In an interview on 06/02/10 at 11:30 a.m., the facility's administrator related he learned from an interview with the social worker (Employee #152) that she had reviewed Resident #48's quarterly statement with Employee #156 and signed off as having completed the review. However, Employee #152 indicated she had not given a copy of this statement to Resident #48 due to her inability to process the information. The social worker stated the resident might misunderstand the information and think someone had stolen money from her. Medical record review disclosed a power of attorney document dated 08/31/00. This document indicated the resident's son and/or daughter-in-law could act as the resident's lawful attorney, with the authority ""... to receive on my behalf all dividends, interest income arising from my personal estate, or any part thereof; and, upon receipt of any monies under these presents to deposit in said bank in my name, and to withdraw the same or any other funds that may be on deposit in said bank in my name. ..."" The facility failed to ensure the resident's legally authorized representative received a quarterly trust fund statement in the resident's stead. .",2015-06-01
10244,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,356,C,0,1,5XSR11,". Based on observation, record review, and staff interview, the facility failed to post nurse staffing data as required, to include the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: registered nurses (RNs), licensed practical nurses (LPNs), and nurse aides. The facility also failed to post the nurse staffing data in a prominent place readily accessible to residents and visitors. This practice had the potential to affect all residents and visitors to the facility. Facility census: 48. Findings include: a) Observation, on 06/02/10, found the nurse staffing data sheet for the facility posted on a cork board located behind the nursing station. The location of this posting was not readily accessible to residents and visitors. Review of the nurse staffing data sheets for 05/30/10 through 06/02/10 found they did not contain a section to capture the total number and actual hours worked by RNs. In an interview on 06/02/10 at approximately 1:00 p.m., Employee #16 (an RN) stated she thought RNs were not included in this posting. However, she agreed to change the posting to reflect the total number and actual hours worked by RNs as well as make the posting more accessible to the public. .",2015-06-01
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
9379,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2010-06-15,157,D,0,1,KN1V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, record review, and staff interview, the responsible party for one (1) of thirty-eight (38) sampled residents was not informed / consulted prior to the commencement of a Medicare Part B skilled service. Resident identifier: #112. Facility census: 112. Findings include: a) Resident #112 During an interview of the daughter / medical power of attorney representative (MPOA) of Resident #112 at 10:00 a.m. on 06/09/10, the MPOA stated that, for the last month, the therapist had been treating the resident for swallowing problems and she questioned why this had been done. When asked if anyone had spoken to her prior to starting this treatment, she said, No. and stated she only found out when she received a bill for $20.00 and another for $535.00. She stated there has been no change in the way her mother eats and swallows in over a year, and when she did ask the nurse about this last week, she was told that her mother was going to have her diet changed from all pureed foods and thickened liquids to chopped foods and regular liquids. She said she was very happy about this, because her mother does not always eat the pureed foods; she did not believe they were needed, because she brought the resident food from McDonalds which the resident ate with no problem. There was no mention of any swallowing difficulties in the nurses' notes and no evidence that the therapy evaluation and treatment had been discussed with the MPOA. During an interview with the speech language pathologist (Employee #110) at 9:30 a.m. on 06/10/10, she stated she had been asked to see the resident by the occupational therapist (OT - Employee #122) and had secured a physician's orders [REDACTED]. The evaluation was completed on 05/13/10. After reviewing the documentation on the Eating & Swallowing Evaluation form, she stated she believed she had spoken to the resident's granddaughter, who was visiting, about the evaluation. She acknowledged she had not spoken to the resident's daughter. The OT, when interviewed at 9:45 a.m. on 06/10/10, stated she had requested the evaluation, because the nursing assistants told her the resident had quit feeding herself, and she could see no physical reason for this, but she also admitted she had not spoken to the family about the request. The social worker (SW - Employee #2), when interviewed at 10:45 a.m. on 06/10/10, stated she had not spoken to the resident's family about the speech therapy services. She said the resident's daughter was very active in her care and that she would talk to her as soon as possible. She did verify the facility's practice was to notify the family prior to any change of services.",2015-11-01
9380,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2010-06-15,272,D,0,1,KN1V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately identify a significant weight loss on the resident assessment instrument for two (2) residents of twenty-eight (28) Stage II sample residents. Resident identifiers: #151 and #141. Facility census: 112. Findings include: a) Resident #151 A review of Resident #151's clinical record revealed the resident had a significant weight loss which was not identified in Section K3A of the Medicare 30-Day MDS with an ARD of 04/09/10. His weight had been entered as 173, which was a 28# loss since the Medicare 14-Day MDS with an ARD of 03/30/10. During an interview with the director of care delivery (Employee #48) at 11:45 a.m. on 06/10/10, the nurse stated, after reviewing the record, that the weights were accurate and had been rechecked. She stated the resident had a lot of [MEDICAL CONDITION] and was receiving several diuretics. During an interview with the MDS coordinator (Employee #120) at 2:00 p.m. on 06/10/10, she stated she had spoken to the dietician, who stated she usually waited a full thirty (30) days to calculate a significant weight loss before indicating this on the MDS. She stated this would be rectified immediately. b) Resident #141 A review of Resident #141's clinical record revealed two (2) significant weight losses which were not identified in section K3A of the MDS. They were as follows: - The Medicare 14-Day MDS (ARD of 01/02/10) identified a weight of 166#, which was a loss of 35# since the admission MDS (ARD of 12/02/09), but the entry in K3A did not indicate a loss. - The Medicare 60-Day MDS (ARD of 02/02/10) identified a weight of 146#, which was a loss of 20# since the Medicare 30-Day MDS (ARD of 01/04/10), but the entry on K3A did not indicate a loss. During an interview with Employee #120 at 2:00 p.m. on 06/10/10, she stated she had spoken to the dietician, who stated she usually waited a full thirty (30) days to calculate a significant weight loss before indicating this on the MDS. She stated this would be rectified immediately.",2015-11-01
9381,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2010-06-15,279,E,0,1,KN1V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to develop a care plan for each resident that adequately addressed all of the resident's needs based on the comprehensive assessment, for four (4) of twenty-eight (28) Stage II sampled residents. Resident identifiers: #112, #12, #63, and #83. Facility census: 112. Findings include: a) Resident #112 A review of Resident #112's clinical record revealed an [AGE] year old female with [DIAGNOSES REDACTED]. Her annual minimum data set assessment (MDS) contained the following information: - Section G1AB - she was totally dependent for transfers; - Sections G1AC and G1AD - she did not ambulate; - Section G4DA - she had limited range of motion in both legs; and - Section G9 - there had been no change in activities of daily living (ADL) since the last MDS. In Section V, staff indicated that care planning would be done to address the above issues. An observation of this resident, at 1:15 p.m. on 06/07/10, revealed she had contractures of both legs, with them curving inward when she was up in the wheelchair. During interviews with three nurses (Employees #142, #85, and #24) at 2:15 p.m. on 06/07/10, they all stated the resident could not stand and she had limited movement of both legs. In an interview at 2:30 p.m. on 06/07/10, the physical therapist (PT - Employee #49) verified the resident did have contractures of both legs which required special positioning when she was up in the wheelchair and with a strap added to the chair to assist her in maintaining that positioning. Neither the PT nor the nurses knew how long the contractures had been present. They knew they were not present on admission in 2008, and all agreed the contractures occurred over a year ago. (Subsequent to these interviews, no documentation of the onset of contractures was provided prior to the survey exit.) A review of the resident's current care plan (last revised on 05/13/10) did not find evidence of nursing interventions to prevent the further deterioration of contractures and/or maintain the resident's present level of functioning. There was no mention of the use of heel protectors, compression sleeve on left arm, TED hose, geri sleeves to right arm, and/or geri-hipsters, all of which had been ordered by the physician. There was no intervention noted in her care plan addressing the special wheelchair positioning or the use of a strap to maintain that positioning. During an interview with the nurse (Employee #87) at 4:30 p.m. on 06/10/10, she provided the Resident Information Sheet for Resident #112, used by the nursing assistant as instructions for care giving. This sheet indicated the geri-sleeve was not being used (although the order was active and its use was documented on the medication administration record); hipsters were to be used; and a scoot chair was to be used (a scoot chair had never been ordered and/or used). Employee #87 stated the ADL books also contained information for the nursing assistants to use. Review of the ADL book for Resident #112 found it contained PT instructions that were out-of-date and no longer applied to this resident. They included the following: - 05/02/08 - Pt (patient) is approp. (appropriate) for stand-turn with nursing staff. - 06/03/08 - Pt needs cues to push up from the W/C (wheelchair) for sit to stand. Ambulate to and from the rest room. (The resident could no longer bear weight or ambulate.) During an interview with the MDS nurses (Employees #1 and #120) at 2:45 p.m. on 06/13/10, they acknowledged Resident #112's current care plan did not address the resident's contractures and that the out-of-date PT instructions should not have remained in the ADL book. Employee #120 stated that a scoop chair had never been used and that it must have been an error. b) Resident #12 On 06/07/10 at 2:01 p.m., initial observation of Resident #12 found her in bed. Brief introduction and conversation indicated an apparent limitation of movement and possible contracture of the hands. An interview was conducted with a licensed practical nurse (LPN - Employee #85) on at 9:45 a.m. on 06/08/10. This LPN indicated Resident #12 had contractures to her wrists and hands and that air splints were ordered to be applied at night. The nurse discussed her understanding of the physician's orders [REDACTED]. A review of Resident #12's medical record, conducted on 06/11/10 at 9:00 a.m., found no mention of the application of air splints in the care plan. In the annual MDS with an ARD of 03/19/10, the assessor coded the resident as having limitations in range of motion to both arms and both hands, with partial loss of voluntary movement. An occupational therapy rehabilitation summary, completed on 03/17/10, documented passive range of motion exercises and the application of an air splint to the right hand at night to maximize comfort, skin, and joint integrity of the right hand. Documentation indicated the resident refused to have splints applied to both hands and that, because good position was seen, no splinting was needed for the left hand. Review of the resident's treatment administration records (TARs) found documentation to indicate the air splint was applied as ordered in April, May, and thus far in June 2010. Resident #12, when again interviewed on 06/10/10 at 2:16 p.m., confirmed the air splint was being applied at night and that she did not want splints applied to both hands. She stated she did not think the splint did much good, but if they thought it helped, it was fine with her. In an interview on 06/14/10 at 10:45 a.m., the director of nursing (DON - Employee #61) and the MDS coordinator (Employee #120) confirmed that the air splint had not been included in the resident's care plan, but it had been added to the care plan on 06/09/10, after this surveyor's discussion with staff. c) Resident #63 An observation of the resident, on 06/09/10 at 11:00 a.m., revealed the resident was contracted in all extremities. Record review revealed the resident's diagnoses, on admission to the facility on [DATE], included amyotrophic lateral [MEDICAL CONDITION] (ALS). review of the resident's medical record revealed [REDACTED]. Resident wears splints up to two hours a day. PT was discontinued related to resident having a [MEDICAL CONDITION] disease causing paralysis progressively. Splints for 2-4 hrs a day to decrease further deterioration of contractures. Passive range of motion for extremities for the rest of her life to prevent further contractures. A review of the resident's care plan (initiated on 01/20/10 and revised on 01/26/10) did not find any mention of the resident receiving passive range of motion to all extremities to prevent further contractures. An interview with the two (2) MDS coordinators (Employees ##1 and #120), on 06/15/10 at 10:00 a.m., revealed the physical therapy recommendation for passive range of motion to all extremities to prevent further contractures was brought to her attention, so that she could place the interventions on the care plan. d) Resident #83 Record review revealed Resident #83 was evaluated by the speech language pathologist (SLP) for swallowing difficulty and placed on thickened liquid for fluids. This was updated on 04/02/10, with the resident receiving regular consistency fluids and a mechanical soft diet. A rehabilitation progress note indicated the SLP recommended changing her diet from regular liquids back to nectar thick liquids on 03/22/10, related to suspected aspiration evidence by coughing with drinks and recent chest x-ray results indicating the presence of an upper respiratory infection. Resident agreed to try for a few days. However, today she decided she no longer wants to comply with the recommended fluid diet. Risks have been explained to her in detail. Diet changed back to regular liquids per resident request. Safe swallow strategies continue to encouraged. An interview with the resident, on 06/14/10 at 11:55 a.m., revealed the resident was drinking regular fluids. She stated she would not drink the thickened liquids and wanted her regular fluids. No evidence was found on the care plan to indicate what safe swallow strategies were to be encouraged as interventions for this resident who refused to drink thickened liquids. In an interview on 06/15/10 at 10:00 a.m., Employee #1 revealed she was not aware of the SLP wanting safety measures for the resident related to her refusal to drink thickened liquids.",2015-11-01
9382,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2010-06-15,280,D,0,1,KN1V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview, staff interview, and facility policy review, the facility failed, for three (3) of twenty-eight (28) Stage II sample residents, to ensure each resident's comprehensive care was was revised when changes occurred with the resident condition and/or treatment plan. Resident #23's care plan was not revised to reflect the presence of a second pressure ulcer. Resident #112's care plan was not revised to reflect changes made to her therapeutic diet. Resident #12's care plan was not revised when interventions to prevent falls / promote safety were no longer in use. Resident identifiers: #23, #112, and #12. Facility census: 112. Findings include: a) Resident #23 Medical record review, on 06/07/10, revealed Resident #23 two (2) Stage II pressure ulcers, one (1) on each buttock. A physician order, dated 06/01/10, directed staff to cleanse the area on the right buttock with sterile normal saline, apply Skin integrity to the wound, and cover with [MEDICATION NAME] foam every day, and check every shift for placement. Another physician's orders [REDACTED]. An observation of these ulcerations, on the morning of 06/10/09, found two (2) Stage II ulcerations - one (1) on the right side of the coccyx and one (1) on the left side of the coccyx; the surrounding tissue was pink, and serosanguinous drainage was seeping from the wounds. On 06/14/10 at 11:00 a.m., Resident #23 was interviewed in her room. During this interview, she reported she had pain when she sits up in the chair, especially if she sits up too long, and this was one (1) of the reasons why she did not like to get up into the chair. On 06/14/10 at 11:42 a.m., two (2) nurses (Employees #142 and #95) were interviewed at the nurses' station. They both identified the resident's family brings snacks to the facility, the resident often snacks in her room, and they have done a lot of education with the family to bring in healthy snacks. Additionally, they identified that Resident #23 does not like to get up in the chair, and these issues contributed to delays in healing for this resident. Review of the resident's care plan found the interdisciplinary team, on 12/19/06, identified Resident #23 was at risk for skin breakdown. Her care plan was updated on 06/02/10, to address the presence of an open area on the resident's right buttock. The plan was not revised to address the presence of a pressure area on the resident's left buttock. The plan addressing the wound on the right buttock identified as a goal: Resident will show significant improvement to open area on coccyx by the next review. Interventions to attain this goal included: Dress area per MD ordered, Braden scale every week times four (4), body audit per licensed nurse every day, and wound will be assessed and measured weekly. Aside from dressing the area as ordered, none of these interventions would result in attainment of the goal. Additionally, the plan was not revised to address the issues identified by the nurses (e.g., refusal to get up in a chair, eating unhealthy snacks throughout the day). b) Resident #112 A review of Resident #112's clinical record revealed the previous three (3) minimum data set assessments indicated, in Section K1, the resident had both chewing and swallowing difficulties and the resident was on altered consistency diet. A review of the physician's orders [REDACTED]. The care plan, revised on 06/01/10, stated the resident was to receive nectar liquids and it did not include interventions regarding monitoring for choking / aspiration related to her new order to receive regular, unthickened liquids. During an interview with the minimum data set (MDS) coordinators (Employees #1 and #120) at 2:45 p.m. on 06/13/10, they acknowledged Resident #112's care plan did not address the changes made to the resident's diet and consistency of liquids, and they acknowledged that the resident's information sheet (used by the nursing assistants when rendering care) had not been updated. c) Resident 12 A review of Resident #12's medical record, on 06/14/10 at 10:00 a.m., revealed the resident had not been ambulatory since at least 12/19/09, as documented on a quarterly minimum data set (MDS) of that date. However, review of her current care plan found it still contained an approach to address the potential for falls by encouraging and assisting the resident to wear proper and non-slip footwear. Also, the current care plan contained an approach for bed bolsters to reduce the potential for falls, although the use of the bed bolsters was discontinued on 04/05/10. During an interview with Employee #120 on 06/14/10 at 10:45 a.m., she confirmed these approaches were no longer appropriate for the resident and had not been removed from the resident's active care plan.",2015-11-01
9383,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2010-06-15,281,D,0,1,KN1V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record reviews, review of professional references and facility policies and procedures, and resident interview, the facility failed to meet professional standards in the administration and documentation of an ordered sliding scale insulin dose (based on blood glucose monitoring that occurred after, instead of before, a meal), failed to implement diet order changes timely, and failed to obtain a physician's order for passive range of motion (ROM) and the use of hand splints. These practices affected three (3) of twenty-eight (28) Stage II sample residents. Resident identifiers: #128, #112, and #63. Facility census: 112. Findings include: a) Resident #128 Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set assessment (MDS), with an assessment reference date (ARD) of 04/26/10, revealed the resident was moderately impaired for daily decision making, made self understood and sometimes understood others, and was dependent for activities of daily living (ADLs). Review of the annual MDS, with an ARD of 01/27/10, revealed the resident was moderately impaired for daily decision making, made self understood and sometimes understood others, and was dependent for ADLs. On 06/09/10 at 9:20 a.m., during observation of medication administration, Employee #70 (a licensed practical nurse - LPN) performed blood glucose (blood sugar) monitoring on Resident #128 by finger stick (pricking the finger with a lancet to obtain a drop of blood) using a glucometer. (A glucose meter or glucometer is a medical device for determining the approximate concentration of glucose in the blood ). The result of the blood glucose monitoring revealed the resident's blood glucose level was 300 mg/dl. Employee #70 then administered 4 units of [MEDICATION NAME](a fast acting insulin) by subcutaneous (under the skin) injection to Resident #128 in accordance with the sliding scale insulin dosage (an insulin dose ordered for a specific measured level of glucose in the blood) ordered for a glucose of 300 mg/dl. Observation in the resident's room at the time of the glucose monitoring and subsequent administration of the insulin revealed the resident had already consumed her entire breakfast meal except for a glass of milk. During an interview at the time of the medication administration (9:20 a.m.), Employee #70 indicated it was the usual procedure to conduct glucose monitoring and administer sliding scale insulin as indicated by the physician's order, which was 7:00 a.m. Employee #70 further indicated the blood glucose result was probably not the same now (after the resident had already eaten breakfast) as it would have been at 7:00 a.m. (before breakfast), the time the glucose monitoring and related sliding scale insulin was ordered to be provided. Interview with two (2) nursing assistants (Employees #9 and #78), on 06/09/10 at 1:27 p.m., revealed the breakfast trays arrived on the unit that morning at the approximate time they were due, which was 7:40 a.m., and it took approximately twenty (20) minutes to pass the trays out to the residents, which would have been 8:00 a.m. Review of the clinical record revealed a June 2010 physician's recapitulation order for FSBS (finger stick blood sugar) four (4) times daily with [MEDICATION NAME] per SSC (sliding scale coverage) for DM (diabetes mellitus). The times for testing the blood glucose and administering the indicated sliding scale insulin doses were listed as 7:00 a.m., 11:00 a.m., 4:00 p.m., and 8:00 p.m. The sliding scale insulin to be administered to Resident #128 for a blood glucose result of 251 - 300 mg/dl was indicated as 4 units of [MEDICATION NAME] Insulin 100 units/ml. Review of the resident's June 2010 Medication Administration Record [REDACTED]300, unit 4U, site 4. There was no indication on the MAR indicated [REDACTED] Review of the nurse's note, dated 06/09/10 at 12:30 p.m., revealed the physician was notified that the F/S (finger stick) not obtained at time as ordered. The note did not indicate that the physician was informed the sliding scale insulin was administered based on a blood glucose level measured after the resident had consumed a meal. During an interview on 06/09/10 at 1:50 p.m., the director of care delivery (Employee #48) stated the facility did not have a policy specific to administering sliding scale insulin for a blood glucose taken after eating a meal. The expectation was to follow the doctor's order for testing glucose and administering insulin coverage. Employee #48 further stated the nurse should have called the doctor. Employee #48 also stated that the professional reference for administration of medication used by the facility was the 2010 Mosby's Nursing Drug Reference. Review of the 2010 Mosby's Nursing Drug Reference revealed that [MEDICATION NAME]is a rapid acting insulin to be given just prior to a meal. Review of the Novo [MEDICATION NAME] Incorporated manufacturer's medication information (package insert) for [MEDICATION NAME]revealed, [DIAGNOSES REDACTED] may occur as a result of an excess of insulin relative to food intake . Review of the Omnicare, Incorporated Long Term Care (LTC) Center's Pharmacy Policy and Procedure Manual Policy 6.0 titled General Dose Preparation and Medication Administration (dated 12/01/07) revealed the following: Procedure 3 - Prior to Medication Administration: 3.1 - Facility Staff should verify each time a medication is administered that it is the correct drug, at the correct dose, the correct route, at the correct rate, at the correct time, for the correct resident. Review of the facility policy titled Glucose Monitoring (also Finger Stick Blood Sugar) found Procedure 1 - Verify Physician's order. Review of the facility policy titled Medication Management Guidelines: 'Six Rights' Plus One (1) of Medication Administration indicated the following: Purpose: To provide a guideline for the safe and accurate administration of medications. Right Dose - Use a double check system with two clinicians prior to the administration of certain high-alert medication such as [MEDICATION NAME], insulin or chemotherapeutic agents. Right Time - . Be aware of administration timing relative to meals, concurrent medications or other recommendations using the manufacturer's package insert, standards of practice or discussion with the consultant pharmacist. Right Documentation - Document medication administration using the MAR. Document medication administration after the patient receives the medication. Provide additional information regarding medication administration in the progress notes if needed. b) Resident #112 A review of Resident #112's clinical record revealed a physician's order, written on 06/01/10, changing the diet consistency from Pureed CHO (carbohydrate) Controlled, Nectar-like thick liquid to Mech/soft (mechanical soft) CHO Controlled with regular liquids. The older diet was on the list of resident diet orders provided by dietary staff to the surveyors on 06/07/10, which identified it as the current diet order being served to this resident. During an interview with the speech language pathologist (SLP - Employee #110) at 9:30 a.m. on 06/10/10, she stated she had requested an order changing the consistency of the resident's diet after evaluating her swallowing ability, and that the new order had been received on 06/01/10. The resident was observed at 1:00 p.m. on 06/07/10, feeding herself while sitting in her wheelchair. Her meal was entirely pureed, served in separate bowls, and accompanied by thickened liquids. During an interview with a nursing assistant (Employee #23) at 11:00 a.m. on 06/09/10, she stated the resident still received thickened liquids but she had no difficulty swallowing the regular liquids brought in by her family. Employee #23 stated that, a lot of the time, the resident would turn her nose up when offered the pureed foods. At the noon meal on 06/10/10, the resident was observed in the dining room. The meal she received was mechanical soft with only the meat pureed, and the liquids were of regular consistency. The SLP was observing as Resident #112 self-fed her meal. During an interview with the minimum data set (MDS) coordinator (Employee #120) at 2:45 p.m. on 06/13/10, she acknowledged that, after a previous conversation regarding the resident, she had noticed the new diet order had not been sent to the kitchen, and Employee #120 had delivered it the the kitchen herself on the morning of 06/10/10. c) Resident #63 An observation of the resident, on 06/09/10 at 11:00 a.m., revealed the resident was contracted in all extremities. Record review revealed the resident's diagnoses, on admission to the facility on [DATE], included ALS. Physical Therapy evaluated the resident on 1-15-10 and determined to require bilateral quad sensory Resident wears splints up to two hours a day. Physical Therapy was discontinued on 2/26/10 related to resident having a [MEDICAL CONDITION] disease causing paralysis progressively. Recommendations were made by the physical therapist for splints for 2-4 hrs a day to decrease further deterioration of contractures. Passive range of motion for extremities for the rest of her life to prevent further contractures. A review of the physician's orders found no orders for the passive ROM to all extremities or for the use of hand splints. An interview with a registered nurse (RN - Employee #142), on 06/09/10 at 11:00 a.m., revealed the resident would ask for splints to be placed on her hands usually everyday. She confirmed no physician orders were written for Resident #63 to use hand splints or to receive passive ROM. The resident came into the facility with the contractures, they had not changed, and she was no receiving passive ROM. She stated the facility no longer had restorative nursing assistants; the other nursing assistants were to assume the duties of providing restorative nursing services, and several residents in the facility continued to receive ROM as ordered. Interview with resident, on 06/09/10 at 2:10 p.m., revealed she asked for hand splints every day.",2015-11-01
9384,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2010-06-15,309,D,0,1,KN1V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, clinical record reviews, review of facility policies and procedures, and resident interview, the facility failed to follow the physician's order for blood glucose monitoring and the related administration of sliding scale insulin, and failed to provide for effective pain management, for two (2) of twenty-eight (28) Stage II sample residents. Resident identifiers: #128 and #23. Facility census: 112. Findings include: a) Resident #128 Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set assessment (MDS), with an assessment reference date (ARD) of 04/26/10, revealed the resident was moderately impaired for daily decision making, made self understood and sometimes understood others, and was dependent for activities of daily living (ADLs). Review of the annual MDS, with an ARD of 01/27/10, revealed the resident was moderately impaired for daily decision making, made self understood and sometimes understood others, and was dependent for ADLs. On 06/09/10 at 9:20 a.m., during observation of medication administration, Employee #70 (a licensed practical nurse - LPN) performed blood glucose (blood sugar) monitoring on Resident #128 by finger stick (pricking the finger with a lancet to obtain a drop of blood) using a glucometer. (A glucose meter or glucometer is a medical device for determining the approximate concentration of glucose in the blood ). The result of the blood glucose monitoring revealed the resident's blood glucose level was 300 mg/dl. Employee #70 then administered 4 units of [MEDICATION NAME](a fast acting insulin) by subcutaneous (under the skin) injection to Resident #128 in accordance with the sliding scale insulin dosage (an insulin dose ordered for a specific measured level of glucose in the blood) ordered for a glucose of 300 mg/dl. Observation in the resident's room at the time of the glucose monitoring and subsequent administration of the insulin revealed the resident had already consumed her entire breakfast meal except for a glass of milk. During an interview at the time of the medication administration (9:20 a.m.), Employee #70 indicated it was the usual procedure to conduct glucose monitoring and administer sliding scale insulin as indicated by the physician's order, which was 7:00 a.m. Employee #70 further indicated the blood glucose result was probably not the same now (after the resident had already eaten breakfast) as it would have been at 7:00 a.m. (before breakfast), the time the glucose monitoring and related sliding scale insulin was ordered to be provided. Interview with two (2) nursing assistants (Employees #9 and #78), on 06/09/10 at 1:27 p.m., revealed the breakfast trays arrived on the unit that morning at the approximate time they were due, which was 7:40 a.m., and it took approximately twenty (20) minutes to pass the trays out to the residents, which would have been 8:00 a.m. Review of the clinical record revealed a June 2010 physician's recapitulation order for FSBS (finger stick blood sugar) four (4) times daily with [MEDICATION NAME] per SSC (sliding scale coverage) for DM (diabetes mellitus). The times for testing the blood glucose and administering the indicated sliding scale insulin doses were listed as 7:00 a.m., 11:00 a.m., 4:00 p.m., and 8:00 p.m. The sliding scale insulin to be administered to Resident #128 for a blood glucose result of 251 - 300 mg/dl was indicated as 4 units of [MEDICATION NAME] Insulin 100 units/ml. Review of the resident's June 2010 Medication Administration Record [REDACTED]300, unit 4U, site 4. There was no indication on the MAR indicated [REDACTED] Review of the nurse's note, dated 06/09/10 at 12:30 p.m., revealed the physician was notified that the F/S (finger stick) not obtained at time as ordered. The note did not indicate that the physician was informed the sliding scale insulin was administered based on a blood glucose level measured after the resident had consumed a meal. Review of the Novo [MEDICATION NAME] Incorporated manufacturer's medication information (package insert) for [MEDICATION NAME]revealed, [DIAGNOSES REDACTED] may occur as a result of an excess of insulin relative to food intake . Review of the Omnicare, Incorporated Long Term Care (LTC) Center's Pharmacy Policy and Procedure Manual Policy 6.0 titled General Dose Preparation and Medication Administration (dated 12/01/07) revealed the following: Procedure 3 - Prior to Medication Administration: 3.1 - Facility Staff should verify each time a medication is administered that it is the correct drug, at the correct dose, the correct route, at the correct rate, at the correct time, for the correct resident. Review of the facility policy titled Glucose Monitoring (also Finger Stick Blood Sugar) found Procedure 1 - Verify Physician's order. Review of the facility policy titled Medication Management Guidelines: 'Six Rights' Plus One (1) of Medication Administration indicated the following: Purpose: To provide a guideline for the safe and accurate administration of medications. Right Dose - Use a double check system with two clinicians prior to the administration of certain high-alert medication such as [MEDICATION NAME], insulin or chemotherapeutic agents. Right Time - . Be aware of administration timing relative to meals, concurrent medications or other recommendations using the manufacturer's package insert, standards of practice or discussion with the consultant pharmacist. Right Documentation - Document medication administration using the MAR. Document medication administration after the patient receives the medication. Provide additional information regarding medication administration in the progress notes if needed. During an interview on 06/09/10 at 1:50 p.m., the director of care delivery (Employee #48) stated the facility did not have a policy specific to administering sliding scale insulin for a blood glucose taken after eating a meal. The expectation was to follow the doctor's order for testing glucose and administering insulin coverage. Employee #48 further stated the nurse should have called the doctor. -- b) Resident #23 Medical record review, completed on 06/09/10, revealed Resident #23 had two (2) Stage II pressure ulcers on her coccyx. Nurses notes on 06/07/10 indicated the ulcer on the right side measured 3 cm x 1 cm and the ulcer on the left side measured 1 cm x 5 cm. Documentation also noted this resident often refused to get up in the chair. An observation of these ulcerations, on the morning of 06/10/09, found two (2) Stage II ulcerations - one (1) on the right side of the coccyx and one (1) on the left side of the coccyx; the surrounding tissue was pink, and serosanguinous drainage was seeping from the wounds. On 06/14/10 at 11:00 a.m., Resident #23 was interviewed in her room. During this interview, she reported she had pain when she sits up in the chair, especially if she sits up too long, and this was one (1) of the reasons why she did not like to get up into the chair. On 06/14/10 at 11:42 a.m., interview with the registered nurse (RN) supervisor (Employee #142) revealed Resident #23 had an order for [REDACTED].#142 said she would contact the physician today concerning this matter. Record review, on 06/15/10, found the physician increased the frequency of Resident #23's Tylenol #3 from two (2) times a day to three (3) times a day on 06/14/10, with scheduled doses at 8:00 a.m., 2:00 p.m., and 8:00 p.m.",2015-11-01
9385,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2010-06-15,318,D,0,1,KN1V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and resident interview, the facility failed to ensure one (1) of twenty-eight (28) Stage II sample residents received range of motion (ROM) for severe contractures. Resident #63 has a [DIAGNOSES REDACTED]. Facility census 112. Findings include: a) Resident #63 An observation of the resident, on 06/09/10 at 11:00 a.m., revealed the resident was contracted in all extremities. Record review revealed the resident's diagnoses, on admission to the facility on [DATE], included ALS. review of the resident's medical record revealed [REDACTED]. Resident wears splints up to two hours a day. PT was discontinued related to resident having a [MEDICAL CONDITION] disease causing paralysis progressively. Splints for 2-4 hrs a day to decrease further deterioration of contractures. Passive range of motion for extremities for the rest of her life to prevent further contractures. A review of the physician's orders found no orders for the passive ROM to all extremities or for the use of hand splints. An interview with a registered nurse (RN - Employee #142), on 06/09/10 at 11:00 a.m., revealed the resident would ask for splints to be placed on her hands usually everyday. She confirmed no physician orders were written for Resident #63 to use hand splints or to receive passive ROM. The resident came into the facility with the contractures, they had not changed, and she was no receiving passive ROM. She stated the facility no longer had restorative nursing assistants; the other nursing assistants were to assume the duties of providing restorative nursing services, and several residents in the facility continued to receive ROM as ordered. Interview with resident, on 06/09/10 at 2:10 p.m., revealed she asked for hand splints every day.",2015-11-01
9386,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2010-06-15,329,D,0,1,KN1V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the medication regimen of one (1) of twenty-eight (28) Stage II sample residents was free of unnecessary medication. Resident #63 received an order on admission to the facility for a [MEDICAL CONDITION] medication ([MEDICATION NAME] 0.5 mg) to be administered as needed. Review of the medical record found no documented indications for the use of this medication when it was administered on 02/02/10 and 06/02/10. Facility census: 112. Findings include: a) Resident #63 A review of Resident #63's physician's orders [REDACTED]. ([MEDICATION NAME] is used for anxiety.) These orders were received on the admission date of [DATE]. A review of the resident's February 2010 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A review of nursing notes for 02/02/10 also did not reveal the reason for the medication. On 06/02/10, the resident again received [MEDICATION NAME] 0.5 mg without any documented justification for its use. Behavior monitoring records indicated the resident was ordered [MEDICATION NAME] 0.5 mg as needed twice daily for anxiety attacks. Beginning on 01/15/10 and continuing to 06/10/10, the resident did not have any behaviors documented. An interview with a registered nurse (RN) supervisor (Employee #142), on 06/10/10 at 9:05 a.m., revealed the resident only received the [MEDICATION NAME] on 02/02/10 and 06/02/10. She came in from the hospital on [DATE], and the order came with the resident from the hospital. The RN stated this was something they should discontinue, because they were really not using the medication; it was given only twice since admission. An interview with the director of nursing (DON), on 06/10/10 at 10:40 a.m., revealed staff was told the resident needed to be given time to decide about her care and other things. She can get anxious at times, but if you talk with her and go slowly, this will work. The [MEDICATION NAME] is something that we can discontinue, because she is on [MEDICATION NAME] and it seems to be helping the resident.",2015-11-01
9387,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2010-06-15,333,D,0,1,KN1V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, clinical record review, and review of professional references and facility policies and procedures, the facility failed to ensure appropriate and timely administration of sliding scale insulin. The nurse administered fast-acting insulin based on a blood glucose measurement taken two and one-half (2-1/2) hours after the time it was ordered by the physician and after the resident had consumed a meal. This practice affected one (1) of twenty-eight (28) Stage II sample residents. Resident identifier: #128. Facility census: 112. Findings include: a) Resident #128 Resident #128 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set assessment (MDS), with an assessment reference date (ARD) of 04/26/10, revealed the resident was moderately impaired for daily decision making, made self understood and sometimes understood others, and was dependent for activities of daily living (ADLs). Review of the annual MDS, with an ARD of 01/27/10, revealed the resident was moderately impaired for daily decision making, made self understood and sometimes understood others, and was dependent for ADLs. On 06/09/10 at 9:20 a.m., during observation of medication administration, Employee #70 (a licensed practical nurse - LPN) performed blood glucose (blood sugar) monitoring on Resident #128 by finger stick (pricking the finger with a lancet to obtain a drop of blood) using a glucometer. (A glucose meter or glucometer is a medical device for determining the approximate concentration of glucose in the blood ). The result of the blood glucose monitoring revealed the resident's blood glucose level was 300 mg/dl. Employee #70 then administered 4 units of [MEDICATION NAME](a fast acting insulin) by subcutaneous (under the skin) injection to Resident #128 in accordance with the sliding scale insulin dosage (an insulin dose ordered for a specific measured level of glucose in the blood) ordered for a glucose of 300 mg/dl. Observation in the resident's room at the time of the glucose monitoring and subsequent administration of the insulin revealed the resident had already consumed her entire breakfast meal except for a glass of milk. During an interview at the time of the medication administration (9:20 a.m.), Employee #70 indicated it was the usual procedure to conduct glucose monitoring and administer sliding scale insulin as indicated by the physician's order, which was 7:00 a.m. Employee #70 further indicated the blood glucose result was probably not the same now (after the resident had already eaten breakfast) as it would have been at 7:00 a.m. (before breakfast), the time the glucose monitoring and related sliding scale insulin was ordered to be provided. Interview with two (2) nursing assistants (Employees #9 and #78), on 06/09/10 at 1:27 p.m., revealed the breakfast trays arrived on the unit that morning at the approximate time they were due, which was 7:40 a.m., and it took approximately twenty (20) minutes to pass the trays out to the residents, which would have been 8:00 a.m. Review of the clinical record revealed a June 2010 physician's recapitulation order for FSBS (finger stick blood sugar) four (4) times daily with [MEDICATION NAME] per SSC (sliding scale coverage) for DM (diabetes mellitus). The times for testing the blood glucose and administering the indicated sliding scale insulin doses were listed as 7:00 a.m., 11:00 a.m., 4:00 p.m., and 8:00 p.m. The sliding scale insulin to be administered to Resident #128 for a blood glucose result of 251 - 300 mg/dl was indicated as 4 units of [MEDICATION NAME] Insulin 100 units/ml. Review of the resident's June 2010 Medication Administration Record [REDACTED]300, unit 4U, site 4. There was no indication on the MAR indicated [REDACTED] Review of the nurse's note, dated 06/09/10 at 12:30 p.m., revealed the physician was notified that the F/S (finger stick) not obtained at time as ordered. The note did not indicate that the physician was informed the sliding scale insulin was administered based on a blood glucose level measured after the resident had consumed a meal. During an interview on 06/09/10 at 1:50 p.m., the director of care delivery (Employee #48) stated the facility did not have a policy specific to administering sliding scale insulin for a blood glucose taken after eating a meal. The expectation was to follow the doctor's order for testing glucose and administering insulin coverage. Employee #48 further stated the nurse should have called the doctor. Employee #48 also stated that the professional reference for administration of medication used by the facility was the 2010 Mosby's Nursing Drug Reference. Review of the 2010 Mosby's Nursing Drug Reference revealed that [MEDICATION NAME]is a rapid acting insulin to be given just prior to a meal. Review of the Novo [MEDICATION NAME] Incorporated manufacturer's medication information (package insert) for [MEDICATION NAME]revealed, [DIAGNOSES REDACTED] may occur as a result of an excess of insulin relative to food intake . Review of the Omnicare, Incorporated Long Term Care (LTC) Center's Pharmacy Policy and Procedure Manual Policy 6.0 titled General Dose Preparation and Medication Administration (dated 12/01/07) revealed the following: Procedure 3 - Prior to Medication Administration: 3.1 - Facility Staff should verify each time a medication is administered that it is the correct drug, at the correct dose, the correct route, at the correct rate, at the correct time, for the correct resident. Review of the facility policy titled Glucose Monitoring (also Finger Stick Blood Sugar) found Procedure 1 - Verify Physician's order. Review of the facility policy titled Medication Management Guidelines: 'Six Rights' Plus One (1) of Medication Administration indicated the following: Purpose: To provide a guideline for the safe and accurate administration of medications. Right Dose - Use a double check system with two clinicians prior to the administration of certain high-alert medication such as [MEDICATION NAME], insulin or chemotherapeutic agents. Right Time - . Be aware of administration timing relative to meals, concurrent medications or other recommendations using the manufacturer's package insert, standards of practice or discussion with the consultant pharmacist. Right Documentation - Document medication administration using the MAR. Document medication administration after the patient receives the medication. Provide additional information regarding medication administration in the progress notes if needed.",2015-11-01
9388,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2010-06-15,428,D,0,1,KN1V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) resident of twenty-eight (28) Stage II sample residents received a review of an as needed psychoactive medication ordered without adequate indications for use. Resident #63 was ordered a psychotropic medication (Ativan 0.5 mg) to be administered as needed. The resident received two (2) doses of the medication without evidence of any indication for its, and there was no evidence this was identified as an irregularity by the consultant pharmacist. Facility census: 112. Findings include: a) Resident #63 A review of Resident #63's physician's orders [REDACTED]. (Buspar is used for anxiety.) These orders were received on the admission date of [DATE]. A review of the resident's February 2010 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A review of nursing notes for 02/02/10 also did not reveal the reason for the medication. On 06/02/10, the resident again received Ativan 0.5 mg without any documented justification for its use. Behavior monitoring records indicated the resident was ordered Ativan 0.5 mg as needed twice daily for anxiety attacks. Beginning on 01/15/10 and continuing to 06/10/10, the resident did not have any behaviors documented. An interview with a registered nurse (RN) supervisor (Employee #142), on 06/10/10 at 9:05 a.m., revealed the resident only received the Ativan on 02/02/10 and 06/02/10. She came in from the hospital on [DATE], and the order came with the resident from the hospital. The RN stated this was something they should discontinue, because they were really not using the medication; it was given only twice since admission. An interview with the director of nursing (DON), on 06/10/10 at 10:40 a.m., revealed staff was told the resident needed to be given time to decide about her care and other things. She can get anxious at times, but if you talk with her and go slowly, this will work. The Ativan is something that we can discontinue, because she is on Buspar and it seems to be helping the resident. Another interview with the DON, 06/10/10 at 2:00 p.m., revealed she could not find any information from the pharmacist concerning any irregularities with the Ativan.",2015-11-01
9933,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-06-15,387,D,0,1,85AT12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure the attending physician, for one (1) of thirteen (13) residents reviewed, completed visits to the resident every thirty (30) days for the first ninety (90) days following admission as required. Resident identifier: #68. Facility census: 105. Findings include: a) Resident #68 When reviewed on 06/15/10, the medical record for Resident #68 disclosed the resident had been admitted to the facility on [DATE]. Further review found no evidence the resident had been seen by her attending physician since that time. The facility's administrator, when interviewed on 06/15/10 at 3:15 p.m., could provide no evidence to reflect the resident had been seen by her attending physician since the time of his admission to the facility on [DATE].",2015-08-01
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
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
9940,WELLSBURG CENTER LLC,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2010-07-08,253,E,0,1,GJYW11,". Based on observations and staff interview, the facility failed to ensure wooden furniture located in the dining room and by the nursing station was in good repair and able to sanitized between uses by residents. This had the potential to affect any residents who utilized the wooden chairs, tables, and hutch in these locations. Facility census: 47. Findings include: a) Observations, during the noon meal on 06/28/10, found the wooden chairs and tables in the dining room and the wooden chairs located near the nursing station to be nicked / chipped and with the finish worn off the chairs. The hutch located in the dining room was also nicked and chipped on the shelves, doors, and corners with the finish worn off. The worn-off finish revealed raw wood that could not be effectively sanitized between resident use. On 06/30/10 beginning at 10:00 a.m., observations of the furniture were made with the maintenance director. At this time, the maintenance director reported that about eight (8) of the chairs were refinished each year by the maintenance staff at the facility. He agreed the furniture was nicked, chipped, and the finish was worn off, as had been noted by the surveyor. .",2015-08-01
9941,WELLSBURG CENTER LLC,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2010-07-08,323,E,0,1,GJYW11,". Based on observation and staff interview, the facility failed to secure a cabinet containing various soaps, disinfectants, and hair and shaving products from unauthorized access by cognitively impaired residents who might wander into the shower room on the second floor. This had the potential to affect four (4) such residents who were identified by the director of nursing (DON). Resident identifiers: #4, #18, #41, and #58. Facility census: 47. Findings include: a) Observation of the shower room on the second floor, with a nursing assistant (Employee #37) on 06/30/10 at 10:30 a.m., found the door to the shower room was left open. Upon entry, observation found no staff member was present. The cabinet that housed shampoos and bathing soaps, shaving supplies, deodorants, and a jug of germicide was unlocked, and its contents could be accessed by any cognitively resident who happened to wander into the shower room. On 06/30/10 at 1:00 p.m., the DON and the maintenance director reported that a lock was placed on the cabinet. The DON, when asked, identified four (4) residents with cognitive impairment and the propensity to wander (Residents #4, #18, #41, and #58). .",2015-08-01
9942,WELLSBURG CENTER LLC,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2010-07-08,241,D,0,1,GJYW11,". Based on observation and staff interview, the facility failed to ensure residents who were eating in the dining room were able to complete their meals without staff removing dishes and tablecloths from adjacent tables. Resident #6 was still eating while a staff member put a foot on an adjacent chair, tied her shoe, and then loudly scooted the chair back into position, causing the resident to become startled by the loud noise the chair made. This practice affected four (4) residents who remained eating in the dining room after 1:00 p.m. on 06/28/10. Residents identifier: #6, #18, and #38 and one (1) unidentified resident. Facility census: 49 Findings include: a) Residents #6, #18, and #38 During the noon meal at 12:35 p.m. on 06/28/10, observations found thirty-five (35) residents in the dining room with seven (7) staff members present. At 1:00 p.m., four (4) residents remained in the dining room as nursing staff began removing food trays. A nursing assistant (NA - Employee #55) removed dishes from the same table occupied by Residents #6 and #38, who were still eating. An unidentified nursing staff member removed dishes and tablecloths from tables adjacent to Resident #18 while she was still eating. Another NA (Employee #33) put her foot on the chair located next to Resident #6 (who was eating); Employee #33 tied her shoe, stood up, and then shoved the chair back under the table, making a loud screeching noise. Observation noted Resident #6 was startled by this noise. During an interview on 07/08/10 at 8:15 a.m., the director of nursing reported the staff was trying to hurry in order to get all their tasks completed in the dining room before returning to care for the residents on the floor. .",2015-08-01
9943,WELLSBURG CENTER LLC,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2010-07-08,520,J,0,1,GJYW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, staff interview, facility policy review, the facility's quality assessment and assurance (QAA) committee failed to identify quality deficiencies - of which it should have been aware - that were reflective of system failures in the area of medication administration, and failed to develop and implement appropriate plans of action to correct these quality deficiencies. Two (2) of twenty-three (23) Stage II sample residents (#79 and #36), who were recently admitted to the facility, were receiving medications from medicine bottles brought from home. Review of the medical records for Residents #79 and #36 found no evidence these home medications had been examined by a physician or pharmacist prior to administration to the residents in accordance with facility policy, to verify the contents of the bottles (right drug) and to verify the labels on the bottles matched the current physician's orders [REDACTED]. Members of the facility ' s QAA committee, including the director of nursing (DON) and the pharmacist, were aware of the practice of administering to newly admitted residents medications they had brought from home. When interviewed, the pharmacist stated he ""usually"" reviewed these home medications with a nurse over the phone, because coming to the facility each time to personally check them would ""be a hardship"", although he had no documentation that this telephone review was done for Residents #79 and #36. He further offered his opinion that using medications brought from home was not an ideal practice, because ""... You didn't know where they had been stored or that pills in the bottle were the correct ones."" He agreed the label on the medicine bottles did not always match the physician's orders [REDACTED]. The QAA committee should have been aware of this quality deficiency and should have developed and implemented a corrective plan of action to ensure residents could safely use medications brought from home. This failure placed two (2) of twenty-three (23) Stage II sample residents (#79 and #36) at immediate risk for serious harm related to the potential to receive medications the identity of which had not been verified and for which the dispensing instructions on the labels were inconsistent with current physician's orders [REDACTED]. After removal of the immediate jeopardy, the potential for more than minimal harm continued to exist for newly admitted residents until the facility corrected its system related to verifying medications (and their dispensing instructions) brought from home. Facility census: 49. Findings include: a) Resident #79 During medication pass at 8:50 a.m. on 06/30/10, observation found the nurse (Employee #73) pouring medications for Resident #79 from brown medicine bottles, not from the bubble packs used for the other residents. When questioned, Employee #73 stated it was facility practice to use up any medications brought in from a resident's home before ordering them from the facility's vendor pharmacy. This practice was verified by two (2) other nurses on the floor (Employees #48 and #57). Examination of the brown medicine bottles for Resident #79 found the labels on the bottles did not always correlate with the resident's current physician's orders [REDACTED]. 1. The dispensing instruction on the label read, ""[MEDICATION NAME] (a stool softener) 100 mg by mouth twice daily."" According to the physician's orders [REDACTED]."" 2. The dispensing instruction on the label read, ""[MEDICATION NAME] (a gastric-acid pump inhibitor used to treat reflux) DR (Delayed Release) 20 mg by mouth daily."" According to the physician's orders [REDACTED]. 3. The dispensing instruction on the label read, ""[MEDICATION NAME] (a glucocorticosteroid) 4 mg ? tab twice daily."" According to the physician's orders [REDACTED]."" [MEDICATION NAME] 2 mg was administered correctly, but this required the nurse to break a 4 mg tablet in half. The nurse commented that she would be glad when the pills were gone, so they would no longer have to break the pills each time. Further record review revealed Resident #79 was admitted to the facility on [DATE]. -- b) Resident #36 During medication pass at 8:59 a.m. on 06/30/10, observation found Employee #73 pouring medications for Resident #36 from brown medicine bottles, not from the bubble packs used for the other residents. Employee #73 confirmed these brown medicine bottles were brought from Resident #36's home. The label on the brown medicine bottle for Resident #36 included the instructions: ""[MEDICATION NAME] 25 mg by mouth twice daily."" According to the physician's orders [REDACTED]. Further record review revealed Resident #36 was admitted to the facility on [DATE]. -- c) The DON, when asked about this practice during an interview at 10:00 a.m. on 06/30/10, verified that home medications were administered to residents but that a nurse always verified them with the physician. A copy of the facility's current pharmacy policy and procedure manual was requested at that time. -- d) During a telephone interview with the facility's consultant pharmacist at 11:15 a.m. on 06/30/10, he acknowledged he was aware the facility used medications brought by new residents from home on admission to the facility until they were gone. He added that, at times, payment was refused when a prescription had recently been filled and a resident was on Medicare Part D. He stated he ""usually"" reviewed them with a nurse over the phone, because coming to the facility each time to personally check them would ""be a hardship"", although he had no documentation that this telephone review was done for Residents #79 and #36. He further offered his opinion that using medications brought from home was not an ideal practice, because ""... You didn't know where they had been stored or that pills in the bottle were the correct ones."" He agreed the label on the medicine bottles did not always match the physician's orders [REDACTED]. When asked if there were a policy for the use of medications brought from home, he stated he knew of none. -- e) Two (2) hours after the initial request was made, at about 12:00 p.m. on 06/30/10, the DON produced the facility's pharmacy policy and procedure manual for review by the survey team. A review of the manual failed to disclose any evidence to reflect the facility's governing body or duly-appointed designee had initially reviewed, approved, and adopted the manual; at the bottom of each page of the manual was ""Effective Date: _______"" with no date entered in the blank provided. There was no evidence, after a review of the entire manual, to reflect its contents had been periodically revised and revised (as needed) since it was provided to the facility on [DATE], to ensure it was reflective of current standards of professional practice. On pages 4 and 5 of the manual under ""2. Provider Pharmacy - Requirements"", ""d. The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to ... 7) Performing an initial medication use assessment for each new residents to ensure that the medication regimen meets the resident's needs."" On page 37 under ""12. Medications Brought to Facility by Resident or Family Member"", ""Policy: Medications brought into the facility by a resident or family member are used only upon written order by the resident's attending physician, after the contents are verified, and if the packaging meets the facility's guidelines. Other unauthorized medications are not accepted by the facility."" -- f) Review of the medical records for Residents #79 and #36 which found no evidence these home medications had been examined by a physician or pharmacist prior to administration to the residents, to verify the contents matched the labels on the bottles. Additionally, there were no orders from the physician authorizing the administration of these home medications, and there were no notations on the residents' MARs to indicate that medications brought from home were to be administered. The survey team determined these practices placed both Residents #36 and #79 in immediate jeopardy, due to the potential for medication errors associated with administering medications without verification by a qualified health care professional that the contents of these medicine bottles matched the labels on the bottles and the current physician's orders [REDACTED]. The administrator and the DON were notified of the finding of immediate jeopardy at 1:55 p.m. on 06/30/10. -- g) Review of the contents of the facility's medication carts (to determine what additional home medications were available for administration to residents), in the presence of two (2) facility nurses (Employee #73 and #48) beginning at 2:00 p.m. on 06/30/10, found a total of thirteen (13) medicine bottles for Resident #79. Three (3) of the bottles were empty; three (3) medications had been discontinued but not removed from the cart, and one (1) over-the-counter medication had no label at all. This review also found five (5) medicine bottles for Resident #36, two (2) of which were empty. Employee #73 confirmed Resident #36 was receiving [MEDICATION NAME] (an antidepressant) 50 mg daily, [MEDICATION NAME] (an antihypertensive) 0.3 mg twice daily, and [MEDICATION NAME] (an antihypertensive) 50 mg daily from the medicine bottles brought from home. -- h) The DON presented a proposed plan of correction (POC) at 3:30 p.m. on 06/30/10, which stated, ""In coordination with pharmacy a policy and procedure will be written and thoroughly in-serviced to all nurses."" The DON expressed surprise when informed there already was a policy in the manual to address this. The POC was initially rejected as it did not address all aspects of the immediate jeopardy situation. A revised POC was approved at 4:05 p.m. on 06/30/10, and the immediate jeopardy situation was declared removed at 4:13 p.m., after verification by the survey team that the revised POC had been implemented, to include verification that all medications brought from home were removed from the medication carts and were no longer available for use. -- i) The DON agreed, when interviewed at 4:15 p.m. on 06/30/10, the discontinued medications should have been removed from the cart. She also acknowledged the differences between the labels on the medicine bottles from home and the current physician's orders [REDACTED]. -- j) In an interview with the pharmacist at 1:30 p.m. on 07/06/10, he stated the pharmacy manual had been provided to the facility on [DATE], and he provided a letter verifying this. The letter stated, ""Please find enclosed a (sic) updated Policy and Procedures (sic) to be reviewed for approval and placed into your manuals."" The pharmacist also stated he did not remember attending any meetings where the manual was reviewed. During an interview with the DON at 8:10 a.m. on 07/07/10, she stated she could locate no documentation of any committee review of this manual. During an interview with the administrator (who was also responsible for overseeing the facility's quality assurance activities) at 9:30 a.m. on 07/07/10, he explained the owner of the facility was, in effect, the ""governing body"" of the facility and was responsible for these functions. He stated the owner attended committee meetings periodically but not on a regularly scheduled basis. On 07/08/10 at 9:15 a.m., the administrator verified the pharmacy policy and procedure manual was not signed by the governing body to reflect review and approval of its contents. The administrator also verified the facility did not identify this area as a potential concern. At the time of exit at 10:00 a.m. on 07/08/10, no additional information was provided by the facility as evidence to the contrary.",2015-08-01
9944,WELLSBURG CENTER LLC,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2010-07-08,371,F,0,1,GJYW11,". Based on observation, staff interview, and review of manufacturer's recommendations, the facility failed to assure food was stored, prepared, distributed, and/or served under sanitary conditions. The facility's dishwasher was not functioning as designed to ensure dishware was properly cleaned and sanitized between uses; air conditioning air vents that blew across the tray line were visibly dirty; and staff entered the kitchen during tray line distribution without hair restraints and walked by tray line preparation area. These actions had the potential to affect all residents who receive nourishment from the dietary department. Facility census: 49. Findings include: a) Dishwasher Observation of the kitchen, on 06/28/10 at 10:30 a.m., revealed the dietary department had been using paper products since the dishwasher was not functioning properly. At this time, a repairman was working on the hot water booster to the dishwasher. A subsequent observation, on 07/01/10 at 10:12 a.m., found the dishwasher in use; the wash cycle lasted only thirty-two (32) seconds, and the rinse cycle lasted only five (5) seconds. Employee #42 was informed of the situation and observed the operation of the dishwasher at this time. Following five (5) wash / rinse cycles, the unit washed for forty (40) seconds and rinsed for eight (8) seconds, but the temperature of the rinse water did not reach 180 degrees Fahrenheit (F) for the entire eight (8) seconds. Review of the manufacturer's recommendations revealed the wash cycle should run for forty (40) seconds at a temperature of 150 degrees F, and the rinse cycle should run for eighteen (18) seconds at a temperature of 180 degrees F. Employee #42 said she would inform the maintenance supervisor (Employee #24). When interviewed on 07/07/10 at 10:30 a.m., Employee #24 reported a contractor had serviced the unit and he believed they forgot to check the settings once the water heater booster was replaced on the dishwasher unit. When interviewed on 07/08/10 at 9:10 a.m., the administrator (Employee #34) verified the contractor came to the facility and changed the settings on the dishwasher for it to wash and rinse for the proper lengths of time. b) Air Conditioner Vent Observation, on 07/07/10 at 10:30 a.m., found the kitchen staff was concerned that the air conditioner unit was not working properly. At this time, the thermostat on the wall read 78 degrees F, and air could be felt blowing across the food line preparation unit. Observation of the vent through which the air was blowing found it to be visibly dirty. On 07/08/10 at 9:15 a.m., Employee #34, when informed of this situation, agreed that the vent blows air across the tray line area toward the dietary manager's office. c) Staff without hair restraints On 07/07/10 at 11:42 a.m., an unidentified staff member entered the kitchen and walked completely through the kitchen, past the tray line preparation area, without a hair restraint; food was on the tray line at that time. Kitchen staff, when questioned about this, identified that staff members have offices and need to walk through the kitchen to get to their offices. When interviewed on 07/08/10 at 9:10 a.m., the administrator acknowledged the facility did not have any policies and procedures concerning staff entering the kitchen during meal preparation or service without a hair restraint. He expressed this was not a good practice and that he would probably institute a policy to restrict employees from walking through the kitchen during tray line preparation and distribution of resident meal service. .",2015-08-01
9945,WELLSBURG CENTER LLC,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2010-07-08,490,J,0,1,GJYW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, staff interview, facility policy review, the facility's governing body failed to ensure the facility was administered in an effective and efficient manner, as evidenced by the presence of system failures in the area of medication administration. On 06/28/07, the contracted vendor pharmacy provided the facility with a pharmacy policy and procedure manual. Review of the manual found no evidence it had been initially adopted, by the facility's governing body or designee, or periodically reviewed / revised thereafter to ensure the policies and procedures contained therein were consistent with current accepted standards of professional practice. Two (2) of twenty-three (23) Stage II sample residents (#79 and #36), who were recently admitted to the facility, were receiving medications from medicine bottles brought from home. Review of the medical records for Residents #79 and #36 found no evidence these home medications had been examined by a physician or pharmacist prior to administration to the residents in accordance with facility policy, to verify the contents of the bottles (right drug) and to verify the labels on the bottles matched the current physician's orders [REDACTED]. These practices placed two (2) current residents at immediate risk for serious harm related to the potential to receive medications the identity of which had not been verified and for which the dispensing instructions on the labels were inconsistent with current physician's orders [REDACTED]. After removal of the immediate jeopardy, the potential for more than minimal harm continued to exist for newly admitted residents until the facility corrected its system related to verifying medications (and their dispensing instructions) brought from home. Facility census: 49. Findings include: a) Resident #79 During medication pass at 8:50 a.m. on 06/30/10, observation found the nurse (Employee #73) pouring medications for Resident #79 from brown medicine bottles, not from the bubble packs used for the other residents. When questioned, Employee #73 stated it was facility practice to use up any medications brought in from a resident's home before ordering them from the facility's vendor pharmacy. This practice was verified by two (2) other nurses on the floor (Employees #48 and #57). Examination of the brown medicine bottles for Resident #79 found the labels on the bottles did not always correlate with the resident's current physician's orders [REDACTED]. 1. The dispensing instruction on the label read, ""[MEDICATION NAME] (a stool softener) 100 mg by mouth twice daily."" According to the physician's orders [REDACTED]."" 2. The dispensing instruction on the label read, ""[MEDICATION NAME] (a gastric-acid pump inhibitor used to treat reflux) DR (Delayed Release) 20 mg by mouth daily."" According to the physician's orders [REDACTED]. 3. The dispensing instruction on the label read, ""[MEDICATION NAME] (a glucocorticosteroid) 4 mg ? tab twice daily."" According to the physician's orders [REDACTED]."" [MEDICATION NAME] 2 mg was administered correctly, but this required the nurse to break a 4 mg tablet in half. The nurse commented that she would be glad when the pills were gone, so they would no longer have to break the pills each time. Further record review revealed Resident #79 was admitted to the facility on [DATE]. -- b) Resident #36 During medication pass at 8:59 a.m. on 06/30/10, observation found Employee #73 pouring medications for Resident #36 from brown medicine bottles, not from the bubble packs used for the other residents. Employee #73 confirmed these brown medicine bottles were brought from Resident #36's home. The label on the brown medicine bottle for Resident #36 included the instructions: ""[MEDICATION NAME] 25 mg by mouth twice daily."" According to the physician's orders [REDACTED]. Further record review revealed Resident #36 was admitted to the facility on [DATE]. -- c) The director of nurses (DON), when asked about this practice during an interview at 10:00 a.m. on 06/30/10, verified that home medications were administered to residents but that a nurse always verified them with the physician. A copy of the facility's current pharmacy policy and procedure manual was requested at that time. -- d) During a telephone interview with the facility's consultant pharmacist at 11:15 a.m. on 06/30/10, he acknowledged he was aware the facility used medications brought by new residents from home on admission to the facility until they were gone. He added that, at times, payment was refused when a prescription had recently been filled and a resident was on Medicare Part D. He stated he ""usually"" reviewed them with a nurse over the phone, because coming to the facility each time to personally check them would ""be a hardship"", although he had no documentation that this telephone review was done for Residents #79 and #36. He further offered his opinion that using medications brought from home was not an ideal practice, because ""... You didn't know where they had been stored or that pills in the bottle were the correct ones."" He agreed the label on the medicine bottles did not always match the physician's orders [REDACTED]. When asked if there were a policy for the use of medications brought from home, he stated he knew of none. -- e) Two (2) hours after the initial request was made, at about 12:00 p.m. on 06/30/10, the DON produced the facility's pharmacy policy and procedure manual for review by the survey team. A review of the manual failed to disclose any evidence to reflect the facility's governing body or duly-appointed designee had initially reviewed, approved, and adopted the manual; at the bottom of each page of the manual was ""Effective Date: _______"" with no date entered in the blank provided. There was no evidence, after a review of the entire manual, to reflect its contents had been periodically revised and revised (as needed) since it was provided to the facility on [DATE], to ensure it was reflective of current standards of professional practice. On pages 4 and 5 of the manual under ""2. Provider Pharmacy - Requirements"", ""d. The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to ... 7) Performing an initial medication use assessment for each new residents to ensure that the medication regimen meets the resident's needs."" On page 37 under ""12. Medications Brought to Facility by Resident or Family Member"", ""Policy: Medications brought into the facility by a resident or family member are used only upon written order by the resident's attending physician, after the contents are verified, and if the packaging meets the facility's guidelines. Other unauthorized medications are not accepted by the facility."" -- f) Review of the medical records for Residents #79 and #36 which found no evidence these home medications had been examined by a physician or pharmacist prior to administration to the residents, to verify the contents matched the labels on the bottles. Additionally, there were no orders from the physician authorizing the administration of these home medications, and there were no notations on the residents' MARs to indicate that medications brought from home were to be administered. The survey team determined these practices placed both Residents #36 and #79 in immediate jeopardy, due to the potential for medication errors associated with administering medications without verification by a qualified health care professional that the contents of these medicine bottles matched the labels on the bottles and the current physician's orders [REDACTED]. The administrator and the DON were notified of the finding of immediate jeopardy at 1:55 p.m. on 06/30/10. -- g) Review of the contents of the facility's medication carts (to determine what additional home medications were available for administration to residents), in the presence of two (2) facility nurses (Employee #73 and #48) beginning at 2:00 p.m. on 06/30/10, found a total of thirteen (13) medicine bottles for Resident #79. Three (3) of the bottles were empty; three (3) medications had been discontinued but not removed from the cart, and one (1) over-the-counter medication had no label at all. This review also found five (5) medicine bottles for Resident #36, two (2) of which were empty. Employee #73 confirmed Resident #36 was receiving [MEDICATION NAME] (an antidepressant) 50 mg daily, [MEDICATION NAME] (an antihypertensive) 0.3 mg twice daily, and [MEDICATION NAME] (an antihypertensive) 50 mg daily from the medicine bottles brought from home. -- h) The DON presented a proposed plan of correction (POC) at 3:30 p.m. on 06/30/10, which stated, ""In coordination with pharmacy a policy and procedure will be written and thoroughly in-serviced to all nurses."" The DON expressed surprise when informed there already was a policy in the manual to address this. The POC was initially rejected as it did not address all aspects of the immediate jeopardy situation. A revised POC was approved at 4:05 p.m. on 06/30/10, and the immediate jeopardy situation was declared removed at 4:13 p.m., after verification by the survey team that the revised POC had been implemented, to include verification that all medications brought from home were removed from the medication carts and were no longer available for use. -- i) The DON agreed, when interviewed at 4:15 p.m. on 06/30/10, the discontinued medications should have been removed from the cart. She also acknowledged the differences between the labels on the medicine bottles from home and the current physician's orders [REDACTED]. -- j) In an interview with the pharmacist at 1:30 p.m. on 07/06/10, he stated the pharmacy manual had been provided to the facility on [DATE], and he provided a letter verifying this. The letter stated, ""Please find enclosed a (sic) updated Policy and Procedures (sic) to be reviewed for approval and placed into your manuals."" The pharmacist also stated he did not remember attending any meetings where the manual was reviewed. During an interview with the DON at 8:10 a.m. on 07/07/10, she stated she could locate no documentation of any committee review of this manual. During an interview with the administrator (who was also responsible for overseeing the facility's quality assurance activities) at 9:30 a.m. on 07/07/10, he explained the owner of the facility was, in effect, the ""governing body"" of the facility and was responsible for these functions. He stated the owner attended committee meetings periodically but not on a regularly scheduled basis. On 07/08/10 at 9:15 a.m., the administrator verified the pharmacy policy and procedure manual was not signed by the governing body to reflect review and approval of its contents. On 07/08/10 at 9:15 a.m., the administrator verified the pharmacy policy and procedure manual was not signed by the governing body to reflect review and approval of its contents. The administrator also verified the facility did not identify this area as a potential concern. At the time of exit at 10:00 a.m. on 07/08/10, no additional information was provided by the facility as evidence to the contrary. .",2015-08-01
9946,WELLSBURG CENTER LLC,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2010-07-08,329,D,0,1,GJYW11,"**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 the medication regimens of three (3) residents of twenty-three (23) Stage II sample residents were free of unnecessary drugs, used in excessive dose, without adequate monitoring, without adequate indications for use, and/or in the presence of adverse consequences which indicate the dose should be reduced or discontinued. Resident identifiers: #58, #8, and #28. Facility census: 49. Findings include: a) Resident #58 Review of Resident #58's medical record revealed this [AGE] year old female was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her physician's orders [REDACTED]. 12/10/09). Review of the resident's comprehensive admission assessment, with an ARD of 12/15/09 again found the assessor noted the resident did not exhibit any indicators of depression, anxiety, and/or sad mood in the preceding thirty (30) day period. The assessor did note the resident exhibited the following behavioral symptoms during the preceding seven (7) day period: wandering (daily), verbally abusive (1-3 days), physically abusive (1-3), and resists care (1-3 days). Further record review revealed her most recent assessment was a comprehensive significant change in status assessment with an assessment reference (ARD) 03/30/10. In Section E of this assessment addressing mood and behavior patterns, the assessor noted the resident did not exhibit any indicators of depression, anxiety, and/or sad mood in the preceding thirty (30) day period and did not exhibit any behavioral symptoms in the preceding seven (7) day period. The assessor also noted the resident's behavioral symptoms had improved over the preceding ninety (90) day period. An interview with the assessment coordinator (Employee #20), on 07/01/10 at 11:00 a.m., revealed the resident had been very ill and her behaviors had decreased, but now they had increased. A review of the resident's care plan revealed, ""Behavior problems wandering daily makes her at risks for falls. Physical and verbal abuse less than daily related to dementia has shown an improvement due to a decline in her health."" - A pharmacy note, dated 03/23/10, stated, ""This patient is receiving [MEDICATION NAME] ([MEDICATION NAME]) 1 mg three times a day for anxiety. The recommended geriatric dose is 2 mg per day. Please consider a gradual dose reduction to the recommended geriatric dose."" On 04/01/10, the physician ordered: ""Discontinue all previous [MEDICATION NAME]. Begin [MEDICATION NAME] 0.5 mg twice a day at 9 AM and 5 PM due to anxiety state. [MEDICATION NAME] 1 mg at 9 PM."" A facility form ""Physicians Communication Form"", dated 04/08/10, contained a recommendation from the pharmacist to the physician to decrease the total daily dosage of [MEDICATION NAME] from 3 mg to 2.5 mg and to continue with the gradual dose reduction to 2 mg, noting that the maximum daily dose of [MEDICATION NAME] recommended for the elderly was 2 mg daily. The physician's response was: ""See progress note."" A physician's progress note, dated 04/13/10, stated, ""Continue [MEDICATION NAME] as some increase in aggression noted recently."" Nursing notes from 04/02/10 to 04/21/10 reflected no behavior problems exhibited by the resident. - On 04/21/10 at 3:45 a.m., a nursing note indicated, ""Resident has been awake all night, chooses not to go to bed. Up out of wheelchair without assistance multiple times. 1:1 (one-on-one intervention) effective for short intervals."" At 4:50 a.m. on 04/21/10, a nursing note indicated, ""In front of nursing station, stood and fell hitting head on left side. Neuro checks recorded, denies pain. No injuries from previous fall, slept all night."" On 04/25/10 at 3:00 p.m., a nursing note revealed, ""Resident sitting in wheelchair at nurse's station (sic) alarm to chair went off. Observed resident stand and then sit on floor. No injuries."" On 04/26/10 at 3:10 a.m., a nursing note indicated, ""Resident awake until 2:45 a.m. (sic) was highly agitated for a short time, yelling and cursing at staff very loudly. Was about to administer PRN (as needed) [MEDICATION NAME] when resident calmed down and fell asleep in her wheelchair. Resident awakened and began to yell again. The resident became calmer after a short time. "" On 04/28/10 at 3:30 a.m., a nursing note stated, ""Resident sitting in wheelchair at nurse's station refusing to go to bed (sic) delusions that she needs to go home. 1:1 ineffective."" At 1:30 p.m. on 04/28/10, a nursing note stated, ""Discussed with physician verbal aggression continues today, unable to get along with other residents. Increased ambulation in hallways independently, yelling at others for no apparent reason. Physician order [REDACTED]."" On 04/28/10, the physician increased the [MEDICATION NAME] to 1 mg three (3) times a day, for a total daily dose of 3 mg. - An interview with the clinical care coordinator, on 07/06/10 at 10:05 a.m., revealed the resident's behaviors were better today. The resident was able to ambulate but leaned forward and her gait was unsteady. She was very tired a lot and needed to be reminded to use her walker. ""If you remind her to use the walker, she will get agitated easily."" An interview with a nurse (Employee #53), on 07/06/10 at 10:15 a.m., revealed [MEDICATION NAME] is used when the resident becomes agitated, and this is the only thing that will calm her down. Employee #53 also noted, due to the amount of psychoactive medication she was taking, the resident was a falls risk and she had had falls in the past. In addition to the routine doses of [MEDICATION NAME] and [MEDICATION NAME], a review of the resident's medication administration records (MARs) found she received [MEDICATION NAME] 2 mg IM injections on 02/01/10, 02/02/10, 02/03/10, 05/01/10, 05/02/10, and 06/26/10. A review of the facility's accident / incident reports for April, May, and June 2010 revealed that the resident had seven (7) falls during this time period. The resident did not sustain injuries. - An interview with the staff development nurse (Employee #57), on 07/06/10 at 10:45 a.m., revealed the behavior management system was broken. Staff was not documenting what the resident was actually doing in the medical record. She further stated the physician had done a lot that also was not documented. She stated she documented interventions in the nursing notes and not in the care plan. At 10:48 a.m., the director of nursing (DON) came into the interview and agreed with Employee #57. - An interview with the pharmacy consultant, on 07/06/10 at 1:30 p.m., revealed the [MEDICATION NAME] 2 mg PRN injection was not suitable unless the resident was a hospice patient. The pharmacy consultant stated he should have written a recommendation to address the use of [MEDICATION NAME] PRN. He further stated this was a drug that you would not want the nurse using their discretion to administer. - An interview with the DON, on 07/08/10 at 10:00 a.m., revealed the resident had certain staff that could work with her, and, depending on the approach used by staff, the resident would not exhibit the aggressive behaviors. A review of the care plan did not find any interventions regarding how to approach the resident so as not to trigger the aggressive behaviors, as mentioned by the DON during the interview at 10:00 a.m. on 07/08/10. -- b) Resident #8 Medical record review, on 06/30/10, revealed Resident #8, a [AGE] year old female admitted to the facility on [DATE], exhibited behaviors including tearfulness, verbal abuse, and repetitive health complaints, and the physician ordered the antipsychotic medication [MEDICATION NAME] 25 mg by mouth daily for [MEDICAL CONDITION]. Review of the resident's behavioral monitoring tracking record found the behavioral symptoms occurred infrequently, with only two (2) episodes in the months of April and May 2010. On 05/16/10, she was verbally abusive, and on 04/26/10, she was physically abusive; documentation indicated, in both instances, the behaviors were easily altered with 1:1 interventions. When interviewed on 07/01/10 at 9:23 a.m., a nurse (Employee #62) related that it was unusual for Resident #8 to have behaviors, and she had not personally witnessed the resident exhibiting any of these behaviors. When interviewed on 07/01/10 at 9:35 a.m., another nurse (Employee #48) reported Resident #8's behaviors occurred infrequently; the last time she exhibited any behaviors was on 06/24/10 and, prior to that, it was in May. Employee #48 also identified that, when the resident exhibited behaviors in June, she was successfully redirected with 1:1 staff interaction. Review of the resident's care plan found no plan had been developed to ensure non-pharmacologic interventions (such as 1:1 staff intervention) were attempted in an effort to decrease the episodes of behaviors. -- c) Resident #28 Medical record review, on 07/06/10, disclosed Resident #28, an [AGE] year old male, was admitted to the facility on [DATE]. He was hosptalized on [DATE] and returned to the facility on [DATE]. According to his nursing notes, in the early morning hours of 04/12/10, Resident #28 began experiencing increased anxiety. At 1:30 a.m., staff contacted the physician, who ordered an antianxiety medication ([MEDICATION NAME] 0.5 mg one (1) time only due to anxiety) and a respiratory treatment ([MEDICATION NAME] unit dose one (1) time dose due to [MEDICAL CONDITION]). On 04/20/10 around 3:00 a.m., Resident #28 again began to have increased anxiety. Staff contacted the physician, who again ordered [MEDICATION NAME] 0.5 mg by mouth now one (1) time dose due to increased anxiety and [MEDICATION NAME] unit dose one (1) time dose due to increased shortness of breath. On 04/20/10 at 5:30 p.m., the physician ordered an antidepressant, [MEDICATION NAME] 25 mg every day for seven (7) days then increase to 50 mg every day. On this same date at 8:20 p.m., the physician also ordered [MEDICATION NAME] 0.5 mg three (3) times a day as needed for anxiety. When interviewed on 07/01/10 at 9:40 a.m., Employee #48 reported Resident #28 behaviors were mainly triggered when he was due for a bath or to be turned. Review of the resident's current care plan, dated 05/20/10, found the addition of both the antianxiety and antidepressant medications, but only in the context of the need to monitor for potential adverse drug-related complications associated with these medications. The care plan did not address what behaviors the resident exhibited that indicated he was experiencing increased anxiety. There was no discussion of causative factors in the environment that may have triggered this increased anxiety (such as how staff approached him for bathing and turning), nor was there any mention of non-pharmacologic interventions to be attempted prior to medicating the resident with the as needed [MEDICATION NAME]. Additionally, there was no discussion of what causal or contributing factors were identified with respect to the resident's signs / symptoms of depression. -- d) When interviewed on 07/06/10 at 10:44 a.m., the staff development coordinator (Employee #57) revealed the care plans only had information concerning the side effects of the psychoactive medication being used; they did not address any non-pharmacologic interventions for modifying behaviors. Employee #57 stated, ""Our behavioral management system is broken, and we do a lot of talking that is not captured .... The behavior management care plan is something that we need to work on."" .",2015-08-01
9947,WELLSBURG CENTER LLC,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2010-07-08,272,D,0,1,GJYW11,". Based on medical record review and staff interview, the facility failed, for two (2) of twenty-three (23) Stage II sample residents, to ensure the comprehensive assessment was accurate and complete in accordance to each resident's functional status. Resident identifiers: #68 and #8. Facility census: 49. Findings include: a) Resident #68 Medical record review, on 07/06/10, revealed staff completed a comprehensive assessment to address a significant change in this resident's status on 06/01/10. Review of this assessment, in comparison to the annual assessment completed on 03/02/10, found she had improved in the self-performance of various activities of daily living (ADLs), from requiring extensive assistance to only requiring limited assistance; however, the overall change in ADL self-performance (Item G9) was marked as ""deteriorated"", not ""improved"". Further review of the 06/01/10 assessment found her urinary continence status had deteriorated, she had sustained a fall in the last thirty (30) days, and she had experienced a weight loss. However, review of Section Q found her overall health status was marked as ""no change"". In an interview on 07/06/10 at 3:25 p.m., the assessment coordinator (Employee #20) identified that Resident #68 actually had improved in her ADL self-performance and Item G9 was incorrectly encoded as ""deteriorated"". Employee #20 confirmed Resident #68 did have a decline in urinary continence, had fallen in the last thirty (30) days, and had weight loss. At this time, Employee #20 expressed she was not sure if Section Q coded correctly. Following her review of resident assessment instrument user's manual, she reported Section Q was also encoded incorrectly and needed to be changed to ""deteriorated"". -- b) Resident #8 Medical record review, on 06/30/10, revealed staff completed a comprehensive assessment to address a significant change in this resident's status on 06/08/10. Review of the assessment, in comparison to the abbreviated quarterly assessment completed on 03/09/10, found she had improved in the self-performance of various ADLs, although Item G9 was encoded to indicate the resident's ADL self-performance had ""deteriorated"" over the past ninety (90) days. Item H4 was also encoded to indicate the resident had deteriorated in urinary continence over the past ninety (90) days. In contrast, review of Item Q2 found it was encoded to reflect the resident's overall progress in the past ninety (90) days had ""improved"". When interviewed on 07/06/10 at 3:25 p.m., the assessment coordinator (Employee #36) confirmed Resident #8 actually had an improvement in ADL self-performance and Item G9 was encoded incorrectly. Employee #36 also confirmed Resident #8 had a decline in her urinary continence, but her overall health status was improved since she required less assistance with care and services. .",2015-08-01
9948,WELLSBURG CENTER LLC,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2010-07-08,279,E,0,1,GJYW11,"**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-three (23) Stage II sample residents, to develop a comprehensive plan of care for each resident exhibiting behavioral symptoms for which he/she is receiving [MEDICAL CONDITION] medication, to include non-pharmacologic interventions to address these behaviors. Resident identifiers: #8, #28, #4, and #58. Facility census: 49. Findings include: a) Resident #8 Medical record review, on 06/30/10, revealed Resident #8, a [AGE] year old female admitted to the facility on [DATE], exhibited behaviors including tearfulness, verbal abuse, and repetitive health complaints, and the physician ordered the antipsychotic medication [MEDICATION NAME] 25 mg by mouth daily for [MEDICAL CONDITION]. Review of the resident's behavioral monitoring tracking record found the behavioral symptoms occurred infrequently, with only two (2) episodes in the months of April and May 2010. On 05/16/10, she was verbally abusive, and on 04/26/10, she was physically abusive; documentation indicated, in both instances, the behaviors were easily altered with one-on-one (1:1) staff interventions. When interviewed on 07/01/10 at 9:23 a.m., a nurse (Employee #62) related that it was unusual for Resident #8 to have behaviors, and she had not personally witnessed the resident exhibiting any of these behaviors. When interviewed on 07/01/10 at 9:35 a.m., another nurse (Employee #48) reported Resident #8's behaviors occurred infrequently; the last time she exhibited any behaviors was on 06/24/10 and, prior to that, it was in May. Employee #48 also identified that, when the resident exhibited behaviors in June, she was successfully redirected with 1:1 staff interaction. Review of the resident's care plan found no plan had been developed to ensure non-pharmacologic interventions (such as 1:1 staff intervention) were attempted in an effort to decrease the episodes of behaviors. -- b) Resident #28 Medical record review, on 07/06/10, disclosed Resident #28, an [AGE] year old male, was admitted to the facility on [DATE]. He was hosptalized on [DATE] and returned to the facility on [DATE]. According to his nursing notes, in the early morning hours of 04/12/10, Resident #28 began experiencing increased anxiety. At 1:30 a.m., staff contacted the physician, who ordered an antianxiety medication ([MEDICATION NAME] 0.5 mg one (1) time only due to anxiety) and a respiratory treatment ([MEDICATION NAME] unit dose one (1) time dose due to [MEDICAL CONDITION]). On 04/20/10 around 3:00 a.m., Resident #28 again began to have increased anxiety. Staff contacted the physician, who again ordered [MEDICATION NAME] 0.5 mg by mouth now one (1) time dose due to increased anxiety and [MEDICATION NAME] unit dose one (1) time dose due to increased shortness of breath. On 04/20/10 at 5:30 p.m., the physician ordered an antidepressant, [MEDICATION NAME] 25 mg every day for seven (7) days then increase to 50 mg every day. On this same date at 8:20 p.m., the physician also ordered [MEDICATION NAME] 0.5 mg three (3) times a day as needed for anxiety. Review of the resident's current care plan, dated 05/20/10, found the addition of both the antianxiety and antidepressant medications, but only in the context of the need to monitor for potential adverse drug-related complications associated with these medications. The care plan did not address what behaviors the resident exhibited that indicated he was experiencing increased anxiety. There was no discussion of causative factors in the environment that may have triggered this increased anxiety, nor was there any mention of non-pharmacologic interventions to be attempted prior to medicating the resident with the as needed [MEDICATION NAME]. Additionally, there was no discussion of what causal or contributing factors were identified with respect to the resident's signs / symptoms of depression. When interviewed on 07/01/10 at 9:40 a.m., Employee #48 reported Resident #28 behaviors were mainly triggered when he was due for a bath or to be turned. -- c) When interviewed on 07/06/10 at 10:44 a.m., the staff development coordinator (Employee #57) revealed the care plans only had information concerning the side effects of the psychoactive medication being used; they did not address any non-pharmacologic interventions for modifying behaviors. Employee #57 stated, ""Our behavioral management system is broken, and we do a lot of talking that is not captured .... The behavior management care plan is something that we need to work on."" -- d) Resident #4 Review of Resident #4's medical record revealed this [AGE] year old female resident had a physician's orders [REDACTED]. The medication was originally ordered on [DATE]. According to the facility's forms titled ""Behavioral Monitoring"" for the months of December 2009 through April 2010, Resident #4 was receiving [MEDICATION NAME] for the behaviors of physical abuse, eating off others' meal trays inappropriately, resisting care, verbal abuse, and exit-seeking behavior. According to documentation on these forms, the resident exhibited these target behaviors as follows: - On 12/14/09 and 12/15/09, the resident ""went to 200 hall door and turned around and exited 200 hall door (sic) effective for re-direction."" - One (1) episode occurred in January 2010 - the resident opened the 200 hall. - Three (3) episodes occurred in February 2010 - the resident ""yelled at nurse very loud hey"", ""yelled at CNA (certified nursing assistant) very loud hey"", and ""attempted to exit 200 hall door"". - Seven (7) episodes of ""attempting to exit the facility"" occurred in March 2010. - One (1) episode occurred in April 2010 - the resident ""attempted to exit the 200 hall door."" No other behaviors were listed during this five (5) month period of time. - Review of the resident's social service progress notes found an entry, dated 02/24/10, stating, ""Resident is alert and confused / disoriented, which leads to wandering in facility and attempts to exit building looking for family. The resident is redirected unless very confused then can become combative. The resident is out of the room daily ambulating in the facility hallways."" - An interview with a registered nurse (RN - Employee #23), on 06/30/10 at 11:30 a.m., revealed Resident #4 did not exhibit exit-seeking behaviors very often. She would want to go out the door if she hears the ambulance or if she sees a car that resembles a family member's vehicle. According to Employee #23, Resident #4 was not a problem with behaviors. - An interview with the director of nursing (DON - Employee #46), on 06/30/10 at 12:30 p.m., revealed she was unaware why the physician did not address the pharmacist's recommendation to provide a gradual dose reduction for [MEDICATION NAME]. She was aware the resident ambulated at will and would occasionally exit-seek. - A review of the resident's care plan found no evidence of interventions to address the resident's attempts to exit the facility. In the care plan problem area, the resident was identified as being an elopement risk, but no non-pharmacologic interventions were listed to address / reduce this behavior. -- e) Resident #58 Review of Resident #58's medical record revealed this [AGE] year old female was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her physician's orders [REDACTED]. 12/10/09). Review of the resident's comprehensive admission assessment, with an ARD of 12/15/09 again found the assessor noted the resident did not exhibit any indicators of depression, anxiety, and/or sad mood in the preceding thirty (30) day period. The assessor did note the resident exhibited the following behavioral symptoms during the preceding seven (7) day period: wandering (daily), verbally abusive (1-3 days), physically abusive (1-3), and resists care (1-3 days). Further record review revealed her most recent assessment was a comprehensive significant change in status assessment with an assessment reference (ARD) 03/30/10. In Section E of this assessment addressing mood and behavior patterns, the assessor noted the resident did not exhibit any indicators of depression, anxiety, and/or sad mood in the preceding thirty (30) day period and did not exhibit any behavioral symptoms in the preceding seven (7) day period. The assessor also noted the resident's behavioral symptoms had improved over the preceding ninety (90) day period. An interview with the assessment coordinator (Employee #20), on 07/01/10 at 11:00 a.m., revealed the resident had been very ill and her behaviors had decreased, but now they had increased. - Nursing notes from 04/02/10 to 04/21/10 reflected no behavior problems exhibited by the resident. On 04/21/10 at 3:45 a.m., a nursing note indicated, ""Resident has been awake all night, chooses not to go to bed. Up out of wheelchair without assistance multiple times. 1:1 (one-on-one intervention) effective for short intervals."" At 4:50 a.m. on 04/21/10, a nursing note indicated, ""In front of nursing station, stood and fell hitting head on left side. Neuro checks recorded, denies pain. No injuries from previous fall, slept all night."" On 04/25/10 at 3:00 p.m., a nursing note revealed, ""Resident sitting in wheelchair at nurse's station (sic) alarm to chair went off. Observed resident stand and then sit on floor. No injuries."" On 04/26/10 at 3:10 a.m., a nursing note indicated, ""Resident awake until 2:45 a.m. (sic) was highly agitated for a short time, yelling and cursing at staff very loudly. Was about to administer PRN (as needed) [MEDICATION NAME] when resident calmed down and fell asleep in her wheelchair. Resident awakened and began to yell again. The resident became calmer after a short time. "" On 04/28/10 at 3:30 a.m., a nursing note stated, ""Resident sitting in wheelchair at nurse's station refusing to go to bed (sic) delusions that she needs to go home. 1:1 ineffective."" At 1:30 p.m. on 04/28/10, a nursing note stated, ""Discussed with physician verbal aggression continues today, unable to get along with other residents. Increased ambulation in hallways independently, yelling at others for no apparent reason. Physician order [REDACTED]."" On 04/28/10, the physician increased the [MEDICATION NAME] to 1 mg three (3) times a day, for a total daily dose of 3 mg. - An interview with the clinical care coordinator, on 07/06/10 at 10:05 a.m., revealed the resident's behaviors were better today. The resident was able to ambulate but leaned forward and her gait was unsteady. She was very tired a lot and needed to be reminded to use her walker. ""If you remind her to use the walker, she will get agitated easily."" An interview with a nurse (Employee #53), on 07/06/10 at 10:15 a.m., revealed [MEDICATION NAME] is used when the resident becomes agitated, and this is the only thing that will calm her down. Employee #53 also noted, due to the amount of psychoactive medication she was taking, the resident was a falls risk and she had had falls in the past. An interview with the staff development nurse (Employee #57), on 07/06/10 at 10:45 a.m., revealed the behavior management system was ""broken"". Staff was not documenting what the resident was actually doing in the medical record. She further stated the physician had done a lot that also was not documented. She stated she documented interventions in the nursing notes and not in the care plan. At 10:48 a.m., the DON came into the interview and agreed with Employee #57. An interview with the DON, on 07/08/10 at 10:00 a.m., revealed the resident had certain staff that could work with her, and, depending on the approach used by staff, the resident would not exhibit the aggressive behaviors. - A review of the resident's care plan revealed, ""Behavior problems wandering daily makes her at risks for falls. Physical and verbal abuse less than daily related to dementia has shown an improvement due to a decline in her health."" There was no mention of any interventions regarding how to approach the resident so as not to trigger the aggressive behaviors, as mentioned by the DON during the interview at 10:00 a.m. on 07/08/10. .",2015-08-01
9949,WELLSBURG CENTER LLC,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2010-07-08,309,J,0,1,GJYW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, staff interview, and policy review, the facility failed to provide necessary care and services to attain or maintain each resident's highest practicable physical well-being. Two (2) of twenty-three (23) Stage II sample residents (#79 and #36), who were recently admitted to the facility, were receiving medications from medicine bottles brought from home. Review of the medical records for Residents #79 and #36 found no evidence these home medications had been examined by a physician or consultant pharmacist prior to administration to the residents, to verify the contents of the bottles (right drug) and to verify the labels on the bottles matched the current physician's orders [REDACTED]. These practices placed two (2) current residents at immediate risk for serious harm related to the potential to receive medications the identity of which had not been verified and for which the dispensing instructions on the labels were inconsistent with current physician's orders [REDACTED]. After removal of the immediate jeopardy, the potential for more than minimal harm continued to exist for newly admitted residents until the facility corrected its system related to verifying medications (and their dispensing instructions) brought from home. Resident identifiers: #36 and #79. Facility census: 49. Findings include: a) Resident #79 During medication pass at 8:50 a.m. on 06/30/10, observation found the nurse (Employee #73) pouring medications for Resident #79 from brown medicine bottles, not from the bubble packs used for the other residents. When questioned, Employee #73 stated it was facility practice to use up any medications brought in from a resident's home before ordering them from the facility's vendor pharmacy. This practice was verified by two (2) other nurses on the floor (Employees #48 and #57). Examination of the brown medicine bottles for Resident #79 found the labels on the bottles did not always correlate with the resident's current physician's orders [REDACTED]. 1. The dispensing instruction on the label read, ""[MEDICATION NAME] (a stool softener) 100 mg by mouth twice daily."" According to the physician's orders [REDACTED]."" 2. The dispensing instruction on the label read, ""[MEDICATION NAME] (a gastric-acid pump inhibitor used to treat reflux) DR (Delayed Release) 20 mg by mouth daily."" According to the physician's orders [REDACTED]. 3. The dispensing instruction on the label read, ""[MEDICATION NAME] (a glucocorticosteroid) 4 mg ? tab twice daily."" According to the physician's orders [REDACTED]."" [MEDICATION NAME] 2 mg was administered correctly, but this required the nurse to break a 4 mg tablet in half. The nurse commented that she would be glad when the pills were gone, so they would no longer have to break the pills each time. Further record review revealed Resident #79 was admitted to the facility on [DATE]. -- b) Resident #36 During medication pass at 8:59 a.m. on 06/30/10, observation found Employee #73 pouring medications for Resident #36 from brown medicine bottles, not from the bubble packs used for the other residents. Employee #73 confirmed these brown medicine bottles were brought from Resident #36's home. The label on the brown medicine bottle for Resident #36 included the instructions: ""[MEDICATION NAME] 25 mg by mouth twice daily."" According to the physician's orders [REDACTED]. Further record review revealed Resident #36 was admitted to the facility on [DATE]. -- c) The director of nurses (DON), when asked about this practice during an interview at 10:00 a.m. on 06/30/10, verified that home medications were administered to residents but that a nurse always verified them with the physician. A copy of the facility's current pharmacy policy and procedure manual was requested at that time. -- d) During a telephone interview with the facility's consultant pharmacist at 11:15 a.m. on 06/30/10, he acknowledged he was aware the facility used medications brought by new residents from home on admission to the facility until they were gone. He added that, at times, payment was refused when a prescription had recently been filled and a resident was on Medicare Part D. He stated he ""usually"" reviewed them with a nurse over the phone, because coming to the facility each time to personally check them would ""be a hardship"", although he had no documentation that this telephone review was done for Residents #79 and #36. He further offered his opinion that using medications brought from home was not an ideal practice, because ""... You didn't know where they had been stored or that pills in the bottle were the correct ones."" He agreed the label on the medicine bottles did not always match the physician's orders [REDACTED]. When asked if there were a policy for the use of medications brought from home, he stated he knew of none. -- e) At about 12:00 p.m. on 06/30/10, the DON produced the facility's pharmacy policy and procedure manual for review by the survey team. Review of the manual revealed the following, on page 37 under ""12. Medications Brought to Facility by Resident or Family Member"", ""Policy: Medications brought into the facility by a resident or family member are used only upon written order by the resident's attending physician, after the contents are verified, and if the packaging meets the facility's guidelines. Other unauthorized medications are not accepted by the facility."" Elsewhere in the manual, on pages 4 and 5 under ""2. Provider Pharmacy - Requirements"", ""d. The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to ... 7) Performing an initial medication use assessment for each new residents to ensure that the medication regimen meets the resident's needs."" -- f) Review of the medical records for Residents #79 and #36 which found no evidence these home medications had been examined by a physician or consultant pharmacist prior to administration to the residents, to verify the contents matched the labels on the bottles. Additionally, there were no orders from the physician authorizing the administration of these home medications, and there were no notations on the residents' MARs to indicate that medications brought from home were to be administered. The survey team determined these practices placed both Residents #36 and #79 in immediate jeopardy, due to the potential for medication errors associated with administering medications without verification by a qualified health care professional that the contents of these medicine bottles matched the labels on the bottles and the current physician's orders [REDACTED]. The administrator and the DON were notified of the finding of immediate jeopardy at 1:55 p.m. on 06/30/10. -- g) Review of the contents of the facility's medication carts (to determine what additional home medications were available for administration to residents), in the presence of two (2) facility nurses (Employee #73 and #48) beginning at 2:00 p.m. on 06/30/10, found a total of thirteen (13) medicine bottles for Resident #79. Three (3) of the bottles were empty; three (3) medications had been discontinued but not removed from the cart, and one (1) over-the-counter medication had no label at all. This review also found five (5) medicine bottles for Resident #36, two (2) of which were empty. Employee #73 confirmed Resident #36 was receiving [MEDICATION NAME] (an antidepressant) 50 mg daily, [MEDICATION NAME] (an antihypertensive) 0.3 mg twice daily, and [MEDICATION NAME] (an antihypertensive) 50 mg daily from the medicine bottles brought from home. -- h) The DON presented a proposed plan of correction (POC) at 3:30 p.m. on 06/30/10, which stated, ""In coordination with pharmacy a policy and procedure will be written and thoroughly in-serviced to all nurses."" The DON expressed surprise when informed there already was a policy in the manual to address this. The POC was initially rejected as it did not address all aspects of the immediate jeopardy situation. A revised POC was approved at 4:05 p.m. on 06/30/10, and the immediate jeopardy situation was declared removed at 4:13 p.m., after verification by the survey team that the revised POC had been implemented, to include verification that all medications brought from home were removed from the medication carts and were no longer available for use. -- i) The DON agreed, when interviewed at 4:15 p.m. on 06/30/10, the discontinued medications should have been removed from the cart. She also acknowledged the differences between the labels on the medicine bottles from home and the current physician's orders [REDACTED]. -- j) Review of the monthly pharmacy review reports for 2010, at 8:15 a.m. on 07/08/10, found the last pharmacy review was completed on 06/12/10. There was no mention in the report to indicate the reviewer acknowledged the presence of home medications in the medication carts. .",2015-08-01
9950,WELLSBURG CENTER LLC,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2010-07-08,385,D,0,1,GJYW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, staff interview, and facility policy review, the facility failed to assure the physician supervised the medical care of two (2) of twenty-three (23) sampled residents, by failing to obtain a written physician's order for the administration of medications brought from home per facility policy and/or by having no evidence that these medications were reviewed with the physician, per facility policy, prior to their use. Resident identifiers: #79 and #36. Facility census: 49. Findings include: a) Resident #79 While observing medication pass at 8:50 a.m. on 06/30/10, the nurse (Employee #73) was seen administering medications to Resident #79 from brown medicine bottles (not the bottle packs found used with other residents) that were labeled from an outside pharmacy. When questioned, Employee #73 stated it was facility practice to use medications brought in from the resident's home before ordering them from the facility's vendor pharmacy. This practice was verified by two (2) other nurses on the floor (Employees #48 and #57). The director of nurses (DON), when asked about this practice during an interview at 10:00 a.m. on 06/30/10, verified that home medications were administered to residents but that a nurse always verified them with the physician. Review of Resident #79's medical record found no evidence of such a review of home medications by the physician. b) Resident #36 During the observation of a medication pass at 8:59 a.m. on 06/30/10, Employee #73 was seen administering medications to Resident #36 from brown medicine bottles (not the bottle packs found used with other residents) that were labeled from an outside pharmacy. When surveyors reviewed the facility's medication carts at 2:00 p.m. on 06/30/10, in the presence of two (2) facility nurses (Employees #73 and #48), Resident #36 was found to have five (5) medicine bottles labeled from an outside pharmacy. Two (2) of the containers were empty but remained in the cart. Employee #73 confirmed Resident #36 was receiving [MEDICATION NAME] 50 mg daily, [MEDICATION NAME] 0.3 mg twice daily, and [MEDICATION NAME] 50 mg daily from the medicine bottles brought from home. A review of Resident #36's clinical record revealed no physician's order for use of the home medications and no evidence in the record that these bottles of medicine had been examined and/or reviewed by the consultant pharmacist or the physician prior to their use, to verify the contents of the bottles. During an interview with the DON at 8:10 a.m. on 07/07/10, she acknowledged, after reviewing the resident's record, that there was no documentation in the record to indicate the physician was aware of the use of the medications brought from home. c) Review of the facility's policy titled ""Medications Brought to Facility by Resident or Family Member"" found: ""Medications brought into the facility by a resident or family member are used only upon written order by the resident's attending physician, after the contents are verified, and if the packaging meets the facility's guidelines. Other unauthorized medications are not accepted by the facility."" .",2015-08-01
9951,WELLSBURG CENTER LLC,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2010-07-08,280,D,0,1,GJYW11,"**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 twenty-three (23) Stage II sample residents with weight loss when changes were made in physician-ordered nutritional supplements. Resident identifier: #66. Facility census: 49. Findings include: a) Resident #66 Review of Resident #66's closed record disclosed he was admitted to the facility on [DATE], for physical therapy, occupational therapy, and treatment of [REDACTED]. He was admitted with an order for [REDACTED]. His weight was 157 pounds (#), and his [MEDICATION NAME] level was 14. The dietician's assessment note, dated 02/24/10, stated the wounds were healed, and his weight was 156#, which was within his ideal body weight (IBW) range. She suggested discontinuing the [MEDICATION NAME] and starting the resident on ProSource. A physician's orders [REDACTED]. The resident's weight, on 03/08/10, was 149.4#, representing a loss of 7.6# in less than two (2) weeks. The initial care plan, dated 02/16/10, addressed the resident's poor oral intake, his need for assistance with eating, and the use of the [MEDICATION NAME] for wound healing, but there were no dietary progress notes or care plan changes after the [MEDICATION NAME] was discontinued and the ProSource was ordered on [DATE]. During an interview with the certified dietary manager at 9:30 a.m. on 07/07/10, she agreed, after reviewing the resident's care plan, that it should have been updated. She stated the procedure was for her to notify the clinical coordinator of the changes, and the clinical coordinator would update the care plan. She also stated that, due to personnel changes, the clinical coordinator was no longer at this facility. .",2015-08-01
9952,WELLSBURG CENTER LLC,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2010-07-08,441,D,0,1,GJYW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, staff interview, and a review of facility policies regarding cohorting residents with Clostridium difficile (C. diff), the facility failed to ensure one (1) of twenty-three (23) Stage II sample residents (#80), who was newly admitted with two (2) portals of entry (a central intravenous line and an indwelling urinary catheter) on 07/01/10, was no cohorted with a resident (#72) who was in contact isolation for [DIAGNOSES REDACTED]. Facility census: 47. Findings include: a) Residents #72 and #80 Initial entrance to the facility, for an annual Medicare / Medicaid certification resurvey and concurrent State licensure inspection, began at 10:15 a.m. on 06/28/10. Observation of Resident #72, on 06/30/10 at 2:00 p.m., found signage posted outside of the resident's room indicating the resident was in contact isolation; no other resident occupied this room with Resident #72 at this time. Review of Resident #72's medical record found the resident was in contact isolation due to [DIAGNOSES REDACTED]. The survey team departed the facility at 5:00 p.m. on 06/30/10 and re-entered at 8:30 a.m. on 07/06/10 to resume the survey event. Observation of Resident #72's room, on 07/06/10 at 12:00 p.m., found the resident now had a roommate (Resident #80). Resident #80's family, when interviewed at that time, reported the resident was admitted to the facility on [DATE]. Observation of Resident #80 found the resident had an place an indwelling Foley urinary catheter. Review of Resident #80's medical record found in the physician's orders [REDACTED]. Both the central line and the indwelling catheter presented open portals for the introduction of infectious organisms. On 07/08/10 at 8:35 a.m., the infection control nurse (Employee #57) reviewed the facility's policy and procedures for ""Isolation - Categories of Transmission-Based Precautions; Contact Precautions"" (dated 2001 and revised on 12/06 and 10/07), which stated, ""In addition to Standard Precautions, implement Contact Precautions 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."" Elsewhere in the policy / procedure, under ""Resident Placement"", was: ""(1) Co-hort the individual with someone who does not have indwelling tubes, catheters, or open wounds."" Employee #57 agreed that Resident #80 should not have been cohorted with Resident #72. .",2015-08-01
9953,WELLSBURG CENTER LLC,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2010-07-08,425,E,0,1,GJYW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, staff interview, and facility policy review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate and safe acquiring and administering of all drugs) to meet the needs of each resident and failed to ensure the licensed pharmacist collaborated with facility leadership to coordinate pharmaceutical services within the facility. Two (2) of twenty-three (23) Stage II sample residents (#79 and #36), who were recently admitted to the facility, were receiving medications from medicine bottles brought from home. Review of the medical records for Residents #79 and #36 found no evidence these home medications had been examined by a physician or pharmacist prior to administration to the residents, to verify the contents of the bottles (right drug) and to verify the labels on the bottles matched the current physician's orders [REDACTED]. The consultant pharmacist was aware of these unsafe practices but did not collaborate with facility leadership to resolve them. This had the potential to affect any newly admitted resident who brought medications from home. Facility census: 49. Findings include: a) Resident #79 During medication pass at 8:50 a.m. on 06/30/10, observation found the nurse (Employee #73) pouring medications for Resident #79 from brown medicine bottles, not from the bubble packs used for the other residents. When questioned, Employee #73 stated it was facility practice to use up any medications brought in from a resident's home before ordering them from the facility's vendor pharmacy. This practice was verified by two (2) other nurses on the floor (Employees #48 and #57). Examination of the brown medicine bottles for Resident #79 found the labels on the bottles did not always correlate with the resident's current physician's orders [REDACTED]. 1. The dispensing instruction on the label read, ""Colace (a stool softener) 100 mg by mouth twice daily."" According to the physician's orders [REDACTED]."" 2. The dispensing instruction on the label read, ""Prilosec (a gastric-acid pump inhibitor used to treat reflux) DR (Delayed Release) 20 mg by mouth daily."" According to the physician's orders [REDACTED]. 3. The dispensing instruction on the label read, ""Decadron (a glucocorticosteroid) 4 mg ? tab twice daily."" According to the physician's orders [REDACTED]."" Decadron 2 mg was administered correctly, but this required the nurse to break a 4 mg tablet in half. The nurse commented that she would be glad when the pills were gone, so they would no longer have to break the pills each time. Further record review revealed Resident #79 was admitted to the facility on [DATE]. -- b) Resident #36 During medication pass at 8:59 a.m. on 06/30/10, observation found Employee #73 pouring medications for Resident #36 from brown medicine bottles, not from the bubble packs used for the other residents. Employee #73 confirmed these brown medicine bottles were brought from Resident #36's home. The label on the brown medicine bottle for Resident #36 included the instructions: ""Atenolol 25 mg by mouth twice daily."" According to the physician's orders [REDACTED]. Further record review revealed Resident #36 was admitted to the facility on [DATE]. -- c) The director of nurses (DON), when asked about this practice during an interview at 10:00 a.m. on 06/30/10, verified that home medications were administered to residents but that a nurse always verified them with the physician. A copy of the facility's current pharmacy policy and procedure manual was requested at that time. -- d) During a telephone interview with the facility's consultant pharmacist at 11:15 a.m. on 06/30/10, he acknowledged he was aware the facility used medications brought by new residents from home on admission to the facility until they were gone. He added that, at times, payment was refused when a prescription had recently been filled and a resident was on Medicare Part D. He stated he ""usually"" reviewed them with a nurse over the phone, because coming to the facility each time to personally check them would ""be a hardship"", although he had no documentation that this telephone review was done for Residents #79 and #36. He further offered his opinion that using medications brought from home was not an ideal practice, because ""... You didn't know where they had been stored or that pills in the bottle were the correct ones."" He agreed the label on the medicine bottles did not always match the physician's orders [REDACTED]. When asked if there were a policy for the use of medications brought from home, he stated he knew of none. -- e) At about 12:00 p.m. on 06/30/10, the DON produced the facility's pharmacy policy and procedure manual for review by the survey team. Review of the manual revealed the following, on page 37 under ""12. Medications Brought to Facility by Resident or Family Member"", ""Policy: Medications brought into the facility by a resident or family member are used only upon written order by the resident's attending physician, after the contents are verified, and if the packaging meets the facility's guidelines. Other unauthorized medications are not accepted by the facility."" Elsewhere in the manual, on pages 4 and 5 under ""2. Provider Pharmacy - Requirements"", ""d. The provider pharmacy agrees to perform the following pharmaceutical services, including but not limited to ... 7) Performing an initial medication use assessment for each new residents to ensure that the medication regimen meets the resident's needs."" -- f) Review of the medical records for Residents #79 and #36 which found no evidence these home medications had been examined by a physician or pharmacist prior to administration to the residents, to verify the contents matched the labels on the bottles. Additionally, there were no orders from the physician authorizing the administration of these home medications, and there were no notations on the residents' MARs to indicate that medications brought from home were to be administered. -- g) Review of the contents of the facility's medication carts (to determine what additional home medications were available for administration to residents), in the presence of two (2) facility nurses (Employee #73 and #48) beginning at 2:00 p.m. on 06/30/10, found a total of thirteen (13) medicine bottles for Resident #79. Three (3) of the bottles were empty; three (3) medications had been discontinued but not removed from the cart, and one (1) over-the-counter medication had no label at all. This review also found five (5) medicine bottles for Resident #36, two (2) of which were empty. Employee #73 confirmed Resident #36 was receiving Sertraline (an antidepressant) 50 mg daily, Clonidine (an antihypertensive) 0.3 mg twice daily, and Atenolol (an antihypertensive) 50 mg daily from the medicine bottles brought from home. -- h) The DON agreed, when interviewed at 4:15 p.m. on 06/30/10, the discontinued medications should have been removed from the cart. She also acknowledged the differences between the labels on the medicine bottles from home and the current physician's orders [REDACTED]. -- i) According to WV Legislative Rule Title 15, Series 1, the Rules and Regulations of the Board of Pharmacy: ""23. Pharmacist Consultants. ""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: a. Prescriptions; b. Floor stock; c. Emergency boxes or kits; d. Investigational drugs; e. Samples; and f. 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: a. Transcribing drug orders and prescription ordering; b. Prescription delivery system and in-house verification; c. Drug recall; d. Automatic stop orders; e. Formulary or standards for drug quality; f. Systematic review of drug orders; g. Reconciliation of controlled substances; h. Disposition by the following means of prescriptions not totally consumed by the patient: 1. Return to pharmacy for credit; and 2. Destruction by the pharmacist in the presence of a registered nurse; and i. In-service drug education of other personnel."" -- j) Review of the monthly pharmacy review reports for 2010, at 8:15 a.m. on 07/08/10, found the last pharmacy review was completed on 06/12/10. There was no mention in the report to indicate the reviewer acknowledged the presence of home medications in the medication carts. .",2015-08-01
9954,WELLSBURG CENTER LLC,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2010-07-08,428,D,0,1,GJYW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure the physician acted upon recommendations by the consultant pharmacist, to include documenting the clinical rationale for not accepting a recommendation for a gradual dose reduction. Resident identifier: #4. Facility census: 49. Findings include: a) Resident #4 Review of Resident #4's medical record revealed this [AGE] year old female resident had a physician's orders [REDACTED]. The medication was originally ordered on [DATE]. According to the facility's forms titled ""Behavioral Monitoring"" for the months of December 2009 through April 2010, Resident #4 was receiving Ativan for the behaviors of physical abuse, eating off others' meal trays inappropriately, resisting care, verbal abuse, and exit-seeking behavior. According to documentation on these forms, the resident exhibited these target behaviors as follows: - On 12/14/09 and 12/15/09, the resident ""went to 200 hall door and turned around and exited 200 hall door (sic) effective for re-direction."" - One (1) episode occurred in January 2010 - the resident opened the 200 hall. - Three (3) episodes occurred in February 2010 - the resident ""yelled at nurse very loud hey"", ""yelled at CNA (certified nursing assistant) very loud hey"", and ""attempted to exit 200 hall door"". - Seven (7) episodes of ""attempting to exit the facility"" occurred in March 2010. - One (1) episode occurred in April 2010 - the resident ""attempted to exit the 200 hall door."" No other behaviors were listed during this five (5) month period of time. - On 12/01/09, the pharmacy consultant recorded on a physician communication form, ""This patient is receiving Lorazepam (Ativan) 0.5 mg three times a day for anxiety since 8/2009. Please consider Lorazepam 0.5 mg three times a day as needed to determine if the drug is needed three (3) times a day."" On 12/01/09, the physician responded by noting, ""See progress note."" On 04/13/10, the pharmacy consultant wrote, ""This patient is receiving Lorazepam 0.5 mg three times a day for anxiety since 8/2009. Please consider Lorazepam 0.5 mg three times a day as needed to determine if the drug is needed three times a day."" On 04/13/10, the physician responded by noting, ""Continue as is (sic) see order."" In neither case was there documentation by the physician of any clinical rationale to continue the existing order for the Ativan. - An interview with a registered nurse (RN - Employee #23), on 06/30/10 at 11:30 a.m., revealed Resident #4 did not exhibit exit-seeking behaviors very often. She would want to go out the door if she hears the ambulance or if she sees a car that resembles a family member's vehicle. According to Employee #23, Resident #4, was not a problem with behaviors. - An interview with the director of nursing (DON - Employee #46), on 06/30/10 at 12:30 p.m., revealed she was unaware why the physician did not address the pharmacist's recommendation to provide a gradual dose reduction for Ativan. .",2015-08-01
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
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
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
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
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
9908,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-08-05,250,D,0,1,2XEX12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, facility policy review, and review of information submitted by the facility to the State survey agency following the survey team's exit conference, the facility failed to provide medically-related social services by failing to develop and implement a discharge plan to ensure a safe and orderly discharge from the facility. This was found for one (1) of five (5) residents whose closed records were reviewed. Resident identifier: #57. Facility census: 54. Findings include: a) Resident #57 1. On 08/03/10 at 3:00 p.m., review of Resident #57's medical record revealed this [AGE] year old female was admitted to the nursing facility from a local hospital on [DATE], and she was discharged to a legally unlicensed care home on 07/29/10. Review of Resident #57's admission record (face sheet) revealed her [DIAGNOSES REDACTED]. According to her hospital discharge summary, dictated and transcribed on 07/06/10, she was admitted to the hospital on [DATE]. Her discharge [DIAGNOSES REDACTED]. On page 2 of the discharge summary, the physician noted, ""...Because of her moderate dementia and alcohol dependence she was given Valium to prevent withdrawal. ..."" Also on page 2 was stated, ""Physical Therapy notes that patient does require a walker and assistance for ambulation and has easy fatigue and endurance. They do emphasize that she is not safe of independent gait and transfers at this time."" (This last sentence was written in bold font and was underlined.) On page 3 under Discharge Disposition and Special Discharge Instructions was: ""5. Activity is ambulation with assist and a walker."" A progress note by the certified physician's assistant (PA-C), dated 07/16/10, noted under ""A/P"" (""assessment"" and ""plan""): ""5. Alcohol dependence: Abstain from future use ...."" - 2. According to her comprehensive admission assessment, with an assessment reference date (ARD) of 07/13/10, she had problems with both long and short term memory, she was not oriented to person, place, or season, her cognitive skills for daily decision making were moderately impaired, she required the extensive physical assistance of one (1) person for bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, and bathing, and she was frequently incontinent of both bowel and bladder. During this assessment reference period, the resident did not walk, and her primary mode of locomotion was via a wheelchair. She received the services of speech, occupational, and physical therapy five (5) days a week during this assessment period, and a trunk restraint was used daily. According to a Medicare 14-day full assessment, with an ARD of 07/17/10, she had problems with both long and short term memory, she was not oriented to person, place, or season, her cognitive skills for daily decision making were moderately impaired, she required the extensive physical assistance of one (1) person for locomotion, dressing, and personal hygiene, and she required the extensive physical assistance of two (2) persons for bed mobility, transfer, and toilet use. During this assessment reference period, the resident did not walk. She received the services of speech, occupational, and physical therapy five (5) days a week during this assessment period, and a trunk restraint was used daily. - 3. Documentation by the physical therapist revealed Resident #57 received physical therapy from 07/07/10 through 07/27/10. Under the heading ""Summary of Care"" was noted: ""Summary of Progress:: pt. (sic) not progressing well, difficulty with cooperation and partiicipation (sic) secondary to dementia and decreased insight and safety, decreased intake as well as making participation difficult. family (sic) not in for training or education. recommend (sic) assist and continued PT if able to maximize functional mobility and assisted mobility."" Under the heading ""Discharge Recommendations"" was noted: ""Discharge Setting: Other (personal care home); Recommended services upon discharge: Home Health Services, A (assistance) with all mobility; Equipment recommended upon discharge: w/c (wheelchair)."" Documentation by the occupational therapist revealed she received occupational therapy from 07/07/10 through 07/28/10. Under the heading ""Summary of Care"" was noted: ""Summary of Progress:: Pt. demo(nstrated) limited progress toward goals due to cognitive level and lack of participation in therapy. Pt. at times will refuse or become beligerant (sic) with therapist. Family and SW (social worker) decided to transfer patient to a personal care home closer to family. Discharge skilled OT treatment."" Under the heading ""Discharge Recommendations"" was noted: ""Discharge Setting: Other (personal care home); Recommended services upon discharge: 24/7 care; Equipment recommended upon discharge: pt. could benefit from w/c and FWW (front-wheeled walker)."" Review of the speech therapy progress notes, for 07/20/10, revealed under the heading ""Current Status"": ""Precautions: puree (diet); nectar-thick fluids; fall risk; easily agitated per hospital records; sundowners"". Under the heading ""Encounter Summary"" was noted: ""... SLP (speech language pathologist) suggested that PCH (personal care home) staff come to facility next week to observe pt in tx (treatment) and determine if she will be appropriate for their setting. Pt's POA (power of attorney) to set this up for next week. ..."" Review of the resident's telephone orders found an order dated 07/27/10 for: ""Home Health w/ (with) PT & OT."" Review of the social service notes revealed Resident #57 was discharged from the nursing facility at 6:00 p.m. on 07/29/10. Review of facility records found no evidence to reflect there had been any discussion between the social worker and the resident's legal representative regarding the appropriateness of discharging Resident #57 from a skilled nursing facility to a legally unlicensed care home in the community, in view of the resident's assessed needs with respect to her level of dependence on staff with activities of daily living, her dysphagia, and her need for monitoring related to her recently diagnosed urinary tract infection. - 4. In an interview on 08/04/10 at 10:45 a.m., the facility's social worker (Employee #59) reported there was no discharge planning meeting held or discharge notice given to the resident's legal representative, but they did discuss discharge during the resident's last care plan meeting. Review of the care plan meeting notes with the social worker, at this time, found no mention of any discharge plan. The social worker reported the physical therapist expressed that Resident #57 had reached a plateau. The social worker reported she then contacted the resident's legal representative, who set everything up for the discharge herself. The social worker did contact the unlicensed care home to ensure they had a mechanical (Hoyer) lift available for use at the facility and twenty-four (24) hour care. The social worker confirmed that no follow-up appointment with a physician had been made, she did not communicate to staff at the unlicensed home that the resident had a history of [REDACTED]. - 5. In a telephone interview on 08/04/10 at 11:10 a.m., Resident #57's legal representative reported she did not receive anything in writing from the facility, but that the social worker called and informed her that Resident #57 had reached a plateau in therapy and needed to be discharged . The legal representative stated the resident's intended discharge date was projected to be in August, but no set date was mentioned, and upon admission she knew there were no long term care beds available at the nursing facility. The legal representative was not sure why the discharge date was moved up and she wished Resident #57 could have stayed at the nursing facility longer, since she was only able to take a few steps with the assistance of two (2) people, one (1) on each side of her. She also reported that Resident #57's transition from the nursing facility to the unlicensed care home was ""rough"". According to the legal representative, Resident #57 had resided in an assisted living facility in Ohio prior to being admitted to the hospital on [DATE]; while there, staff gave Resident #57 alcoholic beverages to drink, and during a visit there, the legal representative found both the resident and her caregiver were intoxicated. During a visit at the unlicensed care home (after her discharge from the nursing facility on 07/29/10), the legal representative found that staff at the unlicensed care home was giving Resident #57 alcoholic beverages; the legal representative quickly intervened but noted the nursing facility failed to inform staff at the unlicensed care home of the need for Resident #57 to abstain from alcohol. Additional information obtained from Resident #57's legal representative during this telephone interview included: - No information had been communicated to the staff at the unlicensed home regarding how to safely assist Resident #57 out of the legal representative's personal vehicle (from a sitting to a standing position), and she reported the mechanical lift at the facility was broken. - No information was communicated to the staff at the unlicensed home of the need to obtain follow-up services from a physician related to the resident's urinary tract infection. The legal representative reported having to take Resident #57 to an Urgent Care provider after her discharge from the facility, because the resident's urine was dark-colored and foul-smelling, and she could not get an appointment with a primary care physician until 08/30/10. - No physical therapy or occupational therapy services had yet been provided to Resident #57 since her admission to the unlicensed care home. -- b) During an interview with the nursing facility's administrator (Employee #53) on 08/04/10 at 12:03 p.m., she stated that discharge planning was primarily the responsibility of the facility's social worker. She confirmed that no reason for the transfer / discharge of Resident #57 was documented, that no written notice prior to transfer was documented, and that no arrangements were made for appropriate transportation, follow-up physician appointment, and ordered adaptive equipment. She agreed there was no evidence to reflect appropriate medical history had been communicated to the receiving facility. She stated the social worker was hired about six (6) months ago, had no previous long term care experience, and, although she had received orientation, she was in need of education on long term care requirements and services. -- c) A review of facility policy and procedures for discharge and transfer, conducted on 08/05/10 at 8:00 a.m., found the following: - Under the section ""Policy"" is stated: ""Customers and/or legal representatives will be provided proper notice in accordance with state and federal regulations should a transfer or discharge be initiated by a Genesis ElderCare Center."" - Under the section ""Process"" is stated as #1: ""The social services department is responsible for coordinating transfers and discharges."" -- d) A review of facility policy and procedures for discharge planning, conducted on 08/05/10 at 8:20 a.m., found under the section ""Policy"": ""Upon admission, all customers will be asked about their discharge goals and assessed for discharge potential. For customers anticipating a short stay, discharge/transition planning will begin upon admission and be completed as part of the Interdisciplinary Care Plan process."" Under the section ""Purpose"" is stated: ""To ensure the most appropriate discharge/transition plan for all customers"" and, ""To provide comprehensive discharge information for all customers, family members, and post-discharge care providers."" -- e) On 08/09/10, the surveyor received additional information that had been submitted by the facility to the State survey agency after the survey team's exit. Among these materials were found ""Rehab UM Meeting"" notes and a discharge transition plan. - Review of the facility's ""Rehab UM Meeting"" notes for Resident #57 on 07/21/10 revealed, ""... D/C (discharge) plan? Lap buddy. Transfers with mod A (moderate assistance) for safety. AMb (sic) (ambulate) - 30ft with Mod A and RW (roller walker).; MBSS (modified barium swallow study) on 7/22 at noon. PO (oral) intake is extremely poor; drinks better on nectar (thickened liquids)."" - Review of the facility's ""Rehab UM Meeting"" notes for Resident #57 on 07/27/10 revealed, ""... D/C plan? Lap buddy. Transfers with max A (maximum assistance) for safety. Pt now not ambulating.; Question pt with UTI (urinary tract infection). Pt with decreased performance."" Handwritten in the block containing Resident #57's name was: ""DC tom (discharge tomorrow) pm"". Review of the resident's discharge transition plan, dated 07/29/10, revealed the following: - ""You can get around (at discharge): With a little help. Devices used: wheelchair"" (There was no mention of a front-wheeled or roller walker.) - ""Get up/down from a seated position (at discharge): W/ at great deal of help"" (There was no mention of the need for the use of any devices when transferring, such as a walker or a mechanical lift.) - ""Your dietary recommendations are: Regular Diet"" (There was no mention pureed foods or thickened liquids.) - On page 3, under the heading of ""Your physician follow-ups"", nothing was written to direct either the resident's family or the receiving facility's staff to contact any physician. (There was no mention of the need to monitor the resident for signs / symptoms of a UTI.) - On page 5 of this document, under the heading ""Your health services provider follow-ups"" were checked ""Physical Therapy"", ""Home Medical Equipment / Supplies"", and ""Pharmacy Provider"". None of the services under ""Home Care Services"" was checked, nor was ""Occupational Therapy"" checked under ""Therapy Services"", as had been ordered by the physician on 07/27/10. Under ""Home Medical Equipment / Supplies"", someone had scratched through information regarding the provider of a wheelchair, but there was no information to indicate a walker had been ordered. There was no mention anywhere on the document of the need to monitor the resident for falling, in view of the fact that she had used a lap buddy when at the nursing facility and had been identified as being at risk for falls by all of the rehabilitative therapy services. No information was communicated in the discharge transition plan regarding any special feeding techniques or alterations needed in the consistencies of foods and fluids to address her dysphagia, the transition plan incorrectly identified her diet as being of regular consistency, and there was no evidence that staff from the unlicensed home had come to the nursing facility to observe the resident during speech therapy to determine if she will be appropriate for their setting, as recommended by the SLP. .",2015-08-01
9909,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-08-05,203,D,0,1,2XEX12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, facility policy review, and review of information submitted to the State survey agency following the survey team's exit conference, the facility failed, for one (1) of five (5) residents whose closed records were reviewed, to provide a written notice of transfer or discharge (to include the reasons for the move and a notice of the right to appeal this action to the State) to the resident's legal representative at least thirty (30) days before the resident was transferred or discharged . Resident identifier: #57. Facility census: 54. Findings include: a) Resident #57 1. On 08/03/10 at 3:00 p.m., review of Resident #57's medical record revealed this [AGE] year old female was admitted to the nursing facility from a local hospital on [DATE], and she was discharged to a legally unlicensed care home on 07/29/10. The resident's closed record contained no evidence that a written notice of transfer or discharge was provided by the facility to the resident's legal representative at least thirty (30) days before the resident was moved, to include the reasons for the transfer / discharge and a notice of the right to appeal this action to the State. - 2. In an interview on 08/04/10 at 10:45 a.m., the facility's social worker (Employee #59) reported there was no discharge planning meeting held or discharge notice given to the resident's legal representative, but they did discuss discharge during the resident's last care plan meeting. Review of the care plan meeting notes with the social worker, at this time, found no mention of any discharge plan. The social worker reported the physical therapist expressed that Resident #57 had reached a plateau. The social worker reported she then contacted the resident's legal representative, who set everything up for the discharge herself. The social worker did contact the unlicensed care home to ensure they had a mechanical (Hoyer) lift available for use at the facility and twenty-four (24) hour care. - 3. In a telephone interview on 08/04/10 at 11:10 a.m., Resident #57's legal representative reported she did not receive anything in writing from the facility, but that the social worker called and informed her that Resident #57 had reached a plateau in therapy and needed to be discharged . The legal representative stated the resident's intended discharge date was projected to be in August, but no set date was mentioned, and upon admission she knew there were no long term care beds available at the nursing facility. The legal representative was not sure why the discharge date was moved up and she wished Resident #57 could have stayed at the nursing facility longer, since she was only able to take a few steps with the assistance of two (2) people, one (1) on each side of her. - 4. Review of the facility policy titled ""2.11 Discharge and Transfer"" (revision date 04/01/03), on 08/05/09 at 9:00 a.m., found: ""1. The social service department is responsible for coordinating transfers and discharges. ""2. All customers will receive a Notice of Transfer or discharge whenever a voluntary or involuntary transfer / discharge occurs. This includes customers being transferred to the hospital of discharges from a certified bed to a non-certified bed. ""2.1. The charge nurse will provide the Notice of Transfer or Discharge in the absence of the social worker. ""3. If the discharge is involuntary, 30 days advance notice in writing of the proposed transfer or discharge must be given to the customer, family member, or legal representative (if known). A copy of the notice is placed in the clinical record and a copy forwarded to the local district Ombudsmen council. ""4. The notice must include the appeal procedure."" - 5. On 08/09/10 at 12:03 p.m., the State survey agency forwarded to this surveyor information received from the facility following the survey team's exit. These materials contained no evidence to reflect the facility had provided a written notice at least thirty (30) days before the resident's transfer / discharge from the facility, to include the reasons for the move. Other items that should also have been included in such a written notice were: the effective date of transfer or discharge; the location to which the resident was being transferred or discharged ; a statement that the resident has the right to appeal the action to the State; the name, address and telephone number of the State long term care ombudsman; for nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. .",2015-08-01
9910,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-08-05,204,D,0,1,2XEX12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, and review of information provided by the facility to the State survey agency after the survey team's exit, the facility failed, for one (1) of five (5) residents whose closed records were reviewed, to take steps within its control to ensure a safe and orderly discharge of Resident #57 from the nursing facility to a legally unlicensed care home. Resident identifier: #57. Facility census: 54. Findings include: a) Resident #57 1. On 08/03/10 at 3:00 p.m., review of Resident #57's medical record revealed this [AGE] year old female was admitted to the nursing facility from a local hospital on [DATE], and she was discharged to a legally unlicensed care home on 07/29/10. Review of Resident #57's admission record (face sheet) revealed her [DIAGNOSES REDACTED]. According to her hospital discharge summary, dictated and transcribed on 07/06/10, she was admitted to the hospital on [DATE]. Her discharge [DIAGNOSES REDACTED]. On page 2 of the discharge summary, the physician noted, ""...Because of her moderate dementia and alcohol dependence she was given [MEDICATION NAME] to prevent withdrawal. ..."" Also on page 2 was stated, ""Physical Therapy notes that patient does require a walker and assistance for ambulation and has easy fatigue and endurance. They do emphasize that she is not safe of independent gait and transfers at this time."" (This last sentence was written in bold font and was underlined.) On page 3 under Discharge Disposition and Special Discharge Instructions was: ""5. Activity is ambulation with assist and a walker."" A progress note by the certified physician's assistant (PA-C), dated 07/16/10, noted under ""A/P"" (""assessment"" and ""plan""): ""5. Alcohol dependence: Abstain from future use ...."" - 2. According to her comprehensive admission assessment, with an assessment reference date (ARD) of 07/13/10, she had problems with both long and short term memory, she was not oriented to person, place, or season, her cognitive skills for daily decision making were moderately impaired, she required the extensive physical assistance of one (1) person for bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, and bathing, and she was frequently incontinent of both bowel and bladder. During this assessment reference period, the resident did not walk, and her primary mode of locomotion was via a wheelchair. She received the services of speech, occupational, and physical therapy five (5) days a week during this assessment period, and a trunk restraint was used daily. According to a Medicare 14-day full assessment, with an ARD of 07/17/10, she had problems with both long and short term memory, she was not oriented to person, place, or season, her cognitive skills for daily decision making were moderately impaired, she required the extensive physical assistance of one (1) person for locomotion, dressing, and personal hygiene, and she required the extensive physical assistance of two (2) persons for bed mobility, transfer, and toilet use. During this assessment reference period, the resident did not walk. She received the services of speech, occupational, and physical therapy five (5) days a week during this assessment period, and a trunk restraint was used daily. - 3. Documentation by the physical therapist revealed Resident #57 received physical therapy from 07/07/10 through 07/27/10. Under the heading ""Summary of Care"" was noted: ""Summary of Progress:: pt. (sic) not progressing well, difficulty with cooperation and partiicipation (sic) secondary to dementia and decreased insight and safety, decreased intake as well as making participation difficult. family (sic) not in for training or education. recommend (sic) assist and continued PT if able to maximize functional mobility and assisted mobility."" Under the heading ""Discharge Recommendations"" was noted: ""Discharge Setting: Other (personal care home); Recommended services upon discharge: Home Health Services, A (assistance) with all mobility; Equipment recommended upon discharge: w/c (wheelchair)."" Documentation by the occupational therapist revealed she received occupational therapy from 07/07/10 through 07/28/10. Under the heading ""Summary of Care"" was noted: ""Summary of Progress:: Pt. demo(nstrated) limited progress toward goals due to cognitive level and lack of participation in therapy. Pt. at times will refuse or become beligerant (sic) with therapist. Family and SW (social worker) decided to transfer patient to a personal care home closer to family. Discharge skilled OT treatment."" Under the heading ""Discharge Recommendations"" was noted: ""Discharge Setting: Other (personal care home); Recommended services upon discharge: 24/7 care; Equipment recommended upon discharge: pt. could benefit from w/c and FWW (front-wheeled walker)."" Review of the speech therapy progress notes, for 07/20/10, revealed under the heading ""Current Status"": ""Precautions: puree (diet); nectar-thick fluids; fall risk; easily agitated per hospital records; sundowners"". Under the heading ""Encounter Summary"" was noted: ""... SLP (speech language pathologist) suggested that PCH (personal care home) staff come to facility next week to observe pt in tx (treatment) and determine if she will be appropriate for their setting. Pt's POA (power of attorney) to set this up for next week. ..."" Review of the facility's ""Rehab UM Meeting"" notes for Resident #57 on 07/21/10 revealed, ""... D/C (discharge) plan? Lap buddy. Transfers with mod A (moderate assistance) for safety. AMb (sic) (ambulate) - 30ft with Mod A and RW (roller walker).; MBSS (modified [MEDICATION NAME] swallow study) on 7/22 at noon. PO (oral) intake is extremely poor; drinks better on nectar (thickened liquids)."" Review of the facility's ""Rehab UM Meeting"" notes for Resident #57 on 07/27/10 revealed, ""... D/C plan? Lap buddy. Transfers with max A (maximum assistance) for safety. Pt now not ambulating.; Question pt with UTI (urinary tract infection). Pt with decreased performance."" Handwritten in the block containing Resident #57's name was: ""DC tom (discharge tomorrow) pm"". Review of the resident's telephone orders found an order dated 07/27/10 for: ""Home Health w/ (with) PT & OT."" Review of the social service notes revealed Resident #57 was discharged from the nursing facility at 6:00 p.m. on 07/29/10. Review of facility records found no evidence to reflect there had been any discussion between the social worker and the resident's legal representative regarding the appropriateness of discharging Resident #57 from a skilled nursing facility to a legally unlicensed care home in the community, in view of the resident's assessed needs with respect to her level of dependence on staff with activities of daily living, her dysphagia, and her need for monitoring related to her recently diagnosed urinary tract infection. - 4. In an interview on 08/04/10 at 10:45 a.m., the facility's social worker (Employee #59) reported there was no discharge planning meeting held or discharge notice given to the resident's legal representative, but they did discuss discharge during the resident's last care plan meeting. Review of the care plan meeting notes with the social worker, at this time, found no mention of any discharge plan. The social worker reported the physical therapist expressed that Resident #57 had reached a plateau. The social worker reported she then contacted the resident's legal representative, who set everything up for the discharge herself. The social worker did contact the unlicensed care home to ensure they had a mechanical (Hoyer) lift available for use at the facility and twenty-four (24) hour care. The social worker confirmed that no follow-up appointment with a physician had been made, she did not communicate to staff at the unlicensed home that the resident had a history of [REDACTED]. - 5. In a telephone interview on 08/04/10 at 11:10 a.m., Resident #57's legal representative reported she did not receive anything in writing from the facility, but that the social worker called and informed her that Resident #57 had reached a plateau in therapy and needed to be discharged . The legal representative stated the resident's intended discharge date was projected to be in August, but no set date was mentioned, and upon admission she knew there were no long term care beds available at the nursing facility. The legal representative was not sure why the discharge date was moved up and she wished Resident #57 could have stayed at the nursing facility longer, since she was only able to take a few steps with the assistance of two (2) people, one (1) on each side of her. She also reported that Resident #57's transition from the nursing facility to the unlicensed care home was ""rough"". According to the legal representative, Resident #57 had resided in an assisted living facility in Ohio prior to being admitted to the hospital on [DATE]; while there, staff gave Resident #57 alcoholic beverages to drink, and during a visit there, the legal representative found both the resident and her caregiver were intoxicated. During a visit at the unlicensed care home (after her discharge from the nursing facility on 07/29/10), the legal representative found that staff at the unlicensed care home was giving Resident #57 alcoholic beverages; the legal representative quickly intervened but noted the nursing facility failed to inform staff at the unlicensed care home of the need for Resident #57 to abstain from alcohol. Additional information obtained from Resident #57's legal representative during this telephone interview included: - No information had been communicated to the staff at the unlicensed home regarding how to safely assist Resident #57 out of the legal representative's personal vehicle (from a sitting to a standing position), and she reported the mechanical lift at the facility was broken. - No information was communicated to the staff at the unlicensed home of the need to obtain follow-up services from a physician related to the resident's urinary tract infection. The legal representative reported having to take Resident #57 to an Urgent Care provider after her discharge from the facility, because the resident's urine was dark-colored and foul-smelling, and she could not get an appointment with a primary care physician until 08/30/10. - No physical therapy or occupational therapy services had yet been provided to Resident #57 since her admission to the unlicensed care home. - 6. On 08/09/10, the surveyor received additional information that had been submitted by the facility to the State survey agency after the survey team's exit. Review of these materials, including the resident's discharge transition plan dated 07/29/10, revealed the following: ""You can get around (at discharge): With a little help. Devices used: wheelchair"" (There was no mention of a front-wheeled or roller walker.) ""Get up/down from a seated position (at discharge): W/ at great deal of help"" (There was no mention of the need for the use of any devices when transferring, such as a walker or a mechanical lift.) ""Your dietary recommendations are: Regular Diet"" (There was no mention pureed foods or thickened liquids.) On page 3, under the heading of ""Your physician follow-ups"", nothing was written to direct either the resident's family or the receiving facility's staff to contact any physician. (There was no mention of the need to monitor the resident for signs / symptoms of a UTI.) On page 5 of this document, under the heading ""Your health services provider follow-ups"" were checked ""Physical Therapy"", ""Home Medical Equipment / Supplies"", and ""Pharmacy Provider"". None of the services under ""Home Care Services"" was checked, nor was ""Occupational Therapy"" checked under ""Therapy Services"", as had been ordered by the physician on 07/27/10. Under ""Home Medical Equipment / Supplies"", someone had scratched through information regarding the provider of a wheelchair, but there was no information to indicate a walker had been ordered. There was no mention anywhere on the document of the need to monitor the resident for falling, in view of the fact that she had used a lap buddy when at the nursing facility and had been identified as being at risk for falls by all of the rehabilitative therapy services. No information was communicated in the discharge transition plan regarding any special feeding techniques or alterations needed in the consistencies of foods and fluids to address her dysphagia, the transition plan incorrectly identified her diet as being of regular consistency, and there was no evidence that staff from the unlicensed home had come to the nursing facility to observe the resident during speech therapy to determine if she will be appropriate for their setting, as recommended by the SLP. The facility failed to take steps within its control to ensure a safe and orderly discharge of Resident #57 from the nursing facility to a legally unlicensed care home. .",2015-08-01
9911,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-08-05,284,D,0,1,2XEX12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, facility policy review, and review of information submitted by the facility to the State survey agency following the survey team's exit conference, the facility failed, for one (1) of five (5) residents whose closed records were reviewed, to develop a post-discharge plan of care that accurately and completely identified and communicated to the resident's family and receiving facility the care and services the resident would require in order to ensure a safe and orderly discharge. The discharge transition plan developed by the nursing facility for Resident #57 failed to communicate significant information about the resident's medical history (including a recent history of alcohol dependence) and current health status, failed to identify the need for home health services and occupational therapy as ordered by the physician, and failed to accurately communicate the need for such things as diet modifications and special equipment. Facility census: 54. Findings include: a) Resident #57 1. On 08/03/10 at 3:00 p.m., review of Resident #57's medical record revealed this [AGE] year old female was admitted to the nursing facility from a local hospital on [DATE], and she was discharged to a legally unlicensed care home on 07/29/10. Review of Resident #57's admission record (face sheet) revealed her [DIAGNOSES REDACTED]. According to her hospital discharge summary, dictated and transcribed on 07/06/10, she was admitted to the hospital on [DATE]. Her discharge [DIAGNOSES REDACTED]. On page 2 of the discharge summary, the physician noted, ""...Because of her moderate dementia and alcohol dependence she was given [MEDICATION NAME] to prevent withdrawal. ..."" Also on page 2 was stated, ""Physical Therapy notes that patient does require a walker and assistance for ambulation and has easy fatigue and endurance. They do emphasize that she is not safe of independent gait and transfers at this time."" (This last sentence was written in bold font and was underlined.) On page 3 under Discharge Disposition and Special Discharge Instructions was: ""5. Activity is ambulation with assist and a walker."" A progress note by the certified physician's assistant (PA-C), dated 07/16/10, noted under ""A/P"" (""assessment"" and ""plan""): ""5. Alcohol dependence: Abstain from future use ...."" - 2. According to her comprehensive admission assessment, with an assessment reference date (ARD) of 07/13/10, she had problems with both long and short term memory, she was not oriented to person, place, or season, her cognitive skills for daily decision making were moderately impaired, she required the extensive physical assistance of one (1) person for bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, and bathing, and she was frequently incontinent of both bowel and bladder. During this assessment reference period, the resident did not walk, and her primary mode of locomotion was via a wheelchair. She received the services of speech, occupational, and physical therapy five (5) days a week during this assessment period, and a trunk restraint was used daily. According to a Medicare 14-day full assessment, with an ARD of 07/17/10, she had problems with both long and short term memory, she was not oriented to person, place, or season, her cognitive skills for daily decision making were moderately impaired, she required the extensive physical assistance of one (1) person for locomotion, dressing, and personal hygiene, and she required the extensive physical assistance of two (2) persons for bed mobility, transfer, and toilet use. During this assessment reference period, the resident did not walk. She received the services of speech, occupational, and physical therapy five (5) days a week during this assessment period, and a trunk restraint was used daily. - 3. Documentation by the physical therapist revealed Resident #57 received physical therapy from 07/07/10 through 07/27/10. Under the heading ""Summary of Care"" was noted: ""Summary of Progress:: pt. (sic) not progressing well, difficulty with cooperation and partiicipation (sic) secondary to dementia and decreased insight and safety, decreased intake as well as making participation difficult. family (sic) not in for training or education. recommend (sic) assist and continued PT if able to maximize functional mobility and assisted mobility."" Under the heading ""Discharge Recommendations"" was noted: ""Discharge Setting: Other (personal care home); Recommended services upon discharge: Home Health Services, A (assistance) with all mobility; Equipment recommended upon discharge: w/c (wheelchair)."" Documentation by the occupational therapist revealed she received occupational therapy from 07/07/10 through 07/28/10. Under the heading ""Summary of Care"" was noted: ""Summary of Progress:: Pt. demo(nstrated) limited progress toward goals due to cognitive level and lack of participation in therapy. Pt. at times will refuse or become beligerant (sic) with therapist. Family and SW (social worker) decided to transfer patient to a personal care home closer to family. Discharge skilled OT treatment."" Under the heading ""Discharge Recommendations"" was noted: ""Discharge Setting: Other (personal care home); Recommended services upon discharge: 24/7 care; Equipment recommended upon discharge: pt. could benefit from w/c and FWW (front-wheeled walker)."" Review of the speech therapy progress notes, for 07/20/10, revealed under the heading ""Current Status"": ""Precautions: puree (diet); nectar-thick fluids; fall risk; easily agitated per hospital records; sundowners"". Under the heading ""Encounter Summary"" was noted: ""... SLP (speech language pathologist) suggested that PCH (personal care home) staff come to facility next week to observe pt in tx (treatment) and determine if she will be appropriate for their setting. Pt's POA (power of attorney) to set this up for next week. ..."" Review of the resident's telephone orders found an order dated 07/27/10 for: ""Home Health w/ (with) PT & OT."" Review of the social service notes revealed Resident #57 was discharged from the nursing facility at 6:00 p.m. on 07/29/10. Review of facility records found no evidence to reflect there had been any discussion between the social worker and the resident's legal representative regarding the appropriateness of discharging Resident #57 from a skilled nursing facility to a legally unlicensed care home in the community, in view of the resident's assessed needs with respect to her level of dependence on staff with activities of daily living, her dysphagia, and her need for monitoring related to her recently diagnosed urinary tract infection. - 4. In an interview on 08/04/10 at 10:45 a.m., the facility's social worker (Employee #59) reported there was no discharge planning meeting held or discharge notice given to the resident's legal representative, but they did discuss discharge during the resident's last care plan meeting. Review of the care plan meeting notes with the social worker, at this time, found no mention of any discharge plan. The social worker reported the physical therapist expressed that Resident #57 had reached a plateau. The social worker reported she then contacted the resident's legal representative, who set everything up for the discharge herself. The social worker did contact the unlicensed care home to ensure they had a mechanical (Hoyer) lift available for use at the facility and twenty-four (24) hour care. The social worker confirmed that no follow-up appointment with a physician had been made, she did not communicate to staff at the unlicensed home that the resident had a history of [REDACTED]. - 5. In a telephone interview on 08/04/10 at 11:10 a.m., Resident #57's legal representative reported she did not receive anything in writing from the facility, but that the social worker called and informed her that Resident #57 had reached a plateau in therapy and needed to be discharged . The legal representative stated the resident's intended discharge date was projected to be in August, but no set date was mentioned, and upon admission she knew there were no long term care beds available at the nursing facility. The legal representative was not sure why the discharge date was moved up and she wished Resident #57 could have stayed at the nursing facility longer, since she was only able to take a few steps with the assistance of two (2) people, one (1) on each side of her. She also reported that Resident #57's transition from the nursing facility to the unlicensed care home was ""rough"". According to the legal representative, Resident #57 had resided in an assisted living facility in Ohio prior to being admitted to the hospital on [DATE]; while there, staff gave Resident #57 alcoholic beverages to drink, and during a visit there, the legal representative found both the resident and her caregiver were intoxicated. During a visit at the unlicensed care home (after her discharge from the nursing facility on 07/29/10), the legal representative found that staff at the unlicensed care home was giving Resident #57 alcoholic beverages; the legal representative quickly intervened but noted the nursing facility failed to inform staff at the unlicensed care home of the need for Resident #57 to abstain from alcohol. Additional information obtained from Resident #57's legal representative during this telephone interview included: - No information had been communicated to the staff at the unlicensed home regarding how to safely assist Resident #57 out of the legal representative's personal vehicle (from a sitting to a standing position), and she reported the mechanical lift at the facility was broken. - No information was communicated to the staff at the unlicensed home of the need to obtain follow-up services from a physician related to the resident's urinary tract infection. The legal representative reported having to take Resident #57 to an Urgent Care provider after her discharge from the facility, because the resident's urine was dark-colored and foul-smelling, and she could not get an appointment with a primary care physician until 08/30/10. - No physical therapy or occupational therapy services had yet been provided to Resident #57 since her admission to the unlicensed care home. -- b) During an interview with the nursing facility's administrator (Employee #53) on 08/04/10 at 12:03 p.m., she stated that discharge planning was primarily the responsibility of the facility's social worker. She confirmed that no reason for the transfer / discharge of Resident #57 was documented, that no written notice prior to transfer was documented, and that no arrangements were made for appropriate transportation, follow-up physician appointment, and ordered adaptive equipment. She agreed there was no evidence to reflect appropriate medical history had been communicated to the receiving facility. She stated the social worker was hired about six (6) months ago, had no previous long term care experience, and, although she had received orientation, she was in need of education on long term care requirements and services. -- c) A review of facility policy and procedures for discharge and transfer, conducted on 08/05/10 at 8:00 a.m., found the following: - Under the section ""Policy"" is stated: ""Customers and/or legal representatives will be provided proper notice in accordance with state and federal regulations should a transfer or discharge be initiated by a Genesis ElderCare Center."" - Under the section ""Process"" is stated as #1: ""The social services department is responsible for coordinating transfers and discharges."" -- d) A review of facility policy and procedures for discharge planning, conducted on 08/05/10 at 8:20 a.m., found under the section ""Policy"": ""Upon admission, all customers will be asked about their discharge goals and assessed for discharge potential. For customers anticipating a short stay, discharge/transition planning will begin upon admission and be completed as part of the Interdisciplinary Care Plan process."" Under the section ""Purpose"" is stated: ""To ensure the most appropriate discharge/transition plan for all customers"" and, ""To provide comprehensive discharge information for all customers, family members, and post-discharge care providers."" -- e) On 08/09/10, the surveyor received additional information that had been submitted by the facility to the State survey agency after the survey team's exit. Among these materials were found ""Rehab UM Meeting"" notes and a discharge transition plan. - Review of the facility's ""Rehab UM Meeting"" notes for Resident #57 on 07/21/10 revealed, ""... D/C (discharge) plan? Lap buddy. Transfers with mod A (moderate assistance) for safety. AMb (sic) (ambulate) - 30ft with Mod A and RW (roller walker).; MBSS (modified [MEDICATION NAME] swallow study) on 7/22 at noon. PO (oral) intake is extremely poor; drinks better on nectar (thickened liquids)."" - Review of the facility's ""Rehab UM Meeting"" notes for Resident #57 on 07/27/10 revealed, ""... D/C plan? Lap buddy. Transfers with max A (maximum assistance) for safety. Pt now not ambulating.; Question pt with UTI (urinary tract infection). Pt with decreased performance."" Handwritten in the block containing Resident #57's name was: ""DC tom (discharge tomorrow) pm"". Review of the resident's discharge transition plan, dated 07/29/10, revealed the following: - ""You can get around (at discharge): With a little help. Devices used: wheelchair"" (There was no mention of a front-wheeled or roller walker.) - ""Get up/down from a seated position (at discharge): W/ at great deal of help"" (There was no mention of the need for the use of any devices when transferring, such as a walker or a mechanical lift.) - ""Your dietary recommendations are: Regular Diet"" (There was no mention pureed foods or thickened liquids.) - On page 3, under the heading of ""Your physician follow-ups"", nothing was written to direct either the resident's family or the receiving facility's staff to contact any physician. (There was no mention of the need to monitor the resident for signs / symptoms of a UTI.) - On page 5 of this document, under the heading ""Your health services provider follow-ups"" were checked ""Physical Therapy"", ""Home Medical Equipment / Supplies"", and ""Pharmacy Provider"". None of the services under ""Home Care Services"" was checked, nor was ""Occupational Therapy"" checked under ""Therapy Services"", as had been ordered by the physician on 07/27/10. Under ""Home Medical Equipment / Supplies"", someone had scratched through information regarding the provider of a wheelchair, but there was no information to indicate a walker had been ordered. There was no mention anywhere on the document of the need to monitor the resident for falling, in view of the fact that she had used a lap buddy when at the nursing facility and had been identified as being at risk for falls by all of the rehabilitative therapy services. No information was communicated in the discharge transition plan regarding any special feeding techniques or alterations needed in the consistencies of foods and fluids to address her dysphagia, the transition plan incorrectly identified her diet as being of regular consistency, and there was no evidence that staff from the unlicensed home had come to the nursing facility to observe the resident during speech therapy to determine if she will be appropriate for their setting, as recommended by the SLP. .",2015-08-01
9912,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-08-05,325,D,0,1,2XEX12,"**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 fifteen (15) sampled residents, to ensure the resident received appropriate treatment and services to maintain acceptable parameters of nutritional status, by failing to ensure all direct care staff was aware of interventions identified by the rehabilitative therapy staff to reduce distractions during meal times and promote good oral 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. In an interview on 08/03/10 at 2:16 p.m., a CNA (Employee #10) reported that Resident #3 eats in the dining room and acknowledged that she (Employee #10) assists this and other residents in the dining room during the lunch meal. Employee #10 identified that, sometimes, Resident #3 eats independently and sometimes she does not; when she does not feed herself, staff provides verbal cues. When asked, Employee #10 stated there was no certain position the resident needs to be in during meals. The last two (2) to three (3) times she has assisted the resident with eating, the resident played with the butter and sugar packets. - 6. In an interview on the afternoon of 08/03/10, the SLP (Employee #67) reported having provided education to staff on 06/15/10 regarding how to assist Resident #3 during meals, noting the inservice sheet was in her office. She returned shortly with the inservice sheet. Review of this inservice sheet found only seven (7) CNAs were educated concerning mealtime techniques to be used with Resident #3. Employee #10 was not among those who received this training. Also at this time, the dietary manager (Employee #54) was in the conference room and was not aware of the interventions suggested by either ST or OT. The assistant director of nurse (ADON - Employee #58), who was also the facility's nurse educator, was in the room, and she was not aware of the inservice provided to CNAs regarding Resident #3. The ADON reviewed the inservice sheet and noted there were no signatures of licensed nurses or dietary staff. The following day (08/04/10), the ADON reported she had been on vacation during the time this staff education was provided. - 7. 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."" .",2015-08-01
9703,LOGAN CENTER,515175,P.O. BOX 540,LOGAN,WV,25601,2010-08-12,164,D,0,1,RDGV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observation, the facility failed to protect the privacy of one (1) of thirty-five (35) Stage II sample residents while care was being rendered. Resident identifier: #67. Facility census: 65. Findings include: a) Resident #67 Observation, on 08/10/10 at 1:05 p.m., found Employee #77 (a respiratory therapist) placing a suctioning catheter into the resident's [MEDICAL CONDITION] and applying suction. The resident coughed and flopped her arms and legs about in the bed. The corridor door was open, and a male visitor was observed to stop in the hallway and watch the employee during the procedure.",2015-10-01
9704,LOGAN CENTER,515175,P.O. BOX 540,LOGAN,WV,25601,2010-08-12,203,E,0,1,RDGV12,"Based on record review and staff interview, the facility failed to provide the correct information for the right to appeal in their uniform notice of transfer / discharge information. The facility's form guided residents to appeal a transfer / discharge decision to the regional ombudsman, the State long-term care (LTC) ombudsman, and the Office of Inspector General (OIG), whereas the OIG is on the only State agency vested with the authority to hear and act upon such appeal requests. This was true for two (2) of nine (9) sampled residents and one (1) resident of random opportunity and had the potential to affect any resident who may be transferred / discharged from the facility. Resident identifiers: #25, #59, and #66. Facility census: 65. Findings include: a) Resident #25 Record review revealed this resident was given a notification of transfer / discharge form when she was transported to scheduled appointments outside the facility on 08/31/10, 09/09/10, 09/16/10, 09/21/10, 10/04/10, 10/12/10, 10/26/10, and 11/01/10. Information on the reverse side of the form identified the resident's right to appeal the action to the regional ombudsman, the State LTC ombudsman, and the OIG. b) Resident #59 Record review revealed this resident was given a notification of transfer / discharge form when she was transported to a scheduled appointment outside the facility on 11/01/10. Information on the reverse side of the form identified the resident's right to appeal the action to the regional ombudsman, the State LTC ombudsman, and the OIG. c) Resident #66 During interview with the licensed social worker (LSW) on 11/03/10, she produced a discharge record of her choice (for Resident #66). Review of this resident's closed record revealed he was discharged to home on 10/29/10 and was given a notification of transfer / discharge form which identified his right to appeal the action to the regional ombudsman, the State LTC ombudsman, and the OIG. The LSW acknowledged the OIG was the only State agency that heard such appeal requests, although the facility's uniform notice identified the regional ombudsman and the State LTC ombudsman as other agencies to which such appeal could be made. The LSW later contacted the corporate website and downloaded the correct transfer / discharge information, and she stated all the old transfer / discharge forms were thrown away.",2015-10-01
9705,LOGAN CENTER,515175,P.O. BOX 540,LOGAN,WV,25601,2010-08-12,225,E,0,1,RDGV11,"Based on review of the facility's complaint records (for the period of 02/02/10 through 07/20/10) and staff interview, the facility failed to ensure all reports of missing items were thoroughly investigated to assure misappropriation of resident property had not occurred. This was true for six (6) of sixteen (16) complaint records involving missing items. Resident identifiers: #26, #36, #42, #20, #6, and #100. Facility census: 65. Findings include: a) Resident #26 Review of the facility's complaint files, on 08/06/10, revealed a complaint record dated 02/12/10. The resident's family complained of shampoo and personal items, which had been bought by the family, were disappearing. The facility's resolution was to keep the resident's personal items at the nursing station and noted on the complaint form that the issue was resolved. There was no evidence of efforts by the facility to ascertain whether the complainant believed the items were lost or stolen. - b) Resident #36 Review of the facility's complaint files, on 08/06/10, revealed a complaint record dated 04/28/10. The resident's family complained, during a care planning conference, of a missing hair dryer, combs, and brushes. The facility replaced the items and noted on the complaint form that the issue was resolved. There was no evidence of efforts by the facility to ascertain whether the complainant believed the items were lost or stolen. - c) Resident #42 Review of the facility's complaint files, on 08/06/10, revealed a complaint record dated 04/12/10. The resident's family complained of a pair of missing earrings. The facility advised the family to purchase a new pair of earrings and the facility would reimburse the family for the earrings. There was no evidence of efforts by the facility to ascertain whether the complainant believed the items were lost or stolen. - d) Resident #20 Review of the facility's complaint files, on 08/06/10, revealed a complaint record dated 04/22/10. The resident's family complained of a missing white cosmetic bag, a striped coin purse containing a $5 bill, and a powder compact. The facility replaced the $5 and indicated, on the complaint form, that the issue was resolved. There was no evidence of efforts by the facility to ascertain whether the complainant believed the items were lost or stolen. - e) Resident #6 Review of the facility's complaint files, on 08/06/10, revealed a complaint record dated 03/30/10. The resident complained he had $10 in a wallet in his drawer, and it was missing. The facility provided the resident with a lock box and indicated on the complaint form that the issue was resolved. There was no evidence of efforts by the facility to ascertain whether the resident believed the money was lost or stolen. - f) Resident #100 Review of the facility's complaint files, on 08/06/10, revealed a complaint record dated 02/24/10. The resident complained someone came into his room while he was gone and took fifteen (15) Ziploc bags, three (3) gel pens, and two (2) permanent markers. There was no evidence of efforts by the facility to ascertain whether the resident believed the items were lost or stolen. Interview with the social worker (SW), at 4:00 p.m., on 08/09/10 revealed the items were provided the resident by the facility, so she did not realize these missing items required reporting and/or investigating. - g) Interview with the SW, at 4:00 p.m. on 08/09/10, revealed she was unaware that, if the missing items were replaced and/or if the resident and family were satisfied with the resolutions, the facility needed to investigate missing items to rule out misappropriation of property within the facility. The SW was of the belief that a resident or family member had to state that someone had taken or stolen something before she was required to investigate and report this as possible misappropriation of resident property.",2015-10-01
9706,LOGAN CENTER,515175,P.O. BOX 540,LOGAN,WV,25601,2010-08-12,226,D,0,1,RDGV11,"Based on observation and staff interview, the facility failed to implement policies and procedures to prohibit neglect for one (1) resident identified during a random opportunity for observation. This resident was asking, over and over, for assistance, and five (5) staff members who were within close proximity failed to respond. Resident identifier: #74. Facility census: 65. Finding include: a) Resident #74 On 08/04/10 at 1:00 p.m., observation found this resident seated in front of the nurse's station. She was loudly calling help, help over and over again. No nursing assistants were observed in the area; however, further observation found Employee #7 was passing medications on the 300 Hall, and Employee #14 was passing medications on the 100 Hall. Each of these employees was a licensed practical nurse. In addition, three (3) non-nursing personnel (Employees #1, #70, and #62 - all laundry personnel) were having a conversation at the door of the lounge across from the nurse's station. All five (5) facility employees were close enough to hear the resident. When no staff approached the resident, the surveyor approached the resident and asked her if she needed something. The resident stated, I have to go to the bathroom so bad I'm afraid I'm going to wet myself. The surveyor approached Employee #7 and explained the situation. Employee #7 summoned Employee #8 (a nursing assistant) and asked Employee #8 to take the resident to the bathroom. The resident was then immediately taken to the bathroom At 1:10 p.m. on 08/04/10, an interview was conducted with Employee #8. Upon inquiry, Employee #8 stated the resident had voided when she was taken to the bathroom.",2015-10-01
9707,LOGAN CENTER,515175,P.O. BOX 540,LOGAN,WV,25601,2010-08-12,252,D,0,1,RDGV11,"Based on observation, the facility failed to provide a clean, comfortable, homelike environment for each resident. Two (2) resident rooms were noted to have a pungent odor of urine. One (1) of the residents was noted to have a dried, light brown stain on the bottom sheet of his bed in the area of his hips. Both residents had roommates who were alert and oriented. Resident identifiers: #29 and #8. Facility census: 65. Findings include: a) Resident #29 1. On 08/03/10 at 7:29 a.m., the resident received his morning medications. The resident was sitting up in bed and had begun eating breakfast. A strong odor of urine was noted. Three (3) urinals were observed - one (1) was on his bedside table and two (2) were hanging off of the wastebasket by his bed. None of the urinals appeared to contain urine. The odor persisted for at least one (1) hour. 2. A slight urine odor was noted on 08/24/10 at approximately 1:45 p.m., while the resident was being interviewed. At this time, two (2) of his three (3) urinals contained medium yellow urine. - b) Resident #8 On 08/04/10 at 9:59 a.m., observations of this resident were conducted. A strong odor of stale urine was detected in his room which was more pungent when near his bed. A dried, brown urine ring was noted on the sheet covering his mattress, in the area of his hips. A second observation was made at 10:05 a.m. with another survey team member for verification.",2015-10-01
9708,LOGAN CENTER,515175,P.O. BOX 540,LOGAN,WV,25601,2010-08-12,272,D,0,1,RDGV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of medical records, and review of facility documents, the facility failed to assess one (1) of thirty-five (35) Stage II sample residents for physical functioning and structural problems. This resident had two (2) incidents in which she sustained skin tears from her nails while being turned by staff. At the time of the survey, her nails appeared neatly trimmed for the most part, but some of her nails were found to have sharp corners. Resident identifier: #43. Facility census: 65. Findings include: a) Resident #43 Review of the resident's medical record noted physician's orders [REDACTED]. She also had partial loss of voluntary movement. Review of facility reports found a report, dated 06/29/10 at 3:00 a.m., which noted, Resident in bed while being turned by staff, resident's thumb nail slid across (R) (right) elbow causing sm (small) tear to (R) elbow. New orders to clean (R) elbow /c (with) NSS (normal saline solution) dry drg (dressing) apply exuderm q (every) 3 days. Another report, dated 07/28/10 at 9:30 a.m., noted, CNA (certified nursing assistant) was turning resident and resident's left hand scraped her right forearm with her finger nail causing a (sic) eccomotic (sic) area to open, 1 cm x 1 cm, fingernails trimmed. Observations, during the afternoon on 08/11/10, found the resident had a sharp corner on the index finger of her left hand and one (1) on the middle finger of her right hand. There was no evidence the similar injuries had been identified and addressed by the facility.",2015-10-01
9709,LOGAN CENTER,515175,P.O. BOX 540,LOGAN,WV,25601,2010-08-12,278,D,0,1,RDGV12,"Based on record review and staff interview, the facility failed to assure the accuracy of a minimum data set (MDS) assessment for one (1) of nine (9) sampled residents. A resident who was coded as having moderate or severe visual impairment was erroneously coded as having no vision appliances (glasses). Resident identifier: #38. Facility census: 65. Findings include: a) Resident #38 Record review revealed the assessor, in Section D of this resident's admission MDS 2.0 with an assessment reference date (ARD) of 07/20/10, encoded the resident as having highly impaired vision and not using any glasses, contact lenses, or a magnifying glass. Record review revealed the assessor, in Section B of the quarterly MDS 3.0, signed 10/12/10, encoded the resident as to have moderately impaired vision and as having no corrective lenses. Observations of the resident, on 11/01/10, 11/02/10, and 11/03/10, found her to be wearing eye glasses. Review of her current care plan revealed she was care planned for vision deficits and for the use of glasses. During an interview with Employee #60 on 11/03/10, she acknowledged the MDS nurse had encoded the assessments in error to indicate the resident had no glasses. Subsequently, she corrected the admission MDS 2.0 but said she was uncertain if the quarterly MDS 3.0 could be corrected with the new system and it may need to wait until the next MDS is due. She also reported she checked the care plans of this and all residents to verify the preference for and/or use of glasses was included. This information was provided to the person in charge (Employee #26) on 11/03/10, and no additional information was produced prior to exit.",2015-10-01
9710,LOGAN CENTER,515175,P.O. BOX 540,LOGAN,WV,25601,2010-08-12,280,D,0,1,RDGV11,"Based on observation, medical record review, care plan review, and staff interview, the facility failed to review / revise the care plan of one (1) of thirty-five (35) Stage II sample residents, to reflect the resident's current needs and preferences. Resident identifier: #47. Facility census: 65. Findings include: a) Resident #47 Medical record review and care plan review for Resident #47, conducted on 08/09/10 at approximately 8:00 a.m., revealed he wore glasses. The care plan for activities stated the facility would remind the resident to wear his glasses when out of bed and especially when going to activities. On the afternoon of 08/09/10, Resident #47 attended an activity in the dining room. He did not have glasses on at that time. The activity director, who was present in the dining room for this activity, did not know the resident needed glasses. The resident ate breakfast in the dining room on 08/10/10 and did not have glasses on at that time. Employee #51 (nurse aide) stated the resident did not like to wear his glasses. Another observation of the resident, at lunch on 08/10/10, again found he was not wearing his glasses. During an interview at 8:30 a.m. on 08/11/10, the clinical reimbursement coordinator (Employee #57) stated the resident wore glasses when he first came to the facility, but he did not wear them now. The activity staff, nurse aides, director of nursing, and clinical reimbursement coordinator all stated the resident rarely wore his glasses. The clinical reimbursement coordinator agreed the care plan needed to reflect the resident's preference to not wear his glasses in spite of his need for them.",2015-10-01
9711,LOGAN CENTER,515175,P.O. BOX 540,LOGAN,WV,25601,2010-08-12,281,E,0,1,RDGV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, review of medication package inserts from the manufacturers, and review of the facility's medication schedules, the facility failed to administer certain medications (such as antibiotics) at regularly spaced intervals to attain optimal benefit; instead, the doses were administered at intervals that would not ensure optimal blood levels of the antibiotics were maintained over the course of a twenty-four (24) hour period. Review of medication administration records (MARs) found four (4) of thirty-five (35) Stage II sample residents received antibiotics in such a manner. Resident identifiers: #16, #41, #47, and #36. Facility census: 65. Findings include: a) Residents #41 and #16 During reconciliation of medications, it was noted that the majority of medications ordered twice-a-day (BID) were scheduled for administration either at 8:00 a.m. and 4:00 p.m. or at 9:00 a.m. and 5:00 p.m. This applied to all types of medications, including but not limited to antibiotics, antipsychotics, antihypertensives, and cardiac drugs. These schedules provide the two (2) daily doses in a nine (9) hour period, leaving an interval of fifteen (15) hours between the last dose of the day and the first dose of the next day, which would not maintain consistent blood levels of the antibiotic. Review of medication administration records found the following examples: 1. Resident #41 On 08/03/10, an order had been written for: [MEDICATION NAME] 500 mg by mouth 2 x daily x 10 days for UTI (urinary tract infection). The medication was scheduled for administration at 9:00 a.m. and 5:00 p.m., and not at regular intervals of every twelve (12) hours. This would not maintain the levels of the antibiotic in the resident's system to achieve optimal benefit. (This antibiotic was changed after six (6) doses.) On 08/06/10, [MEDICATION NAME] 100 mg by mouth two times daily 10 days UTI had been ordered. This was also scheduled for administration at 9:00 a.m. and 5:00 p.m. Again, this would not maintain the levels of the antibiotic in the resident's system to achieve optimal benefit. 2. Resident #16 An order had been written for: Bactrim DS 1 tab - by mouth (PO) BID - x 14 days. This was scheduled for administration at 9:00 a.m. and 5:00 p.m. This would not maintain the levels of the antibiotic in the resident's system to achieve optimal benefit. - b) Resident #47 On 08/09/10, the physician ordered: Keflex ([MEDICATION NAME]) 500 mg by mouth 3 x daily for [MEDICAL CONDITION] lower ext. (extremities). This medication was scheduled for administration at 8:00 a.m. - 1:00 p.m. - 5:00 p.m. and not at regular intervals of every eight (8) hours. This schedule provided these three (3) daily doses in a nine (9) hour period, leaving an interval of fifteen (15) hours between the last dose of the day and the first dose of the next day, which would not maintain consistent blood levels of the antibiotic. - c) Resident #36 Review of this resident's medications revealed a physician's orders [REDACTED]. This was brought to the attention of the director of nursing (DON), who reviewed the facility's drug handbook, Nursing 2010 Drug Handbook, and reported it contained the same information regarding the recommended dosage spacing for [MEDICATION NAME] 875 mg. - d) The copy of the facility's medication pass times provided with the requested documents at the time of entrance to the facility was reviewed. The instructions at the top of the page included: Routine medications are to be administered according to the following schedule: The policy indicate that BID was either 8am and 4pm or 9am and 5pm. There were no specific provisions for scheduling of antibiotics (or other medications for which it would be beneficial to maintain blood levels) at alternate times. Review of package inserts (obtained from the Food and Drug Administration's website) from the pharmaceutical companies for each of these antibiotics found, under the section for: Dosage and Administration for each drug, the instructions included 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. In an interview with the director of nursing (DON), in the mid-day on 08/11/10, she said they were trying to streamline the drug pass and to keep from waking people up at night. She agreed the antibiotics should not be scheduled at these stated routine times.",2015-10-01
9712,LOGAN CENTER,515175,P.O. BOX 540,LOGAN,WV,25601,2010-08-12,310,D,0,1,RDGV11,"Based on observations and resident interview, the facility failed to ensure residents were positioned to facilitate each resident's ability to eat independently. Two (2) of thirty-five (35) Stage II sample residents were found to be eating breakfast in bed without having been positioned to enhance their abilities to feed themselves. Resident identifiers: #95 and #15. Facility census: 65. Findings include: a) Resident #95 Observation, on 08/03/10 at 7:36 a.m., found the resident in bed while eating breakfast. The head of her bed had been elevated, and pillows had been placed behind her. She had slid down in the bed, so that she was actually only elevated to about 45 degrees. She was leaning slightly to her left and eating with her right hand. When interviewed, she said it was a bit difficult to reach her food on the overbed table. The resident was again observed while eating breakfast on 08/11/10. Her torso was elevated to approximately 75 degrees. She had slid down in the bed and was leaning on the flat surface of the bed on her left elbow. When asked if she thought it would help to sit up straighter, she said, It would help. A staff member was informed of the resident's need for assistance. After the resident was repositioned, she said it had made it easier for her to eat. The resident's most recent minimum data set (MDS) assessment, a Medicare 14-day assessment, indicated the resident needed extensive assist for bed mobility. This was also noted on her admission MDS with an assessment reference date (ARD) of 07/30/10. - b) Resident #15 Observation, on 08/03/10, found the resident eating breakfast while in bed. The head of her bed was at approximately 45 degrees. She had slid down in her bed, causing her back to bend in the lumbar area. This positioning made it more difficult for her to reach her food tray sitting on her overbed table. According to the resident's admission MDS assessment, with an ARD of 05/05/10, she required extensive assist for bed mobility. She needed assistance from staff for positioning in bed to facilitate ease in consuming her meal.",2015-10-01
9713,LOGAN CENTER,515175,P.O. BOX 540,LOGAN,WV,25601,2010-08-12,312,D,0,1,RDGV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, family comments, and staff interview, the facility failed to provide, to two (2) of thirty-five (35) Stage II sample residents who were unable to carry out activities of daily living (ADLs), with the necessary care and services to maintain good grooming and personal hygiene. Resident identifiers: #43 and #8. Facility census: 65. Findings include: a) Resident #43 Record review found the resident was assessed as requiring extensive assistance to being totally dependent for activities of daily living. She also had partial loss of voluntary movement Observation of the resident, on 08/04/10 and throughout the survey, found she moved about very little independently. She would demonstrate some spastic type movements when moved about by staff. During review of the resident's medical record, it was noted she had orders for treatment of [REDACTED]. Documentation also noted the resident had fragile skin. The resident's care plan included goals for: The resident will not experience any injury d/t (due to) husband repositioning her. Another goal was for her not to . experience any problems related to husband feeding her or repositioning her or providing care. There was also a goal for grooming which included an intervention for: Staff to provide daily care: . provide oral care, hair care, nail / skin care. Observations, in mid-afternoon on 08/11/10, found the resident had a sharp corner on the index finger of her left hand and another sharp corner on the middle finger of her right hand. At this time, her husband, who was visiting, commented that he trimmed her nails. - b) Resident #8 Observation, on 08/04/10 at 9:59 a.m., found the resident to have what appeared to be several days worth of beard growth, to be in need of nail care (soiled fingernails), to have bed linens with a dried urine stain and the strong odor of stale urine present, and to have exudate stringing between his parted lips.",2015-10-01
9714,LOGAN CENTER,515175,P.O. BOX 540,LOGAN,WV,25601,2010-08-12,313,D,0,1,RDGV11,"Based on observation, medical record review, care plan review, and staff interview, the facility failed to ensure the need for corrective vision wear (glasses), for one (1) of thirty-five (35) Stage II sample resident, was adequately assessed or addressed. Resident identifier: #47. Facility census: 65. Findings include: a) Resident #47 Care plan review for Resident #47, conducted on 08/09/10, found an intervention directing staff to remind him to wear his glasses when out of bed and especially when going to activities. On the afternoon of 08/09/10, observation found Resident #47 attending an activity in the dining room. He did not have glasses on at that time. When asked, the staff did not know if he needed or had glasses. The activity director, also present in the dining room for this activity, did not know whether the resident needed glasses. The resident ate breakfast in the dining room on 08/10/10 and did not have glasses on at that time. Employee #51 (nurse aide) stated the resident did not like to wear his glasses. Another observation of the resident, at lunch on 08/10/10, found he, again, was not wearing his glasses. In an interview at 8:30 a.m. on 08/11/10, the clinical reimbursement coordinator (Employee #57) stated the resident wore glasses when he first came to the facility but did not wear them now. At approximately 10:00 a.m. on 08/11/10, the activity assistant (Employee #35) had found the resident's glasses. Prior to surveyor intervention on 08/09/10, no one had noticed the resident had a need for glasses when going to meals and activities.",2015-10-01
9715,LOGAN CENTER,515175,P.O. BOX 540,LOGAN,WV,25601,2010-08-12,317,D,0,1,RDGV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and review of medical records, the facility failed, for one (1) of thirty-five (35) Stage II sample residents, to ensure a resident entered the facility without limited range of motion did not experience a reduction in range of motion unless the resident's clinical condition demonstrated a reduction in range of motion was unavoidable. According to her assessments, Resident #43 had entered the facility without contractures. She had current orders for hand rolls to be placed in her hands, but these were absent during the majority of observations. Resident identifier: #43. Facility census: 65. Findings include: a) Resident #43 The resident was observed, on the morning of the initial tour (08/03/10) and on subsequent days, without hand rolls in her hands as directed by her care plan. Review of this [AGE] year old resident's minimum data set (MDS) assessments found she had developed contractures of her hands and wrists in the last year. Her annual assessment, with an assessment reference date (ARD) of 08/07/09, indicated she had no contractures of the upper extremities. She went to the hospital on [DATE] and returned on 10/14/09. Her quarterly assessment, with an ARD of 11/06/09, did not reflect any contractures of the upper extremities, nor did her quarterly assessment with an ARD of 02/03/10. However, the 05/03/10 quarterly assessment indicated she had contractures of the hand, wrist, elbow, shoulder, and neck. A physician's orders [REDACTED]. Periodic observations throughout the survey did not find hand rolls in place. For example: - On 08/10/10 at 9:00 a.m., the resident was observed not to have her hand rolls in place. At 10:05 a.m., the resident still had no devices in hands. - On 08/10/10 at 11:25 a.m., Employee #2 (a licensed practical nurse) started the resident's tube feeding. The resident had a rolled washcloth in place in her left hand, but the one (1) in the right hand had come. An hour later, the hand roll still had not been replaced in her right hand.",2015-10-01