rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
498,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,578,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the resident's advance directives, communicated via the Physician order [REDACTED]. Resident identifier: #38. Facility census: 100. Findings included: a) Resident #38 Review of the medical record found the Resident lacked capacity to make medical decisions, and her son was her legal representative. Review of the current POST form noted the Resident did not wish to be resuscitated, have comfort measures, a feeding tube, or IV fluids for a trial period of no longer than 3-5 days. Under the heading, signature of Patient/Resident, the form noted verbal consent was obtained from (Name of son) via phone on 09/29/19. The physician signed the POST form on 08/01/19, although the POST form indicated the Resident's son did not complete the form until 09/29/19. The date the form was prepared by a facility nurse was 07/29/19. The resident's electronic medical record as well as the current care plan directed, do not attempt resuscitation, or comfort measures. Review of the instructions for the 2016 edition entitled, Using the POST form, section D, found: The patient or representative/surrogate and physician/APRN (Advanced Practice Registered Nurse) must sign the form in this section. These signatures are mandatory. A form lacking these signatures is NOT valid. The physician/APRN then prints his/her name, phone number, and the date and time the orders were written. On 01/29/20 at 10:10 AM, the facility social worker (SW) #81 verified the Resident's son did not sign the POST form. SW #81 said she did not know anything about the POST form because she was not present when the POST form was completed. The POST form was discussed with the administrator at 8:06 AM on [DATE]. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
499,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,580,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record interview and interview, the facility failed to notify the physician when medications were held for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #98. Facility census: 100. Findings included: a) Resident #98 Review of Resident #98's medical records found the resident was ordered to receive [MEDICATION NAME] 5/325 milligrams (mg) via the feeding tube three times daily for pain and [MEDICATION NAME] 0.25 mg via feeding tube three times a day for anxiety. Review of Resident #98's nurses progress notes found on 10/31/19 at 6:55 PM, a Licensed Practical Nurse (LPN) #138 held the [MEDICATION NAME] and [MEDICATION NAME]. Note attached to the holding of [MEDICATION NAME] and [MEDICATION NAME] as follows: Medication held due to drowsiness, spoke with son and he was also in agreement to hold the medication. There was no documentation the physician was notified of the withholding of the medication. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/03/20 at 1:15 PM, they verified after reviewing the medical records for Resident #98, the physician had not been notified of the withholding of [MEDICATION NAME] and [MEDICATION NAME] on 10/31/19. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
500,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,584,D,0,1,CN2N11,"Based on record review and interview, the facility failed to ensure reasonable care for the protection of resident's personal property from loss or theft for one (1) of one (1) resident reviewed for the care area of personal property. Resident identifier: #58. Facility census: 100. Findings included: a) Resident #58 On 0[DATE] 03:01 PM, the Resident's son said he had no problems with the facility other than, They lose clothes in laundry sometimes they find them, sometimes not. It's just aggravating not a big problem. I have been labeling them myself. Sometimes they don't label them, and I think that is what causes the problem. Review of the notes in the electronic medical record found a progress note, dated 06/27/19 at 9:14 AM, during a care conference for the resident, his son raised his concern that his mother had some articles of clothing that are missing. At 11:44 AM on 01/28/20, the Social Worker (SW) #33 confirmed she could not find information to indicate the investigation into the allegation of missing clothing. SW #33 said someone at the facility should have completed a complaint form, then this allegation would have been assigned to someone in environmental services. She said if an item is missing and we can confirm the Resident had the item, the facility would reimburse the family member or replace the missing item. At 8:06 AM on [DATE], the Administrator was informed of the above information. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
501,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,623,D,0,1,CN2N11,"Based on record review and staff interview, the facility failed to provide the Ombudsman with notification of a resident's transfer to the hospital for one (1) of two (2) residents reviewed for the care area of hospitalization . Resident identifier: #[AGE]. Facility census: 100. Findings included: a) Resident #[AGE] A record review for Resident #[AGE] on 01/28/20, revealed two (2) Minimum Data Sets dated [DATE] and 12/24/20 for transfer to an acute care hospital. Further review indicated there had been no notifications of these hospitalization s sent to the Ombudsman. On 02/03/20 at 1:52 PM, the Nursing Home Administrator (NHA) verified there were no notices sent to the Ombudsman for hospitalization s on [DATE] and 12/24/19. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
502,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,641,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) for three of 20 residents. Resident identifiers: #99, #38, #98. Facility census: 100. Findings included: a) Resident #99 Review of Resident #99's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 01/12/20, stated the resident had two (2) Stage 2 pressure ulcers. Resident #99's Pressure Ulcer Reassessment dated [DATE], documented a Stage 4 pressure ulcer on the left buttock. An initial Pressure Ulcer Assessment also performed on 01/07/20 documented a new unstageable pressure ulcer on Resident #99's sacrum. Resident #99's Pressure Ulcer Reassessments dated 01/14/20 documented a Stage 4 pressure ulcer on the left buttock and a Stage 3 pressure ulcer on the left buttock. During an interview on 02/03/20 at 11:46 AM, the Regional Director of Operations stated Resident #99's MDS with ARD 1/12/20 was incorrect. She stated Resident #99 did not have two (2) Stage 2 pressure ulcers at that time. No further information was provided through the completion of the survey. b) Resident #38 Review of Resident's quarterly, Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/19, coded the resident as receiving an anticoagulant for 2 days during the assessment period. Review of the Medication Administration Record [REDACTED]. At 2:26 PM on 01/29/20, during an interview with the nursing coordinator #139, it was confirmed the MDS was incorrectly coded, and the resident did not receive an anticoagulant. c) Resident #98 Review of the Resident's medical record found a comprehensive (5-day) minimum data set (MDS) with an assessment reference date (ARD) of [DATE], coded as the Resident received a hypnotic medication. Review of the November 2019, physician orders [REDACTED]. At 01/31/20 at 12:54 pm, the MDS registered nurse employee #139, confirmed the MDS was incorrect. In addition, E #139 confirmed the resident was not ordered a hypnotic. E #139 said she would correct this MDS error. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
503,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,656,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a person-centered comprehensive care plan for one of twenty (20) residents reviewed. The care plan for Resident #57 was not developed for the [DIAGNOSES REDACTED].#57. Facility census: 100. Findings included: a) Resident #57 A record review on 01/29/20, revealed the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/20/20, indicated the Resident had a [DIAGNOSES REDACTED]. During an interview on 01/29/20 at 11:15 AM, the Director of Nursing (DON) verified the care plan had not been developed for the [DIAGNOSES REDACTED].#57. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
504,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,657,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise the comprehensive care plan for one of 20 residents reviewed. Resident identifier: #17. Facility census: 100. Findings included: a) Resident #17 Review of Resident #17's comprehensive care plan revealed the following focus, (Resident's name) has an ADL Self Care Performance Deficit r/t (related to) stroke, left [MEDICAL CONDITION]. Interventions included, Bathing: The resident requires 1 staff participation with bathing.Resident receives a shower on Monday/Thursday and a bed bath the remaining days. Review of Resident #17's task report for January 2020, revealed she received showers on Tuesdays and Fridays. During an interview on 01/29/20 at 9:49 AM, the Director of Nursing (DON) verified Resident #17 received showers on Tuesdays and Fridays, but her care plan stated she received showers on Mondays and Thursdays. The DON stated she would update the care plan to reflect Resident #17 received showers on Tuesdays and Fridays. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
505,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,684,E,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure one (1) of five (5) residents discharged from the facility received treatment and care in accordance with professional standards of practice. Nursing staff failed to follow physician's orders [REDACTED]. Resident identifier: #103. Facility census: 100. Findings included: a) Resident #103 Record review found the Resident was admitted to the facility on [DATE]. The Resident was discharged to home on 07/12/19. On 06/25/19 the physician wrote an order for [REDACTED].>Accu-Check ac and hs; notify FNP (family nurse practioner) or MD ( if greater than 350 or less than [AGE]. before meals and at bedtime. This order remained in effect until the Resident was discharged on [DATE]. Review of the Medication Administration Record [REDACTED]. On the following dates and times, the Resident's blood sugar (BS) was over 350 and the physician was not notified: --06/25/19 at 9:00 PM, BS- 392 --06/26/19 at 11:30 AM, BS - 399 --06/26/19 at 5:30 PM, BS - 387 --06/26/19 at 9:00 PM, BS - 400 --06/27/19 at 11:30 AM, BS 396 --06/27/19 at 5:30 PM, BS - 3[AGE] --06/28/19 at 11:30 AM, BS - 371 --07/01/19 at 5:30 PM, BS - 390 --07/02/19 at 9:00 PM, BS - 392 --07/03/19 at 5:30 PM, BS - 389 --07/03/19 at 9:00 PM, BS - 399 --07/06/19 at 9:00 PM, BS - 370 --07/07/19 at 9:00 PM, BS - 367 --07/09/19 at 11:30 AM, BS - 366 --07/11/19 at 9:00 PM, BS - 394 On 15 occasions during the resident's 19 day stay at the facility the Resident's BS was over 350 and the physician was not notified. In addition the Resident's blood sugar was over 400 on two (2) occasions when the physician was contacted. On 06/25/19 the physician was contacted for a blood sugar reading of 404 at 5:30 PM. New orders were written to start sliding scale [MED] ([MEDICATION NAME]) for 7 days and give 10 units of [MEDICATION NAME] at this time. Sliding scale [MED] was to be administered per sliding scale at 7:30 AM, 11:30 AM, 5:30 PM and 9:00 AM. There was no indication on the MAR indicated [REDACTED]. This new order noted the physician should be contacted when BS was over 400. However, the original order continued on the MAR indicated [REDACTED]. On 07/06/19 a new order was written to give [MEDICATION NAME] solution 100 unit/ML, sliding scale at 9:00 AM and 9:00 PM. On 07/06/19 at 9:00 PM the BS was recorded as 387 under this order. But at the same time the Resident's BS was recorded to be 370 on another order at 9:00 PM. At 2:00 PM on 01/28/20, during an interivew with the Director of Nursing (DON) reviewed the MAR's with the surveyor. The DON confirmed the facility did not notify the physician when the resident's BS was over 350 on 15 occasions as directed by the order on the MAR. The DON was unable to find evidence the Resident received 10 units of [MEDICATION NAME] at 5:30 PM on 06/25/19. The DON said a onetime order should have been written to give the 10 units of [MEDICATION NAME] at 5:30 PM on 06/25/19. On 02/03/20 03:59 PM, the Resident's physician reviewed the orders with the surveyor. The physician confirmed there was no evidence to indicate he was contacted when the Resident's BS was over 350. The physician said, He (indicating the Resident) had a long acting [MED] also so I would not have changed any orders had I known. At 8:30 AM on [DATE], the above issues were presented to the administrator. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
506,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,690,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident received the appropriate treatment for [REDACTED]. In addition, this placed the resident at risk for developing antibiotic-resistance. Resident identifier: #57. Facility census: 100. Findings included: a) Resident #57 Record review on 01/29/20, revealed on 12/31/19 the physician ordered a urinalysis with culture and sensitivity (UA/C&S). The C&S culture results were received by the facility on 01/04/20 with Escherichia coli (E coli) cultured at a colony count greater than 100,000. The physician was contacted with the results and [MEDICATION NAME] milligrams (mg) two (2) times a day for 10 (ten) days. A review of the Medication Administration Record [REDACTED]. Review of the C&S report found [MEDICATION NAME] (Cipro) is Resistant (R) to E coli and not an effective antibiotic to treat this organism. In an interview with the facility Medical Director (MD) on 01/29/20 at 4:10 PM. The MD reported he would not have [MEDICATION NAME] Resident #57 if he had been told it was resistant. On 01/29/20 at 2:10 PM, the Director of Nursing (DON) confirmed Resident #57 had received the wrong antibiotic. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
507,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,693,E,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure water flushes, for a resident with a feeding tube, were provided as directed by the physician. This was true for one (1) of two (2) residents reviewed for the care area of feeding tube. Resident identifier: #98. Facility Census: 100. Findings included: a) Resident #98 Review of Resident #98's, record found she was admitted to the facility on [DATE]. Record review also revealed, the resident was to have nothing by mouth (NPO) and received all of her nutrition and fluids through the feeding tube due to a prior [MEDICAL CONDITIONS]. Physician order [REDACTED]. --10/07/19 through 10/11/19- Water flushes via the tube feeding- 90 cubic centimeters (cc) every six (6) hours-12 am- 6 am- 12 pm- 6 pm. --10/12/19 through current - Water flushes via the tube feeding- 1[AGE] cc every four (4) hours-12 am- 4 am- 8 am- 11 am- 5 pm and 8pm. Review of Resident #98's Medication Administration Record [REDACTED] --10/07/19 at 6 pm. --10/11/19 at 4 pm. --10/14/19 at 4 pm. --10/16/19 at 4 pm. --10/23/19 at 12 pm. --11/01/19 at 8 am. --11/04/19 at 8 am. --11/25/19 at 8 am. --[DATE] at 4 pm. --12/04/19 at 8 am. --12/06/19 at 11 am. --12/09/19 at 5 pm. --12/13/19 at 5 pm. --[DATE] at 5 pm. --12/22/19 at 8 am. --12/24/19 at 8 am and 11 am. --[DATE] at 11 am. --12/29/19 at 8 am and 11 am. --01/03/20 at 8 am and 11 am. --01/06/20 at 11 am. --0[DATE] at 11 am and 5 pm. --01/13/20 at 5 pm. --[DATE] at 5 pm. --01/20/20 at 11 am and 5 pm. --01/24/20 at 11 am. On 02/03/20 at 1:15 pm, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) verified, after review of the medical records for Resident #98, the water flushes as mentioned above had not been given due to [MEDICAL TREATMENT] treatments. The physician/registered dietician had not been notified to arrange water flushes to accommodate her [MEDICAL TREATMENT] treatments to ensure the proper hydration was maintained. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
508,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,697,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to manage the resident's pain in accordance with facility policy and physician order. This was true for one (1) of three (3) of residents reviewed for the care area of pain. Resident identifier: #17. Facility census: 100. Findings included: a) Policy Review According to the facility's policy entitled, Medication Administration - general guidelines with effective date 1/1/17 When PRN medications are administered, the following documentation is provided: .Complaints or symptoms for which the medication was given, including any nonpharmacologic interventions attempted by the nursing staff prior to administration of the PRN medication. b) Resident #17 Review of Resident #17's physician's orders [REDACTED]. Resident #17 also had an order initiated 03/01/19 to evaluate for signs and symptoms of pain every four (4) hours. This pain assessment was performed daily at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. From January 1, 2020, through January 14, 2020, Resident #17's pain was assessed as 0 on a scale from 1-10. A score of 0 indicates the absence of pain. On 01/13/20 Resident #17's [MED] with [MEDICATION NAME] order was changed from a scheduled order three times per day to one tablet by mouth every six hours as needed for pain. For this medication, the MAR indicated [REDACTED]. On 01/14/20, Resident #17's pain assessment order was changed to evaluate for signs and symptoms of pain every six (6) hours. This pain assessment was performed daily at 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM. Resident #17's pain was assessed as 0 on a scale from 1-10 at each assessment from 01/14/20 through 01/28/20. On 01/14/20 at 6:55 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was assessed as level 6, on a scale from 1-10. The medication was documented as effective. On [DATE] at 8:07 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was reported as level 4, on a scale from 1-10. The medication was documented as effective. On 01/20/20 at 7:39 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was reported as level 5, on a scale from 1-10. The medication was documented as effective. On 01/21/20 at 9:04 AM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was reported as level 5, on a scale from 1-10. The medication was documented as effective. On 01/22/20 at 8:02 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was reported as level 4, on a scale from 1-10. The medication was documented as effective. On 0[DATE] at 8:31 PM, Resident #17 received [MED] with [MEDICATION NAME]. The pain level was assessed as level 0, on a scale from 1-10. The medication was documented as effective. On 01/24/20, Resident's [MED] with [MEDICATION NAME] order was changed to one (1) tablet by mouth every six (6) hours as needed for pain, administer after repositioning for pain is ineffective. For this medication, the MAR indicated [REDACTED]. On 01/25/20 at 10:30 AM, Resident #17 received [MED] with [MEDICATION NAME]. The resident's pain level was not assessed prior to the medication administration. The medication was documented as effective. On 01/26/20 at 9:50 AM, Resident #17 received [MED] with [MEDICATION NAME]. The resident's pain level was not assessed prior to the medication administration. The medication was documented as effective. On 0[DATE] at 9:01 PM, Resident #17 received [MED] with [MEDICATION NAME]. The resident's pain level was not assessed prior to the medication administration. The medication was documented as effective. During an interview on 01/29/20 at 10:21 AM, the Director of Nursing (DON) confirmed Resident #17's pain was not assessed prior to receiving as needed pain medication on 01/25/20, 01/26/20, and 0[DATE]. The DON acknowledged the resident's every six (6) hour pain assessments documented no pain and were performed at 12:00 AM, 6:00 AM, 12:00 PM. and 6:00 PM, and not when the as needed pain medication was administered. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
509,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,698,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident received Phosphorus supplements as requested. This failed practice had the potential to affect a limited numer of residents. Resident identifier: #98. Facility census: 100. Findings included: a) Resident #98 Review of Resident #98's medical record found on [DATE] at 10:23 AM, the [MEDICAL TREATMENT] center physician requested a phosphorus supplement due to the resident's phosphorus level being low at 2. The facility Nurse Practitioner (NP) was notified on [DATE] at 2:17 PM, and said, The nephrologist needs to recommend what phosphorus supplement he wants. On 01/02/20 at 12:16 pm, the [MEDICAL TREATMENT] center was notified concerning what phosphorus supplement the nephrologist wanted. The [MEDICAL TREATMENT] center responded with, (Nephrologist Name) is out of town and will not return till 01/13/20. The Resident's medical record contained no documentation the attending physician was consulted for a phosphorus supplement. In addition, no further communication between the [MEDICAL TREATMENT] center and the facility concerning the phosphorus could be found. During an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/03/20 at 1:30 pm, they confirmed there was no documentation to indicate the attending physician was notified concerning a phosphorus supplement. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
510,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,726,F,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assure nursing staff possess the competencies and skills sets to recognize proper antibiotic use to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifer: #57. Facility census: 100. Findings included: a) Resident #57 Review of Resident #57's medical records found on 12/31/19, the physician ordered a urinalysis with culture and sensitivity (UA/C&S.) The urinalysis result could not be found in the medical record. On 01/04/20 the facility received the results of the C&S. The Registered Nurse (RN) called the physician to report the results. The registered nurse obtained a verbal order from the physician for the [MEDICATION NAME] milligrams (mg) , two times a day for ten (10) days for greater than 100,000 colony count of the organism Escherichia coli (E. coli.). However, the C&S noted the organism was resistant to [MEDICATION NAME]. ([MEDICATION NAME] is the same as Cipro.) There is no indication the registered nurse reported to the physician that the organism was resistant to [MEDICATION NAME] (Cipro). The C&S report was never signed by the physician to indicate he had reviewed the report. The facility continued to administer this antibiotic for 10 days as ordered. As a result, the resident received an antibiotic that was not appropriate to treat her urinary tract infection. She continued to have signs and symptoms of urinary tract infection, specifically burning upon urination and foul-smelling urine. On 01/29/20, after surveyor intervention, the physician ordered another UA/C&S to be obtained. The physician also ordered the antibiotic [MEDICATION NAME] ([MEDICATION NAME]) intravenously for ten (10) days. The urinalysis obtained on 01/29/20 showed 2+ (large amount) of bacteria. The C&S is pending. On 01/29/20 the Director Of Nursing confirmed the Resident received the wrong antibiotic. At 9:30 AM on 1/30/20, the facility confirmed they did not implement an antibiotic use protocol which included reporting laboratory results to the facility physician. On 01/30/20, the Clinical Care Supervisor (CCS) stated she contacted the laboratory. The CCS stated no UA had been performed by the laboratory on 12/31/19, although it had been ordered. There is no indication the facility had called the laboratory to obtain the UA results prior to surveyor intervention. As a result, the facility did not discover the UA had not been performed as ordered. Prior to surveyor intervention, the physician and facility staff, including the infection preventionist, did not identify or attempt to correct this failed practice. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
511,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,758,E,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's [MEDICAL CONDITION] medication regimen was managed and monitored to promote or maintain the resident's highest level of mental, physical, and psychosocial well-being for four (4) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifiers: #40, #38, #98, #57. Facility census: 100. Findings included: a) Resident (R) #40 Record review indicated the facility's physician did not appropriately respond to the Gradual Dose Reduction (GDR) for [MEDICATION NAME] ([MEDICAL CONDITION] medication, selective serotonin reuptake inhibitor used to treat anxiety and depression) recommended by the pharmacist on the on the Medication Regimen Review (MRR) for 01/16/2020. The MRR completed on 01/16/2020 by the pharmacist noted the last GDR evaluation for [MEDICATION NAME] was on 0[DATE] was contraindicated by the physician. The last dose adjustment was on 12/09/19 at which time the physician increased the [MEDICATION NAME] dose from 10mg to 15mg at bedtime (HS). The pharmacist indicated, Residents [MEDICATION NAME] 15 mg HS is due for GDR evaluation which must be attempted unless clinically contraindicated. The physician signed the MRR on 1/20/20 and left the form blank without providing any further comments to indicate his response to the GDR, or any further action to be taken. Review of the Resident's Mediation Administration Record on 02/03/2020 at 10:00 AM, revealed R #40 had been receiving [MEDICATION NAME] 15mg at bedtime for major [MEDICAL CONDITION] since [DATE] through current with no decrease in dose. On 01/29/20 at 12:25 PM, during an interview Regional Director of Operations #129 reviewed and verified the GDR recommendation dated 01/16/2020 was not appropriately acknowledged or completed by the physician. During an interview on 01/29/2020 at 12:35 PM, the Director of Nursing (DON) reviewed the GDR on the MRR dated 01/16/2020, and agreed the physician did not appropriately respond, and the GDR was incomplete. The DON stated, How could you know what he (physician) wanted done? He never filed the comment section or any of the check boxes to say if he agreed or disagreed. This should have been caught. The DON further explained, The facility's new procedure for processing MRR with GDR recommendation is for the pharmacy to review Resident's Medication Regimen, do their recommendations, then the provider addresses the recommendations, and then it is passed down to the Clinical Care Supervisor to ensure the orders are put through. The DON verified nursing staff have not been signing off on the actual MRR/ GDR paperwork, they (nursing) only enter the order and their name will appear on that specific order in the electronic medical record. b) Resident #38 Review of the Resident's medical record found the Resident is receiving [MEDICATION NAME] 0.5 milligrams (mg's), give 1 tablet by mouth, two times a day (BID) related to unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition. Review of the nursing notes, dated 05/07/19, found an entry, (Name of physician) in facility; new orders to increase [MEDICATION NAME] to 0.5 mg. BID; [MEDICATION NAME] cream to face [MEDICAL CONDITION] QS. (Quantum satis (abbreviation q.s. or Q.S.) is a Latin term meaning the amount which is enough. It has its origins as a quantity specification in medicine and pharmacology, where a similar term quantum sufficit (as much as is sufficient) has been used (abbreviated Q.S.) Review of the facility's psychopharmacological medication monitoring logs for May 2019 continuing to January 2020 found the order: Monitor effectiveness of antipsychotic medication ([MEDICATION NAME]) as evidence by patient is free of behaviors, delusions, every day and night shift. The specific behaviors for which the antipsychotic medication, [MEDICATION NAME], was administered was not specified. The daily documentation on the MAR indicated [REDACTED]. Review of the current care plan, revised on 08/03/19, found the problem: (Name of Resident) received antipsychotic medications ([MEDICATION NAME]) related to behavior management as evidenced by wandering, attempting to provide care to other residents. On 01/29/20 at 12:33 PM, the Director of Nursing (DON) was asked to provide evidence the Resident had an increase in behaviors at the time of the increase in [MEDICATION NAME]. The DON said the resident was scratching her face at the time of the increase in medication. The DON said, We were monitoring that as a condition rather than a behavior. On 02/03/20 at 4:00 PM, the Resident's physician was interviewed regarding the increase in [MEDICATION NAME]. The physician reviewed his progress notes scanned into the medical record at the time of the increase. The physician verified no notes, written by himself, were scanned in the electronic medical record on or around 05/08/19. He said he must have written a note regarding the increase in [MEDICATION NAME] but the facility did not scan in his notes. The physician stated, Let me go see if I have any notes around that time. At approximately 4:45 PM on 02/03/20, the physician returned with a typed note for an acute visit dated 05/07/19. This progress note said the patient was scratching, picking at her face and neck, she was standing at the mirror with wash cloth scrubbing left side of her face when we walked into her room, she states, I'm just trying to get all the stuff off. The physician said the medication was increased due to daily self injurious behaviors of picking/scratching her face until she bleeds. On [DATE] at 8:02 AM, the above information was discussed with the Administrator. At the close of the survey on [DATE] at 12:30 PM, no further information was provided by the facility. d) Resident #57 A record review for Resident #57 on 01/29/20, revealed a Gradual Dose Reduction (GDR) dated 08/14/19, recommended decreasing [MEDICATION NAME] from 20 milligrams (mg) to 10 (mg). On 09/09/19 the facility Medical Director (MD) had agreed and signed to decrease [MEDICATION NAME] to 10mg. [MEDICATION NAME] was decreased to 10 mg on 09/30/19. In an interview with the Director of Nursing (DON) on 01/29/20 01:12 PM, verified the order to decrease Celaxa was not completed in a timely manner. c) Resident #98 Review of Resident #98's medication regimen found the resident is currently receiving [MEDICATION NAME] 25 milligrams (mg) three times daily, effective date was [DATE]. Further review found the resident's [MEDICATION NAME] was increased from 25 mg twice daily to three times daily on [DATE]. There was no documented behaviors to indicate the need to increase the medication. Since the increase, the resident continues to have no behaviors to indicate the continued use of the medication. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 02/03/20 at 12:30 pm, confirmed there was no documented behaviors for Resident #98 to indicate the increase of [MEDICATION NAME]. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
512,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,761,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications were stored and labeled in accordance with facility policay for one (1) of eight (8) [MED]'s stored in the B-hallway medication cart. Resident identifier: #[AGE]. Facility census: 100. Findings included: a) Policy Review The facility's policy entitled, Vials and [MEDICATION NAME] of Injectable Medications with effective date 01/01/2017 stated, When a vial is opened, the licensed nurse records the opened date on the vial. b) Resident #[AGE] On 01/28/20 at 9:08 AM, the B-hall medication cart was inspected with Licensed Practical Nurse (LPN) #[AGE] in attendance. Resident #[AGE]'s [MEDICATION NAME] Solution Pen-injector ([MED] [MEDICATION NAME]) was not dated when opened. LPN #[AGE] confirmed Resident #[AGE]'s [MED] pen-injector was not dated when opened. The facility's Administrator was informed of the above findings on 01/28/20 at 9:34 AM. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
513,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,773,D,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to promptly notify the ordering physician of laboratory results outside of the clinical reference range for Resident #98. Additionally, the facility failed to obtain laboratory testing for Resident #57, as directed per physician's orders [REDACTED]. Resident identifiers: #98 and #57. Facility census: 100. Findings included: a) Resident #98 Review of Resident #98's medical records found an order to obtain an ammonia level. This level was obtained on [DATE] at 3:31 pm. The ammonia level was [AGE] which was critically high. Normal ammonia level is 9-35. Review of the progress notes found the attending physician was not notified of the labortory results until 10/21/19 at 5:11 pm. An interview with the Director of Nursing, on 01/30/20 at 1:10 pm, confirmed, after the review of Resident #98's medical record, there was a delay in notifying the physician of a critical lab. b) Resident #57 Record review on 01/29/20, revealed on 12/31/19 the physician had ordered a urinalysis with culture and sensitivity (UA/C&S). The C&S culture results were received by the facility on 01/04/20 with Escherichia coli (E coli) cultured at a colony count greater than 100.000. The physician was contacted with the results and [MEDICATION NAME] milligrams (mg) two (2) times a day for 10 (ten) days. Review of the Medication Administration Record [REDACTED]. Review of the C& S, [MEDICATION NAME] (Cipro) is Resistant (R) to E coli an not an effective antibiotic to treat this organism. In an interview with the facility Medical Director (MD) on 01/29/20 at 4:10 PM. The MD reported he would not have [MEDICATION NAME] Resident #57 if he had been told it was resistant. On 01/29/20 at 2:10 PM the Director of Nursing (DON) confirmed Resident #57 had received the wrong antibiotic. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
514,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,812,F,0,1,CN2N11,"Based on observation and interview, the facility failed to store, prepare, distribute and serve food in a manner to protect for food service safety. During the kitchen tour it was discovered the floor of the reach-in refrigerator had food particles and cardboard stuck to the floor. This had the potential to affect any residents receiving nourishment from the kitchen. Facility census: 100. Findings included: a) Kitchen tour During the kitchen tour on 0[DATE] at 11:24 AM, it was discovered the reach-in refrigerator to be unclean, with food particles and cardboard stuck to the floor. This failed practice provided for unsanitary storage for refrigerated foods. In an interview on 0[DATE] at 11:24 AM with the Dietary Manager (DM), she verified the refrigerator was dirty and needed to be cleaned. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
515,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,868,F,0,1,CN2N11,"Based on record review and interview, the facility failed to ensure the Quality Assessment and Assurance (QAA) committee consisted of the required members. The medical director (MD) or his/her designee did not attend quarterly QAA meetings. This had the potential to affect all residents. Facility census: 100. Findings included: a) QAA Review of the signatures on the attendance sheets for QAA meetings found the medical director only attended 2 quarterly QAA meetings from January 2019 - January 2020. The MD attended meetings held on 10/24/19 and a meeting dated July 2019. The actual date of the meeting was not included on the signature sheet. On [DATE] at 8:07 AM, the Administrator confirmed signature sheets showed the MD only attended 2 quarterly QAA meetings for the year. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
516,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,880,F,0,1,CN2N11,"Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This failed practice had the potential to affect more than an isolated number of residents. Facility census: 100. Findings included: a) B-hallway medication room On 01/28/20 at 9:08 AM, the B-hallway medication room was inspected with Licensed Practical Nurse (LPN) #[AGE] in attendance. Under the sink were stored two (2) cartons with six (6) cups of applesauce in each carton. LPN #[AGE] removed the applesauce from under the sink. On 01/28/20 at 9:34 AM, the facility's Administrator was informed that applesauce was stored in an unsanitary area under the medication room sink. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
517,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2020-02-04,881,K,0,1,CN2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement an antibiotic use protocol, including reporting laboratory results to the facility physician. This resulted in the failure to ensure Resident #57 received appropriate treatment for [REDACTED].) In addition, this placed the resident at risk for developing antibiotic-resistance. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Prior to surveyor intervention, the physician and facility staff, including the infection preventionist, did not identify or attempt to correct this failed practice. Due to the facility's failure to implement an antibiotic stewardship protocol the State Agency (SA) determined there was an immediate jeopardy (IJ) present for more than a limited number of residents residing in the facility. The likelihood of serious harm due to this IJ situation exists because the facility failed to recognize the resident was treated with an inappropriate antibiotic. Being treated with an antibiotic resistant to the organism identified could have resulted in the resident being septic. Due to the system failure to recognize the use of the incorrect antibiotic to treat in antibiotic resistant organism, all residents were potentially at risk for the incorrect antibiotic be prescribed with the negative outcome [MEDICAL CONDITION] being present as well. The following details the timeline of the IJ situation. --The IJ started on 01/04/20. --The facility Nursing Home Administrator (NHA) was notified of the Immediate Jeopardy (IJ) at 12:22 PM on 01/30/20. --The facility submitted their first abatement Plan of Correction (POC) at 1:55 PM on 01/30/20. --The SA requested changes to the abatement POC. --At 2:08 PM and a second abatement POC was submitted by the facility on 01/30/20. --This POC was accepted by the SA at 2:10 PM on 01/30/20. --The IJ was abated at 11:40 AM on 02/03/20 when the SA observed Resident #57's urine culture and sensitivity was received and appropriate antibiotic was ordered by facility's physician/staff. The facility's abatement plan of correction consisted of the following: 1. Resident # 57 was identified as being affected by the alleged deficient practice of failing to implement an antibiotic use protocol, including reporting laboratory results to the facility physician. This resulted in the failure to ensure Resident #57 received appropriate treatment for [REDACTED].#57 physician was notified immediately by the Director of Nurses (DON) on 1/29/2020. Resident #57 physician current course of treatment implemented was to obtain a UA with C & S this was completed on 1/29/2020 by the Unit Charge Nurse (UCN). The Unit Charge Nurse obtained an order for [REDACTED]. Quality Standards Nursing Coordinator educated the Director of Nurses (DON), Clinical Care Supervisor (CCS), and Registered Nursing Assessment Coordinator (RNAC) on antibiotic stewardship data base, documentation expectations, and follow through immediately on 1/30/2020. All Unit Charge Nurses on duty will be educated immediately by a Quality Standards Nursing Coordinator on 1/30/2020 on reading/interrupting a UA with C & S lab results, documentation expectations, communication with physician on lab results, and follow through. Nurse Practitioner examined Resident #57 and reviewed findings with physician in person on 1/30/2020. The CCS or designee will obtain C & S results from the lab by 2/3/2020. The CCS or designee will immediately upon receipt of lab results will report to physician or nurse practitioner for further orders as necessary. 2. DON or designee will educate all nurses at the being of each shift prior to going to the floor until all nurses have been educated starting 1/30/2020 - 2/3/2020. Any nurse on leave of absence will be educated immediately upon return to work prior to going to the floor to provide care. Quality Standards Nursing Coordinator completed an audit of current antibiotic use on 1/29/2020 and no other residents were identified as being affected by the alleged deficient practice. The nurse receiving lab results will review results with the physician or nurse practitioner by the end of the shift. The UCN will document physician or nurse practitioner notification and their response by the end of the shift. The UCN must contact the physician or nurse practitioner and obtain new orders within accordance with antibiotic stewardship. The UCN will document physician or nurse practitioner notification and their response by the end of the shift. The CCS or designee will monitor antibiotic stewardship to ensure diagnostic results have been obtained and the physician or nurse practitioner was made aware and required documentation is completed daily. Antibiotic Stewardship data base will be reviewed daily by the CCS or RNAC or designee daily. 3. The DON will review all findings and report in QAA monthly for follow up to assure POC is effective. Resident identifier: #57. Facility census: 100. Findings included: a) Resident #57 Review of Resident #57's medical records found on 12/31/19, the physician ordered a urinalysis with culture and sensitivity (UA/C&S.) The urinalysis result could not be found in the medical record. On 01/04/20 the facility received the results of the C&S. The Registered Nurse (RN) called the physician to report the results. The registered nurse obtained a verbal order from the physician for the [MEDICATION NAME] milligrams (mg) , two times a day for ten (10) days for greater than 100,000 colony count of the organism Escherichia coli (E. coli.). However, the C&S noted the organism was resistant to [MEDICATION NAME]. ([MEDICATION NAME] is the same as Cipro.) There is no indication the registered nurse reported to the physician that the organism was resistant to [MEDICATION NAME] (Cipro). The C&S report was never signed by the physician to indicate he had reviewed the report. The facility continued to administer this antibiotic for 10 days as ordered. As a result, the resident received an antibiotic that was not appropriate to treat her urinary tract infection. She continued to have signs and symptoms of urinary tract infection, specifically burning upon urination and foul-smelling urine. On 01/29/20, after surveyor intervention, the physician ordered another UA/C&S to be obtained. The physician also ordered the antibiotic [MEDICATION NAME] ([MEDICATION NAME]) intravenously for ten (10) days. The urinalysis obtained on 01/29/20 showed 2+ (large amount) of bacteria. The C&S is pending. On 01/29/20 the Director Of Nursing confirmed the Resident received the wrong antibiotic. At 9:30 AM on 1/30/20, the facility confirmed they did not implement an antibiotic use protocol which included reporting laboratory results to the facility physician. On 01/30/20, the Clinical Care Supervisor (CCS) stated she contacted the laboratory. The CCS stated no UA had been performed by the laboratory on 12/31/19, although it had been ordered. There is no indication the facility had called the laboratory to obtain the UA results prior to surveyor intervention. As a result, the facility did not discover the UA had not been performed as ordered. Prior to surveyor intervention, the physician and facility staff, including the infection preventionist, did not identify or attempt to correct this failed practice. The likelihood of serious harm due to this IJ situation exists because the facility failed to recognize the resident was treated with an inappropriate antibiotic. Being treated with an antibiotic resistant to the organism identified could have resulted in the resident being septic. Due to the system failure to recognize the use of the incorrect antibiotic to treat in antibiotic resistant organism, all residents were potentially at risk for the incorrect antibiotic be prescribed with the negative outcome [MEDICAL CONDITION] being present as well. No further information was provided at the close of the survey at 12:30 PM on [DATE].",2020-09-01
518,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-04-19,583,D,1,0,DQUX11,"> Based on staff interview, family interview and record review, the facility failed to safeguard, ensure, and maintain the privacy and confidentiality of a resident's clinical record. An unauthorized disclosure of Resident#6's clinical record, without Resident#6's consent or knowledge, was given by accident to another resident's family member to take to a consulting physician's appointment. This is true for one (1) of one (1) resident reviewed for privacy and confidentiality. This practice had the potential to affect more than a limited number of residents. Resident identifier: #6. Census: 85. Findings included: a) Resident #6 On 04/16/18 at 1:05 PM, an interview with the Ombudsman information concerning issues that had been brought to the Ombudsman's attention. The Ombudsman stated it was revealed a resident's family member had mistakenly been given another resident's clinical records to take with them to a doctor's appointment. On 04/16/18 at 2:38 PM, an interview with Resident#3's daughter-in-law revealed, upon arriving with Resident #3 at a doctor's appointment in another city, it was discovered she had mistakenly been given Resident #3's roommates medical records to take to the appointment. The daughter-in-law had requested Resident#3 records, but by mistake was given Resident#6's medical records. The daughter-in-law said she returned the records back to the facility, when she returned the resident (Resident #3) back to the facility. Resident#3's daughter-in-law said, she was asked by the facility to not tell Resident #6 (the roommate of Resident #3) what had occurred. The daughter-in-law, also a nurse, said she was very upset about the incident and told the facility she was concerned her mother-in-laws records could also be compromised. On 04/18/18 at 9:30 AM, review of all Resident Council meeting minutes; all Incident/Accident logs; all Grievances/Complaint/Concern logs and reports; and all Reportable incidents with related investigations for the past six (6) months, revealed no incidents or grievances concerning an incident of a resident accidently receiving another resident's medical record to take with them to an appointment. An interview with the director of nursing (DON), on 04/19/18 at 11:29 AM, revealed the DON was aware and confirmed the incident did occur, and that it was a HIPAA (Health Insurance Portability and Accountability Act) violation. The DON, said a nurse accidently gave Resident #3's daughter-in-law Resident#6 medical records, instead of Resident#3's medical records. When asked why it was not logged on the grievance log, the DON said she did not know, but it should have been.",2020-09-01
519,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-04-19,585,E,1,0,DQUX11,"> Based on staff interview, family interview, and record review, the facility failed to promptly address complaints/grievances to resolution and keep the residents appropriately apprised of progress toward resolution of complaints/grievances. This was evident by the lack of documentation of any follow up regarding resident council grievances and concerns; lack of a grievance filed concerning a staff member hanging up on a resident's family member where disciplinary action was taken against the staff member; and failure to promptly address a complaint of finding several feces soiled items stored in a resident's room. This practice had the potential to affect more than a limited number of residents. Resident identifier: #1, and #9. Census: 85. Findings included: a) Resident #9 On 04/16/18 at 3:10 PM, review of Resident Council meeting minutes for the past six (6) months, revealed a lack of documentation and/or evidence as to whether issues and concerns expressed during Resident Council meetings were addressed and followed up on. An interview with Social Worker (SW#90) revealed she does not write down resolutions or outcomes to issues discussed. SW#90 said, We talk about any concerns and, if say it is about food, I'll get someone from the kitchen to come and talk to the residents. I do not write anything down. SW#90 after looking over Resident Council meeting minutes confirmed the minutes did not reflect follow up or outcomes to issues. On 04/17/18 at 3:59 PM, Social Worker (SW#124), requested the surveyors speak with the resident council president, so that the resident council president could tell the surveyors the council's internal process for dealing with issues and concerns. SW#124 said They do it different here, they bring up issues and deal with it right then and there at the meeting. SW#124 left the room to get the Resident Council President, Resident #9. Resident #9 entered the room alone. SW#124 did not return. The Resident Council President was asked by this surveyor, If there is anything you would like to share with us? Resident #9 said, I guess. They said you wanted to know in meetings we just tell them when something is wrong, and they just write it down. When asked if they get back to the council with resolutions or outcomes involving concerns that were discussed. Resident #9 said, I guess, I don't know, we talk about things. The surveyor asked, Has there been any issues of food being served cold? The Resident Council President said, The food was cold just the other day, and one day last week, everyone in dining hall was talking about it This surveyor asked, Do they follow up when you have concerns or issues? Resident #9 said, I don't know. I guess, they talk about it. If you have an issue we tell the Activities supervisor. I've been telling her for a while I need pants, some of mine are missing, and some got ruined with bleach. I never did get them, so I told my family, and they are going to get some pants for me. Review of grievances or resident council minutes did not show Resident#9 had any issues concerning missing pants or pants ruined by bleach. This surveyor informed SW#124 the outcome of the interview with the Resident Council President, and SW#124 said that was the first she heard about Resident #9's pants and she would immediately take care of it. b) Grievance not addressed An interview with the Ombudsman on 04/16/18 at 1:05PM, revealed a resident's family medical power of attorney (MPOA) had a complaint regarding a Social Worker hanging up on her while trying to get some answers concerning the care of her mother. The family member told the ombudsman that she had called the administrator and the corporate office, and neither would return her calls. Review of Resident council meeting minutes, Complaint/grievance/Concern files, Incident/accident reports, and reportable incidents and related investigations for the past six (6) months, on 04/18/18 at 9:30 AM, revealed no evidence of any grievances or complaint concerning an incident of a staff member being rude and/or hanging up on a resident's family member calling to inquiry about issues concerning their loved one. There was no evidence given to this surveyor of a written facility's acknowledgment of the resident's MPOA family member's complaint or grievance. There was no evidence of a written grievance decision that included the date the grievance was received, a summary statement of the resident's MPOA's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's MPOA's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, or the date the written decision was issued. On 04/18/18 at 9:54 AM, review of an employee disciplinary notice dated 02/26/18, revealed a notice involving Social Worker (SW#90) concerning 'rudeness employee/residents/ family/visitors'. According to the disciplinary notice, the employer statement alledged SW#90 hung up on a family member of a resident. The incident occurred on 02/21/18. SW#90 disagreed with the employer's description of the violation, noting the reason as I hung up after thanking her for calling and listening to her yell and holler and try to help her. I got off phone to keep from being rude. Review of grievances and concerns did not reveal a grievance listed or filed concerning the incident described in this disciplinary notice. c) Resident #1 During a family interviw on 04/16/18 at 1:03 p.m. it was revealed the facility staff had not ensured resident cabinets and drawers were free from soiled clothing. This would then create odors in the resident's room that would be presenyt when they came to visit. This issue had been brought to the staff's attention but had not be resovled as yet. Review of the resident's care plan on 04/19/18 at 9:00 a.m. revealed the staff had identifed and was care planning for a problem with the resident removing soiled clothing and putting them in the closet or drawere in the room. The intervention was listed as staff was to monitor the areas every shift. This was not being implemented. An inservice for employuees which was regarding checking for soiled linens left in resident's closets or drawers was held on 12/24/17.",2020-09-01
520,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-04-19,609,D,1,0,DQUX11,"> Based on staff interview, family interview and record review, the facility failed to investigate and report an instance of resident to resident altercation that resulted and one of those involved requiried medical intervention at the hospital. Resident identifier: #1. Census: 85. Findings included: a) Resident #1 During the investigation on 0416/18 at 1:03 PM a family interview revealed there had been in a resident to resident altercation which required Resident #1 to be sent to the hospital for evaluation on 04/09/18. A review of the medical record on 04/17/18 in the morning also confirmed the situation did occur and the resident had been transported to the hospital with additional mental reveiw necessary at another facility before the resident returned to the nursing home. Discussion with the director of nursing and the corporate regional director operations on 04/18/18 confirmed if a resident to resident altercation resulted in medical intervention the staff has to conduct an investgation and report the occurrance to the appropriate agencies. This sitation was not investigated and reported to the appropriate agencies as required.",2020-09-01
521,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-04-19,610,D,1,0,DQUX11,"> Based on staff interview, family interview and record review, the facility failed to investigate and report an instance of resident to resident altercation that resulted and one of those involved requiried medical intervention at the hospital. Resident identifier: #1. Census: 85. Findings included: a) Resident #1 During the investigation on 0416/18 at 1:03 PM a family interview revealed there had been in a resident to resident altercation which required Resident #1 to be sent to the hospital for evaluation on 04/09/18. A review of the medical record on 04/17/18 in the morning also confirmed the situation did occur and the resident had been transported to the hospital with additional mental reveiw necessary at another facility before the resident returned to the nursing home. Discussion with the director of nursing and the corporate regional director operations on 04/18/18 confirmed if a resident to resident altercation resulted in medical intervention the staff has to conduct an investgation and report the occurrance to the appropriate agencies. This sitation was not investigated and reported to the appropriate agencies as required.",2020-09-01
522,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-04-19,745,E,1,0,DQUX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, family interview, and record review, the facility failed to provide medically related social services regarding timely notification of care plan meetings to ensure attendance and participation of residents and/or resident's family members responsible for making decisions concerning resident care. The facility also failed to provide medically related social services to assist residents and/or resident's family members responsible for making decisions in voicing and obtaining resolution to complaints and grievances. This practice had the potential to affect more than a limited number of residents. Resident identifier: #1, #4, #5, and #6. Census: 85. Findings included: Both surveyors on the investigative team conducted an interview, on 04/17/18 at 1:10 PM, with two (2) of the joint Medical Power of Attorneys (MPOAs) for Resident #1. The interview revealed they do get letters notifying them of care plan meetings. The MPOAs issues and concerns where they were not being notified in enough time to make any arrangements at work, so they could attend the care plan meetings. They said they might get a letter on Friday, for a meeting scheduled for the following Monday. They both confirmed it is just too hard to get off work and make any arrangements with such a short notice. The MPOAs revealed an incident where they arrived on the date and time the letter indicated, and as they sat waiting for the meeting, they were informed the meeting had already taken place on a different day. The MPOAs said the facility did go ahead and meet with them that day, because they refused to leave until they did. The MPOAs said they have shared these concerns about timely care plan meeting notices with staff before. Review of grievance and concern records did not reveal any of these issues or concerns had been identified, filed, and/or addressed. On 04/17/18 at 5:10 PM, an interview with Social Worker (SW#62), revealed the following. SW#62 said, I try to send out the notices for care plan meetings a month out. This surveyor requested the last care plan notices sent for Residents #4, #5, and #6. Resident #4 was deemed not to have capacity to make medical decisions due to short term memory loss, disorientation, inability to process information, caused by alcoholic [MEDICAL CONDITION], and dementia. Review of last care plan meeting notice sent for Resident #4 to resident's Medical Power of Attorney (MPOA), was dated 02/27/18, Tuesday, for a care plan meeting scheduled two (2) days later 03/01/18, Thursday. Review of last care plan meeting notice sent to Resident #5's MPOA was dated 02/19/18, Monday, for a care plan meeting scheduled for three (3) days later 02/22/18, Thursday. SW#62 said Resident #6 had capacity and SW#62 hand delivered the care plan meeting notice to Resident #6 himself when she resided at the facility. SW#62 agreed a two (2) or three (3) day notice was not a sufficient amount of time to expect MPOAs or health care surrogates to make any arrangements to attend scheduled care plan meetings. Review of Multidisciplinary care conference progress note for Resident #4, dated 03/01/18, stated under Patient/Responsible Party Invitation/Response: (name of MPOA) invited chose not to attend. Review of Multidisciplinary care conference progress note for Resident #5, dated 03/01/18, stated under Patient/Responsible Party Invitation/Response: (name of responsible party) invited via mail but unable to attend. b) Resolution to complaints and grievances On 04/16/18 at 3:10 PM, review of Resident Council meeting minutes for the past six (6) months, revealed a lack of documentation and/or evidence as to whether issues and concerns expressed during Resident Council meetings were addressed and followed up on. An interview with Social Worker (SW#90) revealed she does not write down resolutions or outcomes to issues discussed. SW#90 said, We talk about any concerns and, if say it is about food, I'll get someone from the kitchen to come and talk to the residents. I do not write anything down. SW#90 after looking over Resident Council meeting minutes confirmed the minutes did not reflect follow up or outcomes to issues. On 04/17/18 at 3:59 PM, Social Worker (SW#124), requested the surveyors speak with the resident council president, so that the resident council president could tell the surveyors the council's internal process for dealing with issues and concerns. The Resident Council President was asked if the facility gets back to the council with resolutions or outcomes involving concerns that were discussed. The Resident Council President answered she guessed they did, however she went on to describe a recurring problem that had been discussed about food being served cold, that was supposed to be served hot. The Resident Council President said, The food was cold just the other day, and one day last week, everyone in the dining hall was talking about it. The Resident Council President went on to say she had been telling the activities supervisor for a while she needed pants because some of hers were missing, and some got ruined with bleach. The Resident Council President said, I never did get them, so I told my family, and they are going to get some pants for me. Review of grievances did not show the Resident Council President had any issues concerning missing pants or pants ruined by bleach. This surveyor informed SW#124 the outcome of the interview with the Resident Council President, and SW#124 said that was the first she heard about Resident #9's pants and she would immediately take care of it. An interview with the Ombudsman, on 04/16/18 at 1:05PM, revealed a grievance reported to the Ombudsman concerning a Social Worker hanging up on a resident's family medical power of attorney (MPOA) while trying to get some answers concerning the care of her mother. The family member told the ombudsman that she had called the administrator and the corporate office, and neither would return her calls. Review of Resident council meeting minutes, Complaint/grievance/Concern files, Incident/accident reports, and reportable incidents and related investigations for the past six (6) months, on 04/18/18 at 9:30 AM, revealed no evidence of any grievances or complaint concerning an incident of a staff member being rude and/or hanging up on a resident's family member calling to inquiry about issues concerning their loved one. There was no evidence given to this surveyor of a written complaint or grievance filed concerning this incident. There was no evidence of a written grievance decision that included the date the grievance was received, a summary statement of the resident's MPOA's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's MPOA's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, or the date the written decision was issued. On 04/18/18 at 9:54 AM, review of an employee disciplinary notice dated 02/26/18, revealed a notice involving Social Worker (SW#90) concerning 'rudeness employee/residents/ family/visitors'. According to the disciplinary notice, the employer statement alleged SW#90 hung up on a family member of a resident. The incident occurred on 02/21/18. SW#90 disagreed with the employer's description of the violation, noting the reason as I hung up after thanking her for calling and listening to her yell and holler and try to help her. I got off phone to keep from being rude. Review of grievances and concerns did not reveal a grievance listed or filed concerning the incident described in this disciplinary notice.",2020-09-01
523,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-04-19,804,E,1,0,DQUX11,"> Based on observation, staff interview, family interview and record review, the facility failed to serve foods that are at proper temperature and palatable. This practice has the potential to affect more than a limited number of residents are consume foods served from this central location. Census: 85. Findings included: a) Review of resident council minutes on 04/18/18 revealed the residents had expressed concern with the food being cold. Such things as coffee being cold was listed in the 03/02/18 meeting and then food being cold if you ate in the room. Chicken noodle soup was described as being poured staight out of the can and not heated. b) Confidential family interview on 04/16/18 after lunch revealed the food does not always look appealing or appetizing. Sandwiches will often be a piece of bread with a slice of lunch meat on it. Did not have condiments or anythisg else on the sandwich. c) This was reviewed with the dietary manager on 04/18 /18 in the morning. She verified the residents had expressed concern about cold foods in resident council meetings and they have been attempting to resolve the issue. d) These issues were discussed with the director of nursing and the corporate regional director of operations on 04/18 /18 in the afternoon. e) Random confidential resident interviews During the initial tour on 04/16/18 at 12:45 PM, observations and interviews with several randomly chosen residents having lunch in their rooms revealed complaints of food being served cold. One resident stated, Lunch is warm today, but it is not always. Another resident said, Sometimes it's cold, the meals were sometimes cold on a few days last week. A different resident shared, Most of the time it (meals) is cold. On 04/17/18 at 3:59 PM, an interview with the Resident Council President revealed a recurring problem about food being served cold, that was supposed to be served hot. The Resident Council President said, The food was cold just the other day, and one day last week, everyone in the dining hall was talking about it.",2020-09-01
524,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-04-19,880,D,1,0,DQUX11,"> Based on staff interview, family interview and record review, the facility failed to implement proper infection control monitoring. Soiled clothing was left in Resident #1's drawers and closets creating an infection control concern. This was evident for one (1) of four (4) sampled residents currently in the faciilty. Census: 85. Findings included: a) Resident #1 During the investigation confidential interviews were conducted with family members on 04/16/18 in the afternoon. It was found that Resident #1 was known to remove soiled clothing and place them in the drawer or closet in their room. This issue was known to staff and the care plan interventions required staff to monitor the draweres and closets in the room every shift for soiled clothing and perform visual checks of the area. This was not being implemented and soiled cloting is still being left in these areas and family will come in and notice odors which are coming from the soiled clothing. This procendure could lead to an infection control issue and soiled clothing is not being handled using proper infection control techniques. The issue was discussed with the director of nursing on 04/17/18 in the afternoon. An inservice was conducted on 12/24/17 but this has still not corrected the problem.",2020-09-01
525,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2017-11-10,241,D,0,1,FJSP11,"Based on observation and staff interview, the facility failed to provide a dining experience with dignity for one randomly observed resident, during a dinner time meal. One (1) nurse aid (NA) approached Resident #149 to set the resident up for the meal without speaking to the resident or letting the resident know what the NA was about to do. Resident identifier: #149 and #99. Facility census: 87. Findings include: a) Resident #149 Random observation during the dinner time meal, on 11/06/17 at 5:12 p.m., revealed Resident #149 was reclining in a geri chair beside a dinner table. Nurse Aide (NA) #44 came up behind Resident #149, and without saying anything to the resident or explaining what he was about to do changed the geri chair from a reclining position to a sitting position. The sudden quick movement from a reclining to a sitting position jarred the resident and caused the resident to scream out. b) Resident #99 Random observation during the dinner time meal, on 11/06/17 at 5:22 p.m., revealed NA #44 was feeding Resident #99 as she was leaning to the right side in her gerri-chair, with her head leaning forward. LPN #26 also in the dining room at the time and after observing NA #44 feeding Resident #99 agreed Resident #99 was not in good body alignment to promote feeding. LPN #26 proceeded to reposition the resident and prop the resident with folded blankets, after surveyor intervention, and instruct NA #44 on proper body alignment to promote feeding.",2020-09-01
526,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2017-11-10,279,D,0,1,FJSP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a care plan had measurable and/or individualized objectives for a resident on anti-anxiety medication. This was evident for one (1) of five (5) residents reviewed for unnecessary medications, out of fifteen (15) Stage II sampled residents. Resident identifier: #88. Facility census: 87. Findings include: a) Resident #88 The medical record was reviewed on 11/09/17. Physician orders [REDACTED]. at bedtime daily for anxiety. Review of the care plan found it lacked individualized, measurable goals for the use of anti--anxiety medications. The care plan did not identify the behaviors the facility intended to treat with the anti-anxiety medication. The care plan did not include measurable goals set for the resident's emotional and/or behavioral condition. Rather, the care plan focus stated (name of resident) receives anti-anxiety medications ([MEDICATION NAME]) r/t (related to) anxiety disorder. The goals stated Patient will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Their only non-pharmacological interventions were to encourage him to vent his feelings, and listen to his concerns. On 11/09/17 at 9:58 a.m. an interview was conducted with the director of nursing (DON). She said this resident does have targeted behaviors, but they were not listed on the care plan. She acknowledged that there was no focus on the behaviors that caused him to need the [MEDICATION NAME]. She acknowledged that there were no individualized or measurable goals for any targeted behaviors they were treating. She said she would correct these issues right away.",2020-09-01
527,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2017-11-10,371,E,0,1,FJSP11,"Based on observation and staff interview, the facility failed to maintain kitchen equipment in a sanitary manner. This practice has the potential to affect more than limited number Residents. Staff Identifiers: #66. Facility Census: 87. Findings include: On 11/06/17 at 2:40 p.m., inspection of the kitchen with the dietary assistant #66, revealed an observation of the food lid to hot bar was dirty. The dietary assistant #66 agreed the food lid to hot bar was dirty and should not have been.",2020-09-01
528,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2017-11-10,431,D,0,1,FJSP11,"Based on observation and staff interview the facility failed to store and label medications. Resident: #48, #81 and #88. 11/08/2017 11:05:14 AM in medication room B and 2 medication carts, LPN #72 Levemir multi vail use wasn't labeled with opened date on vial for Resident #48, LPN #56 11/08/2017 11:15:31 AM Medication Room A and 2 medication carts, LPN #23 pens LPN #4 Humalog pen not labeled with opened date, Resident #81 Novolog pen not labeled with opened date, Resident #88 Based on observations and staff interview, the facility failed to collaborate with the pharmacist, to ensure safety and effective use of medications. An opened and partially used insulin vial was not dated when initially opened. This had the potential to negatively impact the safety and/or potency of the medication. This was evident for three (3) of thirty one (31) opened insulin vials and pens stored in two (2) of four (4) carts. Resident identifiers: #48, #81, #80. Findings include: a) Resident # 48 Observation on 11/08/2017 at 11:05 a.m., found a Levermir vial which belonged to resident # 48 was opened and partially used. There was no date indicating when the vial was intially opened, or the date it should be discarded. The Licensed Practical Nurse (LPN) #72 agreed the date that it was opened should have been on the vial. b) Resident #81 and #80 Observation on 11/08/2017 at 11:15 a.m. found a Humalog pen which belong to Resident # 81 was opened and partially used. There was no date indicating when the pen was was intially opened, or the date to discard. A novolog pen belonging to Resident #80 was opened and partially used. There was no date indicating when the pen was intially opened, or the date to discard. The LPN # 4 agreed that it should have been labeled when it was intially opened. There was a place on the pens to put the opened dates that were blank. Interveiw with the Director of Nursing was completed on 11/09/2017 at 10:30 a.m. she was aware of the findings of the insulin not being dated of when the medication was intially opened and/or to be discarded. She stated the policy required it to be labeled when it is first used with the discard date. The DON says that she has a plan to fix this problem.",2020-09-01
529,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,574,E,0,1,J9FW11,"Based on observation, staff interview and information from the resident council meeting, the facility failed to provide information on how to contact the local ombudsman. This had the potential to affect more than an isolated number of residents. Facility census: 97. Findings include: a) Resident council meeting During the resident council meeting on 11/28/18 at 10:27 AM, the residents in attendance did not know how to contact the ombudsman if they would choose to do so. The facility's Social Worker (SW) #28, was also in attendance at the council meeting. SW #28 told the resident's the name and contact information of the local ombudsman was posted at the nurses station. After the meeting was adjourned, at 10:52 AM on 11/28/18, the SW and the surveyor reviewed the information posted at the nurses station. The name and contact information of the local ombudsman was not available. On 11/28/18 at 03:03 PM, the administrator said the contact information of the local ombudsman, Was posted but someone removed it, we have put it back.",2020-09-01
530,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,583,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to ensure Resident #245's medical record was kept confidential. Resident #245's medication orders were observed to be hanging on the magnetic bulletin board in the residents room. This was a random opportunity for discovery. Resident Identifier: #245. Facility Census: 97 Findings Include: a) Resident #245 Observation of Resident #245's room at 12:34 p.m. on 11/26/18 found her medication list placed on her magnetic bulletin board with a magnet. The list had been printed by the facility and it appeared Resident #245's daughter had placed it on the board with a hand written note which read, Mom's Medications, and No [MEDICATION NAME]. An additional observation with the Director of Nursing (DON) at 1:05 p.m. on 11/27/18, found the medication list was still on the magnetic bulletin board in Resident #245's room. The DON removed the list and indicated it looked like Resident #245's daughter had placed the list there and she would call and talk to them about it. She agreed the medication should not have been posted in the residents room.",2020-09-01
531,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,584,D,0,1,J9FW11,"Based on observation and staff interview the facility failed to ensure Resident #245's wheelchair was in good prepare. The wheelchair was missing an arm rest on one side and the other arm rest was loose. This was a random opportunity of discovery. Resident Identifier: #245. Facility Census: 97 Findings Include: a) Resident #245 An observation of Resident #245's wheelchair at 9:40 a.m. with the Director of Nursing (DON) found the arm rest on the left side of her wheelchair was missing and the residents right arm rest on her wheelchair was loose. The DON stated, I will have (name of Maintenance Director) to fix it right away.",2020-09-01
532,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,622,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to convey all required transfer information to the receiving hospital for one (1) of two (2) residents reviewed for the care area of hospitalization . Resident identifier: #43. Facility census: 97. Findings include: a) Resident #43 On 09/17/18 at 5:18 am, Resident #43 was transferred to the hospital due to chest discomfort, shortness of breath, and upper extremity [MEDICAL CONDITION]. The Acute Care Transfer form provided to the receiving hospital did not include information regarding usual mental status, ambulation status, skin condition at time of transfer, devices and special treatments. The Acute Care Transfer form contained sections to provide this information. However, the sections were blank. During an interview on11/27/18 at 12:20 PM, the Director of Nursing agreed the information had not been completed on Resident #43's Acute Care Transfer form dated 09/17/18.",2020-09-01
533,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,641,E,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview the facility failed to ensure the Minimum Data Sets (MDS)s accurately reflected the resident's status. This was true for six (6) of twenty-six (26) resident's MDSs reviewed during the Long Term Survey Process (LTCSP). Resident #96's MDS was inaccurate in the area of death in the facility. Resident #14 MDS was inaccurate in area of pressure ulcers. Resident #9's MDS was inaccurate in area of falls. Resident #95's MDS was inaccurate in the area of nutrition. Resident #62's MDS was inaccurate in the area of positioning/mobility. Resident #84's MDS was inaccurate in area of unnecessary medications. Resident identifiers: #96, #14, #9, #95, #62 and #84. Facility census 97. Findings include: a) Resident #96 Resident #96 was admitted to the facility on [DATE] from an acute care hospital due to multiple falls at home. Resident's [DIAGNOSES REDACTED]. Further review of nurse's notes found on [DATE] at 8:05 am, the resident was found unresponsive. Cardiopulmonary resuscitation was initiated due to resident's wishes to be Full Code. Resident #96 was transported to local hospital and expired at the hospital. Review of the MDS with an assessment reference date (ARD) of [DATE] was marked, Death in Facility. During the review of the attending physician's discharge summary found: Patient died at (Name of local hospital. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on [DATE] at 3:00 pm, confirmed the resident did not die in the facility and the MDS with ARD of [DATE] was inaccurately coded. They both agreed the MDS should have been coded, Discharge with assessment return not anticipated. b)Resident #14 Medical record review found a Wound Assessment-Pressure Ulcer Assessment, dated [DATE] read: Right and left buttocks, 9.6 centimeters (cm) in length, 9 cm in width and 0.1 cm in depth, stage II. Area less red and not as firm, now with three (3) open areas. Further review found a MDS with ARD of [DATE], was noted Resident #14 had two (2) Stage II pressure ulcers present. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on [DATE] at 1:00 pm, confirmed the resident did not die in the facility and the MDS with ARD of [DATE] was inaccurately coded. They both agreed the MDS should have been coded, Three (3) Stage II pressure ulcers . c) Resident #9 Resident #9's medical records indicated she experienced a fall from her bed on [DATE]. Resident #9 had a quarterly Minimum Data Set (MDS) completed with Assessment Reference Date (ARD) [DATE]. Resident #9 also had a MDS completed with ARD [DATE]. Section J, Health Conditions, indicated she had experienced no falls since the prior assessment. During an interview on [DATE] at 12:06 PM, Registered Nurse Assessment Coordinator (RNAC) #127 stated Resident #9's MDS with ARD [DATE], Section J, Health Conditions, should have indicated the resident experienced one (1) fall since the prior assessment. d) Resident #395 During an interview on [DATE] at 11:33 AM, Resident #395 stated she had lost weight recently and was concerned about the weight loss. She said she used to weigh 214 pounds and her weight had decreased to the 170s during her stay at the facility. Resident #395's weight records, Nutritional Risk Notes, and Minimum Data Set (MDS) assessments were reviewed. A quarterly MDS assessment with an Assessment Reference Date (ARD) of [DATE] was marked No or unknown for loss of five (5)% or more in the last month or loss of ten (10)% or more in the last six (6) months. When determining significant weight loss in section K of the MDS, the RAI manual instructs, Start with the resident's weight closest to 180 days ago and multiply it by .90 (or 90%). The resulting figure represents a 10% loss from the weight 180 days ago. If the resident's current weight is equal to or less than the resulting figure, the resident has lost 10% or more body weight. The current weight entered in Section K was 182 pounds. This weight (rounded per RAI manual instructions) was measured on [DATE], per Resident #395's weight records. The weight closest to 180 days preceding the [DATE] weight was measured on [DATE] and was 208 pounds (rounded per RAI manual instructions). A decrease from 208 pounds to 182 pounds indicated a significant weight loss over six (6) months, per guidance from the RAI manual. A Nutritional Risk Note written in Resident #395's electronic medical record by the facility's Dietary Services Supervisor (DSS) #122 with an effective date of [DATE] was marked for 10% or Greater Loss in 180 days. The weight used for the current weight in this note was the same as the current weight used on Section K of the MDS for the ARD of [DATE]. A discharge MDS assessment for Resident #395 with an ARD of [DATE] was marked No or unknown for loss of five (5)% or more in the last month or loss of ten (10)% or more in the last six (6) months. The current weight entered in Section K was 178 pounds. This weight was measured on [DATE], per Resident #395's weight records. The weight closest to 180 days preceding the [DATE] weight was measured on [DATE], per Resident #395's weight records and was 203 pounds (rounded per RAI manual instructions). A decrease from 203 pounds to 178 pounds indicated a significant weight loss over six (6) months, per guidance from the RAI manual. A Nutritional Risk Note written in Resident #395's electronic medical record by DSS #122 with an effective date of [DATE] was marked for 10% or Greater Loss in 180 days. The weight used for the current weight in this note was the same as the current weight used on the discharge MDS with an ARD of [DATE]. On [DATE] at 10:44 AM, DSS #122 was asked why she did not code either MDS assessment for significant weight loss over six (6) months when she had marked on her Nutritional Risk Notes that Resident #395 had 10% or Greater Loss using the same two (2) current weight values. She stated that the Nutritional Risk Notes did not correspond with the MDS assessments. She stated that although there was significant weight loss in a timeframe close to 180 days, she did not code this on the MDS because the current weight and comparison weight on each MDS were not exactly 180 days apart. She said she had received an email from The Centers for Medicare and Medicaid Services (CMS) telling her that the RAI Manual had changed and she was to code significant weight loss only if it occurred exactly 180 days preceding the current weight entered in Section K of the MDS. She did not locate or provide a copy of this email for review before the end of the survey. During a phone interview on [DATE] at 12:16 PM, Corporate Registered Dietitian (RD) #133 confirmed that company policy dictates that significant weight loss over a time period of 180 days could only be coded on the MDS if the weight loss occurred at exactly 180 days preceding the current weight marked on the MDS Section K. She added that the policy was developed because there was no clarification in the RAI manual of what the word closest meant in the instructions to use the weight closest to 180 days ago. On [DATE] at 4:04 PM, the definition of close was located in Merriam-Webster's online dictionary. The word close, an adjective, means having little space between items or units or being near in time, space, effect, or degree, according to the dictionary entry. On [DATE] at 10:42 AM, the facility's Director of Nursing was informed of the issue. No further information was provided by the facility prior to the end of the survey. e) Resident #62 Observation of the resident at 1:54 PM on [DATE] found the resident appeared to have limited use of her hands and shoulders. Review of the resident's most recent Minimum Data Set (MDS), a annual, with an assessment reference date (ARD) of [DATE], found the resident was coded as having no contractures and having full use of her right dominant side. At 8:45 AM on [DATE], the Registered Nurse Assessment Coordinator (RNAC) #47 said the MDS was incorrectly coded. RNAC #47 said the MDS should be coded as the resident has limitations of her dominant right side. f) Resident #84 On [DATE], the resident was seen by the nurse practioner (NP). The NP prescribed [MEDICATION NAME], an antidepressant, for a [DIAGNOSES REDACTED]. Review of the residents admission Minimum Data Set (MDS) was a Assessment Reference Date (ARD) of [DATE], found the MDS was not coded to reflect the residents [DIAGNOSES REDACTED]. At 3:42 PM on [DATE], the Registered Nurse Corporate Coordinator, [NAME] #135, confirmed the care plan was incorrectly coded.",2020-09-01
534,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,656,E,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to develop/and or implement care plans for 4 of 23 residents whose care plans were reviewed. Resident #44's care plan was not developed to include how the facility would provide care to a Dementia resident. Resident #45's care plan was not was implemented for Dementia care. Residents #6 and #70's care plans were not implemented to anchor catheters. Resident identifiers: #44, #45, #6, and #70. Facility census: 97. Findings include: a) Resident #44 Review of the current care plan, revised on 07/20/17, found the problem: (Name of Resident ) has impaired cognitive function related to Dementia. The goal associated with the problem was: Patient will maintain current level of cognitive function through the review date. Interventions included: Administer Meds ([MEDICATION NAME]) as ordered Document/report to physician any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Engage patient in simple, structured activities that avoid overly demanding tasks. A second care plan problem addressed the resident was receiving [MEDICATION NAME] for delusions and hallucinations. The goal of this care plan was: The resident will be/remain free of drug related complications including movement disorder. Interventions included: Administer medications as ordered and monitor for side effects. Encourage resident to vent feelings. Monitor/record/report to physician as needed side effects and adverse reactions From the guidance to surveyors: Residents living with dementia require specialized services and supports, (e.g., specialized activities, nutrition, and environmental modifications) that vary, based on the individual's abilities and challenges related to their condition. Dementia causes significant intellectual functioning impairments that interfere with life, including activities and relationships. People living with dementia may lose their ability to communicate, solve problems, and cope with stressors. They may also experience fear, confusion, sadness, and agitation. On 06/01/18, the resident's physician prescribed [MEDICATION NAME], an antipsychotic medication, .25 milligrams (mg's) two times a day (BID) for a [DIAGNOSES REDACTED]. The physician documented the reason for starting [MEDICATION NAME] as, Patient will not leave her room to attend activities stating, If I leave the bugs will come in my room and get in my bed, I have to keep the door shut to keep the bugs out, they sometimes knock on my window and try to get in. At 9:15 on 11/29/18, the care plan was discussed with the director of nursing (DON). The DON was unable to provide evidence the care plan addressed interventions as to how the staff were to provide care when the resident was delusional. The DON confirmed the care plan did not discuss what staff should do when the resident had delusions and hallucinations. The DON could not demonstrate how the care plan individualized this resident's dementia care needs. b) Resident #45 Record review found the resident was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED].>[MEDICAL CONDITION], Dementia, and Depression. On 09/12/18, the antipsychotic, [MEDICATION NAME] 25 mg., two times (BID) a day was added to the residents medication regime for behaviors. Review of the current care plan, updated on 04/25/18, found the following problems related to the resident's behaviors: (Name of Resident) is verbally abusive and physically aggressive behaviors toward staff while providing care related to ineffective coping skills. The goal was the patient will demonstrate effective coping skills, as evidenced by not being verbally abusive to staff while providing care through next review date. Interventions included: Analyze key times, places, circumstances, triggers and what de-escalates behavior and document. assess patients coping skills and support system. Anticipate patients needs: food, thirst, toileting needs, comfort level, body positioning, pain etc. Assess patients understanding of the situation. Allow time for the patient to express self and feelings towards the situation. When patient becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation if response is aggressive staff to walk calmly away, and approach later. A second care plan problem, updated on 01/29/18 found: (Name of Resident) has a behavioral problem related to yelling for help instead of utilizing the call bell system for needs and assistance. Resident will hit at staff while providing care. The goal associated with the problem was: The resident will have fewer episodes of yelling for help instead of utilizing the call bell system for requesting her needs. Interventions included: Anticipate and meet patients needs to reduce behavioral symptoms. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take patient to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location time of day persons involved and situations. Document behaviors and potential causes. Report findings to attending physician and or update care plan as appropriate. Privately discuss inappropriate behaviors with patient and explain why his her behavior is unacceptable in the nursing facility. Document discussion. Report outcome to physician and or update care plan as appropriate. At 11/28/18 at 02:41 PM, the director of nursing confirmed she was unable to provide information to substantiate the above approaches were implemented as directed by the care plan. The DON confirmed the interventions were in place before the antipsychotic medication was started. The DON further confirmed the non-pharmacological interventions were not implemented before starting the antipsychotic medication. During an interview with the DON and administrator on 11/29/18 at 10:34 AM, the DON said, I have nothing else to give you. c) Resident #6 On 11/26/18 at 1:35 pm, an observation with Employee #52, Clinical Care Supervisor (CCS) found Resident #6 had an indwelling Foley Catheter. The catheter was not anchored to the resident's leg. Care Plan from electronic chart reviewed: Focus: Resident #6 has an Indwelling Catheter due to a pressure ulcer on coccyx, 20 FR with 10 cc balloon. Goal: Patient will be/remain free from catheter-related trauma through review date. Intervention: 1. Change catheter every 4 weeks and as needed. 2. Document pain/discomfort/intolerance due to catheter and report to physician as necessary. 3. Document/report to physician s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Provide patient-specific catheter care as ordered 4. URINARY CATHETER: Patient has a Foley. Position drainage bag and tubing below the level of the bladder to allow free flow of urine into the bag. Secure tubing. Cover drainage bag with appropriate privacy bag. Report any concerns to the Unit Charge Nurse. Provide catheter care and record volume of urine every shift. An interview on 11/27/18 at 10:00 am with the DON, the DON was informed of findings. No further information provided. e) Resident #70 On 11/28/18 at 9:23 AM, Indwelling Foley Catheter care observation with Nursing Assistant (NA) #40, it was noted the catheter anchor (used to prevent injury and accidental removal) was not on the resident's leg. Both NA #40 and NA #85 agreed that the anchor was not there and should be on the leg. During an interview on 11/28/18 at 10:04 AM, DoN was notified of findings that were observed. She stated that she was disappointed. The Facility Policy, Catheter Care, Urinary Dated; 8/2002. reads: -Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note; Catheter tubing should be strapped to the resident's inner thigh.) Care Plan from electronic chart: Resident #70 has an Indwelling Catheter for [MEDICAL CONDITION] bladder, 16 FR with 10cc balloon. - Patient will be/remain free from catheter-related trauma through review date. Change catheter every 4 weeks and as needed. Document pain/discomfort/intolerance due to catheter and report to physician as necessary. Document/report to physician s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Provide patient-specific catheter care as ordered URINARY CATHETER: Patient has a Foley. Position drainage bag and tubing below the level of the bladder to allow free flow of urine into the bag. Secure tubing. Cover drainage bag with appropriate privacy bag. Report any concerns to the Unit Charge Nurse. Provide catheter care and record volume of urine every shift.",2020-09-01
535,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,657,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to revise care plans when residents had changes in their care related to advance directives, position and mobility, and [MEDICAL TREATMENT] schedule. This was found to be true for three (3) of 23 sampled residents reviewed during the Long-Term Care Survey Process. Resident identifiers: #395, #62, #16. Facility census: 97. Findings included: a) Resident #395 On [DATE] at 1:32 PM it was noted through the screening portion of the Long-Term Care Survey Process that the code status marked on Resident #395's profile in the electronic medical record did not match the code status indicated on the care plan. The code status on the profile in the electronic medical record stated, Resuscitate (CPR); Feeding Tube Long-Term; Patient has a completed POST form dated: [DATE]; Limited Additional Interventions; IV Fluids for a trial period of no longer than: ,[DATE] days. A review of the current Physician order [REDACTED].#395's representative on [DATE], stated to Attempt Resuscitation/CPR and to provide Limited Additional Interventions, IV fluids for a trial period of no longer than ,[DATE]d(ays), and Feeding tube long-term. A previous POST form, signed by Resident #395's representative on [DATE], indicated to provide full interventions as well as IV fluids for a trial period of no longer than ,[DATE]d(ays). It was marked VOID. Resident #395's physician orders [REDACTED]. However, the advance directives documented on the care plan stated, Full interventions, IV fluids for a trial period of no longer than ,[DATE] days, Feeding tube long term. According to date stamps on the care plan, this information was last revised on [DATE] by Registered Nurse Assessment Coordinator (RNAC) #47. During an interview on [DATE] at 2:20 PM, RNAC #47 acknowledged that the advance directive information on the POST form and the care plan did not match and stated she would fix the problem immediately. On [DATE] at 10:42 AM, the facility's Director of Nursing (DoN) was informed of the issue. No further information was provided by the facility prior to the end of the survey. b) Resident #62 Review of the resident current care plan, revised on [DATE], found the following problem: (Name of Resident) has an ADL (activities of daily living) self care performance deficit related to altered mental status,[MEDICAL CONDITION], dementia, [MEDICAL CONDITIONS], contracture to left arm and hand and [MEDICAL CONDITION]. Review of the most recent minimum data set (MDS) an annual, with an assessment reference date (ARD) of [DATE], found the resident was coded as having no contractures. At 8:45 AM on [DATE], the Registered Nurse Assessment Coordinator (RNAC) #47, said the care plan was incorrect. The RNAC noted the resident had contractures when she was admitted to the facility on [DATE]. When the contractures resolved the care plan was never updated to reflect the resident currently has no contractures to the left arm and hand. c) Resident #16 A reviewed of Resident #16's medical record at 9:26 a.m. on [DATE] found the following physician order [REDACTED]. A review of Resident #16's care plan found the following focus statement, : [MEDICAL TREATMENT] related to [MEDICAL CONDITION]. This focus statement was added to the care plan on [DATE]. The goal associated with this focus statement read, : Will have no signs or symptoms complications fro [MEDICAL TREATMENT] through the review date. The revision date for this goal was [DATE] with a target date of [DATE]. The goals associated with this focus statement and goal included, Encourage patient to go for the scheduled [MEDICAL TREATMENT] appointments. Patient receives [MEDICAL TREATMENT] Tuesdays, Thursdays, and Saturdays at 6:15 a.m. at (Name of local [MEDICAL TREATMENT] center) . This intervention was added to the care plan on [DATE]. An interview with Registered Nurse Assessment Coordinator (RNAC) #47, at 9:56 a.m. on [DATE] confirmed Resident #16's care plan was not revised when her [MEDICAL TREATMENT] days and times changed on [DATE] at it should have been.",2020-09-01
536,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,660,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a plan was in place to address the the residents expressed desire to talk to someone about in-home and community agencies available before her discharge to home. This was true for one (1) resident reviewed for the care area of discharge to the community. Resident identifier: #95. Facility census: 97. Findings include: a) Resident #95 Record review at 9:20 AM on 11/27/18, found the resident was admitted to the facility on [DATE]. The resident was discharged to her home on 08/31/18. Review of the minimum data set (MDS), a 5 day Medicare Part A Stay, with an assessment reference date (ARD) of 06/19/18, found the resident participated in completing the MDS. The resident expected to be discharged to the community. When asked the question on the MDS, Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? The residents response was, yes. The Resident Assessment Instrument (RAI) manual provides the following direction when answering yes to the above question on the MDS: The goal of follow-up action is to initiate and maintain collaboration between the nursing home and the local contact agency to support the resident's expressed interest in talking to someone about the possibility of leaving the facility and returning to live and receive services in the community. This includes the nursing home supporting the resident in achieving his or her highest level of functioning and the local contact agency providing informed choices for community living and assisting the resident in transitioning to community living if it is the resident's desire. The underlying intention of the return to the community item is to insure that all individuals have the opportunity to learn about home and community based services and have an opportunity to receive long term services and supports in the least restrictive setting. CMS (Centers for Medicare and Medicaid Services) has found that in many cases individuals requiring long term services, and/or their families, are unaware of community based services and supports that could adequately support individuals in community living situations. Local contact agencies (LCAs) are experts in available home and community-based service (HCBS) and can provide both the resident and the facility with valuable information. On 11/27/18 at 10:06 AM, the social worker (SW) #28 was asked for verification of information provided to the resident about all community based services and support systems. There were no notes in the electronic medical record from social services discussing discharge placement. SW #28 said referrals for medical equipment were made and the resident was referred to a Home Health agency before discharge. He was unable to provide any documentation a discussion was held with the resident to determine what other agencies were available in her community. Such as agencies who provide meals, chore services, transportation, and other in-home care and community based services that could be available. On 11/27/18 at 10:17 AM, the supervisor of therapy services, Employee #118, said the therapists recommended the equipment needed at home. We always refer residents to a Home Health agency upon discharge, for a safe transition to the community. [NAME] #118 said her department does not look at other agencies available in the community, That is Social Services. At 10:40 AM on 11/27/18, a visiting social worker, from another company facility, SW #134 said, We will get some training in place to address this.",2020-09-01
537,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,684,E,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, observation, resident interview, and the National Pressure Ulcer Advisory Panel's (NPUAP), the facility failed to provide quality treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' preferences, goals for care and professional standards of practice that will meet each resident's physical, mental, and psychosocial needs. This was true for six (6) of twenty-three (23) residents reviewed. For Residents #37, #14, #345, and #9 had wounds not assess, monitor and treat wounds as indicated. Resident #43 did not have a follow appointment as directed by the discharging physician. Additionally, Resident #59's bowel and bladder incontinence was not accurately assessed. Resident identifiers: #37, #14, #345, #9, #43, and #59. Facility census: 97. Findings include: a) Resident #37 Medical record review found Resident #37 was admitted to the facility on [DATE]. Additionally, Resident #37 had a facility acquired pressure ulcer to the Matrix. Review of Resident #37 nursing assessment and wound assessments: Nursing assessments for 01/09/18, 04/10/18, and 04/10/18- No pressure ulcers noted. --10/02/18- Initial wound assessment dated [DATE]: coccyx- Stage II- measured 0.9 centimeter (cm) in length (l) and 0.6 cm in width (w) and 0.1 cm depth (d). --10/05/18 - Nursing assessment- Coccyx- dressing intact, see detailed initial pressure ulcer assessment (dated 10/02/18). Right inner foot - see detailed non-pressure wound evaluation. (None could be found). --10/08/18- Coccyx- Stage II- measured 0.8 cm l and 0.4 cm w. and 0.1 cm in depth. --10/09/18-Initial assessment-right inner heel- Stage II- blister which had ruptured and measured 3.0 cm in l and 3.5 cm in w and 0.1 cm in d. --10/17/18- coccyx- stage II- measured 0.4 cm l and 0.1 cm w. and 0.1 cm in depth right heel Stage II- measured 2.2 cm l and 3.0 cm w. and 0.1 cm in depth --10/24/18- coccyx- stage II- measured 0.4 cm l and 0.1 cm w. and 0.1 cm in depth right heel- Unstageable- measured 1.0 cm l and 1.5 cm w. and unknown depth-area with da ark red scab surrounding area red and blanches --10/31/18- coccyx- stage II- area closed right heel Unstageable- area with dark red scab surrounding area red and blanches. measured 1.0 cm l and 1.5 cm w. and depth unknown. --11/05/18- Initial Assessment- left trochanter (hip) Suspected deep tissue injury 1.5 cm in length and 1.5 cm width and unknown depth. Wound bed is dark purple in color --11/07/18- coccyx stage II- area closed for 2 weeks however surrounding skin is dark red and does not blanche. right inner heel Unstageable- area with dark red scab surrounding area red and blanches left trochanter (hip) Suspected deep tissue injury 1.5 cm in length and width and unknown depth. Wound bed is dark purple in color --11/14/18- right inner heel Unstageable- area with dark red scab surrounding area red and blanches measured 2.0 cm l and 2.0 cm w. and unknown in depth. --11/15/18- coccyx- stage II- area closed no redness noted. left trochanter (hip) - area closed red but blanches. --11/21/18- coccyx Suspected deep tissue injury- area 8 cm in length and 6 cm in width and unable to determine. right inner heel Unstageable- area with dark red scab surrounding area red and blanches --11/22/18- Initial assessment: Left heel- blister measured 3 cm x 3 cm unstageable. coccyx stage II- area closed for 2 weeks however surrounding skin is dark red and does not blanche. right inner heel Unstageable- area with dark red scab surrounding area red and blanches left trochanter (hip) Suspected deep tissue injury 1.5 cm in length and 1 cm in width and unknown depth. Wound bed is dark purple in color. b) Resident #14 Review of Resident #14's medical record revealed she was admitted to the facility on [DATE]. Further review found the following nursing assessments and wound assessments found: --Initial wound assessment -07/10/18- right buttock- Stage 2- measured 1.5 cm in l and 1.0 cm w and 0.1 cm in d. Follow wound assessments: --7/17/18- right buttocks - Stage 2- measured 2.0 cm in l and 2.0 cm w and 0.1 cm in d. --7/24/18- right buttock- Stage 2- measured 2.0 cm in l and 1.4 cm w and 0.1 cm in d. --7/31/18- right buttock- Stage 2- measured 2.0 cm in l and 1.3 cm w and 0.1 cm in d. --8/7/18- right buttock- Stage 2- measured 2.8 cm in l and 1.2 cm w and 0.1 cm in d. --8/14/18- right buttock- Stage 2- measured 2.0 cm in l and 1.0 cm w and 0.1 cm in d. --8/21/18- right buttock- Stage 2- measured 2.0 cm in l and 1.2 cm w and 0.1 cm in d. --08/28/18- right/left buttocks- Stage 2- measured 13.0 cm in l and 11.0 cm w and 0.1 cm in d. Additional notes: Area has now spread to left buttock, entire area is dark red/purple, warm to touch and does not blanche. Has multiple open areas varying in sizes, complaint of itching, bowel movements are now soft and formed, allows staff to turn more frequently, fluid intake fair. Wound care provided. --8/31/18-Nursing assessment: Stage II - sacrum- measured 13.0 cm in l x 11.0 cm in w. Multiple areas draining small amount of bright red fluid draining , no odor present. Stage II observed to sacral area- skin warm dark red/purple, non-blanchable, multiple open areas, small amount of bright red drainage present. --9/4/18- right and left buttocks- Stage II- measured 10.2 cm in l and 10.5 cm in l and 0.1 cm in d. four (4) open areas remain. --09/12/18- right and left buttocks- Stage II - measured 9.6 cm in l and 9.0 cm in l and 0.1 cm in d. three (3) open areas. --09/12/18- Nursing Assessment- right buttock and left buttock- Both reads: Unable to observe due to bordered foam dressing. No drainage or odor noted. --09/18/18- #1) coccyx - Stage II Stage II- measured 3.7 cm in l and 2.5 cm in l and 0.1 cm in d. - Area was being measured as one big area, but now open in multiple areas. Scant amount of bloody drainage observed, no odor observed. #2) - right buttock- Stage II-- measured 1.0 cm in l and 0.5 cm in l and 0.1 cm in d #3) left buttock- Stage II- measured 2.0 cm in l and 0.8 cm in l and 0.1 cm in d. --9/25/18 #1- coccyx- Stage II- measured 3.7 cm in l and 2.4 cm in l and 0.1 cm in d. #2 left buttock- Stage II- measured 2.0 cm in l and 0.7 cm in l and 0.1 cm in d. #3- right buttock- Stage II- measured 0.8 cm in l and 0.5 cm in l and 0.1 cm in d. --10/02/18- #1- coccyx- Stage II- measured 3.0 cm in l and 2.4 cm in l and 0.1 cm in d. #2 left buttock- Stage II- measured 0 cm in l and 0 cm in l and 0 cm in d. #3- right buttock- Stage II- measured 0.4 cm in l and 0.4 cm in l and 0.1 cm in d. --10/09/18- #1- coccyx- Stage II- measured 3.5 cm in l and 1.5 cm in l and 0.1 cm in d. #2 left buttock- Stage II- measured 0 cm in l and 0 cm in l and 0 cm in d. #3- right buttock- Stage II- measured 0.3 cm in l and 0.3 cm in l and 0.3 cm in d. --10/16/18- #1- coccyx- Stage III- measured 3.1 cm in l and 1.5 cm in l and 0.1 cm in d. #2 - right buttock- Stage II- measured 0.5 cm in l and 0.5 cm in l and 0.1 cm in d. --10/23/18- #1- coccyx- Stage III- measured 3.5 cm in l and 1.5 cm in l and 0.1 cm in d. #2 - right buttock- Unstageable- measured 0.5 cm in l and 0.5 cm in l and unknown d. --10/31/18- #1- coccyx- Stage III- measured 3.4 cm in l and 1.3 cm in l and 0.1 cm in d. #2 - right buttock- Unstageable- measured 0.4 cm in l and 0.4 cm in l and unknown d. --11/06/18- #1- coccyx- Stage III- measured 3.0 cm in l and 1.0 cm in l and 0.1 cm in d. #2 - right buttock- Unstageable- measured 0.2 cm in l and 0.3 cm in l and unknown d. --11/13/18- #1- coccyx- Stage III- measured 3.1 cm in l and 1.0 cm in l and 0.1 cm in d. #2- right buttock- Healed. --11/27/18- #1- coccyx- Stage III- measured 2.8 cm in l and 1.0 cm in l and 0.1 cm in d. The updated staging system developed by the National Pressure Ulcer Advisory Panel (NPUAP) includes the following definitions: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage IV. Interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 11/28/18 at 3:30 pm confirmed the nursing assessments and the wound sheets were not consist and accurate in type of wound, staging and location. they confirmed they had identified the inconsistency. c) Resident #9 Resident #9 was interviewed on 11/26/18 at 10:52 AM. She was noted to have a 4x4 secured with tape on the front of her right lower leg. Resident #9 stated she also had an open area on the back of her right lower leg. She stated she had completed a course of antibiotics for [MEDICAL CONDITION] but continued to have weeping of fluid from her leg requiring a dressing. Review of Resident #9's medical records revealed she had a [DIAGNOSES REDACTED]. There was no documentation of the application of a dressing to Resident #9's right lower leg. There were no physician orders regarding the application of a dressing to Resident #9's right lower leg. On 11/28/18 at 1:46 PM, Resident #9 was observed in her wheelchair in the hallway outside her room. She stated she did not have a dressing on her right lower leg at that time. She stated she was waiting for a nurse to look at it because she had been having drainage from her leg. While surveyor was speaking to Resident #9, Licensed Practical Nurse (LPN) #108 took Resident #9 into her room to assess her right lower leg. LPN #108 stated Resident #9 had an open area on the back of her right lower leg. LPN #108 stated she would have the unit's Clinical Care Supervisor (CCS) assess the area. On 11/28/18 at 2:35 PM, Resident #9 was observed in the hallway in her wheelchair. She had a dressing on her right lower leg. A wound assessment written by LPN #108 11/28/18 at 2:03 PM stated, An evaluation of this patient's wound was completed by this nurse. Wound location is: Posterior RLE (right lower extremity). Interventions for treatment and healing of this wound are contained in the patient's physician orders and interdisciplinary plan of care. Monitoring and re-evaluation of this wound will be on-going. A wound evaluation- non-pressure wound assessment was completed by LPN #108 on 11/28/18 at 2:03 PM. The wound evaluation stated, Resident c/o (complained of) sock feeling wet. UCN (unit charge nurse) assessed area. RLE with weeping vascular area that measures 1.5x 1cm x less than 0.1 cm. Area is moist and pinkish white in color. Active clear drainage noted. No odor noted. Resident does have [MEDICAL CONDITION] to BLE. (Physician's name) notified. New orders to cleanse area with skin-tegrity pat dry, apply ABD (abdominal) pad and cover with kling. Resident is not a candidate for increase in diuretics due to renal function. AMA (against medical advice) on file for refusals of ace wraps to BLE (bilateral lower extremity) and is also non-compliant with that at times. Resident aware of above. A physician's order written on 11/28/18 at 2:08 PM stated, Cleanse vascular area to RLE with skin-tegrity, pat dry, apply ABD pad and cover with kling every shift for weeping vascular area. During an interview on 11/28/18 at 3:30 PM, CCS #19 stated she had no information regarding when the right lower leg dressing observed on Resident #9 on 11/26/18 had been applied or who applied the dressing. CCS #19 was unable to locate any previous documentation regarding this dressing or a prior assessment of Resident #9's right lower leg skin condition. She stated Resident #9's leg was assessed today and a wound care order was obtained from the physician. CCS #19 stated the physician would assess the resident's leg. d) Resident #43 On 09/17/18, Resident #43 was transferred to the hospital due to chest discomfort, shortness of breath, and upper extremity [MEDICAL CONDITION]. Resident #43 was discharged from the hospital on [DATE]. The discharge summary provided by the hospital to the facility gave the plan as follows (typed as written): - Discharge back to nurse or not rehab - Resume home medications - Follow up with her regular cardiologist within the next 1-2 weeks - See PCP (primary care provider) within the week - Return if worsening concerns. Review of the medical records did not show evidence Resident #43 had seen a cardiologist within one (1) to two (2) weeks of returning to the facility from the hospital on [DATE]. On 11/07/18, Resident #43 returned to the hospital due to shortness of breath. During an interview on 11/27/18 at 12:20 PM, the Director of Nursing (DoN) was asked if an appointment with Resident #43's cardiologist had been made when she returned to the facility on [DATE] as was recommended by the discharging physician. During an interview on 11/28/18 at 9:44 AM, the DoN confirmed Resident #43 did not see a cardiologist within one (1) to two (2) weeks of returning to the facility from the hospital on [DATE]. The DoN stated on 11/27/18 an appointment with a cardiologist had been made for 12/12/18. e) Resident #345 On 11/26/18 at 11:13 AM, it was noted Resident #345 had an opened wound without any dressing on the bottom of his left foot. During an interview on11/27/18 at 9:31 AM, Licensed Practical Nurse (LPN) #23 looking for current notes about wound on foot. After looking at his foot which it appeared to be dry with a thick callus, an area that appeared to have a hole estimating 3.5 centimeters (cm) by 4 cm, with a yellowish colored layer dipping down. She said that he had this on return to the facility but could not recall when that was. During an interview on 11/27/18 at 12:00 PM, asked DoN about wound care and documentation for the wound on the left foot. It was pointed out to her that the documentation was incomplete and inconsonant. She stated that she would look to see if she can more documentation. During an interview on 11/29/18 at 8:38 AM, Administrator was asked about the wound on the left foot of Resident #345. She was asked if she could follow the skin evaluations and the wound assessments? She stated she aware of the poor documentation and is working on that currently. She agreed that the documentation did not paint a clear picture of his wound and the changes concerning the wound. Review of the medical chart revealed that the Skin Evaluation dates started 1/04/18 thru 08/28/18 never had a statement about the wound on the left foot. On the Wound Assessment portion, the first time it was documented was on 04/09/18. On 05/03/18 was the first time it was documented in the Wound Document portion. On 9/13/18 was the first time any nurse had documented any measurements. Review of the Infections Nursing Notes Portion revealed an infection to the left foot on two (2) separate occasions 05/16/18 thru 05/22/18 he received an antibiotic and then again from 08/21/18/to 08/30/18. At this time on 08/21/18 a culture and sensitivity were obtained. A review of the medical records revealed the Nurses were referring to this wound an avulsion (is when skin is pulled off). The Physician who was treating the foot referred to the wound as an ulcer. The Care Plan referred to the wound as a diabetic ulcer. Resident #345 has the following medical Diagnosis: [REDACTED]. f) Resident #59 Review of the residents minimum data set (MDS), a quarterly MDS, with an assessment reference date (ARD) of 10/22/18, found the resident was coded as being occasionally incontinent of urine and frequently incontinent of bowel. Review of the last nursing assessment, dated 10/18/18, found the resident was coded as using the toilet or bedpan and having no episodes of incontinence of urine or bowel. At 9:54 AM on 11/28/18, the Registered Nurse Assessment Coordinator (RNAC) #47, said the nursing assessment was incorrect. RN #47 provided documentation from the nursing assistants to verify the MDS was correct and the nursing assessment was incorrect. RNAC #47 said the nursing assessment should have coded the resident as having episodes of incontinence of both urine and bowel. At 11:56 AM on 11/28/18, the director of nursing (DON) confirmed the nursing assessment was incorrect. On 11/28/18 at 3:18 PM, the documentation on the nursing assessment and the MDS was discussed with the administrator and the vice president of quality care, [NAME] #136. No further information was provided before the close of the survey at 12:15 PM on 11/30/18.",2020-09-01
538,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,690,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review the facility failed to ensure residents, with an indwelling catheter, received the appropriate care based upon current professional standards of practice and services to prevent urinary tract infections to the extent possible. Also failed to ensure the indwelling Foley catheter was secured to the leg was used to prevent injury, accidental removal. This was true for two (2) of two (2) reviewed for catheter care. Identified Residents were Resident #70 and #6. Facility Census 97. Findings included: a) Resident #70 During an interview on 11/26/18 at 11:39 AM, Resident's husband said that she has ESBL in urine she has a catheter. On 11/28/18 at 9:23 AM, Indwelling Foley Catheter care observation with Nursing Assistant (NA) #40, it was noted the catheter anchor was not on the resident's leg. NA#40 wiped once down the sides of the inner legs (groin area), one down stroke over the outside of the vagina. She then emptied the water basin and left room. When she returned with clean wash cloth and water she wiped the catheter tubing but not at the insertion site, only a section of the tubing about 3 inches from the vagina. Licensed Practical Nurse (LPN) #27 brought in a thigh strip to secure the Foley catheter to the leg. NA #85 wiped the buttock crevices toward the vagina, not away from the vagina to prevent Infections. After the two (2) NAs had finished and put the supplies away they were asked the following; - How often are they in-serviced on catheter care? They both said the last time was in (MONTH) this year. - How do they believe they did? NA # 85 said that, she knew that she should not have wiped towards the vagina and NA #40 said she normally does a better job. Both NAs agreed they did not use proper technic for catheter care. During an interview on 11/28/18 at 10:04 AM, DoN was notified of findings that were observed. She stated that she was disappointed. The Facility Policy, Catheter Care, Urinary Dated; 8/2002. reads: -Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note; Catheter tubing should be strapped to the resident's inner thigh.) - report unsecured catheters to the Charge Nurse. The Facility Policy, Perineal Care Dated, 1,2002, reads: -Wash perineal area wiping from front to back. -Separate labia and wash area downward from front to back - gently wash the juncture of the tubing from the urethra down. -Continue to wash the perineum moving from inside outward to and including the thighs alternating from side to side and using downward [MEDICAL CONDITION]. Do not use the same washcloth or water to clean the urethra or labia. -Wash the rectal area thoroughly, wiping the base of the labia towards and extending over the buttocks, do not use the same washcloth or water to clean the labia. Care Plan from electronic chart: Resident #70 has an Indwelling Catheter for [MEDICAL CONDITION] bladder, 16 FR with 10cc balloon. Patient will be/remain free from catheter-related trauma through review date. Change catheter every 4 weeks and as needed. Document pain/discomfort/intolerance due to catheter and report to physician as necessary. Document/report to physician s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Provide patient-specific catheter care as ordered URINARY CATHETER: Patient has a Foley. Position drainage bag and tubing below the level of the bladder to allow free flow of urine into the bag. Secure tubing. Cover drainage bag with appropriate privacy bag. Report any concerns to the Unit Charge Nurse. Provide catheter care and record volume of urine every shift. b) Resident #6 On 11/26/18 at 1:35 pm, an observation with Employee #52, Clinical Care Supervisor (CCS) found Resident #6 had an indwelling Foley Catheter. The catheter was not anchored to the resident's leg. Care Plan from electronic chart reviewed: Focus: Resident #6 has an Indwelling Catheter due to a pressure ulcer on coccyx, 20 FR with 10 cc balloon. Goal: Patient will be/remain free from catheter-related trauma through review date. Intervention: 1. Change catheter every 4 weeks and as needed. 2. Document pain/discomfort/intolerance due to catheter and report to physician as necessary. 3. Document/report to physician s/sx UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. Provide patient-specific catheter care as ordered 4. URINARY CATHETER: Patient has a Foley. Position drainage bag and tubing below the level of the bladder to allow free flow of urine into the bag. Secure tubing. Cover drainage bag with appropriate privacy bag. Report any concerns to the Unit Charge Nurse. Provide catheter care and record volume of urine every shift. An interview on 11/27/18 at 10:00 am with the DON, the DON was informed of findings. No further information provided.",2020-09-01
539,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,698,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview the facility failed to ensure Resident #16 a [MEDICAL TREATMENT] patient received care and services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Resident #16 reported that she is late to [MEDICAL TREATMENT] frequently because the ambulance is always late to get her. Also, Resident #16 had an order for [REDACTED]. This was true for one (1) of one (1) residents reviewed for the care area of [MEDICAL TREATMENT] during the long term care survey process. Resident Identifier: #16. Facility Census: 97 Findings Include: a) Resident #16 1. Transportation to [MEDICAL TREATMENT] During an interview with Resident #16 at 12:00 p.m. on 11/26/18, she stated, I am late for [MEDICAL TREATMENT] on a regular basis. She indicated her appointment was set for 12:00 p.m. and the ambulance often times picked her up after her scheduled appointment time. She stated, I am supposed to be on the machine all ready and I am still sitting her waiting for them to come and get me. She stated, This happens at least once or twice a week. At 12:16 p.m. on 11/26/18, the ambulance company was observed arriving to pick up resident #16 for her [MEDICAL TREATMENT] appointment which was scheduled at 12:00 p.m. A review of Resident #16's medical record at 9:26 a.m. on 11/28/18 found the following physician order [REDACTED].>Further review of the record found the following dates which Resident #16 was picked up for her [MEDICAL TREATMENT] appointment after her scheduled appointment time: All notes are entered by nursing and are appointment/outing notes. The times used are the effective times of the note which would be the time Resident #16 left the building in route to her [MEDICAL TREATMENT] treatment: 07/18/18 at 12:45 p.m. 08/01/18 at 12:55 p.m. 08/27/18 at 12:03 p.m. 09/04/18 at 1:32 p.m. 09/14/18 at 12:19 p.m. 09/24/18 at 12:51 p.m. 09/28/18 at 12:02 p.m. 10/08/18 at 12:10 p.m. 11/02/18 at 12:04 p.m. 11/12/18 at 12:47 p.m. 11/26/18 at 12:15 p.m. 11/29/18 at 12:03 p.m. An interview with the local [MEDICAL TREATMENT] center staff at 10:09 a.m. on 11/28/18 confirmed Resident #16 as consistently late to [MEDICAL TREATMENT]. She stated, She is late at least once or twice a week and it puts us behind for the rest of the day. An interview with the Director of Nursing (DON) at 11:47 a.m. on 11/28/18 confirmed the nursing notes indicated Resident #16 was picked up late for [MEDICAL TREATMENT] on the dates mentioned above. She stated they would have to address it with the ambulance company because this is the first she has heard of it. An interview with Clinical Care Supervisor Registered Nurse #52 at 2:10 p.m. on 11/28/18 found she had spoken with the ambulance company and they stated they would try to do better picking up the resident on time. 2. [MEDICATION NAME] A review of Resident #16's medical record at 9:26 a.m. on 11/28/18 found a physician order [REDACTED].) This ordered was entered into the medical record on 10/08/18. A review of the Medication Administration Record [REDACTED] 10/10/18, 10/12/18, 10/15/18, 10/19/18, 10/22/18, 10/26/18, 10/29/18, 10/31/18, 11/02/18, 11/05/18, 11/07/18, 11/09/18, 11/12/18, 11/14/18, 11/16/18, 11/19/18, 11/21/18, 11/23/18, and 11/26/18. During an interview with the DON at 11:47 a.m. on 11/28/18, the above findings were reviewed she stated she would look into it and let me know what she had found. An interview with Clinical Care Supervisor Registered Nurse #52 at 2:10 p.m. on 11/28/18 confirmed Resident #16's [MEDICATION NAME] was not given as directed by the order and the 5:00 a.m. on Monday, Wednesday and Friday was consistently not held as ordered.",2020-09-01
540,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,744,E,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents diagnosed with [REDACTED]. This was true for three (3) of three (3) residents reviewed for the care area of Dementia. Resident identifiers: #44, #45, and #92. Facility census: 97. Findings include: a) Resident #44 Record review found this seventy-five year old female was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. On 06/01/18, the resident's physician prescribed [MEDICATION NAME], an antipsychotic medication, .25 milligrams (mg's) two times a day (BID) for a [DIAGNOSES REDACTED]. In addition to the [MEDICATION NAME], the resident was receiving the following [MEDICAL CONDITION] medications: [REDACTED] [MEDICATION NAME] 200 mg's by mouth at bedtime for Major [MEDICAL CONDITION], recurrent, unspecified. [MEDICATION NAME] 20 mg. daily for anxiety disorder. The resident was also receiving, Memantine 10 mg's BID, for Dementia in other diseases classified elsewhere with behavioral disturbances. ( Memantine ([MEDICATION NAME]) is used to treat moderate to severe confusion (dementia) related to [MEDICAL CONDITION]. It does not cure [MEDICAL CONDITION], but it may improve memory, awareness, and the ability to perform daily functions.) On 11/27/18 at 12:38 PM, Employee #135, the corporate registered nurse (RN)coordinator, said the facility monitors resident behaviors on the psychopharmacological medication monitoring located in the electronic medical record. Review of the psychopharmacological medication monitoring with RN #135, found no behaviors were documented by nursing staff before the physician ordered [MEDICATION NAME]. Nursing notes, from 05/01/18 through 06/01/18, (the day the [MEDICATION NAME] was initiated), were reviewed with RN #135. There were no behaviors documented in the nursing notes to warrant the initiation of [MEDICATION NAME]. Further review of the physician's progress notes in the electronic medical record with RN #135 at 12:38 PM on 11/27/18, found no information regarding the initiation of [MEDICATION NAME]. On the same day the [MEDICATION NAME] was started (06/01/18, the physician also ordered a urinalysis with reflex culture and sensitivity. Review of the laboratory report with RN #135 found the resident did not have a urinary tract infection. On 8/26/18, the pharmacist reviewed the residents medications and recommended a gradual dose reduction of [MEDICATION NAME]. The physician responded with a GDR was clinically contraindicated and the medication was just started on 06/01/18. At 1:52 PM on 11/27/18, RN #135 and the director of nursing (DON) provided a copy of a nursing home visit note from the residents physician, dated 06/01/18. Both employees confirmed this note had not been scanned into the residents medical record even though it was written over over 5 months ago. The physician had written, Patient will not leave her room to attend activities stating, If I leave the bugs will come in my room and get in my bed, I have to keep the door shut to keep the bugs out, they sometimes knock on my window and try to get in. RN #135 and the DON were unable to provide any documentation to verify facility staff were aware of the delusions, attempted to talk with the resident, or provide any non-pharmacological interventions before starting the antipsychotic medication. Neither employee could find any documentation to indicate this behavior had been witnessed by other staff. Review of the residents current care plan with the DON at 9:15 AM on 11/29/18, found the resident was care planned for receiving [MEDICATION NAME] for delusion and hallucinations. The goal of the care plan was: Patient will remain free of drug related complications including movement disorder. Interventions included: Administer medications as ordered and monitor for side effects. Encourage resident to vent feelings. Monitor/record/report to physician as needed side effects and adverse reactions The DON confirmed the care plan did not discuss what staff should do when the resident had delusions and hallucinations. The DON could not demonstrate how the care plan individualized this resident's dementia care needs. At the close of the survey on 11/29/18 at 12:15 PM, no further information had been provided to substantiate other staff members had documented resident behaviors regarding hallucinations and delusions. No further information was provided to substantiate the facility utilized individualized, non-pharmacological approaches to care (e.g., purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. b) Resident #45 Record review found the resident was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED].>[MEDICAL CONDITION], Dementia, and Depression. The resident was admitted with three antidepressants: [MEDICATION NAME], 75 mg. at bedtime, [MEDICATION NAME], 100 mg, three times (TID) a day [MEDICATION NAME] 30 mg. daily. The resident was not admitted with any antisychotic medication. On 01/19/18, the physician added [MEDICATION NAME] for dementia. On 06/12/18, the [MEDICATION NAME] was discontinued. On 06/13/18 [MEDICATION NAME] 20 mg., daily, was added for depression. The [MEDICATION NAME] was discontinued on 08/27/18. On 06/12/18 [MEDICATION NAME] 0.5 mg. three times a day was started for generalized Anxiety disorder. The [MEDICATION NAME] was discontinued on 11/12/18. On 06/26/18 [MEDICATION NAME] was increased from 75 mg. at bedtime to 150 mg. at bedtime. On 09/12/18, the antipsychotic, [MEDICATION NAME] 25 mg., two times (BID) a day was added to the residents medication regime. The resident continues to take the [MEDICATION NAME], and [MEDICATION NAME]. At 1:00 PM on 11/28/18, the Director of Nursing, (DON) was asked where the facility would have documented any behaviors and non-pharmacological interventions before starting the antipsychotic, [MEDICATION NAME]. On 11/28/18 at 02:41 PM, the DON said, I have looked for non pharmacological interventions, there aren't any documented. The DON said the resident was physically aggressive towards staff and other residents. The DON provided a copy of the nurse practioners (NP) visit, dated 09/12/18. The NP noted the resident had been trying to run over other residents with her wheelchair and was refusing to take her medications and cursing at staff. The Medication Administration Record [REDACTED]. According to the documentation on the MAR, the resident had taken all her medications. The DON was asked if the facility had any incident/accident reports regarding the physical aggression towards other residents? Review of the care plan with the DON found the following interventions were to be implemented when the resident exhibited behaviors: Analyze key times, places, circumstances, triggers and what de-escalates behavior and document. assess patients coping skills and support system When patient becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation if response is aggressive staff to walk calmly away, and approach later. Anticipate and meet patients needs to reduce behavioral symptoms. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take patient to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location time of day persons involved and situations. Document behaviors and potential causes. Report findings to attending physician and or update care plan as appropriate. Privately discuss inappropriate behaviors with patient and explain why his her behavior is unacceptable in the nursing facility. Document discussion. Report outcome to physician and or update care plan as appropriate. The DON was asked to provide information to substantiate the above approaches were implemented as directed by the care plan. During an interview with the DON and administrator on 11/29/18 at 10:34 AM, the DON said, I have nothing else to give you. c) Resident #92 A review of Resident #92's medical record at 12:03 p.m. on 11/28/18 found a physician's orders [REDACTED]. This was ordered on [DATE] by Resident #92's attending physician. The physician progress notes [REDACTED].ORIENTATION: Normal- Alert and orientated X 1. Affect is broad. No visible signs of anxiety or depressed state. Patient is delusional and manic today. They won't let me take care of my husband like I need to, these dogs treat him awful in here. Care Plan .[MEDICAL CONDITION]: [MEDICATION NAME] .25 mg by mouth BID (twice a day). Continue behavior/affect monitoring. Further review of the medical record found Resident #92 use to be a Nurse Aide and her husband is also a resident at this facility. A review of the record from 07/01/18 through 07/31/18 found no documentation of any behaviors from Resident #92 that would justify the use of an antipsychotic medication. The care plan was reviewed and found the following focus statement added to the care plan on 08/03/18, (Last Name of Resident #92) receives antipsychotic medications ([MEDICATION NAME]) r/t behavior management AEB (as evidenced by ) wandering, attempting to provide care to other residents. The goal associated with focus statement was as follows, Patient will be/remain free of drug related complications including movement disorder, discomfort, [MEDICAL CONDITION], gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. The interventions related to this focus statement and goal include:, Administer medications as ordered. Monitor/document for side effects and effectiveness. Encourage family and friends to visit. Encourage out of room activities, such as church activities and special singing. She likes to visit with her husband who resides at the facility Monitor/record/report to physician prn (as needed) side effects and adverse reactions of psychoactive medications : unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideation's, social isolation, blurred vision, diarrhea, fatigue, [MEDICAL CONDITION], loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to one person. Redirect resident when she attempts to provide care for other residents in the facility. The care plan goal and interventions was added after the medication was started. The care plan contains no non pharmacological interventions and there was no indication any non pharmacological interventions were put into place prior to starting the medication [MEDICATION NAME]. During an interview with the Director of Nursing (DON) at 1:37 p.m. on 11/18/18 the above findings were reviewed with her. She was asked to provide any information the facility had in regards to why Resident #92 was started on [MEDICATION NAME] and for any non pharmacological interventions they had in place prior to starting the medication. An interview with Registered Nurse #52 at 2:12 p.m. on 11/28/18 confirmed there was no documented behaviors in the medical record. She stated they looked to see what behaviors led to Resident #92 being started on [MEDICATION NAME] and there was none documented in the medical record.",2020-09-01
541,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,757,D,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #16's drug regimen was free from unnecessary medications. Resident #16's [MEDICATION NAME] was ordered to be held at certain times on [MEDICAL TREATMENT] days and it was not held as ordered. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications. Resident Identifier: #16. Facility Census: 97 Findings Include: a) Resident #16 A review of Resident #16's medical record at 9:26 a.m. on 11/28/18 found a physician order [REDACTED].) This ordered was entered into the medical record on 10/08/18. A review of the Medication Administration Record [REDACTED] 10/10/18, 10/12/18, 10/15/18, 10/19/18, 10/22/18, 10/26/18, 10/29/18, 10/31/18, 11/02/18, 11/05/18, 11/07/18, 11/09/18, 11/12/18, 11/14/18, 11/16/18, 11/19/18, 11/21/18, 11/23/18, and 11/26/18. During an interview with the DON at 11:47 a.m. on 11/28/18, the above findings were reviewed she stated she would look into it and let me know what she had found. An interview with Clinical Care Supervisor Registered Nurse #52 at 2:10 p.m. on 11/28/18 confirmed Resident #16's [MEDICATION NAME] was not given as directed by the order and the 5:00 a.m. on Monday, Wednesday and Friday was consistently not held as ordered.",2020-09-01
542,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,758,E,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents where not placed on [MEDICAL CONDITION] medication before the facility utilized individualized non-pharmacological approaches to care. Therefore these residents medication could not be proven to necessary. This was true for four (4) of five (5) residents reviewed for the care area of unnecessary medications during the Long term care survey process. Resident identifiers: #92, #45, #44, and #84. Facility census: 97. Findings Include: a) Resident #92 A review of Resident #92's medical record at 12:03 p.m. on 11/28/18 found a physician's orders [REDACTED]. This was ordered on [DATE] by Resident #92's attending physician. The physician progress notes [REDACTED].ORIENTATION: Normal- Alert and orientated X 1. Affect is broad. No visible signs of anxiety or depressed state. Patient is delusional and manic today. They won't let me take care of my husband like I need to, these dogs treat him awful in here. Care Plan .[MEDICAL CONDITION]: [MEDICATION NAME] .25 mg by mouth BID (twice a day). Continue behavior/affect monitoring. Further review of the medical record found Resident #92 use to be a Nurse Aide and her husband is also a resident at this facility. A review of the record from 07/01/18 through 07/31/18 found no documentation of any behaviors from Resident #92 that would justify the use of an antipsychotic medication. During an interview with the Director of Nursing (DON) at 1:37 p.m. on 11/18/18 the above findings were reviewed with her. She was asked to provide any information the facility had in regards to why Resident #92 was started on [MEDICATION NAME] and any non pharmacological interventions they had put into place prior to starting the medication. An interview with Registered Nurse #52 at 2:12 p.m. on 11/28/18 confirmed there was no documented behaviors in the medical record. She stated they looked to see what behaviors led to Resident #92 being started on [MEDICATION NAME] and there was none documented in the medical record. She also confirmed there was no documented non pharmacological interventions in the medical record prior to starting Resident #92 on [MEDICATION NAME]. b) Resident #44 Record review found this seventy-five year old female was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. On 06/01/18, the resident's physician prescribed [MEDICATION NAME], an antipsychotic medication, .25 milligrams (mg's) two times a day (BID) for a [DIAGNOSES REDACTED]. In addition to the [MEDICATION NAME], the resident was receiving the following [MEDICAL CONDITION] medications: [REDACTED] [MEDICATION NAME] 200 mg's by mouth at bedtime for Major [MEDICAL CONDITION], recurrent, unspecified. [MEDICATION NAME] 20 mg. daily for anxiety disorder. The resident was also receiving, Memantine 10 mg's BID, for Dementia in other diseases classified elsewhere with behavioral disturbances. ( Memantine ([MEDICATION NAME]) is used to treat moderate to severe confusion (dementia) related to [MEDICAL CONDITION]. It does not cure [MEDICAL CONDITION], but it may improve memory, awareness, and the ability to perform daily functions.) On 11/27/18 at 12:38 PM, Employee #135, the corporate registered nurse (RN)coordinator, said the facility monitors resident behaviors on the psychopharmacological medication monitoring located in the electronic medical record. Review of the psychopharmacological medication monitoring with RN #135, found no behaviors were documented by nursing staff before the physician ordered [MEDICATION NAME]. Nursing notes, from 05/01/18 through 06/01/18, (the day the [MEDICATION NAME] was initiated), were reviewed with RN #135. There were no behaviors documented in the nursing notes to warrant the initiation of [MEDICATION NAME]. Further review of the physician's progress notes in the electronic medical record with RN #135 at 12:38 PM on 11/27/18, found no information regarding the initiation of [MEDICATION NAME]. On the same day the [MEDICATION NAME] was started (06/01/18, the physician also ordered a urinalysis with reflex culture and sensitivity. Review of the laboratory report with RN #135 found the resident did not have a urinary tract infection. On 8/26/18, the pharmacist reviewed the residents medications and recommended a gradual dose reduction of [MEDICATION NAME]. The physician responded with a GDR was clinically contraindicated and the medication was just started on 06/01/18. At 1:52 PM on 11/27/18, RN #135 and the director of nursing (DON) provided a copy of a nursing home visit note from the residents physician, dated 06/01/18. Both employees confirmed this note had not been scanned into the residents medical record even though it was written over over 5 months ago. The physician had written, Patient will not leave her room to attend activities stating, If I leave the bugs will come in my room and get in my bed, I have to keep the door shut to keep the bugs out, they sometimes knock on my window and try to get in. RN #135 and the DON were unable to provide any documentation to verify facility staff were aware of the delusions, attempted to talk with the resident, or provide any non-pharmacological interventions before starting the antipsychotic medication. Neither employee could find any documentation to indicate this behavior had been witnessed by other staff. Review of the residents current care plan with the DON at 9:15 AM on 11/29/18, found the resident was care planned for receiving [MEDICATION NAME] for delusion and hallucinations. The goal of the care plan was: Patient will remain free of drug related complications including movement disorder. Interventions included: Administer medications as ordered and monitor for side effects. Encourage resident to vent feelings. Monitor/record/report to physician as needed side effects and adverse reactions The DON confirmed the care plan did not discuss what staff should do when the resident had delusions and hallucinations. The DON could not demonstrate how the care plan individualized this resident's dementia care needs. At the close of the survey on 11/29/18 at 12:15 PM, no further information had been provided to substantiate other staff members had documented resident behaviors regarding hallucinations and delusions. No further information was provided to substantiate the facility utilized individualized, non-pharmacological approaches to care (e.g., purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. c) Resident #45 Record review found the resident was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED].>[MEDICAL CONDITION], Dementia, and Depression. The resident was admitted with three antidepressants: [MEDICATION NAME], 75 mg. at bedtime, [MEDICATION NAME], 100 mg, three times (TID) a day [MEDICATION NAME] 30 mg. daily. The resident was not admitted with any antisychotic medication. On 01/19/18, the physician added [MEDICATION NAME] for dementia. On 06/12/18, the [MEDICATION NAME] was discontinued. On 06/13/18 [MEDICATION NAME] 20 mg., daily, was added for depression. The [MEDICATION NAME] was discontinued on 08/27/18. On 06/12/18 [MEDICATION NAME] 0.5 mg. three times a day was started for generalized Anxiety disorder. The [MEDICATION NAME] was discontinued on 11/12/18. On 06/26/18 [MEDICATION NAME] was increased from 75 mg. at bedtime to 150 mg. at bedtime. On 09/12/18, the antipsychotic, [MEDICATION NAME] 25 mg., two times (BID) a day was added to the residents medication regime. The resident continues to take the [MEDICATION NAME], and [MEDICATION NAME]. At 1:00 PM on 11/28/18, the Director of Nursing, (DON) was asked where the facility would have documented any behaviors and non-pharmacological interventions before starting the antipsychotic, [MEDICATION NAME]. On 11/28/18 at 02:41 PM, the DON said, I have looked for non pharmacological interventions, there aren't any documented. The DON said the resident was physically aggressive towards staff and other residents. The DON provided a copy of the nurse practioners (NP) visit, dated 09/12/18. The NP noted the resident had been trying to run over other residents with her wheelchair and was refusing to take her medications and cursing at staff. The Medication Administration Record [REDACTED]. According to the documentation on the MAR, the resident had taken all her medications. The DON was asked if the facility had any incident/accident reports regarding the physical aggression towards other residents? Review of the care plan with the DON found the following interventions were to be implemented when the resident exhibited behaviors: Analyze key times, places, circumstances, triggers and what de-escalates behavior and document. assess patients coping skills and support system When patient becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation if response is aggressive staff to walk calmly away, and approach later. Anticipate and meet patients needs to reduce behavioral symptoms. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take patient to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location time of day persons involved and situations. Document behaviors and potential causes. Report findings to attending physician and or update care plan as appropriate. Privately discuss inappropriate behaviors with patient and explain why his her behavior is unacceptable in the nursing facility. Document discussion. Report outcome to physician and or update care plan as appropriate. The DON was asked to provide information to substantiate the above approaches were implemented as directed by the care plan. During an interview with the DON and administrator on 11/29/18 at 10:34 AM, the DON said, I have nothing else to give you. d) Resident #84 Record review found a seventy eight year old female admitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED] The resident was admitted with the [MEDICAL CONDITION] medication, [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mg's every 4 hours for anxiety. The [MEDICATION NAME] was discontinued on 11/03/18. A new order for [MEDICATION NAME] was written on 11/03/18 for [MEDICATION NAME] .25 mg's every 8 hours for anxiety. This order was discontinued on 11/04/18. On 11/05/18 another order was written for [MEDICATION NAME] .5 mg's three times a day for anxiety. This order was discontinued on 11/05/17. On 11/05/17, a new order was written for [MEDICATION NAME] .25 mg's three times a day for anxiety. This order was discontinued on 11/06/18. On 11/06/18 another new order was written for [MEDICATION NAME] .25 mg's two times (BID) a day. (The resident is currently receiving [MEDICATION NAME] .25 mg's BID. On 11/06/18 the physician saw the resident at the facility. According to documentation from the physician, the resident told the physician, .she feels like she is very drugged. States, I think I'm getting too much [MEDICATION NAME]. The physician decreased the [MEDICATION NAME] to .25 mg's two times a day. On 11/06/18 the physician also ordered [MEDICATION NAME] 5 mg's daily. On 11/27/18 at 2:00 PM, the Registered Nurse corporate coordinator, RN #135 was asked why the resident was started on the [MEDICATION NAME]? On 11/27/18 at 3:07 PM, RN #135 said she did not know why the physician started the [MEDICATION NAME]. RN #135 was unable to provide documentation of any resident behaviors and unable to provide documentation of any non-pharmacological interventions provided before starting the [MEDICATION NAME]. RN #135 was unable to find documentation as to why the [MEDICATION NAME] orders were changed on five occasions during a 6 day time frame. RN #135 found documentation the resident was complaining of feeling real shaky on the inside and nervous on 11/05/18, so the physician, started her [MEDICATION NAME] back. However, review of the MAR found the resident received [MEDICATION NAME] .25 mg's at 2:00 PM and 10:00 PM. The resident also received [MEDICATION NAME] .5 mg's at 2:00 PM. The [MEDICATION NAME] was not discontinued on 11/05/18-only the dosage was changed. As the orders are entered into the computer electronically and approved electronically by the physician there is no way to determine if the physician's orders [REDACTED]. At the close of the survey on 11/29/18 at 12:15 PM, no further information was provided to verify the resident received non-pharmacological interventions before starting the antidepressant, [MEDICATION NAME]. Also there was not documentation provided to substantiate the resident was exhibiting behaviors indicating she was depressed and required an anti-depressant medication.",2020-09-01
543,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,812,F,0,1,J9FW11,"Based on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner. Bowls and tray covers were not stored inverted and foods that had passed their use by/best by/expiration dates were found in a refrigerator, a food serving area, and the dry storage area. This had the potential to affect all residents in the facility. Facility census: 97. Findings included: a) Kitchen Tour An initial tour of the facility kitchen began on 11/26/18 at 10:23 AM with Dietary Services Supervisor (DSS) #122. During this tour, one (1) individual bowl of prepared salad with a use by date of 11/22/18 was found in a refrigerator containing resident food across from the tray line. DSS #122 removed the salad at the time of the finding. On shelves underneath the tray line, a box labeled Orange Pekoe and Pekoe Cut Black Tea containing 41 loose tea bags was found to have a best by date of 07/12/15. On the same shelves underneath the tray line, stacks of bowls were found facing up, potentially exposing the insides of the bowls to dust, debris, and/or splatter. Numerous tray covers were found on top of the tray line also facing up, potentially exposing the insides to dust, debris, and/or splatters. Once notified of the above issues, DSS #122 removed the box of loose tea bags. She stated that she did not feel that the bowls and tray covers needed to be stored inverted since they were dry. DSS #122 confirmed that the bowls and tray covers were used in serving resident food. She was then asked for a facility policy indicating that it was acceptable not to invert bowls and tray covers to be used in serving resident food. DSS #122 stated she was not aware of any such policy. In the dry storage room, 11 more boxes of Orange Pekoe and Pekoe Cut Black Tea were found. Each box had a best by date of (MONTH) (YEAR) and contained 100 tea bags. One (1) 11-pound container of vanilla creme icing with a use by date of 11/10/18 was also found in the dry storage area. At 10:37 AM, DSS #122 was notified of the findings and removed the outdated items from storage. On 11/29/18 at 10:42 AM, the facility's Director of Nursing (DoN) was informed of the issues. No further information was provided by the facility prior to the end of the survey.",2020-09-01
544,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2018-11-29,865,E,0,1,J9FW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the Quality Assessment and Assurance committee made good faith attempts to correct quality deficiencies which it did have or should have had knowledge of. The facility failed to identify the fact that three (3) of three (3) residents reviewed for the care area of dementia management was started on antipsychotic medications when no non pharmacological interventions and been put in place prior to the starting of the medication. This practice has the potential to effect more than an isolated number of residents currently residing in the facility. Resident Identifiers: #92, #44, and #45 Facility Census: 97. Findings Include: a) Treatment/Services for Dementia 1. Resident #44 Record review found this seventy-five year old female was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. On 06/01/18, the resident's physician prescribed [MEDICATION NAME], an antipsychotic medication, .25 milligrams (mg's) two times a day (BID) for a [DIAGNOSES REDACTED]. In addition to the [MEDICATION NAME], the resident was receiving the following [MEDICAL CONDITION] medications: [REDACTED] [MEDICATION NAME] 200 mg's by mouth at bedtime for Major [MEDICAL CONDITION], recurrent, unspecified. [MEDICATION NAME] 20 mg. daily for anxiety disorder. The resident was also receiving, Memantine 10 mg's BID, for Dementia in other diseases classified elsewhere with behavioral disturbances. ( Memantine ([MEDICATION NAME]) is used to treat moderate to severe confusion (dementia) related to [MEDICAL CONDITION]. It does not cure [MEDICAL CONDITION], but it may improve memory, awareness, and the ability to perform daily functions.) On 11/27/18 at 12:38 PM, Employee #135, the corporate registered nurse (RN)coordinator, said the facility monitors resident behaviors on the psychopharmacological medication monitoring located in the electronic medical record. Review of the psychopharmacological medication monitoring with RN #135, found no behaviors were documented by nursing staff before the physician ordered [MEDICATION NAME]. Nursing notes, from 05/01/18 through 06/01/18, (the day the [MEDICATION NAME] was initiated), were reviewed with RN #135. There were no behaviors documented in the nursing notes to warrant the initiation of [MEDICATION NAME]. Further review of the physician's progress notes in the electronic medical record with RN #135 at 12:38 PM on 11/27/18, found no information regarding the initiation of [MEDICATION NAME]. On the same day the [MEDICATION NAME] was started (06/01/18, the physician also ordered a urinalysis with reflex culture and sensitivity. Review of the laboratory report with RN #135 found the resident did not have a urinary tract infection. On 8/26/18, the pharmacist reviewed the residents medications and recommended a gradual dose reduction of [MEDICATION NAME]. The physician responded with a GDR was clinically contraindicated and the medication was just started on 06/01/18. At 1:52 PM on 11/27/18, RN #135 and the director of nursing (DON) provided a copy of a nursing home visit note from the residents physician, dated 06/01/18. Both employees confirmed this note had not been scanned into the residents medical record even though it was written over over 5 months ago. The physician had written, Patient will not leave her room to attend activities stating, If I leave the bugs will come in my room and get in my bed, I have to keep the door shut to keep the bugs out, they sometimes knock on my window and try to get in. RN #135 and the DON were unable to provide any documentation to verify facility staff were aware of the delusions, attempted to talk with the resident, or provide any non-pharmacological interventions before starting the antipsychotic medication. Neither employee could find any documentation to indicate this behavior had been witnessed by other staff. Review of the residents current care plan with the DON at 9:15 AM on 11/29/18, found the resident was care planned for receiving [MEDICATION NAME] for delusion and hallucinations. The goal of the care plan was: Patient will remain free of drug related complications including movement disorder. Interventions included: Administer medications as ordered and monitor for side effects. Encourage resident to vent feelings. Monitor/record/report to physician as needed side effects and adverse reactions The DON confirmed the care plan did not discuss what staff should do when the resident had delusions and hallucinations. The DON could not demonstrate how the care plan individualized this resident's dementia care needs. At the close of the survey on 11/29/18 at 12:15 PM, no further information had been provided to substantiate other staff members had documented resident behaviors regarding hallucinations and delusions. No further information was provided to substantiate the facility utilized individualized, non-pharmacological approaches to care (e.g., purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. 2. Resident #45 Record review found the resident was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED].>[MEDICAL CONDITION], Dementia, and Depression. The resident was admitted with three antidepressants: [MEDICATION NAME], 75 mg. at bedtime, [MEDICATION NAME], 100 mg, three times (TID) a day [MEDICATION NAME] 30 mg. daily. The resident was not admitted with any antisychotic medication. On 01/19/18, the physician added [MEDICATION NAME] for dementia. On 06/12/18, the [MEDICATION NAME] was discontinued. On 06/13/18 [MEDICATION NAME] 20 mg., daily, was added for depression. The [MEDICATION NAME] was discontinued on 08/27/18. On 06/12/18 [MEDICATION NAME] 0.5 mg. three times a day was started for generalized Anxiety disorder. The [MEDICATION NAME] was discontinued on 11/12/18. On 06/26/18 [MEDICATION NAME] was increased from 75 mg. at bedtime to 150 mg. at bedtime. On 09/12/18, the antipsychotic, [MEDICATION NAME] 25 mg., two times (BID) a day was added to the residents medication regime. The resident continues to take the [MEDICATION NAME], and [MEDICATION NAME]. At 1:00 PM on 11/28/18, the Director of Nursing, (DON) was asked where the facility would have documented any behaviors and non-pharmacological interventions before starting the antipsychotic, [MEDICATION NAME]. On 11/28/18 at 02:41 PM, the DON said, I have looked for non pharmacological interventions, there aren't any documented. The DON said the resident was physically aggressive towards staff and other residents. The DON provided a copy of the nurse practioners (NP) visit, dated 09/12/18. The NP noted the resident had been trying to run over other residents with her wheelchair and was refusing to take her medications and cursing at staff. The Medication Administration Record [REDACTED]. According to the documentation on the MAR, the resident had taken all her medications. The DON was asked if the facility had any incident/accident reports regarding the physical aggression towards other residents? Review of the care plan with the DON found the following interventions were to be implemented when the resident exhibited behaviors: Analyze key times, places, circumstances, triggers and what de-escalates behavior and document. assess patients coping skills and support system When patient becomes agitated: Intervene before agitation escalates; guide away from source of distress; engage calmly in conversation if response is aggressive staff to walk calmly away, and approach later. Anticipate and meet patients needs to reduce behavioral symptoms. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take patient to alternate location as needed. Monitor behavior episodes and attempt to determine underlying cause. Consider location time of day persons involved and situations. Document behaviors and potential causes. Report findings to attending physician and or update care plan as appropriate. Privately discuss inappropriate behaviors with patient and explain why his her behavior is unacceptable in the nursing facility. Document discussion. Report outcome to physician and or update care plan as appropriate. The DON was asked to provide information to substantiate the above approaches were implemented as directed by the care plan. During an interview with the DON and administrator on 11/29/18 at 10:34 AM, the DON said, I have nothing else to give you. 3. Resident #92 A review of Resident #92's medical record at 12:03 p.m. on 11/28/18 found a physician's orders [REDACTED]. This was ordered on [DATE] by Resident #92's attending physician. The physician progress notes [REDACTED].ORIENTATION: Normal- Alert and orientated X 1. Affect is broad. No visible signs of anxiety or depressed state. Patient is delusional and manic today. They won't let me take care of my husband like I need to, these dogs treat him awful in here. Care Plan .[MEDICAL CONDITION]: [MEDICATION NAME] .25 mg by mouth BID (twice a day). Continue behavior/affect monitoring. Further review of the medical record found Resident #92 use to be a Nurse Aide and her husband is also a resident at this facility. A review of the record from 07/01/18 through 07/31/18 found no documentation of any behaviors from Resident #92 that would justify the use of an antipsychotic medication. The care plan was reviewed and found the following focus statement added to the care plan on 08/03/18, (Last Name of Resident #92) receives antipsychotic medications ([MEDICATION NAME]) r/t behavior management AEB (as evidenced by ) wandering, attempting to provide care to other residents. The goal associated with focus statement was as follows, Patient will be/remain free of drug related complications including movement disorder, discomfort, [MEDICAL CONDITION], gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. The interventions related to this focus statement and goal include:, Administer medications as ordered. Monitor/document for side effects and effectiveness. Encourage family and friends to visit. Encourage out of room activities, such as church activities and special singing. She likes to visit with her husband who resides at the facility Monitor/record/report to physician prn (as needed) side effects and adverse reactions of psychoactive medications : unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideation's, social isolation, blurred vision, diarrhea, fatigue, [MEDICAL CONDITION], loss of appetite, weight loss, muscle cramps, nausea, vomiting, behavior symptoms not usual to one person. Redirect resident when she attempts to provide care for other residents in the facility. The care plan goal and interventions was added after the medication was started. The care plan contains no non pharmacological interventions and there was no indication any non pharmacological interventions were put into place prior to starting the medication [MEDICATION NAME]. During an interview with the Director of Nursing (DON) at 1:37 p.m. on 11/18/18 the above findings were reviewed with her. She was asked to provide any information the facility had in regards to why Resident #92 was started on [MEDICATION NAME] and for any non pharmacological interventions they had in place prior to starting the medication. An interview with Registered Nurse #52 at 2:12 p.m. on 11/28/18 confirmed there was no documented behaviors in the medical record. She stated they looked to see what behaviors led to Resident #92 being started on [MEDICATION NAME] and there was none documented in the medical record. b) QA and A interviews. An interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) at 9:57 a.m. on 11/29/18 confirmed they reviewed antipsychotic medications in the QA and A when they meet monthly. They indicated they had identified they had some issues with documentation of behaviors and non pharmacological interventions but they had not implemented a plan to correct the identified issues. The medications in question were started as early and 06/01/18 and the QA and A committee had numerous months to initiate a plan for improvement, but had failed to do so. and staging was not consistent.",2020-09-01
3271,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,157,D,0,1,UXFJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the responsible party when one (1) of seventeen (17) residents reviewed, experienced changes in medical conditions. The responsible party was not notified when Resident #86 experienced a fall at the facility, and when changes to medication were made due to an irregular laboratory value. Resident identifier: #86. Facility census: 58. Findings include: a) Resident #86 Record review found the resident was admitted to the facility on [DATE]. The medical record contained a copy of a guardian/conservation court appointment dated 08/21/08. The resident's facility physician deemed the resident to lack capacity to make medical decisions on 11/01/16. Review of the nurses notes found the resident had a fall on 02/04/17. The nursing note dated 02/04/17 at 4:07 p.m. revealed she, Heard resident calling for help, when entering room saw resident in floor sitting on buttocks beside w/c (wheelchair) able to move all extremities, unwitnessed and Neuro checks started. Assisted via 2 assist back to w/c. A nursing note dated 02/04/17 at 7:10 p.m. read, Notified DHHR (Department of Health and Human Services) via voice mail. A nursing note dated 02/06/17 read, d/c (discontinue) potassium 20 meq, (milliequivalent) BID (twice a day) PO (by mouth), start potassium 20 meq daily PO, DX (diagnosis), potassium 5.3. DHHR made aware via voice mail. (A normal potassium level is 3.6 to 5.2). The facility social worker (SW) #62, verified at 1:00 p.m. on 02/07/17, the resident's guardian/ conservation, was the resident's brother. She stated, the appointment of the brother in 2008 continues to be in effect and the DHHR is not the resident's responsible party. At 1:29 p.m. on 02/07/17, the director of nursing said, she did not know why the nurse would have contacted DHHR and not the legal representative. She also confirmed the DHHR is not the resident's medical decision maker and should not have been notified of changes in condition. .",2020-09-01
3272,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,164,D,0,1,UXFJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility provided confidential medical information to an entity who was not the resident's responsible party. This was true for one (1) of seventeen (17) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #86. Facility census: 58. Findings include: a) Resident #86 Record review found the resident was admitted to the facility on [DATE]. The medical record contained a copy of a guardian/conservation court appointment dated 08/21/08. The resident's facility physician deemed the resident to lack capacity to make medical decisions on 11/01/16. Review of the nurses notes found the resident had a fall on 02/04/17. The nursing note dated 02/04/17 at 4:07 p.m. revealed she, Heard resident calling for help, when entering room saw resident in floor sitting on buttocks beside w/c (wheelchair) able to move all extremities, unwitnessed and Neuro checks started. Assisted via 2 assist back to w/c. A nursing note dated 02/04/17 at 7:10 p.m. read, Notified DHHR (Department of Health and Human Services) via voice mail. A nursing note dated 02/06/17 read, d/c (discontinue) potassium 20 meq, (milliequivalent) BID (twice a day) PO (by mouth), start potassium 20 meq daily PO, DX (diagnosis), potassium 5.3. DHHR made aware via voice mail. (A normal potassium level is 3.6 to 5.2). The facility social worker (SW) #62, verified at 1:00 p.m. on 02/07/17, the resident's guardian/ conservation, was the resident's brother. She stated, the appointment of the brother in 2008 continues to be in effect and the DHHR is not the resident's responsible party. At 1:29 p.m. on 02/07/17, the director of nursing said, she did not know why the nurse would have contacted DHHR and not the legal representative. She also confirmed the DHHR is not the resident's medical decision maker and should not have been notified of changes in condition. .",2020-09-01
3273,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,241,D,0,1,UXFJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to carry out activities to assist the resident to maintain his self-esteem and self -worth. This was true for one (1) of one (1)resident reviewed for the care area of dignity. Resident #29 had a persistent urine odor. Resident identifier: #29. Facility census: 58. Findings include: a) Resident #29 Observation of the resident in Stage 1 of the Quality Indicator Survey (QIS) at 4:54 p.m. on 02/06/17 found the resident was in his room, in bed and under the covers. Upon entrance to the room, a strong urine odor was detected. The odor was permeating from the area where the resident was located. Review of the resident's current care plan found no information to indicate the resident refused personal care. The care plan addressed the resident's activities of daily living (ADL's) and directed the resident's bathing required the assistance of one (1) staff member for bathing on Tuesday's, Thursday's and Saturday's. Observation of the resident at 9:45 a.m. on 02/08/17, found the odor was still persistent. Review of the resident's shower schedule with Employee #88, the unit secretary, at 10:00 a.m. on 02/08/17, found documentation the resident had received a shower on 02/07/17. At 10:10 a.m. on 02/08/17, Registered Nurse (RN), #8, working on the resident's unit, said the resident usually has a urine odor. She stated sometimes he refuses care. At 10:20 a.m., on 02/08/17, the resident was observed in his bed. The director of nursing (DON) was present for the observation. The DON acknowledged the odor and said it could be his mattress and sometimes the resident hides his briefs. Observation of the room, found no indication the resident had hid his briefs on this day. The DON said she would have the sheets and blankets stripped and his mattress cleaned. She said the facility had recently purchased a new mattress for the resident. She said the resident is known to dribble urine on himself, his bed and the floor of his room. He urinates everywhere. At 10:35 a.m., on 02/08/17, Housekeeper (HSK) #17, was cleaning the resident's room. The resident was not present in his room. HSK #17 acknowledged the urine odor. He and his room just smell like urine. Review of the current minimum data set (MDS) with an assessment reference date (ARD) of 12/25/17, found the resident was always incontinent of bowel and bladder. [DIAGNOSES REDACTED]. The resident was receiving the medications: [REDACTED]. Review of the resident's laboratory values for 02/01/17 found the bun and creatinine were within normal limits, indicating the resident most likely did not have a urinary tract infection. At 6:47 p.m., RN #8 said she has noticed a urine odor in the resident's room. He is incontinent a lot. They pretty much change out the whole bed every day. Observation of the resident by two (2) surveyors at 6:59 p.m. on 02/08/17 found the odor continued to be present in the resident's room. At 7:10 p.m. on 02/08/17, the resident's nurse aide (NA), #38 said, Yeah, the room smells like urine, because he dribbles urine in the room. The nurse surveyor observed incontinence care on the evening of 02/08/2017. At 7:27 p.m. on 02/08/17, the nurse surveyor stated the urine odor, Took my breath, when the brief was removed. Upon entrance to the resident's room at 7:45 p.m. on 02/08/17, the urine odor was only slightly present in the resident's room. At 7:45 p.m., RN #52, said she could find no evidence the resident had seen a urologist since 05/2015. She said the resident was admitted to the facility on [DATE] and there could be more records which she did not have access to review. At 8:05 a.m. on 02/09/17, the DON said, I take offense to you writing that deficiency. We know he has an odor and we work hard to keep him clean. She was asked to provide verification the facility had addressed the urine odor, such as the care plan, nursing notes, urology consults, etc. At 8:30 a.m. on 02/09/17, the DON provided a copy of a urology consult on 05/22/14 ordered for retention of urine and a strong odor. This was the last time the resident has seen the urologist. The DON was unable to read the results of the consult. She said the resident's mattress had been replaced in (MONTH) (YEAR). The resident's physician was interviewed on 02/09/2017 at 9:26 a.m. The physician said, If it has been that long since the urology consult, maybe he needs to go back. At 9:27 a.m. on 02/09/2017, the DON confirmed the care plan did not include the interventions the facility had taken to resolve the odors. The DON was unable to provide further documentation as to how the facility had worked to resolve the urine odor of which they were well aware of. At the close of the survey at 4:45 p.m. on 02/09/17, no further information had been provided.",2020-09-01
3274,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,272,D,0,1,UXFJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to complete an accurate comprehensive assessment for two (2) of seventeen (17) Stage 2 sampled residents whose comprehensive assessments were reviewed. Resident #42 sustained a fall with injury which was not assessed on her annual comprehensive assessment. Resident #43's comprehensive assessment was incorrect in the areas of falls and prognosis. Resident identifiers: #42 and #43. Facility census: 58. Findings include: a) Resident #42 The medical record was reviewed on 02/08/17. According to nurse progress notes, she sustained a fall with injury on 10/31/16, which consisted of a nickel sized bruise to the right knee, and complaints of pain to that area. Nursing notified the physician of the incident, and received new orders for x-rays of the right knee. Nursing administered a scheduled pain medication at that time. Review of this resident's annual minimum data set (MDS) with assessment reference date (ARD) of 12/15/16, incorrectly assessed this resident sustained [REDACTED]. An interview was conducted with MDS registered nurse #26 on 02/08/17 at 2:00 p.m. After she reviewed the 10/31/16 nursing progress note and the 10/31/16 incident report, she said the resident's annual MDS with ARD 12/15/16 should have assessed she sustained one (1) fall with injury since the previous MDS, and it did not. This information was shared with the director of nursing on 02/09/17 at 1:10 p.m. She provided no further information prior to exit. b) Resident #43 1. Falls A review of Resident #43's medical records on 02/08/17 at 1:30 p.m., revealed an admission date of [DATE]. A significant change MDS, with an assessment reference date (ARD) of 09/10/16, indicated Resident #43 had no falls since admission, entry or reentry or prior assessment, whichever is more recent. Review of Resident #43 incident reports for the period of time since the last MDS and the significant change MDS with ARD of 09/10/16, found Resident #43 had one (1) fall during this period on 08/29/16 at 6:12 a.m., resident was sitting in the bathroom floor, he stated he missed sitting on the commode and he stated he hit the back of his head when he fell . Additionally, a significant change MDS, with an ARD of 11/07/16, indicated Resident #43 had had no falls since admission, entry or reentry or prior assessment, whichever is more recent. Review of Resident #43 incident reports for the period of time since last MDS on 09/10/16 found the resident had six (6) falls: --09/30/16 at 10:22 a.m., Slid from side of bed to floor. No injuries. --10/09/16 at 2:37 a.m., Slid from bed to floor. No injuries. --10/09/16 at 1:30 p.m., Found sitting in the floor beside his bed. Complained of right hip and right wrist pain. --10/13/16 at 7:30 a.m., Slid off the edge of wheelchair in the bathroom. No injuries. --10/19/16 at 2:00 a.m., fell while trying to get to the wheelchair from the bed . No injuries. --10/30/16 at 2:56 p.m., Transferring from bed to wheelchair and slid to floor. No injuries. 2. Prognosis A review of Resident #43's medical records on 02/08/17 at 1:30 p.m., revealed an admission date of [DATE]. A significant change MDS, with an assessment reference date (ARD) of 09/10/16, indicated Resident #43 was receiving hospice care. Review of Resident #43 physician progress notes [REDACTED]. Additionally, a significant change MDS, with an ARD of 11/07/16, indicated Resident #43 did not have a condition or chronic disease that may result in a life expectancy of less than six (6) months. Further review of the physician progress notes [REDACTED]. 3. Interview During an interview on 02/09/17 at 9:15 a.m., MDS Coordinator #24 said Resident #43 had one (1) fall on 08/29/16 and should have been noted on the significant change MDS with ARD of 09/10/16 and his hospice services had ended on 08/28/16. Additionally she said the resident had six (6) falls from 09/10/16 through 11/07/16 as previously documented and should have been placed on the significant change MDS with ARD of 11/07/16 and the resident had had a decline and was restarted on hospice services on 10/24/16. The MDS Coordinator confirmed the MDS with an ARD of 09/10/16 and MDS with ARD of 11/07/16 were inaccurate in the areas of falls and hospice/prognosis.",2020-09-01
3275,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,278,D,0,1,UXFJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately complete Resident #43's quarterly Minimum Data Set (MDS), in the areas of prognosis and falls. Resident #51's thirty (30) day MDS was inaccurate in the area of weight loss. This was true for two (2) of seventeen (17) Stage 2 residents MDS's reviewed during the Quality Indicator Survey (QIS). Resident identifiers: #43 and #51. Facility census: 58. Findings include: a) Resident #43 1. Falls A review of Resident #43's medical records on 02/08/17 at 1:30 p.m., revealed a quarterly MDS, with an assessment reference date (ARD) of 02/05/17, which indicated Resident #43 had one (1) fall since the prior assessment. Review of Resident #43's incident reports for the period of time since the last MDS, found Resident #43 had three (3) fall during this period: --On 11/09/16 at 11:30 a.m., Leaned over from his wheelchair to pick something up from the floor and fell to the floor. No injuries. --On 01/05/17 at 2:15 a.m., fell when attempting to get out of bed to check on his wife (roommate). No injuries noted. --On 01/05/17 at 9:00 a.m., Slid out of bed to floor. Resident had a lump on right side of forehead and complained of knee pain. 2. Prognosis Further review of Resident #43's medical records on 02/08/17 at 1:30 p.m., revealed a quarterly MDS, with an assessment reference date (ARD) of 02/05/17, which indicated Resident #43 did not have a life expectancy of six (6) months or less. Review of the physician progress notes [REDACTED]. 3. Interview During an interview on 02/09/17 at 9:15 a.m., MDS Coordinator #24 said Resident #43 had three (3) falls since the last MDS assessment, inlcuding one (1) fall on 11/09/16, and two (2) falls on 01/05/17. She further verified this should have been noted on the quarterly MDS with ARD of 02/05/17. In addition, she verified the resident had a decline in condition and was restarted on hospice services on 10/24/16. The MDS Coordinator confirmed the MDS with an ARD of 02/05/17 was inaccurate in the areas of falls and hospice/prognosis. b) Resident #51 Review of the medical record on 02/08/17 found the admission minimum data set (MDS), with assessment reference date (ARD) 09/02/16, assessed her weight at 255 pounds. The thirty (30) day MDS, with ARD of 10/03/16, assessed her weight at 237 pounds. This amounted to a seven (7) percent weight loss of eighteen (18) pounds. The thirty (30) day MDS erroneously assessed her as having no weight loss of greater than five (5) percent in the past month. An interview was conducted with MDS registered nurse, Employee #26 on 02/08/17 at 8:52 a.m. She reviewed the resident's MDS weight assessments and the resident's weights recorded in the computer. She agreed the resident sustained [REDACTED]. Employee #26 said she believed this was an expected weight loss resulting from a loss of [MEDICAL CONDITION], so she elected to assess her with no weight loss. She said the 30-day MDS should have assessed her with a weight loss greater than five (5) percent, and it did not. These findings were shared with the director of nursing on 1:10 p.m. on 02/09/17. The facility provided no further information prior to exit.",2020-09-01
3276,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,279,D,0,1,UXFJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review and staff interview, the facility failed to develop a comprehensive care plan for one (1) one (1) resident reviewed for the care area of hydration during Stage 2 of the Quality Indicator Survey (QIS). The care plan failed to address how the physician ordered fluid restriction would be implemented and monitored by each discipline, including dietary, nursing and activities. Resident identifier: #40. Facility census: 58. Findings include: a) Resident #40 During Stage 1 of the QIS survey, at 12:17 p.m. on 02/06/17, an interview with Resident #40 found he said he did not receive the fluids he wanted between his meals. He said he thought it was due to a kidney problem. Record review at 4:43 p.m. on 2/07/17, found the resident had a physician's orders [REDACTED]. Further record review found a care plan addressing dehydration/fluid maintenance with a potential for dehydration due to fluid restriction and a [DIAGNOSES REDACTED]. The goal was the resident would remain free of signs/symptoms of dehydration through next review date. The care plan was updated on 02/02/17. The care plan approaches did not detail how much fluid the resident would receive from dietary and how much fluid from the nursing staff. An interview with Registered Nurse (RN) #26, author of the care plan, at 8:23 a.m. on 02/08/17, confirmed the fluid restriction was not detailed in the resident's care plan. At 8:51 a.m. on 02/08/17, the resident's Licensed Practical Nurse (LPN) #11 said the resident is not on a fluid restriction and she verified the resident had a pitcher with water in his room with a straw for drinking. At 8:56 a.m. on 02/08/17, the dietary manager (DM) #23, provided a copy of the tray card for the resident's noon meal on 02/08/17. The tray card directed the resident to receive 4 ounces (oz) of coffee or hot tea and 8 oz's of milk. She was asked how to convert ounces to cubic centimeters. She said she wasn't sure, but would tell me later. On 02/08/17, at 9:10 a.m., DM #23 said the resident would receive 840 milliliters a day from dietary and 1 cc would equal 1 milliliter. When asked how other nursing employees would know how much fluid the resident could receive, she replied, They could look in the computer. At 9:26 a.m. on 02/08/17, the resident's physician was interviewed. He said, I usually don't like fluid restrictions, why are we doing that, I will have to track that back to see. At 10:40 a.m. on 02/08/17, LPN #11 returned and said, I told you wrong, he is on a fluid restriction. I give about 120 cc of fluid with my medication pass. Sometimes the resident drinks it and sometimes he doesn't. She verified she does not record how many cc's of fluid the resident consumed with the medication pass. Review of the care plan for nutritional status contained an approach to, Invite to food related activities and offer food, beverages of choice to encourage intake. The activities assistant (AA) #37, was interviewed at 1:50 p.m. on 02/08/17. AA #37 confirmed she does not record any consumption of fluids or fluids consumed by any resident during activities. She said the resident sometimes comes to morning chat where we pass out coffee. She said the resident was allowed to have coffee. At 11:46 a.m. on 02/09/17, the Registered Dietician (RD) #93, was interviewed. The resident's tray card for lunch on 02/08/17 noted the resident would receive four (4) ounces (oz) of coffee or hot tea and 8 oz of milk. As the fluid restriction was 1500 cc, RD #93 was asked how to convert ounces to cubic centimeters. She said there were 30 cc in one ounce so the resident would be getting 12 ounces of fluid which would be 360 cc of fluid with this meal. She said the resident would receive 360 cc of fluid with each meal so dietary would be providing 1080 cc of fluid a day. At 11:54 a.m. on 02/09/17, the director of nursing (DON) said the facility has a new form they are going to start using to record the resident's daily fluid intake. The daily vitals report used by the nursing staff was reviewed with the DON. Variances were observed in the recordings. For example on 02/06/17, a registered nurse recorded the resident as having consumed 480 milliliters of fluid at 6:43 p.m. No other fluids were recorded on 02/06/17. The DON did not know if this was the only fluids consumed by this resident on this day. On 01/31/17, only one nurse aide recorded a fluid intake of 360 milliliters of fluids. The DON said that did not indicate this was all the resident drank for the day. The DON verified the fluid records were not consistent; therefore, a new form had been developed so the facility could track the daily fluids consumed by the resident.",2020-09-01
3277,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,280,E,0,1,UXFJ11,"**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 Residents #30, #9 and Resident #43's when there was a change in their treatment. Resident #30 and #43 did not have their care plans revised when changes were made to their medication regimen. Resident #9's care plan was not revised when her pressure ulcer interventions changed. For Resident #97 the facility failed to involve him in his care planning process as it related to his preference to have meat for breakfast. This was true for four (4) of seventeen (17) stage 2 sampled residents. Resident Identifiers: #30, #97, #9 and #43. Facility census: 58. Findings include: a) Resident #30 A review of Resident #30's medical record, at 9:22 a.m. on 02/08/17, found a physician's orders [REDACTED]. This order had a discontinue date of 07/08/16. A review of Resident #30's care plan found the following intervention related to her nutritional status problem statement, Administer medications as ordered and monitor for side effects. Med Pass and sliding scale insulin. This intervention had a start date of 03/16/16. An interview with the Director of Nursing (DON) on 02/09/17 at 10:02 a.m., confirmed Resident #30 no longer received sliding scale insulin and the care plan was not revised when this medication was discontinued. b) Resident #97 The medical record was reviewed on 02/07/17 at 11:53 a.m. which revealed a diet order dated 2/01/17 for the resident to receive, double meat/egg portions on trays. On 02/08/17 at 7:54 a.m. Staff #94 stated the resident discussed food preferences with the Registered Dietician on 02/07/17 and because the resident receives [MEDICAL TREATMENT], cannot receive meats served at breakfast. Observed Resident #97 breakfast tray on 02/08/17 at 8:17 a.m., no meat observed on tray. Resident stated understanding of diet recommendations. Resident does not want meat all the time but would like meat sometimes at breakfast but has not received meat with breakfast since admission. On 02/8/17 at 8:49 a.m., an interview with the Registered Dietician stated diet plans came from corporate and cannot be changed. The Registered Dietician stated a conversation will be held with the resident to discuss food preferences and together they can determine what menu options will work. The Dietician stated that perhaps bacon or sausage can be offered occasionally. On 02/08/17 at 10:49 a.m. Staff #94 stated a conversation was held with the resident and meat will be offered at breakfast. c) Resident #9 On 02/07/17 the medical record was reviewed. This resident first came to the facility in 2012. Pertinent [DIAGNOSES REDACTED]. She was always incontinent of bladder. She was totally dependent on staff for toileting. She had impairments of one side of both the upper and the lower extremity. A wheelchair was her only mobility device. Review of a nurse progress note dated 01/20/16, found that a nurse aide brought to the attention of a licensed practical nurse the discovery of a pressure ulcer. Review of the wound assessment and progress review sheets found nursing staff assessed this resident on 01/20/16 with a Stage III pressure ulcer on the coccyx. The tissue type assessed at that time was necrotic slough. Nursing assessed the size at that time as 1.0 centimeter (cm) by 1.5 cm by less than 0.5 cm. The wound had a scant amount of exudate. The facility utilized a Pressure Ulcer Scale for Healing (PUSH) scale that was developed by the national Pressure Ulcer Advisory Panel (NPUAP) as a tool to monitor the improvement or deterioration in pressure ulcer healing using a numerical score. Zero is the best possible score. Review of PUSH scores from 01/20/16 through 02/01/17 found that the pressure ulcer alternately improved and worsened throughout its course. The PUSH scores have ranged from as low as two (2) to as high as nine (9). The most recent PUSH score was seven (7) on 02/01/17. An interview was conducted with wound care registered nurse #80 on 02/07/2017 at 12:44 p.m. She said the pressure ulcer was first identified on 01/20/16 as a Stage III. She said the wound was in-house acquired. When asked about impediments to healing, she said this resident sits a lot. During an interview on 02/07/17 at 12:44 p.m. with licensed practical nurse #22, she said the resident prefers to get up at 3:30 a.m. or 4:00 a.m. daily. She said the resident stays up all day, and goes to bed around 3:30 p.m. or thereafter. An interview was completed with nurse aide (NA) #69 on 02/07/17 at 2:00 p.m. She said the resident gets up really early and sits up in her wheelchair all day. She said sometimes the resident can shift her weight in the wheelchair herself, but some days cannot or does not. The current care plan was reviewed. It directed incontinence care every two (2) hours and as needed, to turn and reposition her at least every two (2) hours. The care plan was silent regarding the resident's preference to stay up in the wheelchair all day long up to twelve (12) hours per day. The care plan was silent regarding the need to shift her position in the wheelchair at set parameters. An interview was completed with the director of nursing (DON) on 02/07/17 at 4:00 p.m. The DON said the resident prefers to stay up in the wheelchair all day long. When asked if she had individualized care planning revisions to note that she is up all day in the wheelchair and required shifts of position when sitting in the wheelchair per set parameters by the facility, she said the aides change her incontinence brief every two (2) hours, so she would be assisted to reposition throughout the day at least every two (2) hours. The facility's policy on the prevention of pressure ulcers was requested to the DON on 02/09/17 at 9:00 a.m., and was soon provided. Review of this policy found general preventive measures for a person in a chair included to change their position at least every hour. When repositioning, reduce friction and shear by lifting (using appropriate lifting technique and equipment) rather than dragging. Review of the current care plan found neither of these interventions listed. During an interview with the DON on 02/09/17 at 1:10 p.m., no further information was provided when informed of the findings of the absence of individualized care plan revisions for this resident who sits up in the chair half of each day. d) Resident #43 Minimum Data Set (MDS) review, with an Assessment Reference Date (ARD) of 02/05/17, revealed this resident received antianxiety, antidepressant, and diuretic. He did not receive antipsychotic, hypnotic, anticoagulant, and antibiotic. Review of the care plan found the identification of the use of Ivanz (antibiotic), [MEDICATION NAME] (antidepressant), [MEDICATION NAME] (heart and blood pressure), [MEDICATION NAME] (diabetes) and Two cal HN ( protein supplement). During interview with the MDS nurse #24, on 02/09/17 at 9:15 a.m., review of the current physician orders [REDACTED]. The MDS nurse #24 confirmed the resident no longer was ordered Inanz, [MEDICATION NAME] and Two cal HN. She further acknowledged she needed to revise Resident #43's care plan.",2020-09-01
3278,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,282,E,0,1,UXFJ11,"Based on resident interview, resident observation, record review and staff interview the facility failed to implement Resident #30's activities of daily living (ADL) care plan on multiple occasions by not providing her showers three times weekly and by not cleaning her glasses every shift as directed by her care plan. This was true for one (1) of three (3) residents reviewed for the care area of ADL's during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #30. Facility census: 58. Findings include: a) Resident #30 1. Showers During a Stage 1interview with Resident #30, at 3:00 p.m. on 02/06/17, when asked if she received the number of showers in a week she would like she stated, No, I am supposed to be showered three (3) times a week and they only shower me once a week or once every two weeks. A review of Resident #30's medical record at 8:29 a.m. on 02/09/17 found the following care plan related to Resident #30's ADL care: --Problem statement with a start date of 08/07/15 read as follows, Inability to maintain health state independently r/t (related to) dementia, limited mobility, and muscle weakness. --The goal associated with this problem read as follows: Residents' care will be provided for based on their preferences and cognitive/functional abilities EB (evidenced by) staff completing P[NAME] (plan of care) Kardex and updating as needed. This goal had a target date of 06/16/16. --The interventions associated with this problem statement and goal included: Bathing PM (evening) Shower assist of 1 Days Monday, Wednesday, and Friday. This intervention was added to the care plan on 03/16/16. Review of the Resident #30's shower documentation from 06/20/16 through present found the following: --For 06/20/16 through 06/30/16, Resident #30 was scheduled to receive five (5) showers and only received two (2) on 06/25/16 and 06/28/16. She did not receive her shower as scheduled on 06/21/16, 06/23/16, and 06/30/16. --For the month of (MONTH) (YEAR) (07/01/16 through 07/31/16), Resident #30 was scheduled to receive 12 showers. She received a shower on 07/05/16, 07/11/16, 07/19/16, and 07/31/16, four (4) of the 12 opportunities. She was out of the facility on 07/07/16 resulting in her not receiving her scheduled shower on this date. Resident #30 had documented refusals of showers on 07/21/16 and 7/23/16. On 07/02/16, 07/09/16, 07/14/16, 07/16/16, and 07/27/16 she did not receive a shower and the record contained no documented reason. --For the month of (MONTH) (YEAR) (08/01/16 through 08/30/16), Resident #30's shower schedule was changed to only receiving two showers per week. This change took place on the week of 08/14/16 and has remained the schedule until present. Documentation was not provided by the facility for the week of 08/07/16 through 08/13/16 therefore it is assumed Resident #13 did not recieve a shower during this week. During the month of August, Resident #30 was scheduled to receive nine (9) showers, she only received four (4) on 08/02/16, 08/23/16, 08/27/16, and 08/30/16. She had a documented refusal on 08/20/16. She did not receive a shower four (4) of the scheduled day on 08/06/17, 08/09/16, 08/12/16, and 08/16/16. The record contained no documented reason as to why she did not receive her showers on these dates. --For the month of (MONTH) (YEAR) (09/01/16 through 09/30/16), Resident #30 was scheduled to receive nine (9) showers. She received a shower on 09/06/16, 09/17/16, and 09/23/16, three (3) of the nine (9) opportunities. Resident #30 had documented refusals of showers on 09/13/16 and 9/30/16. On 09/03/16, 09/10/16, 09/19/16, and 09/26/16 she did not receive a shower and the record contained no documented reason. --For the month of (MONTH) (YEAR) (10/01/16 through 10/31/16), Resident #30 was scheduled to receive nine (9) showers. She received a shower on 10/07/16, 10/14/16, 10/20/16, 10/24/16 and 10/28/16, five (5) of the nine (9) opportunities. Resident #30 had documented refusals of showers on 10/03/16, 10/10/16, and 10/16/16. On 10/31/16, Resident #30 did not receive a shower and the record contained no documented reason. --For the month of (MONTH) (YEAR) (11/01/16 through 11/30/16), Resident #30 was scheduled to receive eight (8) showers. She received a shower on 11/04/16, 11/07/16, and 11/21/16, three (3) of the eight (8) opportunities. Resident #30 had a documented refusal of a shower on 11/14/16. On 11/11/16, 11/25/16, and 11/28/16 she did not receive a shower and the record contained no documented reason. --For the month of (MONTH) (YEAR) (12/01/16 through 12/31/16), Resident #30 was scheduled to receive nine (9) showers. She received a shower on 12/02/16, 12/19/16, and 12/26/16, three (3) of the nine (9) opportunities. Resident #30 had a documented refusal of a shower on 12/09/16. On 12/05/16, 12/12/16, 12/16/16, and 12/26/16 she did not receive a shower and the record contained no documented reason. --For the month of (MONTH) (YEAR) (01/01/17 through 01/31/17), Resident #30 was scheduled to receive nine (9) showers. She received a shower on 01/02/17, and 01/16/17, two (2) of the nine (9) opportunities. Resident #30 had documented refusals of showers on 01/06/17 and 01/13/17. On 01/09/17, 01/20/17, 01/23/17, 1/27/17, and 01/30/17 she did not receive a shower and the record contained no documented reason. --For the month of (MONTH) (YEAR) (02/01/17 through 02/07/17 the day of this review), Resident #30 was scheduled to receive two (2) showers. She received a shower on 02/06/17. However, for 02/02/17, the resident did not receive a shower and the record contained no documented reason. Please note from (MONTH) (YEAR) through present the facility only scheduled Resident #30 for two (2) showers per week. This is not in agreement with the residents care plan and/or the resident interview both of which revealed she should be scheduled for three (3) showers per week. So in addition to the missed showers mentioned above there is one (1) shower per week for 25 weeks that has not even been scheduled or offered to the resident. The Director of Nursing (DON) at 2:00 p.m. on 02/08/17, in an interview stated, The resident was switched to two (2) showers per week per her request. When asked why the care plan still indicated to offer her a shower three (3) times a week she stated, I guess we did not update it. She was then informed Resident #30 had stated she was scheduled to receive three (3) showers per week and she was not getting them. To this she replied, she does not have capacity. A review of Resident #30's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/16 found, her Brief Interview of Mental Status (BIMS) score was a 15 out of 15 indicating she was cognitively intact and fully capable of being interviewed. The DON then reviewed the shower documentation and stated, It looks like our documentation is incomplete, but we are giving her showers. She stated, I think they are forgetting to document refusals on the shower schedule sheet. She was asked to provide any documentation she might have pertaining to the residents request for only two (2) showers per week or that she might have regarding her refusals. She provided no additional information. The DON was then asked to Review Resident #30's care plan she agreed the care plan contained the intervention to shower the resident three times weekly and to clean her glasses every shift. 2. Glasses An observation of Resident #30, on 02/06/17 at 3:00 p.m., found her glasses were unclean and smudged. An additional observation of Resident #30, on 02/09/17 at 8:50 a.m., found her glasses were still dirty and were still smudged in the same place as they were on 02/06/17. At this time Resident #30 was asked if her glasses were working good for her and she stated, Well they could be cleaned and I might see a little better. At this time, Registered Nurse (RN) #52 was asked to come to Resident #30's room to see if her glasses needed to be cleaned. RN #52 took Resident #30's glasses and cleaned them and handed them back to the resident. Resident #30 put her glasses back on and stated, There just like new now. She then thanked RN #52 for cleaning her glasses and also thanked the surveyor for getting someone to clean her glasses for her. A review of Resident #30's medical record, at 08:29 a.m. on 02/09/17, found the following care plan related to Resident #30's ADL care: --Problem Statement with a start date of 08/07/15 read as follows, Inability to maintain health state independently r/t (related to) dementia, limited mobility, and muscle weakness. --The goal associated with this problem read as follows: Residents' care will be provided for based on their preferences and cognitive/functional abilities EB (evidenced by) staff completing P[NAME] (plan of care) Kardex and updating as needed. This goal had a target date of 06/16/16. --The goals associated with this problem statement and goals included: Vision: Adequate, wears glasses. Clean glasses every shift.",2020-09-01
3279,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,309,E,0,1,UXFJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, policy review, resident interview and staff interview, the facility failed to ensure medication was administered as ordered by the physician, failed to coordinate hospice services and failed on multiple occasions when neurological checks directed by the facility's standing orders for Resident #43. For Resident #97, the facility failed to coordinate [MEDICAL TREATMENT] treatments. For Resident #30 and 42, the facility failed to complete neurological checks as directed by the facility's standing orders. For Resident #40, the facility failed to follow a physician ordered fluid restriction. This was true for five (5) of seventeen (17) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #43, #97, #30, #42 and #40. Facility census: 58. Findings include: a) Resident #43 1. Medication Administration A review of Resident #43's medical record at 10:19 a.m. on 02/08/17, found a physician's orders [REDACTED]. Review of Resident #43's Medication Administration Record [REDACTED]. The physician order [REDACTED]. An interview with the Director of Nursing at 11:20 a.m. on 02/08/17, confirmed Resident #43 should have received the medication at 7:00 a.m. and 5:00 p.m. with meals. 2. Hospice Services A medical record review for Resident #43 on 02/08/17 at 1:00 p.m., found the resident received hospice services since 10/24/16. Review of Resident #43's care plan for hospice services found no indication of when and who would be involved in the coordination and implementation of the resident's hospice care. Interview with register nurse (RN) # 52 on 02/09/17 at 8:25 a.m., found the facility staff was unable to provide information for when the hospice personnel were scheduled and who was responsible for the coordination of hospice care with the facility and hospice staff. 3. Neurological checks Review of Resident #43's incident reports found on 08/29/16, 10/19/16, 11/09/16 and 01/05/17 he was ordered neurological (neuro-checks) due to unwitnessed and/or complaint or indication of a head injury as directed in the facility's standing orders for incidents. Incident reports directed the neuro-checks to be done: --Every fifteen (15) minutes - four (4) consecutive times, then --Every hour - two (2) consecutive times, then --Every four (4) hours - two (2) consecutive times, then --Every shift - three (3) consecutive times. The neurological assessment form used by the facility's staff instructed to obtain neuro-checks: --Every fifteen (15) minutes - four (4) consecutive times, then --Every thirty (30) minutes - two (2) consecutive times, then --Once a shift for 24 hours. The facility's standing orders directed to complete neuro-checks: --Every fifteen (15) - four (4) consecutive times, then --Every thirty (30) minutes - two (2) consecutive times, then --Every hour - two (2) consecutive times, then --Once a shift for 24 hours. Interview with the DON on 02/09/17 at 3:00 p.m., found she was unaware of the different directions used for the neuro-checks (incident report, neuro- check forms used by the licensed nurses and facility's standing orders). She confirmed the facility's standing order for neuro-checks should be used. She further confirmed the neuro-checks for Resident #43 for 08/29/16, 10/19/16, 11/09/16 and 01/05/17 had not been completed as directed by the facility's standing orders. b) Resident #97 On 02/07/17 at 11:58 a.m., review of the medical record reflected a care plan dated 01/26/17 that read, communicate with [MEDICAL TREATMENT] center. On 02/07/17 at 1:2:40 p.m., a record review revealed incomplete [MEDICAL TREATMENT] communication forms. On 02/07/17 at 12:50 p.m., an interview with licensed practical nurse (LPN) #23 assigned to care for Resident #97 stated she does not know where the [MEDICAL TREATMENT] communication form are kept in the medical record. On 02/07/17 at 2:58 p.m., registered nurse (RN) #8 stated that she was unsure of where the [MEDICAL TREATMENT] communication forms are filed in the medical record. On 02/08/17 at 8:00 a.m., a review of the, Outpatient [MEDICAL TREATMENT] Services Agreement revealed, The Facility will provide for the interchange of information useful or necessary for the care of the resident. On 02/07/17 at 2:49 p.m., the director of nursing (DON) stated that the [MEDICAL TREATMENT] Center never returns the [MEDICAL TREATMENT] communication form when Resident #97 returns to the facility and it is a problem. . c) Resident #30 A review of Resident #30's medical record at 9:51 a.m. on 02/09/2017, found the resident had fallen on 09/12/16 at 4:00 p.m. A review of the incident report found the following order for a fall with suspected head trauma to initiate neurological checks (neuro checks): --Every fifteen (15) minutes - four (4) consecutive times, then --Every hour - two (2) consectuive times, then --Every two (2) hours - two (2) consectuive times, then --Every four (4) hours - two (2) consectuive times, then --Every shift- - three (3) consectuive times, then Further review of the record found a nursing note dated 09/12/16 which indicated Resident #30 was sent to a local hospital emergency department at 6:35 p.m. on 09/12/16. Prior to Resident #30 leaving the facility she should have had a neuro check at 4:15 p.m., 4:30 p.m., 4:45 p.m., 5:00 p.m. and 6:00 p.m. upon review of the record no neuro checks could be located. At 12:24 p.m. on 02/09/17, registered nurse (RN) #80 indicated Resident #30 did not have any neuro checks because she was sent to the emergency room . She was asked to review the nurses note which indicated Resident #30 did not leave the facility until 6:35 p.m. on 09/12/16. She was then asked if the staff should have initiated the neuro checks during the two (2) and a half hours the resident remained at the facility. She agreed they should have initiated the neuro checks and indicated she would go and look for them. In an interview with the director of nursing (DON) on 02/09/17 at 1:06 p.m., she confirmed they could not find were they done the neuro checks for Resident #30. d) Resident #42 Medical record review on 02/09/17 revealed his resident sustained [REDACTED]. The facility's standing physician's orders [REDACTED]. The neuro checks must begin immediately, then every fifteen (15) minutes for four (4) times; every thirty (30) minutes for two (2) times; every hour for two (2) times, then once per shift for twenty-four (24) hours. This amounted to a minimum of eleven (11) neuro check evaluations. Review of the POS [REDACTED]. At the top of these forms it stated, This assessment should be completed at the following intervals for all falls. A fall that is unwitnessed, or in which the head is struck, requires neurological checks. Review of this resident's neuro check forms found numerous absences of vital sign and neurological assessments as follows: --10/31/16 - Blood pressure, pulse, respiration, and orientation was assessed ten (10) out of eleven (11) opportunities. Strength of extremities was assessed nine (9) out of eleven (11) opportunities. There was no evidence of any assessment of pupil size and reaction. --12/09/16 - Blood pressure, pulse, respiration, and orientation was assessed nine (9) out of eleven (11) opportunities. Strength of extremities was assessed nine (9) out of eleven (11) opportunities. Pupil size and reaction was assessed eight (8) out of eleven (11) opportunities. --01/25/17 - Blood pressure, pulse, respiration, and orientation was assessed nine (9) out of eleven (11) opportunities. Strength of upper extremities was assessed nine (9) out of eleven (11) opportunities. Strength of lower extremities was assessed five (5) out of eleven (11) opportunities. Pupil size and reaction was assessed five (5) out of eleven (11) opportunities. During an interview with the director of nursing on 02/09/17 at 1:10 p.m., she agreed nursing staff did not obtain neurological assessments consistently as the physician's standing orders directed. e) Resident #40 During Stage 1 of the QIS survey, at 12:17 p.m. on 02/06/17, an interview with Resident #40 found he said he did not receive the fluids he wanted between his meals. He said he thought it was due to a kidney problem. Record review at 4:43 p.m. on 2/07/17, found the resident had a physician's orders [REDACTED]. Further record review found a care plan addressing dehydration/fluid maintenance with a potential for dehydration due to fluid restriction and a [DIAGNOSES REDACTED]. The goal was the resident would remain free of signs and symptoms of dehydration through next review date. The care plan was updated on 02/02/17. The care plan approaches did not detail how much fluid the resident would receive from dietary and how much fluid from the nursing staff. An interview with registered nurse (RN), author of the care plan, at 8:23 a.m. on 02/08/17, confirmed the fluid restriction was not detailed in the resident's care plan. At 8:51 a.m. on 02/08/17, the resident's licensed practical nurse (LPN) #11 said the resident is not on a fluid restriction and she verified the resident had a pitcher with water in his room with a straw for drinking. At 8:56 a.m. on 02/08/17, the dietary manager, (DM) #23, provided a copy of the tray card for the resident's noon meal on 02/08/17. The tray card directed the resident to receive 4 ounces (oz) of coffee or hot tea and 8 oz of milk. She was asked how to convert ounces to cubic centimeters (cc) She said she wasn't sure but would tell me later. On 02/08/17, at 9:10 a.m., DM #23 said the resident would receive 840 milliliters (ml) a day from dietary and 1 cc would equal 1 ml. When asked how other nursing employees would know how much fluid the resident could receive, she replied, They could look in the computer. At 9:26 a.m. on 02/08/17, the resident's physician was interviewed. He said, I usually don't like fluid restrictions, why are we doing that, I will have to track that back to see. At 10:40 a.m. on 02/08/17, LPN #11 returned and said, I told you wrong, he is on a fluid restriction. I give about 120 cc of fluid with my medication pass. Sometimes the resident drinks it and sometimes he doesn't. She verified she does not record how many cc's of fluid the resident consumed with the medication pass. Review of the care plan for nutritional status contained an approach to, Invite to food related activities and offer food, beverages of choice to encourage intake. The activities assistant (AA) #37, was interviewed at 1:50 p.m. on 02/08/17, she confirmed she does not record any consumption of fluids or fluids consumed by any resident during activities. She said the resident sometimes comes to morning chat where we pass out coffee. She said the resident was allowed to have coffee. At 11:46 a.m. on 02/09/17, the Registered Dietician (RD) #93, was interviewed. The resident's tray card for lunch on 02/08/17 noted the resident would receive 4 oz of coffee or hot tea and 8 oz of milk. As the fluid restriction was1500 cc, RD #93 was asked how to convert ounces to cubic centimeters. She said there were 30 cc in one ounce so the resident would be getting 12 ounces of fluid which would be 360 cc of fluid with this meal. She said the resident would receive 360 cc of fluid with each meal so dietary would be providing 1080 cc of fluid a day. At 11:54 a.m. on 02/09/17, the director of nursing (DON) said the facility has a new form they are going to start using to record the resident's daily fluid intake. The daily vitals report used by the nursing staff was reviewed with the DON. Variances were observed in the recordings. For example on 02/06/17, a registered nurse recorded the resident as having consumed 480 ml of fluid at 6:43 p.m. No other fluids were recorded. The DON did not know if this was the only fluids consumed by this resident on this day. On 01/31/17, only one nurse aide recorded a fluid intake of 360 ml of fluids. The DON verified the fluid records were not consistent; therefore, a new form had been developed so the facility could track the daily fluids consumed by the resident.",2020-09-01
3280,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,312,E,0,1,UXFJ11,"Based on resident interview, resident observation, record review and staff interview the facility failed to provide Resident #30 who is not able to carry out her own Activities of Daily Living (ADL) care with the necessary ADL care for her to maintain good grooming, and personal hygiene. This was true for one (1) of three (3) residents reviewed for the care area of ADL's during stage 2 of the quality indicator survey (QIS). Resident Identifiers: #30. Facility Census: 58. Findings include: a) Resident #30 1. Showers During a Stage one (1) interview with Resident #30 at 3:00 p.m. on 02/06/17 when asked if she received the number of showers in a week she would like she stated, No I am supposed to be showered three (3) times a week and they only shower me once a week or once every two weeks. A review of Resident #30's medical record at 08:29 a.m. on 02/09/17 found the following care plan related to Resident #30's ADL care: Problem Statement with a problem start date of 08/07/15 read as follows, Inability to maintain health state independently r/t (related to) dementia, limited mobility, and muscle weakness. The goal associated with this problem read as follows: Residents' care will be provided for based on their preferences and cognitive/functional abilities EB (evidenced by) staff completing P[NAME] (plan of care) Kardex and updating as needed. This goal had a target date of 06/16/16. The goals associated with this problem statement and goals included: Bathing PM (evening) Shower assist of 1 Days Monday, Wednesday, and Friday. This intervention was added to the care plan on 03/16/16. Review of the Resident #30's shower documentation from 06/20/16 through present found the following: 06/20/16 through 06/30/16: Resident #30 was scheduled to receive five (5) showers and only received two (2) on 06/25/16 and 06/28/16. She did not receive her shower scheduled on 06/21/16, 06/23/16, and 06/30/16. For the month of (MONTH) (YEAR) (07/01/16 through 07/31/16) Resident #30 was scheduled to receive 12 showers. She received a shower on 07/05/16, 07/11/16, 07/19/16, and 07/31/16 four (4) of the 12 opportunities. She was out of the facility on 07/07/16 resulting in her not receiving her scheduled shower on this date. Resident #30 had documented refusals of showers on 07/21/16 and 7/23/16. On 07/02/16, 07/09/16, 07/14/16, 07/16/16, and 07/27/16 she did not receive a shower and the record contained no documented reason. For the month of (MONTH) (YEAR) (08/01/16 through 08/30/16) Resident #30's shower schedule was changed to two (2) showers per week. This change took place on the week of 08/14/16 and has remained the schedule until present. Documentation was not provided by the facility for the week of 08/07/16 through 08/13/16. During the month of (MONTH) Resident #30 was scheduled to receive nine (9) showers she only received four (4) on 08/02/16, 08/23/16, 08/27/16, and 08/30/16. She had a documented refusal on 08/20/16. She did not receive a shower four (4) of the scheduled days on 08/06/17, 08/09/16, 08/12/16, and 08/16/16. The record contained no documented reason as to why she did not receive her showers on these dates. For the month of (MONTH) (YEAR) (09/01/16 through 09/30/16) Resident #30 was scheduled to receive nine (9) showers. She received a shower on 09/06/16, 09/17/16, and 09/23/16 three (3) of the nine (9) opportunities. Resident #30 had documented refusals of showers on 09/13/16 and 9/30/16. On 09/03/16, 09/10/16, 09/19/16, and 09/26/16 she did not receive a shower and the record contained no documented reason. For the month of (MONTH) (YEAR) (10/01/16 through 10/31/16) Resident #30 was scheduled to receive nine (9) showers. She received a shower on 10/07/16, 10/14/16, 10/20/16, 10/24/16 and 10/28/16 five (5) of the nine (9) opportunities. Resident #30 had documented refusals of showers on 10/03/16, 10/10/16, and 10/16/16. On 10/31/16 Resident #30 did not receive a shower and the record contained no documented reason. For the month of (MONTH) (YEAR) (11/01/16 through 11/30/16) Resident #30 was scheduled to receive eight (8) showers. She received a shower on 11/04/16, 11/07/16, and 11/21/16 three (3) of the eight (8) opportunities. Resident #30 had a documented refusal of a shower on 11/14/16. On 11/11/16, 11/25/16, and 11/28/16 she did not receive a shower and the record contained no documented reason. For the month of (MONTH) (YEAR) (12/01/16 through 12/31/16) Resident #30 was scheduled to receive nine (9) showers. She received a shower on 12/02/16, 12/19/16, and 12/26/16. three (3) of the nine (9) opportunities. Resident #30 had documented refusal of a shower on 12/09/16. On 12/05/16, 12/12/16, 12/16/16, and 12/26/16 she did not receive a shower and the record contained no documented reason. For the month of (MONTH) (YEAR) (01/01/17 through 01/31/17) Resident #30 was scheduled to receive nine (9) showers. She received a shower on 01/02/17, and 01/16/17 two (2) of the nine (9) opportunities. Resident #30 had documented refusals of showers on 01/06/17 and 01/13/17. On 01/09/17, 01/20/17, 01/23/17, 1/27/17, and 01/30/17 she did not receive a shower and the record contained no documented reason. For the month of (MONTH) (YEAR) (02/01/17 through 02/07/17 the day of this review) Resident #30 was scheduled to receive two (2) showers. She received a shower on 02/06/17. However, for 02/02/17 the resident did not receive a shower and the record contained no documented reason. Please note from (MONTH) (YEAR) through present the facility only scheduled Resident #30 for two (2) showers per week. This is not in agreement with the residents care plan and/or the resident interview both of which revealed she should be scheduled for three (3) showers per week. So in addition to the missed showers mentioned above there is one (1) shower per week for 25 weeks that has not even been scheduled or offered to the resident. The Director of Nursing (DON) at 2:00 p.m. on 02/08/17, in an interview stated, The resident was switched to two (2) showers per week per her request. When asked why the care plan still indicated to offer her a shower three (3) times a week she stated, I guess we did not update it. She was then informed Resident #30 had stated she was scheduled to receive three (3) showers per week and she was not getting them. To this she replied, she does not have capacity. A review of Resident #30,s most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/16 found, her Brief Interview of Mental Status (BIMS) score was a 15 out of 15 indicating she was cognitively intact and fully able to be interviewed. The DON then reviewed the shower documentation and stated, It looks like our documentation is incomplete, but we are giving her showers. She stated, I think they are forgetting to document refusals on the shower schedule sheet. She was asked to provide any documentation she might have pertaining to the residents request for only two (2) showers per week or that she might have regarding her refusals. She provided no additional information. 2. Glasses An observation of Resident #30 on 02/06/17 at 3:00 p.m. found her glasses were unclean and smudged. An additional observation for Resident #30 on 02/09/17 at 8:50 a.m. found her glasses were still dirty and were still smudged in the same place as they were on 02/06/17. At this time Resident #30 asked if her glasses were working good for her and she stated, Well they could be cleaned and I might see a little better. At this time Registered Nurse (RN) #52 was asked to come to Resident #30's room to see if her glasses needed to be cleaned. RN #52 took Resident #30's glasses and cleaned them and handed them back to the resident. Resident #30 put her glasses back on and stated, They're just like new now. She then thanked RN #52 for cleaning her glasses and also thanked the surveyor for getting someone to clean her glasses for her. A review of Resident #30's medical record at 08:29 a.m. on 02/09/17 found the following care plan related to Resident #30's ADL care: Problem Statement with a problem start date of 08/07/15 read as follows, Inability to maintain health state independently r/t (related to) dementia, limited mobility, and muscle weakness. The goal associated with this problem read as follows: Residents' care will be provided for based on their preferences and cognitive/functional abilities EB (evidenced by) staff completing P[NAME] (plan of care) Kardex and updating as needed. This goal had a target date of 06/16/16. The goals associated with this problem statement and goals included: Vision: Adequate, wears glasses. Clean glasses every shift.",2020-09-01
3281,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,353,E,0,1,UXFJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, policy review, and observation, the facility failed to ensure qualified nursing staff provided day to day care to meet the resident's needs in an environment which promoted each resident's physical, mental, and psychosocial well-being, to enhance their quality of life. Resident #43 was not administered a breathing ([MEDICATION NAME]) medication as ordered by the physician, failed to ensure the care of a hospice resident was correlate his hospice provider and failed on multiple occasions when neurological checks were indicated to complete as directed by the facility's standing orders. For Resident #97 the facility failed to ensure the care of a [MEDICAL TREATMENT] resident was correlated with the [MEDICAL TREATMENT] center. For Resident #30 and 42, the facility failed to complete neurological checks as directed by the facility's standing orders. For Resident #40, the facility failed to follow a physician ordered fluid restriction. This was true for five (5) of seventeen (17) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #43, #97, #30, #42 and #40. Facility census: 58. Findings include: a) Resident #43 1. Medication Administration A review of Resident #43's medical record at 10:19 a.m. on 02/08/17, found a physician's orders [REDACTED]. Review of Resident #43's Medication Administration Record [REDACTED]. The physician order [REDACTED]. An interview with the Director of Nursing at 11:20 a.m. on 02/08/17, confirmed Resident #43 should have received the medication at 7:00 a.m. and 5:00 p.m. with meals. 2. Hospice Services A medical record review for Resident #43 on 02/08/17 at 1:00 p.m., found the resident received hospice services since 10/24/16. Review of Resident #43's care plan for hospice services found no indication of when and who would be involved in the coordination and implementation of the resident's hospice care. Interview with register nurse (RN) # 52 on 02/09/17 at 8:25 a.m., found the facility staff was unable to provide information for when the hospice personnel were scheduled and who was responsible for the coordination of hospice care with the facility and hospice staff. 3. Neurological checks Review of Resident #43's incident reports found on 08/29/16, 10/19/16, 11/09/16 and 01/05/17 he was ordered neurological (neuro-checks) due to unwitnessed and/or complaint or indication of a head injury as directed in the facility's standing orders for incidents. Incident reports directed the neuro-checks to be done: --Every fifteen (15) minutes - four (4) consecutive times, then --Every hour - two (2) consecutive times, then --Every four (4) hours - two (2) consecutive times, then --Every shift - three (3) consecutive times. The neurological assessment form used by the facility's staff instructed to obtain neuro-checks: --Every fifteen (15) minutes - four (4) consecutive times, then --Every thirty (30) minutes - two (2) consecutive times, then --Once a shift for 24 hours. The facility's standing orders directed to complete neuro-checks: --Every fifteen (15) - four (4) consecutive times, then --Every thirty (30) minutes - two (2) consecutive times, then --Every hour - two (2) consecutive times, then --Once a shift for 24 hours. Interview with the DON on 02/09/17 at 3:00 p.m., found she was unaware of the different directions used for the neuro-checks (incident report, neuro- check forms used by the licensed nurses and facility's standing orders). She confirmed the facility's standing order for neuro-checks should be used. She further confirmed the neuro-checks for Resident #43 for 08/29/16, 10/19/16, 11/09/16 and 01/05/17 had not been completed as directed by the facility's standing orders. b) Resident #97 On 02/07/17 at 11:58 a.m., review of the medical record reflected a care plan dated 01/26/17 that read, communicate with [MEDICAL TREATMENT] center. On 02/07/17 at 1:2:40 p.m., a record review revealed incomplete [MEDICAL TREATMENT] communication forms. On 02/07/17 at 12:50 p.m., an interview with licensed practical nurse (LPN) #23 assigned to care for Resident #97 stated she does not know where the [MEDICAL TREATMENT] communication form are kept in the medical record. On 02/07/17 at 2:58 p.m., registered nurse (RN) #8 stated that she was unsure of where the [MEDICAL TREATMENT] communication forms are filed in the medical record. On 02/08/17 at 8:00 a.m., a review of the, Outpatient [MEDICAL TREATMENT] Services Agreement revealed, The Facility will provide for the interchange of information useful or necessary for the care of the resident. On 02/07/17 at 2:49 p.m., the director of nursing (DON) stated that the [MEDICAL TREATMENT] Center never returns the [MEDICAL TREATMENT] communication form when Resident #97 returns to the facility and it is a problem. c) Resident #30 A review of Resident #30's medical record at 9:51 a.m. on 02/09/2017, found the resident had fallen on 09/12/16 at 4:00 p.m. A review of the incident report found the following order for a fall with suspected head trauma to initiate neurological checks (neuro checks): --Every fifteen (15) minutes - four (4) consecutive times, then --Every hour - two (2) consectuive times, then --Every two (2) hours - two (2) consectuive times, then --Every four (4) hours - two (2) consectuive times, then --Every shift- - three (3) consectuive times, then Further review of the record found a nursing note dated 09/12/16 which indicated Resident #30 was sent to a local hospital emergency department at 6:35 p.m. on 09/12/16. Prior to Resident #30 leaving the facility she should have had a neuro check at 4:15 p.m., 4:30 p.m., 4:45 p.m., 5:00 p.m. and 6:00 p.m. upon review of the record no neuro checks could be located. At 12:24 p.m. on 02/09/17, registered nurse (RN) #80 indicated Resident #30 did not have any neuro checks because she was sent to the emergency room . She was asked to review the nurses note which indicated Resident #30 did not leave the facility until 6:35 p.m. on 09/12/16. She was then asked if the staff should have initiated the neuro checks during the two (2) and a half hours the resident remained at the facility. She agreed they should have initiated the neuro checks and indicated she would go and look for them. In an interview with the director of nursing (DON) on 02/09/17 at 1:06 p.m., she confirmed they could not find were they done the neuro checks for Resident #30. d) Resident #42 Medical record review on 02/09/17 revealed his resident sustained [REDACTED]. The facility's standing physician's orders [REDACTED]. The neuro checks must begin immediately, then every fifteen (15) minutes for four (4) times; every thirty (30) minutes for two (2) times; every hour for two (2) times, then once per shift for twenty-four (24) hours. This amounted to a minimum of eleven (11) neuro check evaluations. Review of the POS [REDACTED]. At the top of these forms it stated, This assessment should be completed at the following intervals for all falls. A fall that is unwitnessed, or in which the head is struck, requires neurological checks. Review of this resident's neuro check forms found numerous absences of vital sign and neurological assessments as follows: --10/31/16 - Blood pressure, pulse, respiration, and orientation was assessed ten (10) out of eleven (11) opportunities. Strength of extremities was assessed nine (9) out of eleven (11) opportunities. There was no evidence of any assessment of pupil size and reaction. --12/09/16 - Blood pressure, pulse, respiration, and orientation was assessed nine (9) out of eleven (11) opportunities. Strength of extremities was assessed nine (9) out of eleven (11) opportunities. Pupil size and reaction was assessed eight (8) out of eleven (11) opportunities. --01/25/17 - Blood pressure, pulse, respiration, and orientation was assessed nine (9) out of eleven (11) opportunities. Strength of upper extremities was assessed nine (9) out of eleven (11) opportunities. Strength of lower extremities was assessed five (5) out of eleven (11) opportunities. Pupil size and reaction was assessed five (5) out of eleven (11) opportunities. During an interview with the director of nursing on 02/09/17 at 1:10 p.m., she agreed nursing staff did not obtain neurological assessments consistently as the physician's standing orders directed. e) Resident #40 During Stage 1 of the QIS survey, at 12:17 p.m. on 02/06/17, an interview with Resident #40 found he said he did not receive the fluids he wanted between his meals. He said he thought it was due to a kidney problem. Record review at 4:43 p.m. on 2/07/17, found the resident had a physician's orders [REDACTED]. Further record review found a care plan addressing dehydration/fluid maintenance with a potential for dehydration due to fluid restriction and a [DIAGNOSES REDACTED]. The goal was the resident would remain free of signs and symptoms of dehydration through next review date. The care plan was updated on 02/02/17. The care plan approaches did not detail how much fluid the resident would receive from dietary and how much fluid from the nursing staff. An interview with registered nurse (RN), author of the care plan, at 8:23 a.m. on 02/08/17, confirmed the fluid restriction was not detailed in the resident's care plan. At 8:51 a.m. on 02/08/17, the resident's licensed practical nurse (LPN) #11 said the resident is not on a fluid restriction and she verified the resident had a pitcher with water in his room with a straw for drinking. At 8:56 a.m. on 02/08/17, the dietary manager, (DM) #23, provided a copy of the tray card for the resident's noon meal on 02/08/17. The tray card directed the resident to receive 4 ounces (oz) of coffee or hot tea and 8 oz of milk. She was asked how to convert ounces to cubic centimeters (cc) She said she wasn't sure but would tell me later. On 02/08/17, at 9:10 a.m., DM #23 said the resident would receive 840 milliliters (ml) a day from dietary and 1 cc would equal 1 ml. When asked how other nursing employees would know how much fluid the resident could receive, she replied, They could look in the computer. At 9:26 a.m. on 02/08/17, the resident's physician was interviewed. He said, I usually don't like fluid restrictions, why are we doing that, I will have to track that back to see. At 10:40 a.m. on 02/08/17, LPN #11 returned and said, I told you wrong, he is on a fluid restriction. I give about 120 cc of fluid with my medication pass. Sometimes the resident drinks it and sometimes he doesn't. She verified she does not record how many cc's of fluid the resident consumed with the medication pass. Review of the care plan for nutritional status contained an approach to, Invite to food related activities and offer food, beverages of choice to encourage intake. The activities assistant (AA) #37, was interviewed at 1:50 p.m. on 02/08/17, she confirmed she does not record any consumption of fluids or fluids consumed by any resident during activities. She said the resident sometimes comes to morning chat where we pass out coffee. She said the resident was allowed to have coffee. At 11:46 a.m. on 02/09/17, the Registered Dietician (RD) #93, was interviewed. The resident's tray card for lunch on 02/08/17 noted the resident would receive 4 oz of coffee or hot tea and 8 oz of milk. As the fluid restriction was1500 cc, RD #93 was asked how to convert ounces to cubic centimeters. She said there were 30 cc in one ounce so the resident would be getting 12 ounces of fluid which would be 360 cc of fluid with this meal. She said the resident would receive 360 cc of fluid with each meal so dietary would be providing 1080 cc of fluid a day. At 11:54 a.m. on 02/09/17, the director of nursing (DON) said the facility has a new form they are going to start using to record the resident's daily fluid intake. The daily vitals report used by the nursing staff was reviewed with the DON. Variances were observed in the recordings. For example on 02/06/17, a registered nurse recorded the resident as having consumed 480 ml of fluid at 6:43 p.m. No other fluids were recorded. The DON did not know if this was the only fluids consumed by this resident on this day. On 01/31/17, only one nurse aide recorded a fluid intake of 360 ml of fluids. The DON verified the fluid records were not consistent; therefore, a new form had been developed so the facility could track the daily fluids consumed by the resident.",2020-09-01
3282,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,356,B,0,1,UXFJ11,"Based on observation of the staff posting and staff interview, the facility failed to post staffing information that accurately reflected the current date; the current resident census; the total number and actual hours worked by registered nurses, licensed nurses, and nurse aides per shift. This had the potential to affect more than an isolated number of residents and/or visitors residing or visiting the facility. Facility census: 58. Findings include: a) Observation of the staff posting on the 2nd floor, during the initial tour of the facility, at 10:34 a.m. on 02/06/17, found the facility staff posting was dated 02/02/17. An interview with the director of nursing, at 10:35 a.m. on 02/06/17, confirmed the facility had not displayed the staff posting information for 02/03/17 through 02/06/17. .",2020-09-01
3283,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,371,F,0,1,UXFJ11,"Based on observation and staff interview, the facility failed to prepare, store and serve food in a safe and sanitary manner. The kitchen walk-in refrigerator had solid matter where floor and wall meet, undated dry goods, un-intact packaged frozen food observed in walk-in freezer and perishable food stored at room temperature. Resident refrigerators on first and second floor contained unlabeled and/or undated food, and soiled food carts were observed. These findings had the potential to affect all residents. Census: 58. a) The Kitchen Observations made on 02/06/17 and 02/08/17 found the following: --02/06/17 at 10:46 a.m. observed non securely packaged pancakes and chicken patties exposed to air inside walk-in freezer. --02/06/17 at 10:53 a.m. observed solid matter in areas of walk-in refrigerator where floor and wall meet. --02/06/17 at 12:44 p.m. observed single serve milk cartons set out at room temp for the duration of meal tray assembly. --02/06/17 at 12:49 Staff #94 states that once a week the refrigerator floor should be cleaned out and that it is a good idea to put the milk on ice if milk will be setting out for a while. --02/08/17 at 10:22 a.m. observed the following opened, undated food items stored on a shelf, bulk Italian seasoning, molasses, cream of wheat, 2 (two) cans of food thickener and 2 (two) jars of chicken base seasoning. The label on the jars of chicken base seasoning reads, refrigeration after opening is required. --02/08/17 at 10:30 a.m. interview with Staff #94 states that items need to be dated when opened and stored in the proper place. b) Observation of the resident's food pantry refrigerator During the tour of the facility at 10:30 a.m. on 2/6/17, observation of the resident's personal refrigerator, located in the medication administration room, on the 1st floor of the facility found 2 packs of sliced, soft, American, cheese. The cheese was not individually wrapped. One package was dated 1/29/17 with discard date of 2/5/16. The second package of cheese was dated 01/20/17 with a discard date of 01/27/17. The director of nursing (DON) was present during the tour. She identified the first date as the date the cheese was placed in the refrigerator and the second date as the date of discard. She said she would throw away the cheese. In addition, the cheese was wrapped loosely with cellophane wrapping which did not create a seal to ensure the cheese did not dry out. At 1:09 p.m. on 02/08/17, the dietary manager (DM) #94 said the cheese was good for 30 days. When asked for the facility policy, the DM presented a copy of a computer print out from a web cite-www.recipetips.com. The information on the print out noted: --Fresh cheese could be kept in the refrigerator for 1 to 2 days, --Soft cheese could be kept in the refrigerator for 3 to 4 days, and --Hard or semi-hard cheese could be kept for 2 to 3 weeks. --The web cite is not an approved food code from the United States (US) Food and Drug Administration's food code. A second policy entitled, Food and Supple Storage Procedures-continued, only noted to discard leftovers not utilized within 48 hours. c) Observation of the evening meal in the main dining room At 6:35 p.m. on 02/08/17, observation of the evening meal, with the DM, in the main dining room, found the open food cart, being used to serve clean trays, was dirty and covered with debris. The wheels and the legs of the cart were covered with food debris, lint, dust, and dirt. In addition, the racks on the cart, used to slide the trays in and out of the open cart were covered with dried debris. d) Nutrition Refrigerator on 2nd Floor An observation of the nutrition pantry refrigerator on 2nd floor was conducted during the initial tour of the facility on 02/06/17 at 10:30 a.m. The following sanitation issues were identified: one (1) open bottle of mayonnaise, one (1) 240 milliliter 2% milk, one half (1/2) gallon of buttermilk, block of sliced cheese, and a 16 ounce bottle of diet Pepsi all items were found opened and no date or resident name. Employee #79, licensed practical nurse (LPN), was present during the observations of the nutrition pantry refrigerator and confirmed the listed items were not appropriately labeled, and/or were not discarded timely.",2020-09-01
3284,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,428,D,0,1,UXFJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, medical record reviews, and review of the consultant pharmacist's recommendations, the facility failed to ensure the pharmacist's recommendations which were approved by the attending physician were acted upon. For Resident #43, the consultant pharmacist recommended Theophylline be given twice daily with meals to reduce gastrointestinal (GI) distress and the attending physician approved this recommendation, but nursing failed to implement the recommendation. This was found for one (1) of five (5) residents reviewed for unnecessary medications. Recommendation. Resident identifier: #43. Facility census: 58. Findings include: a) Resident #43 A review of Resident #43's medical record, at 10:19 a.m. on 02/08/17, found the following a consultant pharmacist recommendation the attending physician agreed to follow on 08/18/16, Theophylline Extended Release (ER) one tablet by mouth twice daily with meals to reduce gastrointestinal (GI) distress Review of Resident #43's Medication Administration Record [REDACTED]. The physician order [REDACTED]. An interview with the Director of Nursing, at 11:20 a.m. on 02/08/17, confirmed Resident #43 should have received the medication at 7:00 a.m. and 5:00 p.m. with meals. She confirmed the consultant pharmacist recommendation was agreed to by the attending physician on 08/18/16 and was not administered as directed.",2020-09-01
3285,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,431,E,0,1,UXFJ11,"Based on observation, staff interview, and policy review, the facility failed, in collaboration with the pharmacist, to ensure the safe and effective use of medications. Two (2) multi-dose vials of insulin which belonged to Residents #77 and #27 were open and had no date, and/or legible date to indicate when the vials were initially opened. Use of medication from multi-dose vials open for a time period greater than recommended by the manufacturer had the potential to negatively impact the safety and/or potency of the medication. Observation of the first floor medication room refrigerator found it was not at the appropriate temperature. This had the potential to affect more than a limited number of residents. Resident identifiers: #77 and #27. Facility census: 58. Findings include: a) Resident #77 Observation on 02/07/17 at 9:07 a.m., found an opened, partially used, ten (10) milliliter (ml) vial of Humulin R insulin. The vial contained no date indicating when it was initially opened. Licensed practical nurse (LPN) #22 said nurses discard vials of Humulin-R insulin thirty (30) days after the date they are opened. She agreed the vial was not marked with the date it was initially used or opened . She discarded the opened vial, and obtained a new, unopened vial of Humulin-R insulin for this resident's use. During an interview with the director of nursing on 02/08/17 at 4:15 p.m., she said nursing staff are supposed to date all multi-dose vials of insulin when they are first opened. b) Resident #27 Observation on 02/08/17 at 4:15 p.m., found an opened, nearly empty, ten (10) ml vial of Levemir insulin. The vial contained an illegible inscription of the date when it was initially opened. The director of nursing (DON) was present at this time, and said she would dispose of this vial since it cannot be accurately determined when it was initially opened. She said nursing staff is supposed to date all multi-dose vials of insulin when they are first opened. She said the opened date on this vial was smudged and illegible. She agreed that Levemir insulin vials should be discarded forty-two (42) days after it is initially opened. The DON provided a copy of the facility's insulin administration policy. In part, the policy directed to check the expiration date of the vial if drawing from an opened multi-dose vial of insulin. If opening a new vial, the policy contained a directive to record the expiration date on the vial. The policy directed to follow manufacturer's recommendations for expiration after opening.",2020-09-01
3286,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,441,E,0,1,UXFJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and manual for glucometer care, the facility failed to ensure an effective infection control program designed to prevent the development and/or transmission of disease and infection to the extent possible. Potential for cross-contamination was observed when nursing staff placed reusable patient care supplies directly onto residents' overbed trays without any type of barrier; nursing staff demonstrated improper cleaning and/or disinfection of a resident-shared glucometer after use; nursing staff touched inanimate objects in a resident's semi-private room without first removing disposable latex gloves previously used while cleaning an incontinent resident; nursing staff soaked washcloths in a resident sink prior to use for incontinence care. These practices had the potential to affect more than a limited number of residents on the first floor long hall, but most directly involved Residents #50, #95, #29. Resident identifiers: #50, #95, #29. Facility census: 58. Findings include: a) Resident #50 During observation on 02/07/17 at 7:22 a.m., licensed practical nurse (LPN) #22 placed a glucometer (small machine used to obtain blood glucose tests) directly onto this resident's overbed tray without the use of any type of barrier. After the test was completed, LPN #22 placed the glucometer directly onto the top of the medication cart. This act contaminated the top of the medication cart, which is where a nurse would pour medications for other residents. She then obtained a wipe from a canister and proceeded to wipe off the glucometer before returning the glucometer to the drawer of the medication cart. Observation of the canister found its only active ingredient was a seventy percent (70%) alcohol solution. She did not clean and/or disinfect the top of the medication cart where the glucometer had been placed. During interview with the director of nursing (DON) on 02/08/2017 9:06 a.m., she said there is no need to place the glucometer on any residents' bedside tray. Rather, the nurses are supposed to carry the machine into the resident's room and hold the glucometer in their hands. She said if a nurse laid the glucometer down in the room, a barrier would be needed such as a paper towel. She agreed that when the nurse laid the glucometer on top of the medication cart after it had previously placed directly on the resident's overbed tray, the nurse should have wiped off the top of the medication cart with a disinfectant wipe from the red lidded Med Line Micro Kill canister. The DON said each cart has either packets of sani-wipes with bleach especially made to clean glucometers between patient uses, and/or canisters with red lids of Med Line Micro Kill that are EPA (environmental protection act) registered to disinfect surfaces and glucometers. She said LPN #22 used a sanitizing wipe from the blue lidded canister whose only active ingredient was 70% alcohol. She said those wipes are used only to clean hands. The DON said this canister with 70% alcohol had no EPA registration. The DON provided the facility's glucometer manufacturer's booklet which listed several product brands on pages 43 and 44 which may be used to disinfect the glucometer between patient uses. Both the Med Line Micro Kill and the individual packets of bleach wipes the facility used were included in the list of approved product brands. The blue lidded canister of 70% alcohol wipes was not included in the list of approved product brands to disinfect the glucometer. b) Resident #95 During observation on 02/07/17 at 9:52 a.m., LPN #22 carried a medication box into this resident's room. The box contained an [MEDICATION NAME] hand-held inhaler. LPN #22 placed the box on the resident's beside table with no barrier beneath it. After the resident used the inhaler, LPN #22 placed the inhaler back into the medication box. She then placed the medication box on the countertop of the resident's sink while she washed her hands. Next, she placed the medication box on top of her medication cart while she unlocked the cart. She then returned the medication box which contained the [MEDICATION NAME] inhaler to a drawer of the medication cart. She did not sanitize the medication box after it had been in contact with the resident's overbed tray and sink. She did not sanitize the top of her medication cart after the exposed medication box was placed on it. During an interview with the director of nursing (DON) on 02/08/17 at 9:06 a.m., she said if a nurse placed an inhaler's medication box on an overbed tray, the nurse should place the box on a barrier such as a paper towel. Otherwise, this could potentially cause cross contamination. She agreed that the nurse should also have sanitized/disinfected the top of her medication cart after the exposed medication box had been placed on it. c) Resident #29 On 02/08/17 at 7:25 p.m., nurse aide (NA) #38 performed urinary incontinence care for Resident #29. She placed clean wash cloths directly into the resident's sink beneath the faucets and atop the drain, and ran warm water over the wash cloths. She squirted some red-colored shower wash onto the washcloth, squeezed out the excess water, then placed the wash clothes on the sink's counter top. The NA stripped the resident's bed. She then assisted the resident into the bathroom, and donned a pair of disposable green gloves. The resident held to the grab bar in the bathroom as she removed his wet diaper. When she removed the diaper, the urine odor was quite acrid and pungent with the strong smell of ammonia. She wiped the front of him, then washed his buttocks. She applied a clean diaper, and helped him into a pair of clean sweat pants. While still wearing the same gloves, she touched the bathroom door, went to his closet, touched numerous items of clothing hanging in the closet before selecting a green shirt. She returned to the bathroom with the shirt, removed his old shirt which she said was wet, and helped him into the clean shirt. Still wearing the same gloves, she took hold of the wheelchair and helped him out of the bathroom and wheeled him by his bed. She placed the bed linens, soiled pants and shirt into a clear plastic bag. At this time, she removed her contaminated gloves. She took the bagged clothing and linens out of the room. A minute or so later, NA #38 returned with a canister of Micro Kill Med Line disinfectant wipes, and placed the canister on his overbed table with no barrier beneath it. She wore disposable gloves, and pulled out a couple of sanitizing wipes and began wiping down his mattress. Upon inquiry, she said staff wipe down the mattresses with these wipes every time they change the sheets. She said she obtained this canister from the common use shower room. On 02/09/17 at 9:45 a.m., an interview was completed with the director of nursing (DON). We discussed the details of the incontinence care of the preceding evening. The DON said the aide should not have placed the washcloths in the resident's sink, or placed the wet washcloths on the sink, as these practices are unsanitary. She said the aide should have filled the resident's wash basin with clean water, and should have taken the basin into the bathroom with her. She agreed that organisms from the sink could have led to cross-contamination of the wash cloths. The DON agreed that the NA should have removed her dirty, contaminated gloves before leaving the bathroom and before touching any of the inanimate objects in the room, as this practice could pose the risk for cross-contamination of organisms into the environment. The DON agreed that the NA should not have brought the shower room canister of Micro Kill wipes into the resident's room, nor should she have placed the canister on the resident's table, as these practices could also contribute to cross-contamination of organisms into the resident's environment.",2020-09-01
3287,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,514,E,0,1,UXFJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the medical record was complete and accurate for Resident #1 and Resident #43 . The medical record did not contain any documentation concerning the change in legal representative for Resident #1 and the delay completing the required process for making such a change. Resident #43 had a bleeding alert on his physician's orders [REDACTED]. However, the order for [MEDICATION NAME] was discontinued over one (1) year ago. Resident identifiers: #1 and #43. Facility census: 58. Findings include : a) Resident #1 A review of Resident #1's medical record at 1:00 p.m. on 02/07/17 found the resident was admitted to the facility in 2005. Upon her admission to the facility the sheriff of the previous county she resided in was her guardian and conservator. This appointment was made in 1988. This guardian remained in effect until 07/15/16 at which time the[NAME]County Department of Health and Human Resources (DHHR) was appointed to serve at the residents Health Care Surrogate (HCS). This HCS remained in effect until 12/15/16 when the physician appointed Resident #1's cousin to serve as her HCS. Further review of the appointment of the cousin to the position of HCS found the resident was notified of this on 10/19/16 at 3:30 p.m. and was happy the her cousin would be making her decisions, and gestured that she loves her cousin. The form however was not signed by the attending physician until 12/15/16 which is the date the form went into effect. A HCS cannot go into effect until the date the physician signs the form. At 2:15 p.m. on 02/07/17, the facility's Licensed Social Worker (LSW) was interviewed. When asked how the resident's cousin came to be her HCS she stated, (Name of Resident) was under an old committee and the Sheriff of (Name of neighboring county) was making her medical and financial decisions. She indicated, she had started looking into this and did not realize the resident had any family. She stated, She had a committee for so long I did not think there was any family who was interested in making her medical decisions. She stated, In (MONTH) I had not seen (name of residents cousin) come to visit and did not become aware of her visits until (MONTH) (YEAR). She continued by saying, When I realized this cousin was coming to visit I spoke with her about becoming the resident's HCS and she agreed. She indicated, That was when I told (Name of Resident #1) that her cousin would be making her decisions for her. When asked why it took the physician two (2) months to sign the HCS she stated, I think the cousin and I kept missing each other when she would be into visit and it took me awhile to get her to sign the form. She indicated, It should be documented in the record what day she actually signed it. She was then asked to provide any notes from the record that explaining why the HCS was changed and/or why it took two (2) months from the time of resident notification to the physician signing the HCS. She indicated she would print them off the system and provide them. During an additional interview with the Social Worker at 2:40 p.m. on 02/07/2017 she confirmed, she had not entered any notes into the medical record. She stated, I must have forgot to write a note about any of this. b) Resident #43 Review of Resident #43's medical records on 02/08/17 at 1:15 p.m., found on the physician orders [REDACTED]. Further review of Resident #43's physician orders [REDACTED]. Interview with the DON on 02/08/17 at 1:45 p.m. confirmed the alert should have been removed after the [MEDICATION NAME] had been discontinued on 10/28/15.",2020-09-01
3288,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,520,F,0,1,UXFJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, review of water temperatures, staff interviews, and resident interviews, the quality assessment and assurance (QA & A) committee failed to identify and address quality deficiencies of which they were aware, or should have been aware. Deficient practices related to quality of life and quality of care were identified during the Quality Indicator Survey (QIS). The issues identified were results of systemic breakdowns in the manner in which the facility staff administered care and services to their residents. The issues had been ongoing for multiple months giving the QA & A committee ample time to identify and correct the deficient practices prior to its QIS survey which began on 02/06/17 and ended on 02/09/17. Quality of Life: The facility failed to maintain an environment which was clean, sanitary, and in good repair. Walls were marred and scratched, door frames and doors were rusted, floor tile was cracked, resident equipment was dirty and/or rusted, shower room floors were dirty, blinds were bent and broken, and facility floors in resident rooms and common areas were dirty. Quality of Care: The facility was notified on 02/08/17 at 6:22 p.m. of an immediate jeopardy (IJ) situation due to elevated water temperatures. It was noted the facility had been monitoring the water temperature and on 02/07/17 had the hot water shut off to room [ROOM NUMBER] and 105 for a period of time. However, on 02/08/17 at 2:21 p.m. the hot water temperature in room [ROOM NUMBER] was 144 degrees and was not turned off, not had the hot water been turned off to the front public restrooms which had also had elevated temperatures. Furthermore, the hot water tank and the mixing valve in question serviced the entire first floor of the facility and no other actions had been taken by the facility to ensure resident safety until the problem is resolved. These deficient practices had to potential to affect all residents residing in the facility. Facility Census:58 Findings include: a) The facility failed to ensure the resident environment over which it had control, was as free from accident hazards as possible. Water temperature measurements taken between 2:30 p.m. and 3:00 p.m. on 02/06/17 with the maintenance department using the facility's laser thermometer found a water temperature of 130 degrees Fahrenheit (F) at a resident's hand sink. Throughout the survey, measurements of water temperatures found significant fluctuations of water temperatures at different times of the day, and in different rooms at the same time of the day. Additionally, the water temperature would peak, and then drop drastically after the water ran for several minutes. The facility identified fifteen (15) residents who had cognitive impairments that were able to use the hand sinks independently for handwashing and other activities; placing them at risk for serious harm because of the elevated water temperatures. Resident identifiers: #55, #44, #50, #42, #98, #2, 35, #15, #29, #22, #66, #11, #78, #95 and #81. Additionally, review of the facility's water temperature logs found water temperatures were often in excess of 120 degrees F for months without evidence of adjustments or evidence of the effectiveness of the adjustments. This was determined to constitute an immediate jeopardy (IJ) to the health and well-being to more than a limited number of the facility's residents. At 6:22 p.m. on 02/08/17, the Nursing Home Administrator (NHA), the Director of Nursing (DON), and the Maintenance Supervisor were notified of the IJ due to the elevated water temperatures. The facility provided an acceptable plan of correction (P[NAME]) at 9:00 p.m. on 02/08/17. After verifying the hot water supply to all resident areas was off, the survey team determined the immediacy of the deficient practice was abated at 9:00 p.m. on 02/08/17. 1. Measurement of Water Temperatures Water temperature measurements taken between 2:30 p.m. and 3:00 p.m. on 02/06/17 with a member of the maintenance department using the facility's laser thermometer found the water temperatures in the resident hands sinks in three (3) resident rooms were: -- room [ROOM NUMBER] the water temperature was 130 degrees Fahrenheit (F) -- room [ROOM NUMBER] the water temperature was 103 degrees F -- room [ROOM NUMBER] the water temperature was 109 degrees F After consulting with the Office of Health Facility Licensure and Certification's (OHFLAC) Life Safety Program Manager on 02/06/17 at 4:00 p.m. concerning the use of a laser thermometer, the facility's maintenance department was asked to use a thermometer that could be immersed in the water in order to obtain a more accurate water temperature. Between 4:15 p.m. and 4:40 p.m. on 02/06/17, water temperature measurements taken with the maintenance department using a submersible thermometer found the following water temperatures in the residents' hand sinks: -- room [ROOM NUMBER] the water temperature was 127.9 degrees Fahrenheit (F) -- room [ROOM NUMBER] the water temperature was 115.9 degrees F -- room [ROOM NUMBER] the water temperature was 112.9 degrees On 02/07/17, the facility provided a list of water temperatures randomly obtained by maintenance of hand sinks on first floor. The water temperatures ranged from 83.1 to 100.6 degrees F. On 02/08/17 at approximately 2:25 p.m., when washing her hands in the public restroom (room [ROOM NUMBER]), Surveyor noted steam rising from the water. The surveyor could not comfortably hold her hands under the water because it was too hot. Upon request at that time, maintenance obtained water temperatures at residents' hand sinks. On 02/08/17 the water temperatures taken between 2:30 p.m. and 3:00 p.m., found the following: -- room [ROOM NUMBER] the water temperature was 144 degrees F. (According to CMS Guidance to Surveyors, a 3rd degree burn can occur in 15 seconds when the water temperature is 133 degrees F.) -- room [ROOM NUMBER] the water temperature was 120.6 degrees F -- Shower room (Bathing 136) the water temperature was 111 degrees F -- Public bathroom (room [ROOM NUMBER]) the water temperature was 105.1 degrees F -- Public bathroom (room [ROOM NUMBER]) the water temperature was 107.3 degrees F Throughout the survey, significant fluctuations of water temperatures were noted at different times of the day and in different rooms at the same time of the day. The water temperature also decreased if allowed to run for several minutes. The temperature of the water would peak for a few minutes, and then drop drastically. At 4:21 p.m. on 02/08/17, the maintenance director obtained the following temperature: -- Public bathroom (room [ROOM NUMBER]) the water temperature was 119.2 degrees F. At 5:32 p.m. on 02/08/17, maintenance obtained the following temperature: -- Public bathroom (room [ROOM NUMBER]) the water temperature was 125.9 degrees F. On 02/07/17, the facility consulted a contractor who found the mixing valve needed replaced, but would not arrive until the morning of 02/09/17. The facility monitored the water temperatures and on 02/07/17, had the hot water shut off to rooms [ROOM NUMBERS] for a period. However, on 02/08/17 at 2:21 p.m. the hot water remained on in room [ROOM NUMBER] and was found to be 144 degrees F. Additionally, the hot water remained on in the front public restrooms which had also had elevated temperatures. Furthermore, the hot water tank and the mixing valve in question serviced the entire first floor of the facility and no other actions were taken by the facility to ensure resident safety until the problem was resolved. 2. CMS Guidance to Surveyors According to Table 1 in the Guidance to Surveyors related to comfortable/safe water temperatures, found in Appendix PP of the CMS State Operations Manual, a third degree burn can occur at: --120 degrees F with an exposure time of five (5) minutes, --124 degrees F with an exposure time of three (3) minutes --127 degrees F with an exposure time of one (1) minute --133 degrees F with exposure time of 15 seconds, and --140 degrees F with an exposure time of 5 seconds, noting [MEDICAL CONDITION] occur even at water temperatures below these levels depending on the exposed individual's condition and length of exposure. 3. Review of Six (6) Months of Water Temperatures At 6:00 p.m. on 02/08/17, review of the facility's Daily Check Form for the previous six (6) months, revealed the following notable high water temperatures: -- 06/17/16 - room [ROOM NUMBER] - water temperature - 121 F -- 06/20/16 - room [ROOM NUMBER] - water temperature - 123 F -- 06/22/16 - room [ROOM NUMBER] - water temperature - 123 F -- 06/23/16 - room [ROOM NUMBER] - water temperature - 121 F -- 06/27/16 - room [ROOM NUMBER] - water temperature - 121 F -- 06/28/16 - room [ROOM NUMBER] - water temperature - 121 F -- 07/01/16 - room [ROOM NUMBER] - water temperature - 121 F -- 07/05/16 - room [ROOM NUMBER] - water temperature - 126 F -- 07/06/16 - room [ROOM NUMBER] - water temperature - 121 F -- 07/07/16 - room [ROOM NUMBER] - water temperature - 121.2 F -- 07/08/16 - room [ROOM NUMBER] - water temperature - 121.6 F -- 07/12/16 - room [ROOM NUMBER] - water temperature - 122 F -- 07/18/16 - room [ROOM NUMBER] - water temperature - 121 F -- 07/19/16 - room [ROOM NUMBER] - water temperature - 121 F -- 07/20/16 - room [ROOM NUMBER] - water temperature - 132.8 F -- 07/20/16 - room [ROOM NUMBER] - water temperature - 129.9 F -- 07/20/16 - room [ROOM NUMBER] - water temperature - 121.6 F -- 07/22/16 - room [ROOM NUMBER] - water temperature - 126.2 F -- 07/25/16 - room [ROOM NUMBER] - water temperature - 121 F -- 07/27/16 - room [ROOM NUMBER] - water temperature - 120.3 F -- 08/01/16 - room [ROOM NUMBER] - water temperature - 121.6 F -- 08/01/16 - room [ROOM NUMBER] - water temperature - 121.6 F -- 08/02/16 - room [ROOM NUMBER] - water temperature - 120.1 F -- 08/04/16 - room [ROOM NUMBER] - water temperature - 121.1 F -- 08/05/16 - room [ROOM NUMBER] - water temperature - 121.3 F -- 08/18/16 - room [ROOM NUMBER] - water temperature - 139.1 F -- 08/19/16 - room [ROOM NUMBER] - water temperature - 123.3 F -- 08/22/16 - room [ROOM NUMBER] - water temperature - 128.2 F -- 08/23/16 - room [ROOM NUMBER] - water temperature - 126.4 F -- 08/24/16 - room [ROOM NUMBER] - water temperature - 121.1 F -- 08/26/16 - room [ROOM NUMBER] - water temperature - 121.3 F -- 08/30/16 - room [ROOM NUMBER] - water temperature - 121.4 F -- 08/31/16 - room [ROOM NUMBER] - water temperature - 123.1 F -- 08/30/16 - room [ROOM NUMBER] - water temperature - 120.3 F -- 09/01/16 - room [ROOM NUMBER] - water temperature - 123.6 F -- 09/02/16 - room [ROOM NUMBER] - water temperature - 121.7 F -- 09/06/16 - room [ROOM NUMBER] - water temperature - 121.3 F -- 09/07/16- room [ROOM NUMBER]-water temperature - 123.6 F -- 09/07/16 - Shower Room A - water temperature - 120.3 F -- 09/08/16 - room [ROOM NUMBER] - water temperature - 121.4 F -- 09/09/16 - room [ROOM NUMBER] - water temperature - 134.4 F -- 09/09/16 - room [ROOM NUMBER] - water temperature - 123.5 F -- 09/12/16 - room [ROOM NUMBER] - water temperature - 138.6 F -- 09/12/16 - room [ROOM NUMBER] - water temperature - 122.3 F -- 09/13/16 - room [ROOM NUMBER] - water temperature - 121.3 F -- 09/13/16 - room [ROOM NUMBER] - water temperature - 122.6 F -- 09/14/16 - room [ROOM NUMBER] - water temperature - 120.1 F -- 09/15/16 - room [ROOM NUMBER] - water temperature - 120.2 F -- 09/15/16 - room [ROOM NUMBER] - water temperature - 121.5 F -- 09/19/16 - room [ROOM NUMBER] - water temperature - 122.5 F -- 09/19/16 - room [ROOM NUMBER] - water temperature - 123 F -- 09/20/16 - room [ROOM NUMBER] - water temperature - 130.8 F -- 09/20/16 - room [ROOM NUMBER] - water temperature - 123.2 F -- 09/22/16 - room [ROOM NUMBER] - water temperature - 138.5 F -- 09/22/16 - room [ROOM NUMBER] - water temperature - 133.4 F -- 09/22/16 - room [ROOM NUMBER] - water temperature - 125.2 F -- 09/22/16 - room [ROOM NUMBER] - water temperature - 124.7 F -- 09/23/16 - room [ROOM NUMBER] - water temperature - 133.7 F -- 09/26/16 - room [ROOM NUMBER] - water temperature - 137.4 F -- 09/26/16 - room [ROOM NUMBER] - water temperature - 129.4 F -- 09/27/16 - room [ROOM NUMBER] - water temperature - 130.9 F -- 09/28/16 - room [ROOM NUMBER] - water temperature - 136.3 F -- 09/29/16 - room [ROOM NUMBER] - water temperature - 123.6 F -- 09/30/16 - room [ROOM NUMBER] - water temperature - 131.3 F -- 10/04/16 - room [ROOM NUMBER] - water temperature - 125.4 F -- 10/06/16 - room [ROOM NUMBER] - water temperature - 122.4 F -- 10/07/16 - room [ROOM NUMBER] - water temperature - 136.5 F -- 10/10/16 - room [ROOM NUMBER] - water temperature - 131.9 F -- 10/11/16 - room [ROOM NUMBER] - water temperature - 137.8 F -- 10/11/16 - room [ROOM NUMBER] - water temperature - 120.3 F -- 10/13/16 - room [ROOM NUMBER] - water temperature - 126.9 F -- 10/14/16 - room [ROOM NUMBER] - water temperature - 134.0 F -- 10/14/16 - room [ROOM NUMBER] - water temperature - 127.5 F -- 10/17/16 - room [ROOM NUMBER] - water temperature - 135.8 F -- 10/18/16 - room [ROOM NUMBER] - water temperature - 129.2 F -- 10/18/16 - room [ROOM NUMBER] - water temperature - 120.5 F -- 10/21/16 - room [ROOM NUMBER] - water temperature - 121.9 F -- 10/24/16 - room [ROOM NUMBER] - water temperature - 130.8 F -- 10/24/16 - room [ROOM NUMBER] - water temperature - 121.8 F -- 10/25/16 - room [ROOM NUMBER] - water temperature - 127.4 F -- 10/26/16 - room [ROOM NUMBER] - water temperature - 128.5 F -- 10/27/16 - room [ROOM NUMBER] - water temperature - 123.7 F -- 11/01/16 - room [ROOM NUMBER] - water temperature - 122.9 F (After (MONTH) (YEAR), water temperatures were measured using the laser thermometer. Because the laser thermometer can be affected by a number of variables, the temperatures were questionable.) The facility had hot water temperatures in excess of 120 degrees F weekly since 06/17/16. On 02/09/17 at 11:15 a.m., when asked about the elevated temperatures recorded on the log, the administrator said, The maintenance department supervisor reviews those water temperatures daily and adjusts the temperature as needed. The facility provided no evidence to support the water temperatures were adjusted or that water temperatures were retaken after adjustments to ensure the adjustments were effective. The facility provided no other information to indicate other measures were implemented in an effort to ensure safe water temperatures despite the continuing problem. The facility identified fifteen (15) residents who had cognitive impairments that were able to use the hand sinks independently for handwashing and other activities; placing them at risk for serious harm because of the elevated water temperatures. The identified residents were #55, #44, #50, #42, #98, #2, 35, #15, #29, #22, #66, #11, #78, #95, and #81. These findings were determined to constitute an immediate jeopardy (IJ) to the health and well-being of more than a limited number of the facility's residents. At 6:22 p.m. on 02/08/17, the Nursing Home Administrator (NHA), the Director of Nursing (DON), and the Maintenance Supervisor were notified of the IJ due to the elevated water temperatures. The facility provided an acceptable plan of correction (P[NAME]) at 9:00 p.m. on 02/08/17. After verifying the hot water supply to all resident areas was off, the survey team determined the immediacy of the deficient practice was abated at 9:00 p.m. on 02/08/17. b) Environment 1. Dining room a. Observation of the main dining room (used for food service and activities) with the Housekeeper/Laundry/Maintenance supervisor, Employee #73, began at 8:10 a.m. on 02/09/17. The following items were found: -- Debris behind the door leading into the dining room. -- The floor around the baseboards was dirty. -- The baseboards were splashed with debris. -- The wall, above the heater had cracked plaster. -- The door frames leading into the dining room were rusted and scraped. -- Trash, straws, napkins and paper products were littered behind the trash can. -- The floors were dirty in the alcove beside the ice machine. -- The floor had the remains of strips of tape which appeared to once be an outline of a shuffle board. --The tape had collected hair, lint and other debris. Employee #73 said the tape could be scraped from the floor, it just needed cleaned. -- The ice cart was splashed with dirt and debris. 2. Main Dinning Room On 02/06/17 at 11:40 a.m., observations of lunch in the main dining room noted the dining room floor soiled with small particles, remains of brown liquid spills and colored liquid spills, and some partially detached adhesive material. On 02/06/217 at 4:42 p.m., residents were seated for dinner at tables in the main dining room. The dining room floor was soiled with small particles, remains of brown liquid spills and colored liquid spills, and some partially detached adhesive material. On 02/07/17 at 7:51 a.m., observations of residents served breakfast in the main dining room noted the dining room floor soiled with small particles, remains of brown liquid spills and colored liquid spills, and some partially detached adhesive material. On 02/07/17 at 9:27 a.m., Staff #84 was mopping the main dining room floor. Staff #84 stated the floor should be mopped three times a day, and it had a lot of coffee and juice stains, and wheelchair marks. On 02/07/17 at 9:31 a.m., Staff #94 stated the main dining room floor es supposed to be cleaned after every meal. 3. Resident rooms Observations during the tour of the facility with the administrator began at 3:20 p.m. on 02/08/17. The following observations were made: -- room [ROOM NUMBER] - The light beside bed A had a cotton cord used to turn on the light over the bed was soiled. The floor tile was cracked in the corner beside bed-[NAME] -- room [ROOM NUMBER] - The plaster was missing at the corner of the closet. The corner behind the entrance door was littered with cob webs and dirt and debris. A wash pan and brief were found on the closet floor. The tile was stained around the commode. The plaster was cracked beside the toilet. Debris was found in the heater. -- room [ROOM NUMBER] - The floor tile of the room was cracked. The crack extended out the doorway and into the main hallway. The door facing, leading into the bathroom was rusted. The tile was chipped with holes beside bed-[NAME] -- room [ROOM NUMBER] - The wall was patched, but not painted under the bed-B window. Debris and dirt were found along the cove molding in the bathroom. -- room [ROOM NUMBER] - The wall beside the closet was marred and scratched. The over-the-bed table was rusted. The veneer on the table top was chipped and cracked. The wooden drawers beside the sink were scratched, marred, and water marked. The door facing, leading into the room was rusted. Upon entrance to the room the bed sheets were soiled with a runny brown/yellow substance on the top sheet of the bed. The administrator changed the sheets on the bed when found. -- room [ROOM NUMBER] - The over-bed table for bed A had rusted legs and splashes of dried debris on the legs. Debris was present along the baseboard in the bathroom. The tile under the sink was cracked. The wall beside the sink was marred and scratched. During the tour, the resident in the bed-B, said the crank at the foot of the bed was missing, making it impossible to raise the head of her bed. The administrator said she would get someone to fix the bed. (Observation found the bed cranking handle was missing from the bed.) There was also a round jagged hole in the resident's footboard at least the size of a fifty-cent piece. The door frame leading into the bathroom was rusted. -- room [ROOM NUMBER] - The walls were scratched with drywall exposed. The dresser drawers beside the sink were scratched and marred with chunks of wood missing. The sink top was discolored and had places of the finish missing. The tile beside the sink was broken. The cove molding and the area on the floor around the cove molding was dirty and splashed with dried debris. The cove molding in the bathroom was dirty around the floor of the bathroom. Debris was able to be cleaned from the cove molding with a piece of wet toilet paper. -- room [ROOM NUMBER] - Debris was found in the wall unit heating and air conditioner. The floor was dirty. The bathroom walls were scraped and marred with missing plaster. -- room [ROOM NUMBER] - A large head of a screw was sticking up out of the floor beside the sink with a broken piece of metal remaining under the screw. The administrator said this was a broken doorstop. The finish on the drywall in the bathroom (above the cove molding behind the toilet) was missing. At 8:10 a.m., on 02/09/17, the remaining tour of the facility resident rooms was conducted with Housekeeping/Laundry/ Maintenance Supervisor #73. -- room [ROOM NUMBER] - The sink was stained and the water from the facet was dripping. The dresser beside the sink was water marked, with the varnish missing, scraped, and marred. The finish on the countertop housing the sink was stained and the finish missing. -- room [ROOM NUMBER] - The door facings were rusted. The plaster beside the closet was marred and scraped. The over-the-bed table was dirty with debris splashed on the legs of the table. -- room [ROOM NUMBER] - The over-the-bed table at A-bed was rusted and dirty. -- room [ROOM NUMBER] - Observation found a dirty build up along the baseboards of the bathroom walls. The floor was dirty. The bed-A over-the-bed table, had legs which were rusted and dirty. -- room [ROOM NUMBER] - The over-the-bed table was rusted. The walls, beside the closet were scratched and marred with missing plaster. -- room [ROOM NUMBER] - The facing of the entrance door was rusted. A strong urine odor was present in the room. The arms of the resident's wheelchair were cracked with rough edges. -- room [ROOM NUMBER] - Observation found pieces of the tile under the sink were missing. The drawers beside the sink were marred, scratched and water marked. The wall beside the sink was marred and scratched. -- room [ROOM NUMBER] - The wall behind bed-A was scraped and scratched. There were holes in the tile beside the sink. Dirt and debris were found in the corner behind the door leading into the hallway. 4. Long hall shower room During the initial tour of the facility, observation of the long hall bathroom at 10:45 a.m. on 02/06/17, found a brown stain that appeared to be feces, on the seat of a shower chair in the bathroom. The director of nursing (DON) was present during this observation. She said she would have staff clean the shower chair. 5. A-Shower room The tour of the facility with Housekeeping/Laundry/Maintenance Supervisor #73 which began at 8:10 a.m., on 02/09/17 found the following issues in the shower room: -- Just inside the door of the shower were several large spots of a dried brown substance. Employee #73 identified the substance as feces. -- Two (2) pairs of gloves, turned inside out and rolled up, were in the sink. -- Several gloves littered the floor of the shower room. -- A dried brown substance was present on a shower chair. -- A comb and a bottle of bath wash were laying on the sink with no name to identify the owner. -- During Stage 1 of the Quality Indicator Survey a confidential interview with a resident found she did not want to take showers in the shower rooms on this floor because of the filth. She said the shower room should be called the, poop room, because everyone just pooped in there. She said it would be on the walls and in the floor of the shower room. She said she only showers in the upstairs shower room, Where it is cleaner. Employee #73 verified no showers had been given in this shower room since the issues with the hot water identified on the evening of 02/08/17. She said, All showers are being given on the upper floor of the facility not affected by the mixing valve. 6. Day room beside the nurses' station Four (4) of the five (5) blinds covering the windows had slats that were broken and bent. The exit door was rusted and cracked leaving exposed jagged edges of metal. There was dirt and debris buildup along the baseboards of the room. 7. room [ROOM NUMBER] At 11:15 a.m. on 02/09/17, observation of the grab bar beside the toilet was made with Employee #73. With a slight touch of the hand, the grab bar was found to move away from the wall. c) Interview Interview with Nursing Home Administrator (NHA) and Director of Nursing (DON) on 02/09/17 at 2:03 p.m., found the water temperatures were never taken to the QA&A committee meetings and the facility had addressed the environmental issues and had even hired a outside housekeeping consultant.",2020-09-01
3289,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,550,D,0,1,NWDF11,"Based on observation and staff interview, the facility failed to ensure Resident #32 was treated with dignity and respect. Nurse Aide #5 (NA), turned her back to the resident and made grumbling sounds and moved shoulders in a rotating motion twice. This was true for one (1) of sixteen (16) residents reviewed for dignity and respect. Resident identifier: #32. Facility census: 46. Findings included: a) Resident #32 An observation on 04/02/18 at 11:30 AM revealed Resident #32 requested a wet paper towel to wash her hands prior to eating her meal from NA #5. NA #5 turned her back on Resident #5 and made a Blaha sound while moving her shoulders in a rotating motion. Resident #32 asked NA #5 for additional paper towels to dry her hands. NA #5 again with back turned from this resident, made the Blaha sound and made rotating motions with her shoulders. Resident #32, who was hard of hearing, did not hear or see NA #5. During an interview on 04/02/18 at 1:59 PM, the Director of Nursing agreed NA #5's actions were disrespectful to Resident #32.",2020-09-01
3290,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,558,E,0,1,NWDF11,"Based on observation and staff interview, the facility failed to provide services with reasonable accommodations for residents. A bathroom in the hallway near the activity room was available for resident use without a safety call light in working condition. This practice had the potential to affect more than a limited number of residents. Facility census: 46. Findings included: a) Observations on 04/04/18 at 10:50 AM, noted a resident using the bathroom near the activity room on the first floor. Observation of this bathroom found no pull string attached to the alarm which would alert staff to provide care if needed. At 3:33 PM on 04/04/18 Maintenance Staff #31 explained the bathroom was for staff and visitors, but was told not to disallow residents to use the bathroom. On 04/04/18 at 3:35 PM, the maintenance supervisor verbalized the residents did use that bathroom. The switch in which a pull string could be attached was tested by the maintenance supervisor and would not work. The bathroom door knob was replaced with a key entry to prevent residents from using the bathroom.",2020-09-01
3291,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,561,D,0,1,NWDF11,"Based on observations, resident interview, staff interview, and record review, the facility failed to provide a resident with her diet of choice. This is true for one (1) of sixteen (16) residents reviewed. Resident identifier: #1. Facility census: 46. Findings include: a) Resident #1 During the initial tour on 04/02/18 at 11:55 AM, observation of Resident #1's lunch tray found it did not include cranberry juice. The tray ticket noted cranberry juice should be on the tray. Resident #1 stated she requested cranberry juice, but I don't often get it. Observation of the lunch tray on 04/03/18 at 12:15 PM, again revealed there was no cranberry juice on the resident's tray. Resident commented, I did have it Sunday. Again on 04/04/18 at 11:45 AM, Resident #1's lunch tray had no cranberry juice. The tray ticket also listed coffee as a request. Resident #1 stated she also did not get coffee on this date, and went on to state she does not make the facility aware of food that is not on her tray unless she does not have chicken noodle soup. On 04/04/18 at 3:10 PM, the dietary manager explained the trays had been checked by dietary staff as food was put on the trays and the cranberry juice should have been on the resident's lunch tray.",2020-09-01
3292,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,578,D,0,1,NWDF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, electronic record review, hard copy (paper) medical record review, and staff interview, the facility failed to ensure a resident's code status was accurate, available, consistent, and communicated to staff. Staff were unable to locate Resident #18 code status in the electronic medical record. In addition, staff found conflicting code statuses when reviewing the hard copy in the resident's medical record. This failed practice was true for one (1) 16 residents reviewed for code status. Resident identifier: #18. Facility census: 46. Findings included: a) Resident #18 On 04/02/18 at 3:00 PM, a review of the electronic medical record (EMR) for Resident #18 revealed a DO NOT RESUSCITATE (DNR) order. An additional review of the paper medical record on 04/03/18 found conflicting orders for Resident #18's code status. The hard copy medical record was labeled to read FULL CODE. Continuing review of the both the EMR and hard copy medical record found the following: --State of West Virginia Medical Power of Attorney (MPOA) stated FULL CODE dated 08/14/1998 --the Physician order [REDACTED]. --the Face Sheet dated admitted : 08/27/13 (latest return) and 06/01/12 Current as a DNR; --admission orders [REDACTED] --physician's orders [REDACTED]. --physician's orders [REDACTED]. --admission orders [REDACTED] --Advanced Directives and code Status Report dated 4/2/18 stated DNR. During an interview on 04/04/18 at 2:00 PM, Nurse Aides (NAs) #46 and #84, and Licensed Practical Nurse (LPN) #72 were asked to demonstrate how to find a resident code status. NAs #46 and #84, and LPN #72, stated that staff were not informed of the code status during shift change, but were sure it was in the computer in the hallway. After searching for about 15 minutes, the NAs and LPN had to be shown were to find a resident's code status on the computer system. When asked to show the code status for Resident #18, they pointed to the screen for Resident #18 that showed DNR. During an interview on 04/04/18 at 2:40 PM, when asked how she knew the code status of a resident. LPN replied, We don't exchange that in report unless there was a change in status because they all know their residents. When asked to show the code status for Resident #18, LPN #72 pointed to the computer screen which displayed DNR. On 04/04/18 at 3:20 PM, Registered Nurse (RN) #44 looked on the hard copy medical record for Resident #18 and stated that she was a full code. Further review of the hard copy medical record with RN #44 found evidence of both DNR and FULL CODE status. RN #44 looked on the desktop computer and found the code status for Resident #18 was DNR. During an interview on 04/04/18 at 4:00 PM, the Director of Nursing (DoN) stated Social Worker (SW) #3 had found a POST form that the Resident #18 signed in 2004 requesting a to be a full code, but the MPOA had changed the code status to a DNR. DoN stated that she felt like the MPOA changed the code status without the consent of Resident #18. The DoN stated that she was not aware that the chart had conflicting code status orders and that the electronic chart code status was incorrect. The DON agreed this was confusing for the staff and the charts both electronic and the hard copy were wrong.",2020-09-01
3293,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,584,E,0,1,NWDF11,"Based on observation, resident interview, and staff interview, the facility failed to maintain a comfortable and homelike environment for three (3) of sixteen (16) sampled residents. There were holes in the fitted sheet on Resident #21's bed. Residents #32 and #19 felt the water temperature during showers was too cool. Resident identifiers: #32, #19, and #21. Facility census: 46. Findings included: a) Resident #21 On 04/04/18 at 4:46 PM, an observation of the fitted sheet on Resident #21's bed revealed the sheet had holes. After showing the sheet to Nurse Aide (NA) #46 and NA #16, they changed the sheet. On 04/04/18 at 5:03 PM, an observation with Licensed Practical Nurse (LPN) #72 revealed the sheet NA #46 and NA #16 put on the bed also had holes. LPN #72 said the facility expected staff to discard linens with holes. b) Resident #19 On 04/02/18 at 4:02 PM, an interview with Resident #19 revealed she often got a shower where the water was too cold, and there did not ever seem be enough hot water. The resident said a nurse aid (could not remember the name) told her the maintenance said she was taking a shower at the wrong time of day because the kitchen used the water for dishes. The resident said the ombudsman even came into the facility and met with the administrator about the cold showers and other issues. When asked about the result of the meeting, the resident said, The administrator said that it takes too long for me to take a shower. I now have a designated time to take a shower, but sometimes the water still gets cold. c) Resident #32 During an interview on 04/02/18 at 11:34 AM, Resident #32 stated while getting a shower the water was too cold. On 04/02/18 at 01:40 PM, in Shower Room A, Nursing Aide (NA) #54 was assisting with checking water temperatures. NA #54 said, It takes a while for the water to heat up. After running the shower for 10 minutes, the water temperature for the left shower reached 96 degrees Fahrenheit (F) and the shower on the right reached 88 degrees F. On 04/02/18 at 1:55 PM, the Director of Nursing (DoN) was informed of the shower water temperatures in Shower Room [NAME] On 04/03/18 at 3:00 PM, in the presence of another surveyor, Life Safety surveyors, and the Maintenance Director, the water temperature in the left shower in Shower Room B was 88 degrees and 78 degrees F in the right shower after running the water for seven (7) minutes.",2020-09-01
3294,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,623,D,0,1,NWDF11,"**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) resident who was discharged to the community received a discharge notice. Resident #40 left the faciity on therapeutic leave and did not return. The facility discharged him, but did not ensure he received a notice. This affected one (1) of two (2) residents reviewed for discharge notices. Resident identifier: #40. Facility census: 46. Findings included: a) Resident #40 Medical record review revealed Resident #40 left the faciity on [DATE]. A progress note dated 02/17/18 at 1:49 PM stated, Late entry for 9:30 am. Resident presents to nurses station requesting phone book or a number for a taxi. When questions he stated he wanted to go to his cousins house. daughter Notified and stated that cousin takes from her father. Resident does have capacity and advised daughter of this. Dr. (name) gave verbal order allowing resident to take therapeutic leave. At 1:15 pm resident observed walking out of back door in facility with a friend. This nurse advised him of need to sign out. Resident stated 'I will be back some time tomorrow.' I asked him to return in the building and allow me to prep some medications for him to take with him. He stated 'I have medication at home.' This nurse unable to coerce resident to sign out or take medications with him. A note dated 02/20/18 at 9:06 AM stated, resident remains oof (out of facility). A note dated 02/20/18 at 7:53 AM stated, SW (social worker) contacted APS (adult protective services) centralized intake hotline to report concerns related to the resident leaving the facility and not returning. Although the resident is alert and capacitated, he is elderly and weak and his daughter had voiced some concerns that neighbors may have taken advantage of him There were no further progress notes reflecting the status of the resident. During an interview with the Social Worker (SW), on 04/04/08 at 9:48 AM, SW said Resident #40 left the faciity on [DATE] and did not return. The SW said the facility did not issue a discharge notice to this resident because he did not return, and he basically discharged himself. During this same time, the administrator said after 30 days had passed the facility considered the resident discharged . The administrator also felt the facility had no obligation to issue a discharge notice to the resident because he went on leave and did not return.",2020-09-01
3295,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,625,D,0,1,NWDF11,"**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 left the building on therapeutic leave received written notice of the facility's bed-hold policy. Although the resident did not return to the facility, there was no evidence the facility attempted to provide its bed-hold policy to the resident. This was found for one (1) of one (1) resident reviewed for notice of the facility's bed-hold policy when going on therapeutic leave. Resident identifier: #40. Facility census: 46. Findings included: a) Resident #40 Medical record review revealed Resident #40 left the faciity on [DATE]. A progress note dated 02/17/18 at 1:49 PM stated, Late entry for 9:30 am. Resident presents to nurses station requesting phone book or a number for a taxi. When questions he stated he wanted to go to his counsins house. daughter Notified and stated that cousin takes from her father. Resident does have capacity and advised daughter of this. Dr. (name) gave verbal order allowing resident to take therapeutic leave. At 1:15 pm resident observed walking out of back door in facility with a friend. This nurse advised him of need to sign out. Resident stated 'I will be back some time tomorrow.' I asked him to return in the building and allow me to prep some medications for him to take with him. He stated 'I have medication at home.' This nurse unable to coerce resident to sign out or take medications with him. A note dated 02/20/18 at 9:06 AM stated, resident remains oof (out of facility). A note dated 02/20/18 at 7:53 AM stated, SW (social worker) contacted APS (adult protective services) centralized intake hotline to report concerns related to the resident leaving the facility and not returning. Although the resident is alert and capacitated, he is elderly and weak and his daughter had voiced some concerns that neighbors may have taken advantage of him There were no further progress notes reflecting the status of the resident. During an interview with the Social Worker (SW) and the administrator on 04/04/08 at 5:30 PM the administrator said the resident did not receive a bed-hold notice. The administrator felt because of the manner in which the resident left, the facility had no obligation to provide a bed-hold notice. No further information was provided.",2020-09-01
3296,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,641,D,0,1,NWDF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation record review, staff interview, policy review the facility failed to ensure accurate assessments were completed for one (1) of 16 residents. Resident #40's assessment did not have an accurate assessment related to discharge. Resident identifier: #40. Facility census: 46. Findings include: a) Resident #40 Medical record review revealed Resident #40 left the faciity on [DATE]. A progress note dated 02/17/18 at 1:49 PM stated, Late entry for 9:30 am. Resident presents to nurses station requesting phone book or a number for a taxi. When questions he stated he wanted to go to his counsins house. daughter Notified and stated that cousin takes from her father. Resident does have capacity and advised daught of this. Dr. (name) gave verbal order allowing resident to take therapeutic leave. At 1:15 pm resident observed walking out of back door in facility with a friend. This nurse advised him of need to sign out. Resident stated 'I will be back some time tomorrow.' I asked him to return in the building and allow me to prep some medicaitons for him to take with him. He stated 'I have medication at home.' This nurse unable to coerce resident to sign out or take medications with him. A note dated 02/20/18 at 9:06 AM stated resident remains oof (out of facility). A note dated 02/20/18 at 7:53 AM stated SW (social worker) contacted APS (adult protective services) centralized intake hotline to report concerns related to the resident leaving the facility and not returning. Although the resident is alert and capacitated, he is elderly and weak and his daughter had voiced some concerns that neighbors may have taken advantage of him There were no further progress notes reflecting the status of the resident. During an interview with the Social Worker (SW), on 04/04/08 at 9:48 AM, SW said Resident #40 left the faciity on [DATE] and did not return. The facility completed a prosepective payment system (PPS) 5 day Minimum Data Set (MDS) assessment for Resident #40 on 02/16/18. During an interview with Registered Nurse (RN) #43, on 04/04/18 at 9:07 AM, the RN said the facility had not completed a discharge assessment for Resident #40.",2020-09-01
3297,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,655,D,0,1,NWDF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop and implement an accurate baseline care plan for Resident #98. The resident's baseline care plan did not include fall risk or care for a wound on the foot, both present at the time of admission. This was true for one (1) of sixteen (16) records reviewed. Resident identifier: #98. Facility census: 46. Findings included: a) Resident #98 Medical records review revealed Resident #98 was admitted to the facility on [DATE]. Review of discharge summary from the hospital where Resident #98 was treated prior to being admitted to the facility, revealed the reason for admission to the hospital was a subtrochanteric fracture (a [MEDICAL CONDITION] bone near the hip) of left hip on 03/03/18. Review of the baseline care plan, with a date of 03/16/18, was absent of any evidence Resident #98 had a risk for falls. physician's orders [REDACTED]. Review of nursing admission assessment with a date of 03/17/18 revealed Resident #98, .was admitted to (initials) Nursing after sustaining a fall in previous nursing home facility. The fall evaluation completed on admission also revealed a high fall risk. Fall risk was not included in the base line care plan. The nursing assessment dated [DATE] identified Resident #98 had a, blister like area on the left heel that has a protective dressing intact. The baseline care plan with a date of 03/16/18 did not include actual skin breakdown or treatment for [REDACTED]. Record review revealed a physician's orders [REDACTED]. The left heel wound was described as an unstageable area 4.5 centimeters (cm) by 4.0 cm with eschar (a collection of dead tissue within the wound bed indicating full thickness tissue loss). On 04/04/18 at 10:30 AM, the DON agreed, the resident's risk of falls and the wound observation on the nursing admission were not identified on the baseline care plan.",2020-09-01
3298,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,656,D,0,1,NWDF11,"Based on record review and staff interview, the facility failed to develop a care plan for care of an indwelling catheter when Resident #18 returned to the facility with an indwelling catheter. This affected one (1) of sixteen (16) from the sample. Facility census: 46. Finding included: a) Resident #18 On 04/02/18 a record review revealed Resident #18 returned to the facility from a local hospital with an indwelling Foley catheter on 03/30/18. The indwelling catheter was not care planned at that time. On review of records on 04/03/18 a care plan was on record showed a date created on 04/03/18. The indwelling catheter was not care planned for four (4 ) days. On 04/02/18 at 4:30 PM, the Director of Nursing (DoN) was asked for a paper copy of the care plan. On 04/03/18 at 4:45 PM, DoN the DoN provided a paper copy of the resident's care plan. At that time, the DoN was informed no care plan was developed for the indwelling catheter until four (4) days after Resident #18 returned from the hospital.",2020-09-01
3299,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,677,D,0,1,NWDF11,"Based on observation and staff interview, the facility failed to provide care and services to maintain good grooming/personal hygiene to one (1) randomly observed resident. Resident #12's fingernails were long and jagged. Several of the resident's fingernails also had a black/brown substance underneath them. Resident identifier: #12. Facility census: 46. Findings included: a) Resident #12 On 04/04/18 at 5:13 PM, an observation of Resident #40's nails revealed they were long, jagged, and had a brown/black substance underneath them. Licensed Practical Nurse (LPN) #72 observed Resident #40's nails on 04/04/18 at 5:20 PM and said she would trim and clean them. On 04/05/18 at 8:12 AM LPN #72 said it took her several times of going back to the resident, but she did get them trimmed and cleaned. On 04/05/18 at 11:00 AM, the administrator and director of nursing said the resident was resistant to care. His care plan revealed he did not like to be shaved and would often wear dirty clothing. The minimum data set (MDS) completed on 01/15/18 reflected the resident needed extensive assistance with personal hygiene. A review of the progress notes revealed a note dated 02/13/18 by Registered Nurse (RN) #43. The note stated the resident allowed his nails trimmed without difficulty, but did not want them cleaned. No further notes showed follow up attempts to clean the resident's nails.",2020-09-01
3300,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,686,D,0,1,NWDF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, record review, and staff interview, the facility failed to identify and provide care related to Pressure Ulcers. Resident #18 was found to have six (6) pressure ulcers, some of which may have developed in-house. In addition, the facility failed to provide care for an unstageable pressure ulcer for Resident #98 for three (3) days. These failed practices were true for two (2) of four (4) residents reviewed for pressure ulcers. Resident identifiers: #18 and #98. Facility census: 46. Findings included: a) Resident #18 Review of the facility's policy titled, Wound Care, revised (MONTH) 2002, found it directed the following information should be recorded in the resident's medical record: - The type of wound care given. - The date and time the wound care was given. - The position in which the resident was placed. - The name and title of the individual performing the wound care. - Any changes in the resident's condition. - All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. - If the resident refused the treatment and the reason(s) why. Review of Resident #18's medical records found she was transferred to a local hospital on [DATE] and returned to the facility on [DATE] at 5:07 PM. Licensed Practical Nurse (LPN) #42's re-admission assessment stated that Resident #18 returned with a dressing to her inner and outer ankle and top of her left foot and bruising to both upper extremities. No evidence was found of pressure ulcers. During an interview, on 04/02/18 at 4:05 PM, LPN #39 stated that Resident #18 only had a Band-Aid to the second toe on the left foot and had no pressure ulcers. LPN #39 stated that Resident #18 was admitted on [DATE] and had no pressure ulcers in the past year. Registered Nurse (RN) #44 showed LPN #39 a nursing note stating that a pressure ulcer on the left heel 1/2018 was a deep tissue injury but had since healed. On 04/03/18 a review of the evidence from the Wound Assessment and Progress Review noted on 04/02/18 at 6:19 PM the following: - Unstageable Deep Tissue Injury (DTI) measuring 2 x 2 cm (centimeter) with eschar measuring 1.8 cm on the left heel. - Unstageable DTI measuring 1.7 x 2 cm on the right heel. - Stage II pressure ulcer measuring 2.4 x 2 cm on the sacrum. - Unstageable DTI measuring 2.4 x 2.2 cm on the left toe. Noted to be purple in color and was not blanchable. - Unstageable DTI measuring 1.2 x 1.5 cm on the right toe with eschar (a collection of dead tissue within the wound bed and indicates full thickness tissue loss) in the center. During an observation of wound care on 04/03/18 at 2:58 PM, by Licensed Practical Nurse (LPN) #39 for Resident #18 revealed there was a dressing of an ABD (absorbent dressing) pad, which was secured with gauze to the left heel. There was no dressing on the right foot. LPN #39 removed the dressing from the left heel which showed eschar with no drainage. No measurements were taken at that time. LPN #39 wiped the area of the left heel with moistened gauze, covered the heel with an ABD pad and wrapped it with gauze. The right heel did not have a dressing. LPN #39 wiped the right heel with moistened gauze and applied skin prep (a protective barrier). She proceeded to cover the right heel with an ABD pad and secure it with gauze. No care was provided to the toes on the left or right foot and/or the sacrum area. On 04/03/18 at 03:25 PM, Registered Nurse (RN/Wound Nurse) #36 came in the Resident's #18's room. RN #36 further explained that it was her opinion that Resident #18 developed those places on her (Resident #18) toes from the hospital and she (RN #36) just saw her (Resident #18) yesterday (04/02/18). During an interview on 04/04/18 at 11:02 AM, when asked how the pressure ulcer on the resident's left heel was staged and what tool(s) did she use, RN/Wound Nurse #36 stated that the wound on the left heel was a Deep Tissue Injury (DTI) because a wound cannot be staged when there was eschar. In addition, she stated that she did not have any tools to refer to, that she did not stage pressure ulcers, and she was not a doctor. RN/Wound Nurse #36 stated that she had only had the Wound Care Nurse position for two (2) weeks and had not had any training. (Note: The presence of eschar indicate a full thickness wound and would be considered an unstageable pressure ulcer due to eschar.) A review of the form titled Wound Assessment and Progress Review found the resident had a suspected deep tissue injury (SDTI) on the left heel on 01/11/18. On 02/28/18, 03/07/18, and 03/14/18, the documentation noted the SDTI was closed on each of these dates. When asked what closed meant, RN/Wound Nurse #36 stated there was a scab on the wound and she put closed because the nurse before her put closed. During an interview on 04/04/18 at 11:33 AM, RN #23 was asked about writing closed on the wound assessment and she said that the wound was closed meaning the wound was clear with no scabs or anything. During an interview on 04/05/18 at 9:08 AM with Resident #18s attending physician, he stated that he had not looked at Resident #18 feet and that's on him. He stated that he relied on the nurses' charting and notes at face value and failed to look at them (Resident #18's feet) himself. In addition, he agreed that the nursing documentation was not consistent or accurate. The attending physician's assessment dated [DATE] included, ASSESSMENT: Deep tissue injury to the left heel, suspected deep tissue injury to the right heel, blister to the right great toe, [DIAGNOSES REDACTED] to the left great toe, likely stage II pressure area on the second toe, and stage II pressure area on the lumbosacral area. During an interview on 04/05/18 at 10:26 AM, the DoN and Administrator agreed that the wounds for Resident #18 were never assessed until 04/02/18. On 04/05/18 at 4:30 PM, the DON was asked again for the report of a skin check for this resident prior to being transferred to the local hospital and the DoN reported that a skin check was not completed, and on readmission there was no evidence Resident #18 returned to the facility with pressure ulcers or unstageable DTIs. b) Resident #98 Review of the admission nursing assessment dated [DATE] revealed Resident #98 had a blister like area on the left heel that has a protective dressing intact. Record review revealed a physician's orders [REDACTED]. The left heel wound was described as an unstageable area 4.5 centimeters (cm) by 4.0 cm with eschar (a collection of dead tissue within the wound bed and indicates full thickness tissue loss). On 04/04/18 at 10:30 AM, the DON agreed the wound identified on 03/17/18 did not receive medical interventions until 03/19/18.",2020-09-01
3301,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,690,D,0,1,NWDF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, observation and staff interview, the facility failed to provide care in accordance with its policy and physician orders, regarding securing an indwelling catheter. A random observation of Resident #18 noted no device to secure the resident's catheter was in place. Resident identifier: #18. Facility census: 46. Findings included: a) Resident #18 Review of the facility's policy titled, Catheter Care, with a reviewed date of (MONTH) 207, found it included that a leg strap must be used to prevent accidental injury and/or removal. An observation of wound care for Resident #18 on 04/03/18 at 3:00 PM, found this resident had an indwelling urinary catheter (Foley catheter). Further observation revealed the catheter was not secured to prevent accidental removal or to reduce the risk of trauma. This was verified with Registered Nurse #44 and Licensed Practical Nurse #39, who agreed the resident should have a stabilization method for the catheter. The physician's orders [REDACTED].",2020-09-01
3302,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,692,D,0,1,NWDF11,"**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 therapeutic diets in accordance with physician orders [REDACTED].#25. Both residents received foods that were not of the correct consistency. This was true for two (2) of seven (7) residents reviewed for the care area of Nutrition/Hydration Status. This practice had the potential to affect a limited number of residents. Resident identifiers: #22 and #25. Facility census: 46 Findings included: a) Resident #22 Review of records revealed Resident #22 had a [MEDICAL CONDITION] (TBI), was a quadriplegic (one affected with partial or complete paralysis of both the arms and legs), had [MEDICAL CONDITION] (an inability to comprehend and formulate language because of damage to specific brain regions). Review of the resident's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 01/19/18, at 09:58 AM on 04/05/18, revealed the resident's Brief Interview for Mental Status (BIMS) score was zero (0), indicating the resident was severely cognitively impaired. The resident was assessed as totally dependent with all activities of daily living (ADLs). Medical record review found Resident #22 had a swallowing disorder that was demonstrated by loss of liquids and solids from his mouth when eating or drinking, and coughing or choking during meals. The resident required a mechanically altered diet that required change in the texture of food and liquids (pureed food and thickened liquids). The physician's orders [REDACTED]. Diet order puree with honey thickened liquids. Observations on 04/03/18 at 11:49 AM, revealed a bowl of thin tomato soup on the resident's lunch tray. Nurse aide (NA) #34 was preparing to feed the resident his lunch. According to the resident's lunch ticket, the resident was to receive pureed vegetable soup honey consistency. When asked what was in the bowl sitting in front of the resident, NA#34 said it looked like tomato soup. Speech Therapist #100 was at another table assisting a resident and turned quickly around and told NA#34, He (Resident #22) can't have that he will choke. Speech Therapist #100 came over and removed the bowl. Interview with Speech Therapist #100, on 04/05/18 at 10:27 AM, revealed she started working at the facility in (MONTH) (YEAR) and had worked with the resident. She said she mostly worked with the resident to help him with positioning because he was at risk for aspiration, and that he could not have anything thin because he was an aspiration risk and would get choked. Speech Therapist #100 said the resident would have hard fits of coughing and choking if not given at least honey thick consistency. Speech Therapist #100 said, The other day (on 04/03/18 at 11:49 AM) I heard you (this surveyor) ask the NA (NA#34) what was in the bowl. That's why when I turned around and I saw the bowl of tomato soup, I spoke out. It's too thin. He can't have that, he gets choked. b) Resident #25 Review of physician orders [REDACTED].#25 was prescribed a regular liberalized diet mechanical soft. On 04/04/18 at 11:50 AM, Resident #25's lunch meal ticket revealed the resident should have shredded lettuce. Observation of the meal tray revealed the lettuce was not shredded, but was in larger pieces. At 3:08 PM the dietary manager agreed the lettuce should be shredded.",2020-09-01
3303,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,710,D,0,1,NWDF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility Physician failed to evaluate and assess medical issues related to the residents skin status for one (1) of four (4) in the care area Pressure Ulcers. Resident identifier #18. Facility census 46. Findings included: a) Resident #18 Review of records revealed Resident #18 was readmitted on [DATE]. There was no mention or description of any pressure ulcers until 04/2/18. During an interview on 04/05/18 at 9:08 AM, Resident #18's physician he stated he had not looked at the pressure ulcers on Resident #18. He stated, that was on him, because he took the nurses' charting and notes at face value and failed to look at the resident himself. He also agreed that the nursing documentation was not consistent or accurate. The progress note he wrote on 04/04/18, reinforced his statement that he had not examined this resident himself.",2020-09-01
3304,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,726,D,0,1,NWDF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, staff interview, and family interview the facility failed to have nursing staff with the appropriate competencies and skills set to provide nursing and related services to attain or maintain the highest practicable physical mental and psychosocial well-being of each resident. Resident identifiers: #18 and #98. Facility census: 46. Findings included: a) Pressure ulcers Resident #18 was found to have six (6) pressure ulcers, some of which may have developed in-house. The facility failed to ensure Resident #18's pressure areas were assessed and when assessed, that they were assessed correctly and timely, and failed to implement timely interventions. The facility also failed to provide care for an unstageable pressure ulcer for Resident #98 for three (3) days. 1. Resident #18 Review of the facility's policy titled, Wound Care, revised (MONTH) 2002, found it directed the following information should be recorded in the resident's medical record: - The type of wound care given. - The date and time the wound care was given. - The position in which the resident was placed. - The name and title of the individual performing the wound care. - Any changes in the resident's condition. - All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. - If the resident refused the treatment and the reason(s) why. Review of Resident #18's medical records found she was transferred to a local hospital on [DATE] and returned to the facility on [DATE] at 5:07 PM. Licensed Practical Nurse (LPN) #42's re-admission assessment stated that Resident #18 returned with a dressing to her inner and outer ankle and top of her left foot and bruising to both upper extremities. No evidence was found of pressure ulcers. During an interview, on 04/02/18 at 4:05 PM, LPN #39 stated that Resident #18 only had a Band-Aid to the second toe on the left foot and had no pressure ulcers. LPN #39 stated that Resident #18 was admitted on [DATE] and had no pressure ulcers in the past year. Registered Nurse (RN) #44 showed LPN #39 a nursing note stating that a pressure ulcer on the left heel 1/2018 was a deep tissue injury but had since healed. On 04/03/18 a review of the evidence from the Wound Assessment and Progress Review noted on 04/02/18 at 6:19 PM the following: - Unstageable Deep Tissue Injury (DTI) measuring 2 x 2 cm (centimeter) with eschar measuring 1.8 cm on the left heel. - Unstageable DTI measuring 1.7 x 2 cm on the right heel. - Stage II pressure ulcer measuring 2.4 x 2 cm on the sacrum. - Unstageable DTI measuring 2.4 x 2.2 cm on the left toe. Noted to be purple in color and was not blanchable. - Unstageable DTI measuring 1.2 x 1.5 cm on the right toe with eschar (a collection of dead tissue within the wound bed and indicates full thickness tissue loss) in the center. During an observation of wound care on 04/03/18 at 2:58 PM, by Licensed Practical Nurse (LPN) #39 for Resident #18 revealed there was a dressing of an ABD (absorbent dressing) pad, which was secured with gauze to the left heel. There was no dressing on the right foot. LPN #39 removed the dressing from the left heel which showed eschar with no drainage. No measurements were taken at that time. LPN #39 wiped the area of the left heel with moistened gauze, covered the heel with an ABD pad and wrapped it with gauze. The right heel did not have a dressing. LPN #39 wiped the right heel with moistened gauze and applied skin prep (a protective barrier). She proceeded to cover the right heel with an ABD pad and secure it with gauze. No care was provided to the toes on the left or right foot and/or the sacrum area. On 04/03/18 at 03:25 PM, Registered Nurse (RN/Wound Nurse) #36 came in the Resident's #18's room. RN #36 further explained that it was her opinion that Resident #18 developed those places on her (Resident #18) toes from the hospital and she (RN #36) just saw her (Resident #18) yesterday (04/02/18). During an interview on 04/04/18 at 11:02 AM, when asked how the pressure ulcer on the resident's left heel was staged and what tool(s) did she use, RN/Wound Nurse #36 stated that the wound on the left heel was a Deep Tissue Injury (DTI) because a wound cannot be staged when there was eschar. In addition, she stated that she did not have any tools to refer to, that she did not stage pressure ulcers, and she was not a doctor. RN/Wound Nurse #36 stated that she had only had the Wound Care Nurse position for two (2) weeks and had not had any training. (Note: The presence of eschar indicate a full thickness wound and would be considered an unstageable pressure ulcer due to eschar.) A review of the form titled Wound Assessment and Progress Review found the resident had a suspected deep tissue injury (SDTI) on the left heel on 01/11/18. On 02/28/18, 03/07/18, and 03/14/18, the documentation noted the SDTI was closed on each of these dates. When asked what closed meant, RN/Wound Nurse #36 stated there was a scab on the wound and she put closed because the nurse before her put closed. During an interview on 04/04/18 at 11:33 AM, RN #23 was asked about writing closed on the wound assessment and she said that the wound was closed meaning the wound was clear with no scabs or anything. During an interview on 04/05/18 at 9:08 AM with Resident #18s attending physician, he stated that he had not looked at Resident #18 feet and that's on him. He stated that he relied on the nurses' charting and notes at face value and failed to look at them (Resident #18's feet) himself. In addition, he agreed that the nursing documentation was not consistent or accurate. The attending physician's assessment dated [DATE] included, ASSESSMENT: Deep tissue injury to the left heel, suspected deep tissue injury to the right heel, blister to the right great toe, [DIAGNOSES REDACTED] to the left great toe, likely stage II pressure area on the second toe, and stage II pressure area on the lumbosacral area. During an interview on 04/05/18 at 10:26 AM, the DoN and Administrator agreed that the wounds for Resident #18 were never assessed until 04/02/18. On 04/05/18 at 4:30 PM, the DON was asked again for the report of a skin check for this resident prior to being transferred to the local hospital and the DoN reported that a skin check was not completed, and on readmission there was no evidence Resident #18 returned to the facility with pressure ulcers or unstageable DTIs. 2. Resident #98 Review of the admission nursing assessment dated [DATE] revealed Resident #98 had a blister like area on the left heel that has a protective dressing intact. Record review revealed a physician's orders [REDACTED]. The left heel wound was described as an unstageable area 4.5 centimeters (cm) by 4.0 cm with eschar (a collection of dead tissue within the wound bed and indicates full thickness tissue loss). On 04/04/18 at 10:30 AM, the DON agreed the wound identified on 03/17/18 did not receive medical interventions until 03/19/18. b) The facility failed to develop and implement an accurate baseline care plan for Resident #98. The resident's baseline care plan did not include fall risk or care for a wound on the foot, both present at the time of admission. 1. Resident #98 Medical records review revealed Resident #98 was admitted to the facility on [DATE]. Review of discharge summary from the hospital where Resident #98 was treated prior to being admitted to the facility, revealed the reason for admission to the hospital was a subtrochanteric fracture (a [MEDICAL CONDITION] bone near the hip) of left hip on 03/03/18. Review of the baseline care plan, with a date of 03/16/18, was absent of any evidence Resident #98 had a risk for falls. physician's orders [REDACTED]. Review of nursing admission assessment with a date of 03/17/18 revealed Resident #98, .was admitted to (initials) Nursing after sustaining a fall in previous nursing home facility. The fall evaluation completed on admission also revealed a high fall risk. Fall risk was not included in the base line care plan. The nursing assessment dated [DATE] identified Resident #98 had a, blister like area on the left heel that has a protective dressing intact. The baseline care plan with a date of 03/16/18 did not include actual skin breakdown or treatment for [REDACTED]. Record review revealed a physician's orders [REDACTED]. The left heel wound was described as an unstageable area 4.5 centimeters (cm) by 4.0 cm with eschar (a collection of dead tissue within the wound bed indicating full thickness tissue loss). On 04/04/18 at 10:30 AM, the DON agreed, the resident's risk of falls and the wound observation on the nursing admission were not identified on the baseline care plan.",2020-09-01
3305,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,761,E,0,1,NWDF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy and procedures review, the facility failed to adequately store and dispose of expired medications. Nine (9) oral medications and three (3) vials 0.9% Sodium Chloride Irrigation were not returned to the pharmacy and/or destroyed in a timely manner as per pharmacy policy and procedure. Additionally, the facility failed to ensure all prescription medications were labeled. This practice had the potential to affect more than an isolated number of residents. Findings includes: a) On 04/03/18 at 09:43 AM, Licensed Practical Nurses (LPNs) #39 and #42 were present during the inspection of the facility's medication room and the long hall medication cart. When asked, neither LPN could explain the facility's policy and/or process for identifying a medication's expiration date, or the record keeping and disposing of expired medications. The facility's stock medications included those labeled and dispensed by (name of pharmacy) as well as two (2) stock medications, which were not labeled. The medications dispensed by the pharmacy included the medication's expiration date on each label: 1. Therems-M (Multivitamin with iron and other minerals): expiration date 11/17/17 2. Vitamin C 500 mg: expiration date 01/23/18 3. [MEDICATION NAME] Coated ASA 81 mg: expiration date 11/17/17 4. Zinc Sulfate 200 mg (50 mg): expiration date 11/29/17 5. ASA 81 mg Chewable: expiration date 01/23/18 6. ASA 325 mg: expiration date 02/08/18 7. [MEDICATION NAME][MEDICATION NAME] 25 mg: expiration date 01/06/18 8. [MEDICATION NAME]-HC 25 mg suppositories: expiration date 04/2018 (no pharmacy label) 9. Fast Acting Mi-Acid Regular Strength Antacid/[MEDICATION NAME] Original: expiration 1/18 (January (YEAR)) 10. 0.9% Sodium Chloride Irrigation, USP 3 vials: expiration date 03/06/18 During the inspection of the medication cart, two (2) unlabeled medications, [MEDICATION NAME] 2.5 mcg (micrograms) (Opened 2/12/18) and [MEDICATION NAME] 160/4.5 (Opened 2/12/18), were discovered. LPN #42 stated, Those inhalers are for (name of Resident #46). When asked why the medications were not labeled, LPN #42 stated, I don't know why they aren't labeled. On 04/03/18 at 10:45 AM, the DON brought the large bottle of Therems-M (Multivitamin with iron and other minerals) with an expiration date of 11/17/17. She stated, We do not follow the expiration date that the Pharmacy puts on the label. We follow the actual original expiration date that is on the bottles When asked her if she was aware that the majority of the pharmacy labels were actually placed over the distributor's expiration dates, and were illegible, she replied, Yes. When asked what did they did in those cases, she had no reply other than, I'm going to ask the Pharmacy to stop sending us these large bottles of stock medications. Review of the requested facility's policies regarding medications, including storage & the protocol regarding returning medications and/or destroying medications discontinued medications, and/or a resident was discharged found the following: -- The Administering Medications policy, updated (MONTH) 1, (YEAR) and effective (MONTH) 16, (YEAR), included, 9. The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. -- The policy did not address the protocol regarding returning medications and/or destroying medications after a medication was discontinued and/or the resident was discharged . During an interview on 04/05/18 at 11:45 AM, the DON stated, The two (2) inhalers came with (Resident #46's name) when she was discharged from (name of acute care hospital) and readmitted to here. Neither the [MEDICATION NAME] or [MEDICATION NAME] were labeled. They have been disposed of, and new ones have been ordered from the pharmacy.",2020-09-01
3306,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,838,E,0,1,NWDF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility assessment, medical record review and staff interview the facility failed to ensure they conducted a facility-wide assessment to determine what resources were necessary to care for the residents competently during both day-to-day operations and emergencies. Nursing staff did not receive training that equipped them with the competencies necessary to provide the level of care needed by the residents. Resident #18 did not receive care and treatment necessary for the prevention of and treatment for [REDACTED].#18. Facility census: 46. Findings include: a) Resident #18 Review of the facility's policy titled, Wound Care, revised (MONTH) 2002, found it directed the following information should be recorded in the resident's medical record: - The type of wound care given. - The date and time the wound care was given. - The position in which the resident was placed. - The name and title of the individual performing the wound care. - Any changes in the resident's condition. - All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. - If the resident refused the treatment and the reason(s) why. Review of Resident #18's medical records found she was transferred to a local hospital on [DATE] and returned to the facility on [DATE] at 5:07 PM. Licensed Practical Nurse (LPN) #42's re-admission assessment stated that Resident #18 returned with a dressing to her inner and outer ankle and top of her left foot and bruising to both upper extremities. No evidence was found of pressure ulcers. During an interview, on 04/02/18 at 4:05 PM, LPN #39 stated that Resident #18 only had a Band-Aid to the second toe on the left foot and had no pressure ulcers. LPN #39 stated that Resident #18 was admitted on [DATE] and had no pressure ulcers in the past year. Registered Nurse (RN) #44 showed LPN #39 a nursing note stating that a pressure ulcer on the left heel 1/2018 was a deep tissue injury but had since healed. On 04/03/18 a review of the evidence from the Wound Assessment and Progress Review noted on 04/02/18 at 6:19 PM the following: - Unstageable Deep Tissue Injury (DTI) measuring 2 x 2 cm (centimeter) with eschar measuring 1.8 cm on the left heel. - Unstageable DTI measuring 1.7 x 2 cm on the right heel. - Stage II pressure ulcer measuring 2.4 x 2 cm on the sacrum. - Unstageable DTI measuring 2.4 x 2.2 cm on the left toe. Noted to be purple in color and was not blanchable. - Unstageable DTI measuring 1.2 x 1.5 cm on the right toe with eschar (a collection of dead tissue within the wound bed and indicates full thickness tissue loss) in the center. During an observation of wound care on 04/03/18 at 2:58 PM, by Licensed Practical Nurse (LPN) #39 for Resident #18 revealed there was a dressing of an ABD (absorbent dressing) pad, which was secured with gauze to the left heel. There was no dressing on the right foot. LPN #39 removed the dressing from the left heel which showed eschar with no drainage. No measurements were taken at that time. LPN #39 wiped the area of the left heel with moistened gauze, covered the heel with an ABD pad and wrapped it with gauze. The right heel did not have a dressing. LPN #39 wiped the right heel with moistened gauze and applied skin prep (a protective barrier). She proceeded to cover the right heel with an ABD pad and secure it with gauze. No care was provided to the toes on the left or right foot and/or the sacrum area. On 04/03/18 at 03:25 PM, Registered Nurse (RN/Wound Nurse) #36 came in the Resident's #18's room. RN #36 further explained that it was her opinion that Resident #18 developed those places on her (Resident #18) toes from the hospital and she (RN #36) just saw her (Resident #18) yesterday (04/02/18). During an interview on 04/04/18 at 11:02 AM, when asked how the pressure ulcer on the resident's left heel was staged and what tool(s) did she use, RN/Wound Nurse #36 stated that the wound on the left heel was a Deep Tissue Injury (DTI) because a wound cannot be staged when there was eschar. In addition, she stated that she did not have any tools to refer to, that she did not stage pressure ulcers, and she was not a doctor. RN/Wound Nurse #36 stated that she had only had the Wound Care Nurse position for two (2) weeks and had not had any training. (Note: The presence of eschar indicate a full thickness wound and would be considered an unstageable pressure ulcer due to eschar.) A review of the form titled Wound Assessment and Progress Review found the resident had a suspected deep tissue injury (SDTI) on the left heel on 01/11/18. On 02/28/18, 03/07/18, and 03/14/18, the documentation noted the SDTI was closed on each of these dates. When asked what closed meant, RN/Wound Nurse #36 stated there was a scab on the wound and she put closed because the nurse before her put closed. During an interview on 04/04/18 at 11:33 AM, RN #23 was asked about writing closed on the wound assessment and she said that the wound was closed meaning the wound was clear with no scabs or anything. During an interview on 04/05/18 at 9:08 AM with Resident #18s attending physician, he stated that he had not looked at Resident #18 feet and that's on him. He stated that he relied on the nurses' charting and notes at face value and failed to look at them (Resident #18's feet) himself. In addition, he agreed that the nursing documentation was not consistent or accurate. The attending physician's assessment dated [DATE] included, ASSESSMENT: Deep tissue injury to the left heel, suspected deep tissue injury to the right heel, blister to the right great toe, [DIAGNOSES REDACTED] to the left great toe, likely stage II pressure area on the second toe, and stage II pressure area on the lumbosacral area. During an interview on 04/05/18 at 10:26 AM, the DoN and Administrator agreed that the wounds for Resident #18 were never assessed until 04/02/18. On 04/05/18 at 4:30 PM, the DON was asked again for the report of a skin check for this resident prior to being transferred to the local hospital and the DoN reported that a skin check was not completed, and on readmission there was no evidence Resident #18 returned to the facility with pressure ulcers or unstageable DTIs.",2020-09-01
3307,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,842,D,0,1,NWDF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, electronic record review, hard copy (paper) medical record review, and staff interview, the facility failed to ensure the accuracy of a resident's code status, and to ensure it was readily available, consistent, and communicated to staff. Staff were unable to locate Resident #18 code status in the electronic medical record. In addition, staff found conflicting code statuses when reviewing the hard copy of the medical record. This failed practice was true for one (1) of sixteen (16) residents reviewed for code status. Resident identifier: #18. Facility census: 46. Findings included: a) Resident #18 On 04/02/18 at 3:00 PM, a review of the electronic medical record (EMR) for Resident #18 revealed a DO NOT RESUSCITATE (DNR) order. An additional review of the hard copy (paper) medical record conflicting orders were found on 04/3/18 for Resident #18's code status. The hard copy medical record was labeled to read FULL CODE. Continuing review of the both the EMR and hard copy medical record found the following: - State of West Virginia Medical Power of Attorney (MPOA) stated FULL CODE dated 08/14/1998 - the Physician order [REDACTED]. - the Face Sheet dated admitted : 08/27/13 (latest return) and 06/01/12 Current as a DNR; - admission orders [REDACTED] - physician's orders [REDACTED]. - physician's orders [REDACTED]. - admission orders [REDACTED] - Advanced Directives and code Status Report dated 4/2/18 stated DNR. During an interview on 04/04/18 at 2:00 PM, Nursing Aides (NAs) #46 and #84, and Licensed Practical Nurse (LPN) #72 were asked to demonstrate how to find a resident code status. The NAs and LPN stated that staff were not informed of the code status during shift change, but were sure it was in the computer in the hallway. After searching for about 15 minutes, the NAs and LPN had to be shown were to find a resident's code status on the computer system. When asked to show the code status for Resident #18, they pointed to the screen for Resident #18 that showed DNR. During an interview on 04/04/18 at 2:40 PM, when asked how she knew the code status of a resident, LPN #72 replied, We don't exchange that in report unless there was a change in status because they all know their residents. When asked to show the code status for Resident #18, LPN #72 pointed to the computer screen which displayed DNR. On 04/04/18 at 3:20 PM, Registered Nurse (RN) #44 looked on the hard copy medical record for Resident #18 and stated that she was a full code. Further review of the hard copy medical record with RN #44 found evidence of both DNR and FULL CODE status. RN #44 looked on the Desk Top Computer and found the code status for Resident 18 was DNR. During an interview on 04/04/18 at 4:00 PM, the Director of Nursing (DoN) stated that Social Worker (SW) #3 had found a POST form that the Resident #18 signed in 2004 requesting to be a full code, but the MPOA had changed the code status to a DNR. The DoN stated that she felt like the MPOA changed the code status without the consent of Resident #18. The DoN stated that she was not aware that the chart had conflicting code status orders and that the electronic chart code status was incorrect. The DON agreed this was confusing for the staff and the charts both electronic and the hard copy were wrong.",2020-09-01
3308,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,880,D,0,1,NWDF11,"Based on observation and staff interview, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of diseases and infection to the extent possible. During random observations, Resident #98's nasal cannula tubing was laying inside a garbage can and Resident #32's nebulizer mouthpiece was lying unprotected on the floor. Resident identifiers: #98 and #32. Facility census: 46. Findings included: a) Resident #98 Observations at 11:12 AM on 04/04/18 found Resident #98's nasal cannula tubing laying in a garbage can. The tubing was still attached to the oxygen concentrator and the was concentrator running. Nursing assistant #66 explained I was in a hurry, and put it in the garbage can because it had bowel movement on it. Because of being in a hurry the tubing was not detached from the oxygen concentrator. At 11:30 AM on 04/04/18, the director of nursing (DON) observed the tubing in the garbage can and agreed it should have been detached from the concentrator. b) Resident #32 An observation on 04/02/18 at 11:19 AM, revealed the resident's nebulizer mouth piece (used to administer breathing treatments) lying unprotected on the floor. This finding was verified with Nurse Aide #5 and Licensed Practical Nurse (LPN) #42. During an interview on 04/02/18 at 11:26 AM, LPN #42 agreed the nebulizer mouth piece should have been stored in a clean bag.",2020-09-01
3309,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2018-04-05,921,E,0,1,NWDF11,"Based on observation and staff interview, the facility failed to provide a safe environment for residents. A container of disinfectant wipes were left unsecured on the back of a commode in shower room B. This practice has the potential to affect more than a limited number of residents. Facility census: 46. Findings included: a) At 11:55 AM on 04/02/18, during the initial tour of the facility, the unlocked shower room B was found to have a container of disinfectant wipes sitting on the commode tank. The safety data sheet (SDS) for this disinfectant included a warning about acute toxicity for eye contact and skin contact. Eye contact first aid should include, immediately flushing the eye with large amounts of water. Skin contact first aid includes immediately flush skin with plenty of water while removing clothing. At 3:00 PM on 04/02/18, the disinfectant wipes remained on the commode tank in shower room B and the facility administrator entered the room and removed the disinfectant wipes. At 9:00 AM on 04/05/18, the facility administrator agreed the disinfectant wipes should not have been in shower room B where residents had easy access.",2020-09-01
3310,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,574,E,0,1,KGJN11,"Based on Resident Council meeting and observation, the facility failed to display the Resident Rights poster easily accessible to all residents wanting to review these rights. This was reported during the Resident Council meeting regarding the posters being too high for residents in wheelchairs to review. This had the potential to affect all residents wishing to review their Resident Rights from a seated position. Facility census: 57. Findings included: a) Resident Rights poster During a Resident Council meeting on 04/09/19 at 11:45 AM, this group of residents reported the Resident Rights poster located on the wall by the Dining Room and on 100 Hallway were too high for any residents in a wheel chair to be able to read. An observation on 04/09/19 at 12:15 PM of the Resident Rights posters located on the wall by the Dining Room and the 100 hallway could be lowered to be more accessible to any residents in a wheel chair. In an interview with the Interim Nursing Home Administrator on 04/09/19 at 12:45 PM, was informed of the Resident Council concern regarding the height of the Resident Rights poster being displayed too high for residents in a wheel chair to review.",2020-09-01
3311,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,600,K,0,1,KGJN11,"Based on observation, record review, resident interview and staff interview, the facility failed to ensure Resident #33 was free from neglect. Resident #33 went 9 and 16 days without a shower. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #33. Facility census: 57. Findings included: a) Resident #48 During an interview on 04/08/19 at 12:04 PM, Resident #48 stated he made a complaint in (MONTH) (YEAR) of a nurse aide talking to him abrasively. He stated he asked the Social Worker to please report her to the state. The resident said the Social Worker told him it would just be her word against his and would not do any good. After reviewing the Grievance and Concerns, there was one completed on 10/25/18 by the Social Worker. The 10/25/18 Grievance and Concern form noted the Resident reported not getting help to go to bed as he wanted because the NA could not get anyone to help her. The Grievance and Concern form noted the following: --The NA came in his room three times and turned off his call light. --The first time was at 3:30 PM. The NA said, it will be a little while and then 15 minutes later at 3:45 PM she said, What did I tell you? We will get to you when we can. --Resident stated that his buttock was getting sore (He did have pressure ulcers on his buttock). --At 4:00 PM, the NA came in his room again and turned off his call light and stated, I told you I had to get help and the other NA had to take the smokers out and she can't make it happen any faster. --It was 4:10 PM when he got to lay down. He told the Social Worker that the attitude of the NA was what bothered him the most. --He also stated that was not the only time that Nurse Aide was verbally abrasive towards him. --The Social Worker wrote a statement that the NA denied being abrasive and would be more careful about the way she speaks to him and other residents. A review of records revealed there was not a reportable completed by the facility for the allegation of verbal/mental abuse and neglect to the required state agencies. During an interview on 04/10/19 at 2:50 PM, the Person In Charge (whom was also the Social Worker) stated that she did not do any type of a reportable concerning this matter. She went on to say that the NA no longer works here. No further information was provided prior to exit. b) Resident #33 During an interview on 04/08/19 at 12:47 PM, Resident #33 stated she went two weeks without a shower. Resident # 33 also stated that she did not refuse a shower during this time. A review of the shower log Resident # 33 did not receive a shower from 2/11/19 to 02/20/19 which was nine (9) days between showers, she also did not receive a shower from 02/22/19 to 03/09/19 which was 16 days without a shower. During an interview on 04/10/19 at 12:34 PM, DoN was asked to verify the Resident went nine (9) and then 16 days without a shower. Her response was, I thought you said a week not two weeks. No other shower records were provided before the end of the survey.",2020-09-01
3312,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,607,E,0,1,KGJN12,"Based on record review, policy review and staff interview the facility failed to implement their Abuse Policy as it pertained to the reporting and investigating of allegations of abuse. This practice has the potential to effect all residents currently residing in the facility. Resident #13 on multiple occasions was sexually abusive toward six (6) different female residents. These allegations were not reported and/or investigated thoroughly as directed by the facility's policy. Resident identifiers: #13, #55, #40, #2, #25, #61 and #15. Facility census: 56 Findings Include: a) Resident #13 A review of the reportable incidents from 05/29/19 through current found an Immediate Fax Reporting of allegations - Nursing Home Program. This form was completed by the facility's social worker on 06/04/19 and faxed to the Office Health Facility Licensure and Certification (OHFLAC) on 06/04/19 at 1:25 p.m. The date of the incident was listed as 06/03/19 and the brief description of the incident read as follows, (First and Last name of Resident #13), resident at the (Name of facility), approached 3 female residents trying to rub his private area against them and put his penis in their mouth. Staff immediately intervened and diffused the situation. Review of the Five Day follow up form found the following under the section titled outcome/results of investigation: (First and Last name of Resident #13), resident at the (Name of Nursing Facility) approached 3 female resident trying to rub private area against them and put his penis in their mouth. Staff intervened immediately and diffused the situations. Families were notified of the incident. Under the section Corrective Action by the facility the following was noted, (First and Last name of Resident #13) was sent out of facility for psychiatric treatment/evaluation. Addressed behavior in care plan to avoid any further incidences. Resident will be assessed upon return for mental status and any further behaviors. A review of the investigation or this incident found only one statement from a staff member attached. This statement was from the receptionist who works in Human Resources Employee #54 about an incident which took place on 06/04/19 at 7:23 a.m. it read as follows, I was buzzed into the building and went to clock in. When I rounded the corner after clocking in, I saw Mr. (Last name of Resident #13) grabbing (First Initial and last name of Resident #55)'s wheel chair and turning it to face him. He then stood up, reached his hand down his elastic panty and showed Ms. (Last name of Resident #55) his penis. I said very firmly Stop. Mr. (Last name of Resident #13) only laughed. I told Mr. (Last name of Resident #13) I don't think it's funny at all to which he responded. I think it's real funny! and continued to laugh. Ms. (Last name of Resident #55) had wheeled away from him by then and I went down the hall to immediately report what I had seen to the [MI]P.N. (Licensed Practical Nurse) at the desk (First and last name of LPN #7). (First and last name of LPN #91) contacted my office a few minutes later and asked me to write a statement. This statement was in regards to an incident that happened 06/04/19 which was not the incident that was reported for 06/03/19. No other statements were attached to this investigation. An interview with the NHA at 1:36 p.m. on 07/23/19 confirmed the statement attached to this investigation was for a different incident and there were no other statements attached and/or obtained in regards to the incident on 06/03/19. A review of Resident #13's medical record at 1:00 p.m. on 07/22/19 found the following pertinent nursing progress notes, -This note was entered as a late entry for a date of 06/03/19 at 4:35 p.m. (Recorded as Late Entry on 06/04/2019 11:41 AM) resident has been wandering up and down hallways and in and out of dining hall. sexually inappropriate behaviors x 3 noted by staff and residents. resident was noted to remove his penis from his pants and rubbing it on another res., face, also putting it in 2 residents mouth. he was approached quickly and re directed away from residents, and q 15 minutes watch was started. This note was written by LPN #82. -06/04/19 at 7:49 a.m. Resident was noted by (First Name of Employee #54) in HR to be exposing himself to a female resident. Resident was walked back to his room by staff. Notified (First and Last name of administrator), Administrator. Resident is to be transported to (Name of local hospital) for evaluation. MPOA notified and was in agreement. (Name of local rescue Squad) called for transport at 0739. Report called to (Name of local hospital) at 0739. VS 128/72 Temp 98.0 HR 78 Resp 18 O2 Sat 98% BRS arrived 0748. Resident transported out of facility at 0755 accompanied by 2 attendants. Please note a statement was not obtained from LPN #82 regarding this incident even though she must have had knowledge of what had happened. Also the nurses note clearly identify four (4) separate occurrences of sexual abuse. Three (3) on 06/03/19 which were reported on 06/04/19 outside of the required two (2) hour time frame and one (1) on 06/04/19 which was not reported at all. -06/19/19 at 12:46 p.m. Resident observed by staff displaying sexually inappropriate behaviors. Q15 minute checks initiated to monitor Resident. -06/20/19 at 4:47 p.m. Resident was walking back from dining room down short hall. CNA reported resident smacked her buttocks as he walked past. Q 15 minute checks in place. Will continue to monitor and observe. -06/20/19 at 5:53 p.m. Resident being transferred to (Name of Local hospital) via (Name of local rescue squad) for evaluation for admittance to (Name of Local Psychiatric Hospital). Resident has been noted by staff to be exhibiting inappropriate sexual behaviors to other residents and staff. (Name of local rescue squad) called at 1736. MPOA (First and last name of MPOA) called at 1737. No answer received. Message left informing of Resident's transfer and instructions to call facility with any questions. Report called to (First name of RN at local hospital), RN at (name of local hospital) ER at 1742. Behavioral observation completed. Transfer/Bed hold form completed and will be sent with resident in transfer packet. -06/28/19 at 12:30 p.m. Resident returned to facility at 1220 via (Name of local Rescue Squad) x 2 attendants. No complaints voiced. No signs symptoms distress noted. Resident shown to new room in (Room Number Redacted for confidently). Resident expressed understanding. VS BP 94/61 HR 68 Temp 98.4 Resp 18 O2 Sats 97%. Skin Assessment performed. Resident cooperative and agreeable. Will continue to monitor. -06/28/19 at 1:30 p.m. Resident observed by staff members exhibiting inappropriate sexual behaviors with other residents in residents room and dayroom. Staff intervened. RN notified. Resident being monitored closely at this time. -06/28/19 at 3:05 p.m. New order received to transfer resident as a direct admit to the (Name of Local Psychiatric Unit). Q 15 minute checks initiated. MPOA (first and last name of MPOA) notified and expressed understanding and agreement. (Name of local rescue squad) called for transport. Report called to (First and Last name of RN at local hospital), RN. (Name of local rescue squad) arrived 1507. VS 94/61 Temp 98.4 Resp 18 HR 68 Resident left facility by stretcher via (Name of local Rescue squad) x 3 attendants at 1507. At 2:00 p.m. on 07/22/19 the Nursing Home Administrator (NHA) was interviewed. When asked if the incident that took place on 06/19/19 and 06/28/19 were reported she indicated they had not been reported. She stated, We reported the first incident, but since he is confused and the victims were confused and they had sent him out they did not think the other incidents were reportable and did not report them. She stated, The residents did not know what was going on so we did not think we needed to report the additional incidents. At 2:20 p.m. on 07/22/19 the Social Worker joined the interview with the NHA, they were asked what the nursing note dated 06/19/19 was referring to. The note was not clear as to who the sexual inappropriate behaviors exhibited by Resident #13 on this date were directed toward. The Social Worker indicated it was Resident #25. When asked what Resident #13 had done to Resident #25 on this date the social worker stated, I think she told me he had just pulled his Junk (Junk is a slang term for a males penis and testicles) out. The social worker stated, I did a concern form about it but did not report it. A review of the concern forms found a form dated 06/20/19 which was completed by the Social Worker. The form was concerning Resident #25 and under the section titled, Describe grievance/compliant using factual terms: the following was hand written by the Social Worker, Resident Stated male resident was being sexually inappropriate (touched her face with penis). This was a one time occurrence. Male Resident is very confused. Under the section title, What other actions were taken to resolve grievance/compliant (be specific)? 15 minute checks were initiated; Resident is encouraged to stay in common areas of facility so staff can monitor the situation male resident was sent out of the facility for an evaluation on 06/21/19. The record also contained no further information regarding the incident on 06/28/19. There was no concern form completed nor a reportable and the victims for this incident were not identified prior to surveyor intervention. During a final Interview with the NHA and Social Worker at 1:36 p.m. on 07/23/19 the above findings were reviewed. The NHA stated we can see now that maybe we did not do enough. We thought that sending him out to the hospital would be enough but now we see that we did not do enough to keep the other residents safe. She agreed the incident on 06/03/19 though it was reported was not thoroughly investigated and the incidents on 06/04/19, 06/19/19 and 06/28/19 were not reported and/or thoroughly investigated. b) Policy Review A review of the facility's policy found the following pertinent information: . Definition of Abuse .Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Implementation of Abuse policy and procedures 5. Investigation: All different types of incidents and complaints will be screened for possible sign of abuse. The complaint coordinator will be responsible Igor the initial reporting, investigation of alleged violations, and reporting results to the proper authorities . 7. Reporting/Response: All alleged violations and substantiated incidents will be reported to the state agency and to all other agencies as required, and depending on the results of the investigation, necessary corrective actions will be taken. The facility will report to the state nurse aide registry or licensing authorities any knowledge it has of any actions )by a court of law which would indicate and employee is unfit for service. The occurrences will be analyzed to determine what changed are needed, if any to policies and procedures to prevent further occurrences.",2020-09-01
3313,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,609,D,0,1,KGJN11,"Based on record review, resident interview and staff interview, the facility failed to report suspected abuse and neglect to the required state agencies. This failed practice had the potential to affect a limited number of residents. Resident identifier: #48. Facility census 57. Findings included: a) Resident #48 During an interview on 04/08/19 at 12:04 PM, Resident #48 stated he made a complaint in (MONTH) (YEAR) of a nurse aide talking to him abrasively. He stated he asked the Social Worker to please report her to the state. The resident said the Social Worker told him it would just be her word against his and would not do any good. After reviewing the Grievance and Concerns, there was one completed on 10/25/18 by the Social Worker. The 10/25/18 Grievance and Concern form noted the Resident reported not getting help to go to bed as he wanted because the NA could not get anyone to help her. The Grievance and Concern form noted the following: --The NA came in his room three times and turned off his call light. --The first time was at 3:30 PM. The NA said, it will be a little while and then 15 minutes later at 3:45 PM she said, What did I tell you? We will get to you when we can. --Resident stated that his buttock was getting sore (He did have pressure ulcers on his buttock). --At 4:00 PM, the NA came in his room again and turned off his call light and stated, I told you I had to get help and the other NA had to take the smokers out and she can't make it happen any faster. --It was 4:10 PM when he got to lay down. He told the Social Worker that the attitude of the NA was what bothered him the most. --He also stated that was not the only time that Nurse Aide was verbally abrasive towards him. --The Social Worker wrote a statement that the NA denied being abrasive and would be more careful about the way she speaks to him and other residents. A review of records revealed there was not a reportable completed by the facility for the allegation of verbal/mental abuse and neglect to the required state agencies. During an interview on 04/10/19 at 2:50 PM, the Person In Charge (whom was also the Social Worker) stated that she did not do any type of a reportable concerning this matter. She went on to say that the NA no longer works here. No further information was provided prior to exit.",2020-09-01
3314,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,610,D,0,1,KGJN11,"Based on record review, resident interview and staff interview, the facility failed to investigate allegations of suspected abuse and neglect. Resident #48 reported an allegation of abuse and neglect and the facility failed to complete a thorough his was a random opportunity for discovery. Facility census 57. Findings included: a) Resident #48 During an interview on 04/08/19 at 12:04 PM, Resident #48 stated he made a complaint in (MONTH) (YEAR) of a nurse aide talking to him abrasively. After reviewing the Grievance and Concerns, there was one completed on 10/25/18 by the Social Worker. The 10/25/18 Grievance and Concern form noted the Resident reported not getting help to go to bed as he wanted because the NA could not get anyone to help her. The Grievance and Concern form noted the following: --The NA came in his room three times and turned off his call light. --The first time was at 3:30 PM. The NA said, it will be a little while and then 15 minutes later at 3:45 PM she said, What did I tell you? We will get to you when we can. --Resident stated that his buttock was getting sore (He did have pressure ulcers on his buttock). --At 4:00 PM, the NA came in his room again and turned off his call light and stated, I told you I had to get help and the other NA had to take the smokers out and she can't make it happen any faster. --It was 4:10 PM when he got to lay down. He told the Social Worker that the attitude of the NA was what bothered him the most. --He also stated that was not the only time that Nurse Aide was verbally abrasive towards him. --The Social Worker wrote a statement that the NA denied being abrasive and would be more careful about the way she speaks to him and other residents. The Grievance and Concern form did not note any protections put into place to safeguard the resident from the alleged perpetrator. The form did not mention any information concerning an investigation. A review of records revealed there was not an investigation completed by the facility for the allegation of verbal/mental abuse and neglect. During an interview on 04/10/19 at 2:50 PM, the Person In Charge (whom was also the Social Worker) stated that she did not do any type of a investigation concerning this matter. She went on to say that the NA no longer works here. No further information was provided prior to exit.",2020-09-01
3315,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,641,D,0,1,KGJN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to complete an accurate medium data set (MDS) assessment of one (1) of sixteen (16) MDS assessments reviewed during the investigation process of the survey. The Restraint section of the MDS assessment for R8 was not coded to include a wander/elopement alarm. Resident identifier: R9. Facility census: 57. Findings included: a) R9 During a medical record review on 04/08/19 of the comprehensive MDS assessment for R9 with an assessment reference date (ARD) of 01/14/19 revealed the section for Restraints and Alarms had not been coded to include the use of a wander/elopement alarm. Further review revealed a physician's orders [REDACTED]. In an interview on 04/09/19 at 11:15 AM with E74, registered nurse (RN) verified the MDS section for Restraints and Alarms did not include the wander/elopement alarm for R9.",2020-09-01
3316,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,655,D,0,1,KGJN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure accurate completion of a 48 hour care plan for one (1) of one (1) resident reviewed for discharge planning. The Resident's 48 hour care plan failed to address the resident wanted to be discharged to the community. Resident identifier: #60. Facility census: 57. Findings included: a) Resident #60 Review of the medical record found the Resident was admitted to the facility on [DATE]. He was discharged to his home on 01/26/19. Review of the 48 hour baseline care plan noted the resident wished to remain in long term care. Record review found a progress note, completed by the social worker: 01/09/2019 01:14 PM This [AGE] year old white male resident is transferred to the care facility yesterday from (name of hospital). He is admitted for rehabilitation following a hospital stay. He is alert and able to verbalize needs and wants to staff. He is pleasant and interacts with staff without difficulty. He has good support from his brother and sister-in-law, with whom he lives. He reports that he often stays up until 12 or 1 am and chats with his brother and will get up around 9 or 10 am. He states his days consist of sitting around and watching TV and playing with the dog and cats. He says he usually only leaves the house for Medical appointments, and occasionally goes out to eat on those days with his brother, who transports him. He hopes to regain ability to walk and toilet himself and eventually return home with his brother. The social worker completed a discharge plan assessment on 01/09/19. The resident's short term goal was described as, To begin therapy and regain ability to walk and toilet self. The long term goal was, To return home with brother and community based services as indicated. At 4:06 PM on 04/09/19, the Registered Nurse care plan coordinator (RN) #74, acknowledged the resident's 48 hours care plan did not reflect the resident's desire to return home. In addition, the 48 hour care plan was never updated to reflect the resident's desire to return to his home.",2020-09-01
3317,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,656,E,0,1,KGJN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to implement and/or develop resident care plans. For Resident #12 and Resident #56 the facility failed to implement their Diabetes Mellitus (DM). For Resident #9 the facility failed to develop a care plan in area of behaviors. Finally, for Resident #54 the facility failed to implement the residents care plan in regards to a smoking cessation program. This was trued for four (4) of 21 care plans reviewed. Resident identifiers: #12, #56, #9 and #54. Facility census: 57. Findings included: a) Resident #12 A review of Resident #12's medical record at 8:00 a.m. on 04/09/19 found the following physician orders: --Order dated 10/08/18 [MEDICATION NAME] R Regular Insulin per sliding scale. 200 - 249 give 2 units, 250 - 299 give 4 units, 300 - 349 give 6 units, 350 - 400 give 8 units. BS (Blood Sugar) greater than 400 call physician. This ordered was an as needed order. --Order dated 10/24/18 Accu Check twice daily at 6:00 a.m. and 6:00 p.m. Further review of the record found on the following occasions when Resident #12's blood sugar was elevated and she should have received sliding scale coverage and she did not: --10/14/18 - 2:58 p.m. blood sugar was 398. --10/16/18 - 8:03 a.m. blood sugar was 337. --10/16/18 - 5:10 p.m. blood sugar was 282. --10/16/18 - 8:19 p.m. blood sugar was 318. --10/21/18 - 7:49 p.m. blood sugar was 365. --10/22/18 - 8:45 p.m. blood sugar was 311. --10/23/18 - 8:46 p.m. blood sugar was 392. --10/24/18 - 4:47 a.m. blood sugar was 226. --10/24/18 - 9:46 a.m. blood sugar was 372. --10/24/18 - 6:09 p.m. blood sugar was 331. --10/26/18 - 5:37 p.m. blood sugar was 203. --10/29/18 - 5:07 a.m. blood sugar was 230. --10/30/18 - 5:44 a.m. blood sugar was 223. --10/31/18 - 5:34 p.m. blood sugar was 379. --11/02/18 - 5:52 p.m. blood sugar was 324. --11/05/18 - 9:09 p.m. blood sugar was 232. --11/12/18 - 5:54 a.m. blood sugar was 230. --11/12/18 - 8:00 p.m. blood sugar was 286. --11/13/18 - 5:24 p.m. blood sugar was 313. --11/14/18 - 5:06 a.m. blood sugar was 233. --11/16/18 - 5:27 a.m. blood sugar was 342. --11/17/18 - 5:04 a.m. blood sugar was 226. --11/17/18 - 5:25 p.m. blood sugar was 222. --11/19/18 - 5:05 a.m. blood sugar was 203. --11/20/18 - 5:46 p.m. blood sugar was 270. --11/21/18 - 5:24 p.m. blood sugar was 360. --11/23/18 - 5:03 p.m. blood sugar was 284. --11/24/18 - 5:13 p.m. blood sugar was 240. --11/25/18 - 5:13 a.m. blood sugar was 221. --11/26/18 - 5:53 p.m. blood sugar was 290. --11/28/18 - 5:01 p.m. blood sugar was 266. --11/30/18 - 5:30 a.m. blood sugar was 268. --11/30/18 - 5:01 p.m. blood sugar was 232. --12/03/18 - 5:09 p.m. blood sugar was 400. --12/07/18 - 5:14 p.m. blood sugar was 261. --12/09/18 - 5:07 a.m. blood sugar was 279. --12/09/18 - 5:35 p.m. blood sugar was 262. --12/15/18 - 6:01 a.m. blood sugar was 238. --12/19/18 - 5:12 p.m. blood sugar was 331. --12/22/18 - 5:42 p.m. blood sugar was 284. --12/23/18 - 5:57 p.m. blood sugar was 252. --12/25/18 - 6:05 a.m. blood sugar was 213. --12/26/18 - 5:15 a.m. blood sugar was 239. --12/27/18 - 9:43 a.m. blood sugar was 240. --12/27/18 - 5:15 p.m. blood sugar was 214. --12/28/18 - 5:45 a.m. blood sugar was 208. --12/31/18 - 5:16 p.m. blood sugar was 271. --01/01/19 - 5:34 a.m. blood sugar was 214. --01/03/19 - 7:19 p.m. blood sugar was 244. --01/04/19 - 5:06 a.m. blood sugar was 234. --01/05/19 - 5:10 p.m. blood sugar was 232. --01/06/19 - 5:00 p.m. blood sugar was 208. --01/11/19 - 5:05 p.m. blood sugar was 219. --01/13/19 - 5:28 p.m. blood sugar was 217. --01/19/19 - 5:08 p.m. blood sugar was 245. --01/23/19 - 5:24 p.m. blood sugar was 250. --01/25/19 - 5:38 p.m. blood sugar was 245. --01/26/19 - 5:45 a.m. blood sugar was 226. --01/31/19 - 5:34 p.m. blood sugar was 236. --02/06/19 - 5:24 a.m. blood sugar was 205. --02/19/19 - 5:16 p.m. blood sugar was 200. --02/24/19 - 6:38 p.m. blood sugar was 200. --03/07/19 - 5:00 a.m. blood sugar was 274. --03/11/19 - 6:18 p.m. blood sugar was 210. --03/12/19 - 5:04 a.m. blood sugar was 209. --03/26/19 - 5:07 a.m. blood sugar was 244. --04/02/19 - 5:09 p.m. blood sugar was 203. --04/07/19 - 5:46 a.m. blood sugar was 302. --04/08/19 - 5:06 a.m. blood sugar was 221. Review of the Medication Administration Record (MAR) found Resident #12 did not receive any sliding scale insulin on the above mentioned dates. An interview with the Director of Nursing (DON) at 11:00 a.m. on 04/09/19 confirmed Resident #12's insulin was not administered in accordance with the sliding scale insulin order. She stated that it should be recorded on the MAR when it is administered and it was not documented that it was given so it appears it was not administered. Review of Resident #12's care plan found the following problem statement: Potential for hyper/[DIAGNOSES REDACTED] other complications Related to [DIAGNOSES REDACTED]. The goal associated with this problem statement read as follows: Will remain free of signs or symptoms or complications related to diabetes evidenced by labs and blood sugar checks will be in normal range through next review. The target date for this goal was 04/16/19. The was initiated on 01/18/19. The interventions associated with this problem and goal included: Administer medications as ordered and monitor for side effects and effectiveness. This goal was added on 10/24/18. An additional interview with the DON on 04/10/19 at 10:30 a.m. confirmed Resident #12's care plan was not implemented. b) Resident #56 A review of Resident #56's medical record at 10:00 a.m. on 04/09/19 found the following physician orders: -- Order Dated 04/28/18 which read Blood Sugar checks once a day at 7:00 p.m. This was an active order at the time of this review. -- Order dated 03/23/18 which read [MEDICATION NAME] R per sliding scale coverage if blood sugar is 201 - 250 give 4 units, 251 - 300 give 6 units, 301 - 350 give 8 units, 351 - 400 give 10 units, 401 - 450 give 14 units, 451 - 500 give 20 units, if blood sugar is greater than 500 call doctor. Further review of the record found on the following occasions when Resident #56's blood sugar was elevated and she should have received sliding scale coverage and she did not: --02/27/19 - 7:50 p.m. blood sugar was 278. --03/29/19 - 9:11 p.m. blood sugar was 235. --04/01/19 - 9:19 p.m. blood sugar was 236. --04/03/19 - 8:56 p.m. blood sugar was 231. An interview with the Director of Nursing (DON) at 11:00 a.m. on 04/09/19 confirmed Resident #56's insulin was not administered in accordance with the sliding scale insulin order. She stated that it should be recorded on the MAR when it is administered and it was not documented that it was given so it appears it was not administered. Review of Resident #56's care plan found the following problem statement: Potential for hyper/[DIAGNOSES REDACTED] other complications Related to [DIAGNOSES REDACTED]. The goal associated with this problem statement read as follows: Will remain free of signs or symptoms or complications related to diabetes evidenced by labs and blood sugar checks will be in normal range through next review. The target date for this goal was 07/18/19. The was initiated on 04/02/19. The interventions associated with this problem and goal included: Administer medications as ordered and monitor for side effects and effectiveness. Receives [MEDICATION NAME] R sliding scale. This goal was added on 02/07/17. An additional interview with the DON on 04/10/19 at 10:30 a.m. confirmed Resident #56's care plan was not implemented. c) R9 During a medical record review on 04/08/19 for R9 revealed the care plan had not been developed to provide any structured programs or activities of interest to minimize his wandering behaviors of entering other residents room and trying to open closed doors. In a interview with the E74 registered nurse (RN) on 04/09/19 at 11:15 AM, verified the care plan had not been developed to provide any redirection interventions for R9's wandering behaviors. d) R54 During a medical record review on 04/08/19 for R54 revealed the care plan had an approach to encourage resident to stop smoking and offer smoking-cessation assistance as desired, consult physician for nicotine patch/gum or other medication as needed. Further review of the Observation Book for the physician had a note on 01/02/19 for R54: Patient has agreed to try and quit smoking would like to start with low dose Nicotine Patch and decrease smoking gradually. In an interview with the director of nursing (DON) on 04/10/19 at 1:20 PM, was unable to locate any evidence that R54 had been offered any smoking-cessation assistance to help her to decrease smoking.",2020-09-01
3318,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,657,D,0,1,KGJN11,"Based on resident interview and staff interview, the facility failed to ensure Resident # 48 was in attendance and /or included in his care plan meeting. This true for one (1) of one (1) reviewed for care planning. Resident identifier: #48. Facility census: 57. Findings included: During an interview, on 04/08/19 at 12:05 PM, Resident #48 stated that he always attends his care planning meeting, but for whatever reason no one came to take him to his last meeting. He stated that he got up and ready, but they must have had it without him. He stated that the letter said it was schedule for 04/04/19. He received a letter requesting him to attend. During an interview on 04/08/19 at 12:17 PM, Registered Nurse (RN) #74 said, that they had his care plan meeting on 3/14/19 in his room. She further stated he did not attend the one held on 04/04/19. The RN stated she did not know he wanted to attend the one for last week. She stated that normally he does attend. She said it may have slipped though the cracks because they have a new Social Worker and she is not sure she knows how they do it yet. She also stated that they would reschedule one for next week for him.",2020-09-01
3319,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,677,E,0,1,KGJN11,"Based on observation, resident interview, staff interview, facility policy and record review, the facility failed to provide a resident with necessary services to maintain grooming and personal hygiene. This was true for two (2) of three (3) residents reviewed in the care area of Activities of Daily Living (ADL). Resdient identifiers: #33 and #5. Facility census 57. Findings included: a) Resident #33 During an interview on 04/08/19 at 12:47 PM, Resident #33 stated that she went two weeks without a shower. Resident # 33 also stated that she did not refuse a shower during this time. A review of the shower log verified Resident # 33 did not receive a shower from 2/11/19 to 02/20/19 which was nine (9) days between showers, and she also did not receive a shower from 02/22/19 to 03/09/19 which was 16 days without a shower. During an interview on 04/10/19 at 12:34 PM, DoN verified the resident went nine (9) and then 16 days without a shower. Her response was, I thought you said a week not two weeks. No other shower records were provided before the end of the survey. b) Resident #5 During an observation of wound care on 04/10/19 at 2:08 PM, Licensed Practical Nurse (LPN) #55 and Nurse Aide (NA) #17 removed the adult brief on Resident #5 and revealed she had had a bowel movement. There was fecal matter on the front and back of this resident. Review of the facility policy titled, Perineal Care with revision date 2005 listed the following: The following equipment and supplies are necessary when performing this procedure: 1. Wash basin 2. Towels 3. Washcloths 4. Soap 5. Gloves --Place wash basin and supplies at bedside for easy access. --Fill the wash basin 1/2 full --For female residents wash perineal area from front to back --Separate the labia and wash area downward --Wash from inside to out including thighs --Do not reuse the same washcloth NA#17 left the room and returned with one wash cloth and one towel. She did not use a basin she wet the wash cloth in the sink and sprayed peri cleaner on the wash cloth. She smeared the fecal matter across the residents pubic area, using the same wash cloth she smeared more fecal matter across her buttock, enough to cover the sacrum area. She and the LPN replaced her brief and pulled her dress back down and was going to take her back to the dining area for activities. The LPN was interviewed about whether the peri-care was appropriately provided. LPN#55 stated that she would get the supplies and make sure she was cleaned properly. On 04/10/19 at 3:00 PM, DoN was informed of the observation and provide a competency for NA#17 that showed she did her yearly competency on 02/12/19. She also stated that she will re-educate this NA on peri care.",2020-09-01
3320,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,684,K,0,1,KGJN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to administer Resident #12's and Resident #56's sliding scale insulin in accordance with the physician's orders [REDACTED].#12's blood sugar was recorded as 57. Resident #12 did not receive her sliding scale insulin coverage on 76 occasions when her blood sugar was in excess of 200 which required sliding scale coverage. This was during the time frame of 10/08/18 through current. Also on 01/25/19 the residents blood sugar was 57 and there was no evidence the facility implemented the hypoglycemic protocol. Resident #56 did not receive her sliding scale coverage on four (4) occasions when her blood sugar was in excess of 201 which required sliding scale coverage. This was from 02/09/19 through current. It was determined by the state agency (SA) that these failures place Resident #12 and Resident #56 at an immediate risk for serious harm and/or death placing Resident #12 and Resident #56 in an immediate jeopardy situation. At 12:30 p.m. on 04/09/19 the Nursing Home Administrator (NHA) and Director of Nursing (DON) was notified of the immediate jeopardy. The facility submitted a plan of correction (P[NAME]) at 1:29 p.m. on 04/09/19. The SA requested changes and new P[NAME] was submitted at 2:00 p.m The SA again requested changes and the final P[NAME] was submitted at 2:19 p.m. and was accepted by the SA at 2:27 p.m. The SA observed for implementation of the P[NAME] and determined it had been implemented. The IJ was abated at 4:50 p.m. on 04/09/19. This was true for two (2) of two (2) residents who receive sliding scale insulin coverage. After the IJ was abated a deficient practice remained therefore the scope and severity was decreased from a K to E. A deficient practice remained for Resident #35 the facility failed to ensure that the physician had provided orders for medications prior to them being administered. Finally, for Resident #54 the facility failed to respond an implement a smoking cessation program when the resident had requested one be implemented. These were all random opportunities for discovery. Resident identifiers: #12, #56, #35, and #54. Facility Census: 57. Findings included: a) Resident #12 1. Sliding Scale Insulin A review of Resident #12's medical record at 8:00 a.m. on 04/09/19 found the following physician orders: -- Order dated 10/08/18 [MEDICATION NAME] R Regular Insulin per sliding scale. 200 - 249 give 2 units, 250 - 299 give 4 units, 300 - 349 give 6 units, 350 - 400 give 8 units. BS (Blood Sugar) greater than 400 call physician. This ordered was an as needed order. -- Order dated 10/24/18 Accu Check twice daily at 6:00 a.m. and 6:00 p.m. Further review of the record found on the following occasions when Resident #12's blood sugar was elevated and she should have received sliding scale coverage and she did not: --10/08/18 - 6:01 p.m. blood sugar was 211. --10/08/18 - 8:02 p.m. blood sugar was 204. --10/10/18 - 1:11 p.m. blood sugar was 321. --10/11/18 - 8:03 a.m. blood sugar was 334. --10/11/18 - 12:09 p.m. blood sugar was 289. --10/12/18 - 8:17 a.m. blood sugar was 319. --10/12/18 - 4:27 p.m. blood sugar was 317. --10/12/18 - 8:13 p.m. blood sugar was 288. --10/14/18 - 2:58 p.m. blood sugar was 398. --10/16/18 - 8:03 a.m. blood sugar was 337. --10/16/18 - 5:10 p.m. blood sugar was 282. --10/16/18 - 8:19 p.m. blood sugar was 318. --10/21/18 - 7:49 p.m. blood sugar was 365. --10/22/18 - 8:45 p.m. blood sugar was 311. --10/23/18 - 8:46 p.m. blood sugar was 392. --10/24/18 - 4:47 a.m. blood sugar was 226. --10/24/18 - 9:46 a.m. blood sugar was 372. --10/24/18 - 6:09 p.m. blood sugar was 331. --10/26/18 - 5:37 p.m. blood sugar was 203. --10/29/18 - 5:07 a.m. blood sugar was 230. --10/30/18 - 5:44 a.m. blood sugar was 223. --10/31/18 - 5:34 p.m. blood sugar was 379. --11/02/18 - 5:52 p.m. blood sugar was 324. --11/05/18 - 9:09 p.m. blood sugar was 232. --11/12/18 - 5:54 a.m. blood sugar was 230. --11/12/18 - 8:00 p.m. blood sugar was 286. --11/13/18 - 5:24 p.m. blood sugar was 313. --11/14/18 - 5:06 a.m. blood sugar was 233. --11/16/18 - 5:27 a.m. blood sugar was 342. --11/17/18 - 5:04 a.m. blood sugar was 226. --11/17/18 - 5:25 p.m. blood sugar was 222. --11/19/18 - 5:05 a.m. blood sugar was 203. --11/20/18 - 5:46 p.m. blood sugar was 270. --11/21/18 - 5:24 p.m. blood sugar was 360. --11/23/18 - 5:03 p.m. blood sugar was 284. --11/24/18 - 5:13 p.m. blood sugar was 240. --11/25/18 - 5:13 a.m. blood sugar was 221. --11/26/18 - 5:53 p.m. blood sugar was 290. --11/28/18 - 5:01 p.m. blood sugar was 266. --11/30/18 - 5:30 a.m. blood sugar was 268. --11/30/18 - 5:01 p.m. blood sugar was 232. --12/03/18 - 5:09 p.m. blood sugar was 400. --12/07/18 - 5:14 p.m. blood sugar was 261. --12/09/18 - 5:07 a.m. blood sugar was 279. --12/09/18 - 5:35 p.m. blood sugar was 262. --12/15/18 - 6:01 a.m. blood sugar was 238. --12/19/18 - 5:12 p.m. blood sugar was 331. --12/22/18 - 5:42 p.m. blood sugar was 284. --12/23/18 - 5:57 p.m. blood sugar was 252. --12/25/18 - 6:05 a.m. blood sugar was 213. --12/26/18 - 5:15 a.m. blood sugar was 239. --12/27/18 - 9:43 a.m. blood sugar was 240. --12/27/18 - 5:15 p.m. blood sugar was 214. --12/28/18 - 5:45 a.m. blood sugar was 208. --12/31/18 - 5:16 p.m. blood sugar was 271. --01/01/19 - 5:34 a.m. blood sugar was 214. --01/03/19 - 7:19 p.m. blood sugar was 244. --01/04/19 - 5:06 a.m. blood sugar was 234. --01/05/19 - 5:10 p.m. blood sugar was 232. --01/06/19 - 5:00 p.m. blood sugar was 208. --01/11/19 - 5:05 p.m. blood sugar was 219. --01/13/19 - 5:28 p.m. blood sugar was 217. --01/19/19 - 5:08 p.m. blood sugar was 245. --01/23/19 - 5:24 p.m. blood sugar was 250. --01/25/19 - 5:38 p.m. blood sugar was 245. --01/26/19 - 5:45 a.m. blood sugar was 226. --01/31/19 - 5:34 p.m. blood sugar was 236. --02/06/19 - 5:24 a.m. blood sugar was 205. --02/19/19 - 5:16 p.m. blood sugar was 200. --02/24/19 - 6:38 p.m. blood sugar was 200. --03/07/19 - 5:00 a.m. blood sugar was 274. --03/11/19 - 6:18 p.m. blood sugar was 210. --03/12/19 - 5:04 a.m. blood sugar was 209. --03/26/19 - 5:07 a.m. blood sugar was 244. --04/02/19 - 5:09 p.m. blood sugar was 203. --04/07/19 - 5:46 a.m. blood sugar was 302. --04/08/19 - 5:06 a.m. blood sugar was 221. Review of the Medication Administration Record (MAR) found Resident #12 did not receive any sliding scale insulin on the above mentioned dates. An interview with the Director of Nursing (DON) at 11:00 a.m. on 04/09/19 confirmed Resident #12's insulin was not administered in accordance with the sliding scale insulin order. She stated that it should be recorded on the MAR when it is administered and it was not documented that it was given so it appears it was not administered. 2. Diabetic Protocol (Hypoglycemic Incident) A review of Resident #12's medical record at 8:00 a.m. on 04/09/19 found Resident #12's blood sugar was only 57. A review of the facility's Diabetic Protocol found the following, .If Glucose less than 60: If Resident is conscious, cooperative, and able to take fluids by mouth: -- Administer *(1) one full tube of glucose paste per package directions. Repeat glucose in 15 minutes. If glucose still less than 60, and resident remains stable as above repeat administration with another full tube of glucose paste (MONTH) give a total of 3 glucose pastes following same protocol before notifying physician. Recheck glucose in 15 minutes. If glucose greater than 60 with resident stable, notify physician on next facility round. Hold Scheduled insulin and oral hypoglycemic's until glucose greater than 200. Monitor glucose every 30 minutes time four (4), then every hour for two hours Further review of the medical record found no evidence the hypoglycemic protocol was ever implemented. An interview with the DON at 11:00 a.m. on 04/09/19 confirmed the hypoglycemic protocol was not implemented when the residents blood sugar was less than 60. b) Resident #56 A review of Resident #56's medical record at 10:00 a.m. on 04/09/19 found the following physician orders: -- Order Dated 04/28/18 which read Blood Sugar checks once a day at 7:00 p.m. This was an active order at the time of this review. -- Order dated 03/23/18 which read [MEDICATION NAME] R per sliding scale coverage if blood sugar is 201 - 250 give 4 units, 251 - 300 give 6 units, 301 - 350 give 8 units, 351 - 400 give 10 units, 401 - 450 give 14 units, 451 - 500 give 20 units, if blood sugar is greater than 500 call doctor. Further review of the record found on the following occasions when Resident #56's blood sugar was elevated and she should have received sliding scale coverage and she did not: -- 02/27/19 - 7:50 p.m. blood sugar was 278. -- 03/29/19 - 9:11 p.m. blood sugar was 235. -- 04/01/19 - 9:19 p.m. blood sugar was 236. -- 04/03/19 - 8:56 p.m. blood sugar was 231. An interview with the Director of Nursing (DON) at 11:00 a.m. on 04/09/19 confirmed Resident #56's insulin was not administered in accordance with the sliding scale insulin order. She stated that it should be recorded on the MAR when it is administered and it was not documented that it was given so it appears it was not administered. c) Facility's Plan of Correction The facility's plan of correction read as follows: 4-9-19 Physician order [REDACTED].#56 and #12 and to monitor glucose checks BID for 14 days, if less than 250mg/dL then decrease to 3 times a week. All licensed nursing staff in the building beginning 4-9-19, will be educated regarding use of Diabetic Protocol, followed by education provided during shift change to all incoming licensed nursing personnel and will continue until all licensed personnel have been educated. Daily audit for four weeks, then a weekly audit four weeks, followed by a random audit to be reviewed in morning meeting and in facility Quality Assurance meetings on any resident receiving sliding scale insulins. d) Resident #35 Review of the medical record found the resident was admitted to the facility on [DATE]. On 03/25/19, the resident returned to the facility from an outpatient procedure with the urologist. The facility had orders to hold the resident's Aspirin (ASA) and Eliquis 7 days prior to the procedure. The medication was held as directed. When the resident returned to the facility, the physician wrote hand written orders for, (MONTH) resume ASA and Eliquis when urine output is clear. Record review found a nurses note dated 03/25/2019 at 5:11 PM. Resident returned from (name of hospital/name of physician) at approximately 4:45 p.m. via (name of ambulance) wheelchair van without incident. Returned with two scripts. Keflex 500 mg one capsule PO (my mouth) Q (every) 8 hrs (hours) x 5 days. [MEDICATION NAME] 10 mg one tab PO QHS. Return appt. (appointment) Monday, (MONTH) 27, 2019 at 10:30 a.m. (MONTH) resume all meds except for anticoagulant medication, may resume that after urine clears up. A second nurses note dated 03/26/19 at 12:55 PM, .Resident had only voided once since returning from (name of hospital) as of medication pass time this AM. Urine is now clear and can resume ASA and Eliquis tomorrow. Review of the medication administration record found the medication was resumed. On 04/10/19 at 9:20 AM, the Director of Nursing (DON) was asked if a nurse can prescribe a medication without calling the physician for orders? The DON said the nurse would have looked at the resident's urine before resuming the medication. The DON could not find any evidence the physician was contacted and told by the nurse the urine was clear so the physician could order the medications ASA and Eliquis to be resumed. The DON was unable to verify how the nurse determined the urine was clear. The Resident's minimum data set (MDS) with an Assessment Reference Date (ARD) of 03/11/19 noted the resident was frequently incontinent of urine. e) R54 During a medical record review on 04/08/19 for R54 revealed the care plan had an approach to encourage resident to stop smoking and offer smoking-cessation assistance as desired, consult physician for nicotine patch/gum or other medication as needed. Further review of the Observation Book for the physician had a note on 01/02/19 for R54: Patient has agreed to try and quit smoking would like to start with low dose Nicotine Patch and decrease smoking gradually. In an interview with the director of nursing (DON) on 04/10/19 at 1:20 PM, she was unable to locate any evidence that R54 had been offered any smoking-cessation assistance to help her to decrease smoking.",2020-09-01
3321,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,697,D,0,1,KGJN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview and record review, the facility failed to provide appropriate pharmacological interventions in accordance with physician's orders [REDACTED]. Resident identifier: #27. Facility census: 57. Findings included: During initial resident screening on 04/08/19 at 12:49 PM, Resident #27 stated My tail bone hurts me when I am up in my wheelchair for a long time, and sometimes my neck hurts. I used to take Tylenol at home, and it helped. Not sure if I am getting it here. Resident has been deemed by the facilily's attending physician to have capacity to make her own decisions, and a Brief Interview for Mental Status (evaluation aimed at evaluating aspects of cognition in elderly patients) score of 15(highest score possible) out of 15 indicating intact cognitive response. Review of Medication Administration Record [REDACTED]. Progress note dated 03/01/19 by Registered Nurse (RN) #38 documented the following (typed as written): Resident up in bed watching TV. C/o (complain of) pain to right side of neck states she slept wrong. States there is a knot there. This nurse could not feel a knot in this area. Long LPN informed of need for pain medication. She states she [MEDICATION NAME] home to sleep and hasn't been sleeping well here. Will put on doctors board (observation book for facility's provider) . On 04/09/19 at 11:27 AM, review of med record revealed resident does not have any current pharmacological orders for pain. Resident's care plan was silent for pain managment interventions. On 04/09/19 at 4:45 PM Licensed Practical Nurse (LPN) #30 verified that the Resident (MONTH) #27 does not have an order for [REDACTED]. Review of medial record on 04/09/19 at 4:42 PM revealed progress note dated 03/01/19 entered by Registered Nurse (RN) #38 that documented the following (typed as written): Resident up in bed watching TV. C/o (complain of) pain to right side of neck states she slept wrong. States there is a knot there. This nurse could not feel a knot in this area. Long LPN informed of need for pain medication. She states she [MEDICATION NAME] home to sleep and hasn't been sleeping well here. Will put on doctors board (observation book for facility's provider) . At 4:50 PM on 04/09/19 review of Observation Book for the facility's attending physician revealed an entry dated 03/01/19 written by RN #38 that stated the following (typed as written): (Resident #27) takes Tylenol for arthritis at home. C/O(complained of) neck pain. Also [MEDICATION NAME] home for [MEDICAL CONDITION]. Here she has 2 tabs = 6mg [MEDICATION NAME]. On 04/10/19 at 9:18 AM during an interview the facility's attending physician verified that the check mark in the doctor's response column within the observation book log for communication regarding the resident with an entry date of 03/01/19 was his check mark and that it indicated he acknowledged the nurses request for Tylenol and [MEDICATION NAME] and he authorized those medications to be given. The facility's attending physician stated, It was also verbally presented to me the resident took these medications at home and I authorized the mediations to be continued, and to use [MEDICATION NAME] in the place of the Ambien. I don't know why the Tylenol was never ordered or given for pain, it should have been.",2020-09-01
3322,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,730,E,0,1,KGJN11,"Based on record review and staff interview, the facility failed to provide evidence of 12 contact hours for 3 of 5 sampled nurse aides. The facility failed to perform performace reviews for 3 of 5 sampled record reviews. Staff identifiers: #73, #69 and #52. Facility census 57. Findings included: a) NA #73 was hired on 09/20/10. Her records did not contain contact hours for inservice training done for (YEAR). The record provided no performance appraisal. b) NA #69 was hired on 09/12/17. Her record contained no inservice contact hours for (YEAR). The record contained no performance appraisal. c) NA #52 was hired on 06/05/18. Her record did not contain contact hours for inservice training done for (YEAR). The record contained no performance appraisal. d) During an interview, on 04/10/19 at 9:30 am, the Director of nursing (DON) stated she was unable to provide the contact hours for NA #73, #69 and #52. The DON stated she had been in the role of staff educator since the previous educator had left several weeks prior to the survey. The administrator was unable to provide explanation of the lack of performance appraisals.",2020-09-01
3323,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,732,E,0,1,KGJN11,"Based on review of facility records assignment sheets, staff postings and timecards, the facility failed to provide accurate staff posting for 04/05/19 and 04/06/19. Facility census 57. Findings included: a) Review of staff posting for 04/05/19 for the 2:00 PM to 10:00 PM shift indicated 4 nurse aides worked. Review of time cards indicated 3 nurse aides worked the entire shift. During an interview, on 04/09/19 at 4:34 pm, the DON stated the staffing assignment sheets and time cards were accurate not the staff posting. b) Review of staff posting for 04/06/19 for the 6:00 AM to 2:00 PM indicated 3 nurse aides worked. Review of the time cards indicated 2 nurse aides left the building during the shift. The DON and administrator both confirmed with the timecards that one NA was in the building from 9:20 AM until 2:22 PM. Both the the DON and administrator were aware of the staffing issue on 04/06/19.",2020-09-01
3324,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,755,E,0,1,KGJN11,"Based on policy review record review and staff interview, the facility failed to conduct appropriate reconciliation of a controlled substance at shift change for two (2) of two (2) medication carts reviewed medication storage. This practice has the potential to affect more than an isolated number of residents. Facility census: 57. Findings included: a) Long hall medication cart During observation of Long Hall medication cart on first floor on 04/09/19 at 1:35 pm, shift to shift narcotic key count record was reviewed and found to be non-compliant. Shift to shift narcotic key count was not completed and co-singed by both nurses (nurse coming on duty, nurse going off duty) for a total of thirteen (13) times for the time frame of 03/02/19 through 04/09/19. No records dating back any further than 03/02/19 were found for Long Hall medication cart. Licensed Practical Nurse (LPN) #30 verified the records were incomplete, and that is the way the facility verifies the narcotic count to be correct at the end of each shift and should be done each time a new nurse accepts keys to the mediation cart for use. During observation of Short Hall medication cart on first floor on 04/09/19 at 2:30 PM, shift to shift narcotic key count record was reviewed and found to be non-compliant. The shift to shift narcotic key count record log was not accurately completed and co-signed by both nurses (nurse going off duty, nurse coming on duty) for a total of seventeen (17) times since 01/09/19. Inaccurate shift to shift narcotic key count log was verified as inaccurate by Licensed Practical Nurse (LPN) #37, and LPN #37 stated that the shift to shift narcotic key count record should be completed at the end of every shift by the nurse responsible for that particular mediation cart. During an interview on 04/09/19 at 3:10 PM, Director of Nursing (DON) #14 verified the shift to shift key count record log used for reconciliation of narcotics at shift change were not completed in an accurate manner, and facility has no way of knowing if the proper reconciliation process for narcotics were performed at shift change. The DON also stated, I do not know where the sheets (shift to shift key count record) are for long hall med (mediation) cart dated any further back than what you have (March 2019), I cannot find them and no one else knows where they are either. Review of Controlled Substances policy revealed the following under shift change controlled drug count highlights: Nursing staff must count controlled mediations at the end of each shift. The nursing coming on duty and going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.",2020-09-01
3325,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,756,E,0,1,KGJN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the consulting pharmacist identified and reported irregularities with Resident #12's drug regimen to the attending physician and the Director of Nursing (DON). This was true for one (1) of seven (7) residents reviewed for the care area of unnecessary medications during the Long Term Care Survey Process. Resident Identifiers: #12. Facility Census: 57. Findings included: a) Resident #12 A review of Resident #12's medical record at 8:00 a.m. on 04/09/19 found the following physician orders: -- Order dated 10/08/18 [MEDICATION NAME] R Regular Insulin per sliding scale. 200 - 249 give 2 units, 250 - 299 give 4 units, 300 - 349 give 6 units, 350 - 400 give 8 units. BS (Blood Sugar) greater than 400 call physician. This ordered was an as needed order. -- Order dated 10/24/18 Accu Check twice daily at 6:00 a.m. and 6:00 p.m. Further review of the record found on the following occasions when Resident #12's blood sugar was elevated and she should have received sliding scale coverage and she did not: --10/08/18 - 6:01 p.m. blood sugar was 211. --10/08/18 - 8:02 p.m. blood sugar was 204. --10/10/18 - 1:11 p.m. blood sugar was 321. --10/11/18 - 8:03 a.m. blood sugar was 334. --10/11/18 - 12:09 p.m. blood sugar was 289. --10/12/18 - 8:17 a.m. blood sugar was 319. --10/12/18 - 4:27 p.m. blood sugar was 317. --10/12/18 - 8:13 p.m. blood sugar was 288. --10/14/18 - 2:58 p.m. blood sugar was 398. --10/16/18 - 8:03 a.m. blood sugar was 337. --10/16/18 - 5:10 p.m. blood sugar was 282. --10/16/18 - 8:19 p.m. blood sugar was 318. --10/21/18 - 7:49 p.m. blood sugar was 365. --10/22/18 - 8:45 p.m. blood sugar was 311. --10/23/18 - 8:46 p.m. blood sugar was 392. --10/24/18 - 4:47 a.m. blood sugar was 226. --10/24/18 - 9:46 a.m. blood sugar was 372. --10/24/18 - 6:09 p.m. blood sugar was 331. --10/26/18 - 5:37 p.m. blood sugar was 203. --10/29/18 - 5:07 a.m. blood sugar was 230. --10/30/18 - 5:44 a.m. blood sugar was 223. --10/31/18 - 5:34 p.m. blood sugar was 379. --11/02/18 - 5:52 p.m. blood sugar was 324. --11/05/18 - 9:09 p.m. blood sugar was 232. --11/12/18 - 5:54 a.m. blood sugar was 230. --11/12/18 - 8:00 p.m. blood sugar was 286. --11/13/18 - 5:24 p.m. blood sugar was 313. --11/14/18 - 5:06 a.m. blood sugar was 233. --11/16/18 - 5:27 a.m. blood sugar was 342. --11/17/18 - 5:04 a.m. blood sugar was 226. --11/17/18 - 5:25 p.m. blood sugar was 222. --11/19/18 - 5:05 a.m. blood sugar was 203. --11/20/18 - 5:46 p.m. blood sugar was 270. --11/21/18 - 5:24 p.m. blood sugar was 360. --11/23/18 - 5:03 p.m. blood sugar was 284. --11/24/18 - 5:13 p.m. blood sugar was 240. --11/25/18 - 5:13 a.m. blood sugar was 221. --11/26/18 - 5:53 p.m. blood sugar was 290. --11/28/18 - 5:01 p.m. blood sugar was 266. --11/30/18 - 5:30 a.m. blood sugar was 268. --11/30/18 - 5:01 p.m. blood sugar was 232. --12/03/18 - 5:09 p.m. blood sugar was 400. --12/07/18 - 5:14 p.m. blood sugar was 261. --12/09/18 - 5:07 a.m. blood sugar was 279. --12/09/18 - 5:35 p.m. blood sugar was 262. --12/15/18 - 6:01 a.m. blood sugar was 238. --12/19/18 - 5:12 p.m. blood sugar was 331. --12/22/18 - 5:42 p.m. blood sugar was 284. --12/23/18 - 5:57 p.m. blood sugar was 252. --12/25/18 - 6:05 a.m. blood sugar was 213. --12/26/18 - 5:15 a.m. blood sugar was 239. --12/27/18 - 9:43 a.m. blood sugar was 240. --12/27/18 - 5:15 p.m. blood sugar was 214. --12/28/18 - 5:45 a.m. blood sugar was 208. --12/31/18 - 5:16 p.m. blood sugar was 271. --01/01/19 - 5:34 a.m. blood sugar was 214. --01/03/19 - 7:19 p.m. blood sugar was 244. --01/04/19 - 5:06 a.m. blood sugar was 234. --01/05/19 - 5:10 p.m. blood sugar was 232. --01/06/19 - 5:00 p.m. blood sugar was 208. --01/11/19 - 5:05 p.m. blood sugar was 219. --01/13/19 - 5:28 p.m. blood sugar was 217. --01/19/19 - 5:08 p.m. blood sugar was 245. --01/23/19 - 5:24 p.m. blood sugar was 250. --01/25/19 - 5:38 p.m. blood sugar was 245. --01/26/19 - 5:45 a.m. blood sugar was 226. --01/31/19 - 5:34 p.m. blood sugar was 236. --02/06/19 - 5:24 a.m. blood sugar was 205. --02/19/19 - 5:16 p.m. blood sugar was 200. --02/24/19 - 6:38 p.m. blood sugar was 200. --03/07/19 - 5:00 a.m. blood sugar was 274. --03/11/19 - 6:18 p.m. blood sugar was 210. --03/12/19 - 5:04 a.m. blood sugar was 209. --03/26/19 - 5:07 a.m. blood sugar was 244. --04/02/19 - 5:09 p.m. blood sugar was 203. --04/07/19 - 5:46 a.m. blood sugar was 302. --04/08/19 - 5:06 a.m. blood sugar was 221. Review of the Medication Administration Record (MAR) found Resident #12 did not receive any sliding scale insulin on the above mentioned dates. An interview with the Director of Nursing (DON) at 11:00 a.m. on 04/09/19 confirmed Resident #12's insulin was not administered in accordance with the sliding scale insulin order. She stated that it should be recorded on the MAR when it is administered and it was not documented that it was given so it appears it was not administered. Further review of the medical record found the consulting pharmacist reviewed Resident #12's drug regimen on the following dates 11/30/18, 12/28/18, 01/29/19, 02/25/19, and 03/26/19. He identified no irregularities on these reviews. An interview with the DON at 10:30 a.m. on 04/10/19 confirmed the consulting pharmacist had not identified the fact Resident #12 had consistently missed doses of her sliding scale insulin.",2020-09-01
3326,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,758,E,0,1,KGJN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #53's drug regimen was free from unnecessary antipsychotic medications. The attending Physician agreed to discontinue Resident #53's Risperadal on/or about 03/26/19 this medication was never discontinued. Also Resident #53 had an as needed (PRN) order for the antipsychotic medication of [MEDICATION NAME] which was in effect for greater than 14 days. Also the medical record did not identify what specific condition and/or behaviors this medication was to be used for. This was true for one (1) of seven (7) residents reviewed for the care area unnecessary medications. Resident Identifier: #53. Facility Census: 57. a) Resident #53 1. [MEDICATION NAME] A review of Resident #53's medical record at 1:52 p.m. on 04/09/19 found an admission physician's orders [REDACTED]. A review of the observation book for (Name of Attending Physician) found the following in regards to Resident #53, 03/26/19 Can we possibly change Respirdone on (last name of Resident #53) to at night or discontinue all together she is more alert when we had to hold it two times on 03/25/19 and 03/26/19. Very lethargic and unresponsive on it. Unable to any meds in her when she is taking all of this. The physician responded to this on/or about 03/27/19 and replied to discontinue this medication. Further review of the medical record found no evidence this medication was discontinued. In fact review of the Medication Administration Record [REDACTED]. An interview with the Physician at 9:17 a.m. on 04/10/19 confirmed that he intended for the [MEDICATION NAME] to be discontinued. He stated, With something direct like that I just answer it in the observation book and the nurses will write the order. An interview with the Director of Nursing (DON) at 10:30 a.m. on 04/10/19 confirmed the [MEDICATION NAME] should have been discontinued and was not. 2. [MEDICATION NAME] A review of Resident #53's medical record at 1:52 p.m. on 04/09/19 found an order for [REDACTED]. Further review of the medical record found no documentation as to what target behaviors Resident #53 would need to exhibit in order for this medication to be administered. Additionally, there were no non pharmacological interventions put into place to attempt prior to the administration of this as needed antipsychotic behavior. An interview with the DON at 10:30 a.m. on 04/10/19 confirmed the record did not identify when to give this as needed [MEDICATION NAME] and no non pharmacological interventions were contained in the record.",2020-09-01
3327,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,770,E,0,1,KGJN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain several laboratory reports ordered by physician. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #35. Facility census: 57. Finding included: a) Resident #35 Review of the medical record found the resident was admitted to the facility on [DATE]. On 03/04/19 the physician ordered the following laboratory reports to be obtained before (MONTH) 31st: --BUN (Blood Urea Nitrogen) --CBC (complete blood count) with differential --Comprehensive Metabolic Panel --CPK ([MEDICATION NAME] phosphokinase) --Creatinine --Electrolytes --Glycohemoglobin --Hepatic Panel --Lipid Panel --Magnesium level --Free, T ([MEDICATION NAME]) 4 On 4/10/19 at 11:43 AM, the director of nursing (DON) verified the labs have never been obtained as ordered by the physician.",2020-09-01
3328,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,804,E,0,1,KGJN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview and record review, the facility failed to provide food and drink at a safe and appetizing temperature. Residents reported being served cold food that was not palatable. This had the potential to affect more than a limited number of residents. Resident identifiers: #25. Facility census: 57. Findings included: a) Resident #25 During an interview on 04/08/19 at 3:15 PM Resident #25 stated, The food isn't very good, I can't see and by the time they get around to feeding me it's always cold. On 04/10/19 11:28 observation for test tray started when staff started passing trays in short hall first floor. At 11:33 AM all lunch trays were reported to have arrived on the unit (long/short hall) with three (3) certified nursing assistants passing trays at that time. At 11:38 AM just prior to being served, notified staff that the last lunch tray left on meal cart will be tested . Test tray temperatures obtained by Dietary Manager (DM) #87 at 11:40 AM consisted of: --Mashed potatoes temperature 135 degrees Fahrenheit (F). --Zucchini temperature 110 degrees (F). --Pork Loin meat temperature 100 degrees (F) --Roasted potatoes temperature 100 degrees (F) --Scalloped apples 80 degrees (F) --Milk in carton temperature 35 degrees (F) DM #87 agreed that the food temperatures she obtained were below appropriate temperature maintenance at the time of service to Resident. DM # 87 provided the following Service Line temperatures for the lunch meal tested on [DATE]: --Mashed potatoes temperature 177 degrees Fahrenheit (F). --Zucchini temperature 176 degrees (F). --Pork Loin meat temperature 187 degrees (F) --Roasted potatoes temperature 181degrees (F) --Scalloped apples 130 degrees (F) --Milk in carton temperature 35 degrees (F)",2020-09-01
3329,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,812,E,0,1,KGJN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure food was stored in accordance with professional standards for food service safety. The kitchen and resident nutrition pantry had food that was expired, or opened an undated as to when it was opened. Also in the walk in cooler in the kitchen their was two 16.9 ounce bottles of water one of witch had been drank from which both belonged to employees and not residents. This practice has the potential to effect more than an isolated number of residents. Facility census: 57. Findings included: a) Initial tour of the kitchen at 11:00 a.m. on [DATE] with the Certified Dietary Manager (CDM) found the following: -- Two (2) 16.9 ounce bottles of water one of which had been drank from. When the CDM was asked if this was resident water or staff water she indicated that they belonged to the staff and should not have been in the walk in cooler. -- A 32 ounce container of honey thickened milk which had been opened an was not dated. -- Half gallon of Almond Milk which has been opened and not dated. A tour of the the first floor nutrition pantry (Refrigerator and items stored in the First Floor Medication room) at 11:15 a.m. on [DATE] found two (2) 32 ounce containers of vanilla med pass both had been opened. One was not dated as to when it was opened and the other one was dated to indicate it had been opened on [DATE]. When asked how long this item was good for after it had been opened the CDM stated it was only good for 72 hours.",2020-09-01
3330,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,835,E,0,1,KGJN12,"Based on record review, policy review and staff interview the facility failed to ensure that it was administered in a manner that used its resources effectively to ensure that each resident was able to maintain and/or attain their highest practicable physical, mental and psychosocial well - being. The facility had a Long Term Care Survey from 04/08/19 through 04/11/19 during which time they were issued citations that included F600, F609, F610, F684, F 697, F732, F755 and F867. The facility submitted a plan of correction and indicated they would have everything corrected by 05/29/19. A revisit survey was conducted from 07/22/19 through 07/23/19 at which time the following tags were recited F600, F609, F610, F684, F 697, F732, F755 and F867. Therefore the facility's administration failed to use its resources to correct identified deficient practices. This practice has the potential to effect all residents currently residing in the facility. Findings included: a) Cross reference deficiency cited at F600 b) Cross reference deficiency cited at F609 c) Cross reference deficiency cited at F 610 d) Cross reference deficiency cited at F684 e) Cross reference deficiency cited at F697 f) Cross reference deficiency cited at F732 g) Cross reference deficiency cited at F755 h) Cross reference deficiency cited at F867",2020-09-01
3331,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,838,C,0,1,KGJN11,"Based on review of the Facility Assessment and staff interview, the facility failed to ensure the assessment contained all the necessary components to evaluate its resident population and identify the resources needed to provide the necessary care and services the residents require. Information regarding staffing levels and competencies, facility resources necessary to provide for resident needs, health information technology resources, evaluation of the physical environment, and community based risk assessment were not included in the Facility Assessment. This had the potential to affect all residents residing at the facility. Facility census: 57. Findings included: a) Facility Assessment review On 04/10/19 at 12:46 PM, the administrator and the company president, Employee #88 were interviewed regarding the Facility Assessment. Information regarding the following components required for the assessment were not included in the copy provided by the facility: The staff competencies that are necessary to provide the level and types of care needed for the resident population. An evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident's needs. A competency-based approach to determine the knowledge and skills required among staff to ensure residents are able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. A review of individual staff assignments and systems for coordination and continuity of care for residents within and across these staff assignments. An evaluation of the facility's training program to ensure any training needs are met for all new and existing staff, individuals providing services under a contractual arrangement, and volunteers, consistent with their expected roles. The assessment should also include an evaluation of what policies and procedures may be required in the provision of care and that these meet current professional standards of practice. The facility assessment must include an evaluation of the physical environment necessary to meet the needs of the residents. This must include an evaluation of how the facility needs to be equipped and maintained to protect and promote the health and safety of residents. This should also include an evaluation of building maintenance capital improvements, or structures, vehicles, or medical and non-medical equipment and supplies. All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care. Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies. Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. The facility assessment must consider health information technology resources, such as managing resident records and electronically sharing information with other organizations. For example, the assessment should address how the facility will securely transfer health information to a hospital, home health agency, or other providers for any resident transferred or discharged from the facility. The facility based and community-based risk assessment, utilizing an all-hazards approach must evaluate the facility's ability to maintain continuity of operations and its ability to secure required supplies and resources during an emergency or natural disaster. The facility's emergency preparedness plans as required should be integrated and compatible with the facility assessment. At 4:30 PM on 04/10/19, the administrator and Employee #88 were interviewed again regarding the facility assessment. The facility provided a single sheet of paper entitled facility resources. [NAME] #88 said this should have been included in the facility assessment. The original document provided noted the facility assessment consisted of 20 pages. The additional page provided was not numbered at the bottom as were the original 20 pages presented. At the close of the survey on 04/10/19 at 7:00 PM, no further information was provided.",2020-09-01
3332,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,867,F,0,1,KGJN11,"Based on staff interviews and review of facility records, the facility failed to review/revise QAPI plan on an annual basis. This has the potential to affect all residents. Facility census 57. Findings included: a) Review of the QAPI plan revealed it was last reviewed (MONTH) 28, (YEAR). The QAPI stated it was to be reviewed and/or revised on an annual basis. b) During an interview on 04/10/19 at 1:57 pm, the administrator stated the QAPI plan had last been reviewed (MONTH) 28, (YEAR).",2020-09-01
3333,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2019-04-11,924,E,0,1,KGJN11,"Based on observation and staff interview the facility failed to ensure the facility corridors had handrails which were accessible to all residents. This failure had the potential to effect 10 of 10 residents residing on the 2nd floor of the facility. This has the potential to effect more than an isolated number of Residents. Facility Census: 57. Findings included: a) A tour of the second (2nd) floor of the facility with the Nursing Home Administrator (NHA) on 04/10/19 at 11:20 a.m. found there were no handrails in the corridors. When asked about this the NHA stated, Yes we know that we need to get hand rails up here. We have talked to the owners and will hopefully have some soon. She further stated, We have never had handrails up here but definitely need too. b) An additional interview with the NHA found that the 2nd floor unit has always been designated as a long term care unit. It has not always had residents on the unit but it has always been designated for long term care residents.",2020-09-01
3884,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2016-08-19,225,E,0,1,5Q6I11,"Based on a random opportunity for discovery, staff interview, policy review, review of the abuse/neglect reporting requirements for West Virginia nursing homes and nursing facilities, and review of an employee disciplinary action form, the facility failed to thoroughly investigate and report allegations of neglect/abuse to the appropriate State agencies immediately in accordance with State law. This had the potential to affect more than an isolated number of residents. Resident identifiers: #91 and #77. Facility census: 75. Findings include: a) Employee disciplinary action form 1. On 08/16/16 at 4:00 p.m., an unrequested employee education and counseling form was found lying beside a surveyor's computer in the conference room where surveyors were working. No personnel files were in the room as there were times when no members of the survey team were present. How the document came to be in the conference room could not be determined. The employee education and counseling form included: - The name of Nurse Aide (NA) #74 - Date of the employee education and counseling form: 06/02/16 - The form required documentation for Area of Improvement: Define Situation. Poor Resident care-Resident's are being left up in wheelchairs without being checked on. Resident's are not being put to bed in a timely manner. (Name of Resident #91) reported that you were very hateful and rough putting her feet in the bed this evening. Also, she stated that last week you took her call light from her. (Name of Resident #77) does not want you to do her showers after your attitude last week. This is unacceptable work performance. Told oncoming CNA (certified nurse aide) that Resident didn't want her shirt off when in fact resident was never checked on. - The resolution for action taken: CNA needs to be aware that we are here to take care of the needs of the resident. This is the 2nd employee counseling/education form from this nurse. Next is written warning, followed by suspension and then termination if this problem isn't corrected. CNA needs to have better time management skills and try to do something's by herself. NA #74 responded to the counseling form by documenting: It's hard to do care when you have to ask 4-5 times for help when the person has to have 2 people to sit over onto the bed to get them changed. I am not rough with any pt. (patient) and I do not have an attitude towards any of them. The counseling form was signed by NA #74 and Licensed Practical Nurse (LPN) #62 on 06/02/16. The counseling form did not list the residents' names that were, Being left up in wheelchairs without being checked on. 2. On 08/16/16 at 4:20 p.m., review of the facility's grievance/concern forms and reportable allegations of abuse/neglect for the period 06/02/16 to present, found no evidence facility reported the allegations related to NA #74 to the required State agencies. Additionally, there was no evidence the facility investigated the allegations regarding NA #74. 3. Staff Interviews At 4:48 p.m. on 08/16/16, after being shown the counseling form, Social Worker (SW) #67 said, This is the first time I have ever seen this. It looks like we would have checked into it to see if it was a reportable. At 5:06 p.m. on 08/16/16, the director of nursing (DON) said, I didn't know anything about this, when shown the counseling form. She stated she would typically see the education forms. She said the Clinical Care Supervisor (CCS) might know something about the form and added The nurse is supposed to get permission from the CCS to discipline employees. At 5:14 on 08/16/16 CCS #95 said, I might have seen this, I don't know. At 8:52 on 08/17/16, SW #67 verified the allegations on the employee education form dated 06/02/16, had never been investigated, or reported. At 10:40 a.m. on 08/17/16, when asked if she had any further information to show the facility had investigated and/or reported the allegations concerning NA#74 to the required State agencies before surveyor intervention, she said the nurse who completed the education form was educated. The DON said the issues detailed on the education form were being reported to the State agencies as required. The DON confirmed the allegations were reported after surveyor intervention. 4. Review of the facility's policy and procedure for, Abuse, Neglect and Misappropriation of Resident Property: Protection of Resident's, Reporting, and Investigation, at 11:00 a.m. on 08/17/16 found it included: . 6. Upon receiving information regarding an allegation of abuse or neglect the Executive director or designee shall: a. Immediately refer to the Step One: Decision Tree for Determining the Reportability of an Incident or Allegation and Step Two: Internal and External Notification of A Reportable Incident or Allegation (see Tables 1 and 2) to assure notification if the event is reportable and initiate an investigation. b. Report the allegation (s) to the appropriate state agencies within the required time frames. Refer to reference, NH (nursing home) Reporting Requirements 06/2012, for information on reporting requirements. c. Initiate an investigation. The investigation shall be immediate and thorough. All interviews will be documented on a witness statement and will be conducted in the presence of the Executive Director or his/her designee e. The investigation will be completed on the state required forms",2020-04-01
3885,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2016-08-19,226,D,0,1,5Q6I11,"Based on a random opportunity for discovery, staff interview, policy review, review of the abuse/neglect reporting requirements for West Virginia nursing homes and nursing facilities, and review of an employee disciplinary action form, the facility failed to implement its policy for investigation and reporting of allegations of abuse and neglect. This had the potential to affect more than an isolated number of residents. Resident identifiers: #91 and #77. Facility census: 75. Findings include: a) Employee disciplinary action form 1. On 08/16/16 at 4:00 p.m., an unrequested employee education and counseling form was found lying beside a surveyor's computer in the conference room where surveyors worked when not out on the nursing units. No personnel files were in the room as there were times when no members of the survey team were present. How the document came to be in the conference room could not be determined. The employee education and counseling form included: - The name of Nurse Aide (NA) #74 - Date of the employee education and counseling form: 06/02/16 - The form required documentation for Area of Improvement: Define Situation. Poor Resident care-Resident's are being left up in wheelchairs without being checked on. Resident's are not being put to bed in a timely manner. (Name of Resident #91) reported that you were very hateful and rough putting her feet in the bed this evening. Also, she stated that last week you took her call light from her. (Name of Resident #77) does not want you to do her showers after your attitude last week. This is unacceptable work performance. Told oncoming CNA (certified nurse aide) that Resident didn't want her shirt off when in fact resident was never checked on. - The resolution for action taken: CNA needs to be aware that we are here to take care of the needs of the resident. This is the 2nd employee counseling/education form from this nurse. Next is written warning, followed by suspension and then termination if this problem isn't corrected. CNA needs to have better time management skills and try to do something's by herself. NA #74 responded to the counseling form by documenting: It's hard to do care when you have to ask 4-5 times for help when the person has to have 2 people to sit over onto the bed to get them changed. I am not rough with any pt. (patient) and I do not have an attitude towards any of them. The counseling form was signed by NA #74 and Licensed Practical Nurse (LPN) #62 on 06/02/16. The counseling form did not list the residents' names that were, Being left up in wheelchairs without being checked on. 2. On 08/16/16 at 4:20 p.m., review of the facility's grievance/concern forms and reportable allegations of abuse/neglect for the period 06/02/16 to present, found no evidence facility reported the allegations related to NA #74 to the required State agencies. Additionally, there was no evidence the facility investigated the allegations regarding NA #74. 3. Staff Interviews At 4:48 p.m. on 08/16/16, after being shown the counseling form, Social Worker (SW) #67 said, This is the first time I have ever seen this. It looks like we would have checked into it to see if it was a reportable. At 5:06 p.m. on 08/16/16, the director of nursing (DON) said, I didn't know anything about this, when shown the counseling form. She stated she would typically see the education forms. She said the Clinical Care Supervisor (CCS) might know something about the form and added The nurse is supposed to get permission from the CCS to discipline employees. At 5:14 on 08/16/16 CCS #95 said, I might have seen this, I don't know. At 8:52 on 08/17/16, SW #67 verified the allegations on the employee education form dated 06/02/16, had never been investigated, or reported. At 10:40 a.m. on 08/17/16, when asked if she had any further information to show the facility had investigated and/or reported the allegations concerning NA #74 to the required State agencies before surveyor intervention, she said the nurse who completed the education form was educated. The DON said the issues detailed on the education form were being reported to the State agencies as required. The DON confirmed the allegations were not reported until after surveyor intervention. 4. State reporting requirements include Nursing Home Licensure Rule Chapter 16, Title 63 and WV Code 9-6-1. 5. Review of the facility's policy and procedure for, Abuse, Neglect and Misappropriation of Resident Property: Protection of Resident's, Reporting, and Investigation, at 11:00 a.m. on 08/17/16 found it included: . 6. Upon receiving information regarding an allegation of abuse or neglect the Executive director or designee shall: a. Immediately refer to the Step One: Decision Tree for Determining the Reportability of an Incident or Allegation and Step Two: Internal and External Notification of A Reportable Incident or Allegation (see Tables 1 and 2) to assure notification if the event is reportable and initiate an investigation. b. Report the allegation (s) to the appropriate state agencies within the required time frames. Refer to reference, NH (nursing home) Reporting Requirements 06/2012, for information on reporting requirements. c. Initiate an investigation. The investigation shall be immediate and thorough. All interviews will be documented on a witness statement and will be conducted in the presence of the Executive Director or his/her designee e. The investigation will be completed on the state required forms",2020-04-01
3886,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2016-08-19,241,D,0,1,5Q6I11,"Based on observations, resident interview, and staff interview, the facility failed to provide dignity for one (1) of three (3) residents for the care area of dignity. The facility failed to assist Resident #31 with removal of long hair on her chin, around her upper lip and the corners of her mouth. Resident identifier: #31. Facility census: 75. Findings include: Resident #31 Observations during Stage I of the Quality Indicator Survey on 08/16/16 at 9:55 a. m. revealed Resident #31 had long hair on her chin and around her upper lip and corners of her mouth. In an interview with the Resident #31 on 08/16/16 at 1:57 p.m., she stated, I am 62, and I cannot remove the hair off my chin or around my lips. They do not remove the hair. I will have to wait until I get out of here in order to have someone to remove the hair. In an interview and observation with Nurse Aide (NA) #117 on 08/16/16 at 2:06 p.m., she confirmed the resident did have long hair on her upper lip, around the corners of her lips, and on her chin. The NA confirmed that she took care of this resident and she had never removed the hair on the resident's face. On 08/16/16 at 2:15 p.m., review of Resident #31's admission minimum data set (MDS) assessment with the assessment reference date (ARD) of 06/09/16 found Resident #31 scored a 15 on her Brief Interview for Mental Status (BIMS - a test to help determine a resident's cognitive abilities), indicating the resident was cognitively intact. The MDS also identified the resident required the extensive assistance of staff to maintain her personal hygiene, which includes shaving. In an interview on 08/16/2016 2:33 p.m., Licensed Practical Nurse (LPN) #36 stated, Yes ma'am, she has hair on her chin, upper lip and corners of her mouth and I do not know if anyone has ever asked her if she would like to have them removed. She said she did not have to go and look at her she knew the resident had hair on her chin and around her lips. The LPN stated, The resident is blind and she cannot see the hair on her chin, and around her lip.",2020-04-01
3887,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2016-08-19,279,D,0,1,5Q6I11,"Based on record review and staff interview the facility failed to develop a comprehensive care plan that contained measurable objectives (goals) regarding his inappropriate sexual behaviors. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #24. Facility Census: 75. Findings Include: a) Resident #24 A review of his medical record on 08/17/16 02 at 12:30 p.m., found the resident's care plan included a focus statement (typed as written) of, Sexual inappropriateness, making comments about staffs body parts. Mades (sic) comments when they bend over or provide any type of continence care. Often says he cannot clean his private area when certain staff are working and demands that they provide the care although he can do so himself. This focus statement was added to his care plan on 09/01/15. The goal associated with this focus statement was (typed as written), Patient will have no complications from (SPECIFY) through next review date. This goal, initiated on 09/01/15, was reviewed/revised on 08/12/16, 07/28/16, 05/04/16, 02/12/16, 02/03/16, and 11/11/15. On none of these dates was there a measurable goal defined. In an interview at 3:24 p.m. on 08/17/16, the Director of Nursing (DON) confirmed the goal was never developed. She agreed they needed to specify what the targeted behaviors were instead of leaving the word specify on the care plan.",2020-04-01
3888,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2016-08-19,280,D,0,1,5Q6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revised the care plans for two (2) of twenty-one (21) residents whose care plans were reviewed during Stage 2 of the Quality Indicator Survey. The facility failed to revise Resident #31's care plan to address her refusal of her showers. In addition, the care plan for Resident #46 was not revised to address how often the resident's Foley catheter should be changed and by whom. Resident Identifiers: #31 and #46. Facility census: 75. Findings include: a) Resident #31 In an interview with Nurse Aide (NA) #117 on 08/16/16 at 1:57 p.m., she reviewed Resident #31's information on the kiosk (a computer system that displays information about a resident's care needs to direct care staff, where they document the care provided) and replied that Resident #31 had refused her shower that day. The NA confirmed the resident was to receive her showers on Tuesday and Friday. The NA said the resident often refused her showers. On 08/16/16 at 1:45 p.m., review of Resident #31's care plan found a plan initiated on 06/16/16 regarding the resident resisting care at times related to anxiety, adjustment to the nursing home, and that she could become verbally abusive toward staff. The care plan focus did not identify the resident refused showers, nor were individualized interventions established for what staff should do when the resident refused her showers. The care plan initiated on 06/14/16 related to the resident's activity of daily living self-care deficit due to [MEDICAL CONDITIONS], anxiety, and a history of falls did not address the resident's refusal of showers either. In an interview with the unit charge nurse, Licensed Practical Nurse (LPN) #36 at 2:27 p.m. on 08/16/16, when asked whether Resident #31 refused her showers, the LPN said the resident did not want her shower today. The LPN said the shower team asked for a NA on the floor to shower the resident in her room as the resident preferred to shower in her room, but the resident had refused that day. The LPN stated, The resident allows the staff to shower her once a week and provided progress notes revealing Resident #31 had refused her showers on 06/03/16, 06/20/16, 07/01/16, 07/08/16, 07/19/16, 07/22/16, 08/05/16, and 08/09/16. After reviewing Resident #31's care plan, the LPN confirmed the care plan needed revised to address the resident's refusal of showers. The LPN stated, I will revise (resident's name) care plan to reflect this. b) Resident #46 On 08/17/16 at 9:00 a.m., review of Resident #46's quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 06/01/16, found Resident #46 had a disorder of his bladder, [MEDICAL CONDITION] (condition in which the flow of urine is blocked), and an indwelling Foley catheter. A review of the Resident #46's (MONTH) (YEAR) physician's orders [REDACTED]. The order directed to change the catheter every month and whenever needed (PRN) and to change the drainage bag whenever the catheter was changed related to obstructive and reflux [MEDICAL CONDITION] (urine flows backward). Resident #46's care plan, reviewed on 08/17/16 9:30 a.m., included a plan for the Foley catheter for [MEDICAL CONDITION]. The plan initiated on 09/09/15 and revised on 03/11/16, include an intervention to change the catheter every six (6) weeks and that the catheter be changed at (doctor's name) office. During an interview with Director of Nursing (DON) #83 on 08/17/16 at 10:17 a.m., the DON reviewed the care plan for changing the catheter every 6 weeks at the doctor's office and the doctor's order for (MONTH) (YEAR) to change the catheter every month. After reviewing the care plan and doctor's orders, the DON said the physician order [REDACTED]. The DON stated, The resident did at first go out to have the Foley catheter changed, but now her staff are allowed to change the Foley. The DON said they change the resident's catheter, not every six (6) weeks as the care plan stated. The DON confirmed the care plan needed revised to reflect the physician's current order. When asked how long had staff been allowed to change the Foley catheter, the DON said she would have to check. The DON reported the nursing staff had been changing Resident #46's Foley catheter monthly since (MONTH) (YEAR).",2020-04-01
3889,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2016-08-19,282,E,0,1,5Q6I11,"Based on record review and staff interview, the facility failed to ensure implementation of his care plan in regards to his risk for dehydration. This was true for one (1) of three (3) residents reviewed for the care area of hydration during Stage 2 of the Quality Indicator Survey. Resident Identifier: #24. Facility Census: 75. Findings include: a) Resident #24 A review of Resident #24's medical record at 8:25 a.m. on 08/18/16 found a care plan focus initiated 12/04/15 of, (typed as written) (Resident #24's Name) has potential dehydration or potential fluid deficit r/t (related to) Diuretic use. The goal associated with this care plan was, (typed as written) Patient will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor through review period. This goal, last reviewed on 08/12/16, had no changes made to it since first initiated on 04/01/15. The interventions related to this focus statement and goal included, (typed as written) Monitor and notify physician of acute symptoms leading to or indicative of dehydration, including persistent symptoms of diarrhea; nausea/vomiting unresolved past 48 hours; persistent output exceeding intake past 48 hours; abnormal labs (laboratory). Further review of his medical record found the resident's intakes and outputs were recorded on a daily basis. Review of the intake and output records found the following: --On 05/11/16 - his output was 75 cubic centimeters (cc) greater than his intake. --On 05/12/16 - his output was 1750 cc greater than his intake. --On 05/13/16 - his output was 930 cc greater than his intake. --On 05/25/16 - his output was 1390 cc greater than his intake. --On 05/26/16 - his output was 170 cc greater than his intake. --On 05/27/16 - his output was 1140 cc greater than his intake. --On 05/28/16 - his output was 1470 cc greater than his intake. --On 06/17/16 - his output was 1940 cc greater than his intake. --On 06/18/16 - his output was 1180 cc greater than his intake. --On 06/19/16 - his output was 250 cc greater than his intake. --On 06/20/16 - his output was 1860 cc greater than his intake. --On 06/29/16 - his output was 260 cc greater than his intake. --On 06/30/16 - his output was 560 cc greater than his intake. --On 07/01/16 - his output was 1900 cc greater than his intake. --On 07/02/16 - his output was 1990 cc greater than his intake. --On 07/03/16 - his output was 1440 cc greater than his intake. --On 07/04/16 - his output was 520 cc greater than his intake. --On 07/05/16 - his output was 1680 cc greater than his intake. --On 07/11/16 - his output was 2640 cc greater than his intake. --On 07/12/16 - his output was 1770 cc greater than his intake. --On 07/13/16 - his output was 1840 cc greater than his intake. --On 07/14/16 - his output was 120 cc greater than his intake. --On 07/15/16 - his output was 50 cc greater than his intake. --On 07/16/16 - his output was 180 cc greater than his intake. --On 07/17/16 - his output was 780 cc greater than his intake. --On 07/18/16 - his output was 780 cc greater than his intake. --On 07/23/16 - his output was 720 cc greater than his intake. --On 07/24/16 - his output was 940 cc greater than his intake. --On 07/25/16 - his output was 1560 cc greater than his intake. --On 07/26/16 - his output was 170 cc greater than his intake. --On 07/27/16 - his output was 2380 cc greater than his intake. --On 07/28/16 - his output was 1220 cc greater than his intake. --On 08/09/16 - his output was 1820 cc greater than his intake. --On 08/10/16 - his output was 280 cc greater than his intake. --On 08/11/16 - his output was 255 cc greater than his intake. Although the resident's output exceed his intake from, - 05/11/16 through 05/13/16, - 05/25/16 through 05/28/16, - 06/17/16 through 06/20/16, - 06/29/16 through 07/05/16, - 07/11/16 through 07/18/16, - 07/23/16 through 07/28/16, and - 08/09/16 through 08/11/16, there was no evidence in the medical record of his attending physician being notified as directed by the resident's care plan. An interview with Clinical Care Supervisor #95 at 9:19 a.m. on 08/18/16 confirmed that according to the care plan the attending physician should have been notified of these instances when his output exceeded his intake for greater than 48 hours. She said she would have to review his medical record to see whether the physician was notified or not. During an additional interview at 10:36 a.m. on 08/18/16, Clinical Care Supervisor #95 reported she could find no evidence his attending physician was notified of the instances when the resident's output exceeded his intake for greater than 48 hours. She agreed they did not implement his dehydration care plan, but made mention that they would need to look at the care plan for possible revision because due to his diuretic use it was an expectation that his output would exceed his intake.",2020-04-01
3890,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2016-08-19,312,D,0,1,5Q6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, and staff interview, the facility failed to ensure residents who were unable to carry out activities of daily living, received care and services for grooming. This was true for two (2) of three (3) residents reviewed for the care area of activities of daily living (ADL). Resident identifiers: #52 and #31. Facility census: 75. Findings include: a) Resident #52 Observation of the resident at 12:02 p.m. on 08/15/16 found she had multiple, noticeable, dark, long hairs on her chin. Review of the resident's most recent minimum data set (MDS), a quarterly, with an assessment reference date (ARD) of 08/01/16, found the resident required the extensive assistance of one staff member for personal hygiene. Personal hygiene is defined on the MDS as combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers). During an interview on 4:12 p.m. on 08/16/16, the resident's Nurse Aide (NA), NA #33, said the resident did not want anything done about the hairs on her chin. At 4:19 p.m. on 08/16/16, the resident was interviewed in her room with Licensed Practical Nurse (LPN) #55 present. The resident said she wanted the hairs gone - I don't want to look like a man. LPN #55 said he would get a razor and have NA #33 take care of the issue immediately. b) Resident #31 Observation on 08/16/16 at 9:55 a. m., during Stage I of the Quality Indicator Survey, revealed Resident #31 had long hair on her chin and around her upper lip and corners of her mouth. In an interview with Resident #31 on 08/16/16 at 1:57 p.m., she stated, I am 62, and I cannot remove the hair off my chin or around my lips. They do not remove the hair. I will have to wait until I get out of here in order to have someone to remove the hair. In an interview and observation with NA #117 on 08/16/16 at 2:06 p.m., NA #117 confirmed the resident did have long hair on her upper lip, around her lips and on her chin. The NA confirmed that she took care of this resident and she had never removed the hair. The NA said the resident required the assistance of one (1) NA for her personal hygiene such as shaving. A review of the care plan found the resident needed assistance with ADL self-care related to [MEDICAL CONDITIONS], anxiety, and a history of falls. The resident required the assistance of one (1) staff member for personal hygiene. On 08/16/16 at 2:15 p.m., review of Resident #31's admission minimum data set (MDS) assessment with an assessment reference date (ARD) of 06/09/16, found Resident #31 scored a 15 on her Brief Interview for Mental Status (BIMS). The BIMS is a test that helps determine a resident's cognitive abilities (such as thinking, understanding, learning, and remembering). A BIMS score of 13-15 indicates an individual is cognitively intact. The MDS also revealed the resident required extensive assistant in order to maintain her personal hygiene, which includes shaving. In an interview, on 08/16/2016 2:33 p.m., Licensed Practical Nurse (LPN) #36 stated, Yes ma'am, she has hair on her chin, upper mouth and corners of her mouth, and I do not know if anyone has ever asked her if she like to have them removed. She said she did not have to go and look at her she knew the resident had hair on her chin and around her lips. The LPN stated, The resident is blind and she cannot see the hair on her chin, and around her lips. The LPN said that Resident #31 was dependent on staff for her personal hygiene. She confirmed staff had not assisted Resident #31 with that aspect of her personal hygiene.",2020-04-01
3891,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2016-08-19,412,D,0,1,5Q6I11,"Based on resident interview, staff interview, and medical record review, the facility failed to ensure one (1) of three (3) resident's reviewed for the care area of dental services, received a follow up dental appointment. Resident identifier: #52. Facility census: 75. Findings include: a) Resident #52 Observation of the resident's oral cavity at 12:05 p.m. on 08/15/16, found the resident had several missing teeth and teeth that appeared to be broken off at the gum line. Review of the last annual minimum data set (MDS) assessment, with an assessment reference date (ARD) of 02/08/16 noted the resident assessed as having obvious or likely cavities or broken natural teeth. On 07/02/15, the resident had a dental consult. The consult noted the resident needed surgical extraction of teeth #03, #05, #18, #20, and #29 (teeth are numbered 1 through 32 beginning with the left upper molar). The resident had poor oral hygiene and generalized gingivitis. Further review of the medical record found no evidence the resident had received a follow up dental appointment to have the teeth extracted. On 08/17/16 at 8:13 a.m., Registered Nurse (RN) #95 was asked if the facility had scheduled a follow up appointment for the resident? At 9:17 a.m. on 08/17/16, RN #95 provided nursing notes dated 07/06/15 and 07/07/15 indicating the facility had tried to contact the resident's responsible party, the Department of Health and Human Services (DHHR). RN #95 said, I guess we dropped the ball, when they (the DHHR) never signed and returned the consent papers. RN #95 was unable to provide any evidence the facility pursued the removal of the resident's teeth after contacting the DHHR on 07/07/15.",2020-04-01
3892,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2016-08-19,514,E,0,1,5Q6I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, physician interview, and staff interview, the facility failed to ensure the medical records of four (4) of twenty-one (21) residents whose medical records were reviewed during Stage 2 of the Quality Indicator Survey were complete and accurate. Resident #1's medical record did not contain the results of an esophagogastroduodenoscopy (EGD). Resident #27's physician orders did not contain the milligrams (mg) of a medication ordered by the physician. Resident #82's medical record contained a physician's order that belonged to a different resident. Resident #52's medical record did not support an attempted Gradual Dose Reduction (GDR) failed. Resident Identifiers: #1, #27, #82, and #52. Facility Census: 75. Findings Include: a) Resident #1 A review of Resident #1's medical record at 1:18 p.m. on 08/16/16 found a nursing progress note dated 04/04/16 that was an appointment/return note. This note indicated that Resident #1 had returned from her scheduled EGD and the results of the EGD were sent back with the resident and reviewed at that time. Further review of the record revealed the results of the EGD were not contained in the medical record. On 08/17/16 at 11:05 a.m., Medical Records Assistant #16 provided a copy of the EGD results. When asked where these results were located, she indicated she had to call and get a new copy faxed to the on that day because the results received on 04/04/16 could not be located at the facility. b) Resident #27 Observation during the medication administration pass on 08/17/16 at 8:14 a.m., revealed Unit Charge Nurse - Licensed Practical Nurse (UCN-LPN) #108 administered Resident #27's Senna 8.6 milligram (mg) two (2) tablets via gastrostomy tube (a tube used to provide nutrition, fluids, and medications who cannot safely swallow.). A review of Resident #27's (MONTH) (YEAR) physician's order on 08/18/16 at 8:45 a.m., revealed the resident received Senna 2 tablets via [DEVICE] 2 times a day for constipation. This was an incomplete order as there was no dosage provided in the order. A review of the resident's (MONTH) (YEAR) Medication Administration Record [REDACTED]. The dosage was not specified. Senna tablets are available in a number of dosages such as 8.6 mg, 17.2 mg, 25 mg, etc. In an interview with LPN #108 at 9:05 a.m., she said the order, originally written on 11/13/14 by their nurse practitioner (NP), was for Senna (a laxative) 2 tablets by mouth twice a day (bid) for constipation. A clarification order was written the same day to change the route of administration from by mouth to by [DEVICE]. The LPN said the NP and physician know we only give stock medication in which the Senna is 8.6 mg. The LPN stated, I will get a clarification order related to the amount of milligrams to be given. On 08/18/16 at 9:15 a.m., the LPN provided a physician's order to clarify the physician wanted the resident to take Senna Plus (a stool softener and laxative combination) 8.6/50 mg 2 tablets 2 times a day. c) Resident #82 Review of Resident #82's medical records, on 08/16/16 at 1:30 p.m., revealed a scanned physician's order dated 05/12/16 for Resident #100. On 08/17/16 10:28 a.m., during an interview with LPN #108, the LPN confirmed the scanned order for Resident #100 should not have been scanned into Resident #82's electronic medical record. Medical records corrected this error. d) Resident #52 Record review at 12:57 p.m. on 08/16/16 found a pharmacist's recommendation dated 06/18/16 for a dose reduction of [MEDICATION NAME] 50 milligrams (mg) at bedtime, which the resident had received since 11/11/15. On 06/23/16, the physician reduced the [MEDICATION NAME] to 25 mg at bedtime. On 06/30/16, the resident's [MEDICATION NAME] was increased to 50 mg (25 mg in the morning and 25 mg at night). Review of a physician's progress note, dated 06/30/16, found, Increase [MEDICATION NAME] to 25 mg BID (two times a day) due to failed GDR (gradual dose reduction). The patient will be treated in a supportive manner. All attempts will be made to make the patient comfortable and safe. The physician also noted .staff reporting change in patient's behavior; refusing to ambulate, yelling out and not helping perform her ADL's (activities of daily living) Review of the nursing notes from 06/23/16 to 06/30/16 found the following documentation: - At 1:15 p.m. on 06/23/16, the resident was yelling out at various intervals, (this behavior was before the actual dose reduction that did not occur until the bedtime dose at 9:00 p.m. on 06/23/16. - At 5:45 a.m. on 06/24/16, .No behaviors observed or reported thus far this shift. - At 11:17 a.m. on 06/24/16, .Has had no abnormal behaviors thus far - At 5:54 a.m. on 06/25/16, .no abnormal behaviors observed or reported thus far this shift - At 2:48 p.m. on 06/25/16, .Resident has been free of behaviors thus far during shift. Calm and cooperative with staff and other residents. - At 12:45 a.m. on 06/26/16, .No yelling observed thus far this shift. No negative behaviors observed or reported due to decrease in [MEDICATION NAME]. - At 2:48 p.m. on 06/26/16, .Resident has been free of behaviors thus far during shift - At 11:27 p.m. on 06/26/16, .No yelling, cursing or negative behaviors observed or reported - 10:14 a.m. on 06/27/16, .No abnormal behaviors have been observed thus far this shift - At 4:18 a.m. on 06/28/16, .No noted distress - 4:15 a.m. on 06/29/16, .No abnormal behaviors observed or reported thus far this shift - At 5:01 p.m. on 06/29/16, .Resident has been free of behaviors thus far during shift - At 4:34 a.m. on 06/30/16, .No behaviors observed thus far this shift At 7:58 a.m. on 08/17/16, after reviewing the nurses' notes, Registered Nurse Clinical Care Supervisor (RNCCS) #95 said the medication was increased because the resident was experiencing behaviors. She said the resident was yelling out, would ask for help, then when staff arrived the resident did not know what she wanted. She also said the resident would not cooperate with daily care. During an interview at 2:10 p.m. on 06/18/16, the resident's physician reviewed the nurses' notes and said, I saw the behaviors myself, that's why I increased the [MEDICATION NAME]. He had no explanation as to why the nursing documentation did not coincide with the behaviors he witnessed. The physician said NA #10 actually asked him to observe a transfer of the resident on the day the [MEDICATION NAME] was increased. The physician said the resident, who normally assisted with transfers, stiffened up and would not cooperate with the transfer. He stated the resident had been refusing to walk. I saw her after the increase and she said her back was actually hurting from walking so much, so I had to deal with her back pain. I increased her medication for that also when I revisited.",2020-04-01
4507,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2015-11-12,166,D,0,1,YR5K11,"Based on record review, family interview, resident interview, staff interview, and review of the facility's grievance policy, the facility failed to make prompt efforts to resolve a grievance concerning dentures for one (1) of three (3) residents reviewed for the care area of dental status and services. Resident identifier: #33. Facility census: 45. Findings include:a) Resident #33 During the Stage I interview with Resident #33 on 11/09/15 at 3:41 p.m., she stated, Somebody took my teeth. Doctor said next time he sees me, he would give me new teeth, can't imagine why anyone would take them. A review of Resident #33's inventory of personal effects on 11/11/15 at 9:00 a.m., revealed the resident had an upper denture plate, and a lower partial denture. On 11/11/15 at 9:05 a.m., a review of the nurse's documentation for Resident #33's quarterly minimum data set (MDS), revealed the resident's oral cavity was observed on 10/31/15 at 8:38 a.m. by Registered Nurse (RN) #88. RN #88's assessment revealed Resident #33 had no natural teeth or tooth fragment(s) (edentulous). The oral cavity assessment stated, The resident lost her dentures, family aware and will replace. Under dentures the section was marked resident does not have dentures. A progress note, dated 08/26/15, written by Licensed Practical Nurse (LPN) #31 on 11/11/2015 at 9:10 a.m., stated, Resident complains of dental pain at this time. Also her dentures are missing at this time. In an interview with Social Worker #34 on 11/11/15 at 10:55 a.m., Social Worker #34 was asked whether she was informed by the staff that Resident #33's upper denture plate and her lower partial were missing. She stated she was not informed by the staff. The social worker said she had a telephone log that indicated the resident's daughter left a message on 09/08/15 concerning Resident #33's missing her upper denture and lower partial. Social Worker #34 said when she called the resident's daughter back the next day, the daughter told the SW she had visited, and she thought someone had thrown away her mother's dentures. Social Worker #34 said she informed the resident's daughter the facility would pay two-hundred dollars ($200.00) to help her with the cost of replacing the dentures. Social Worker #34 said the cost would be around $457.00. The social worker said the daughter was going to arrange the services, but she never did. The facility had never called the daughter back what she had decided to do about the resident's dentures. The social worker was asked whether she had filled out a grievance form. She stated, I did not think this was a complaint. She confirmed that she did not complete a grievance form, but said she would complete one for the concerns regarding the missing dentures. In an interview with the resident's medical power of attorney (MPOA) on 11/11/15 at 12:45 p.m., when asked if her mother's upper dentures and lower partial were lost, she stated, I came into the facility to see my mother at the end of (MONTH) and mother was not wearing her dentures. The MPOA stated, She would not take her teeth out. My mother had pain in her lower gum line around the end of August. The daughter confirmed that she had called the facility and left a voice message about her mother's missing dentures. Observation of Resident #33's teeth on 11/11/15 at 1:03 p.m., found the resident had no upper teeth. She had one tooth on the right bottom side and there were three (3) small worn teeth in the left bottom gum. A review of the grievance policy on 11/11/2015 2:44 p.m., revealed the policy included, If the (facility's name) receives an oral complaint from residents, visitors, or family members, but they (the complainant) do not fill out a complaint form, the staff will fill out a complaint form and start the investigation. The grievance policy stated staff would try to solve the situation immediately, if able. If this could not be solved immediately, an investigation would be started to address the complaint, and it would be done as quickly as possible, by no later than five (5) days from the date of a complaint. Written notification would be given to the person lodging the complaint after a telephone call. A review of the (YEAR) grievance/complaint log, on 11/12/15 at 9:00 a.m., revealed the facility staff would write on the form the date of the complaint, resident name, summary of the complaint, and the date the complaint was resolved. The log did not contain Resident #33's complaint information. As of the time of the survey, there was no evidence of further efforts to resolve the resident's dental issue. There was no evidence of any follow up with the resident's daughter regarding the resident's dentures.",2019-10-01
4508,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2015-11-12,241,E,0,1,YR5K11,"Based on observation, staff interview, and policy review, the facility failed to provide care in a manner and environment which maintained each resident's dignity during the dining process for fourteen (14) of fourteen (14) residents in the restorative dining room. Staff stood while assisting residents to eat and/or did not interact with residents while assisting them. Resident identifiers: #35, #3, #10, #59, #47, #30, #43, #19, #22, #84, #50, #67, #23, and #12. Facility census: 45. Findings include: a) Residents #35, #3, #10, #59, #47, #30, #43, #19, #22, #84, #50, #67, #23, and #12. During an observation of the lunch meal, from 11:15 a.m. to 12:00 p.m. on 11/09/15, the Speech Language Pathologist (SLP) set up the tray for Resident #35, and assisted Residents #23 and #22. The SLP did not attempt any social interaction with these residents. Nurse Aide (NA) #12 assisted Resident #12, NA #72 assisted Resident #84, and NA #80 assisted Resident #59 with their meals. The nurse aides did not converse with the residents while feeding them. Additionally, staff did not converse with any of the fourteen (14) residents in a social manner. b) During a dining observation of the dinner meal on 11/09/15 from 5:30 p.m. through 6:30 p.m., Resident #19 told NA #30 he did not care for his vegetable. NA #30 did not acknowledge the resident ' s comment and continued to tell him what else was on his tray. NA #68 assisted Resident #10, feeding him a few bites of food. The NA stood while feeding the resident. Resident #10 had to raise his head, stretching his neck to reach the utensil. NA #66 also stood while feeding Resident #23. c) Upon request, Licensed Practical Nurse (LPN) #35 completed an observation during the evening meal on 11/09/15, and confirmed staff should not stand while assisting residents to eat. The LPN instructed the nurse aides to sit while feeding the residents. The NAs informed her no chairs were available in the dining room. d) An interview with the director of nursing (DON), on 11/09/15 at 6:30 p.m., confirmed staff should not stand while feeding residents. e) Review of the assistance with meals policy, on 11/10/15 at 10:00 a.m., revealed, Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: (1) Not standing over residents while assisting them with meals. f) During a follow-up interview with the director of nursing, on 11/11/15 at 1:14 p.m., the DON confirmed staff should not stand while feeding residents, and should interact with the residents in a social manner during the dining process.",2019-10-01
4509,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2015-11-12,253,E,0,1,YR5K11,"Based on observation and staff interviews, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior in the main dining room. Fifteen (15) of sixteen (16) chairs in the main dining room had parts of the chair covering missing exposing the wood and/or foam of the chairs. Facility census: 45. Findings include:a) Main dining room chairsObservation of the main dining room chairs with Administrator #46 and Maintenance Staff #48 on 11/11/15 4:15 p.m., found five (5) chairs with missing coverings. The missing coverings left the wood and/or foam on the back of the chairs exposed. The foam of the armrests of these chairs was also exposed. Ten (10) of the chair backs had missing coverings and wood and/or foam exposed. Three (3) of these chairs had a cracked seat where the foam was exposed. During this observation, Maintenance Staff #46 and Maintenance Staff #48 confirmed the chairs were in poor condition and needed replaced.",2019-10-01
4510,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2015-11-12,272,D,0,1,YR5K11,"Based on observation, medical record review and staff interview, the facility failed to complete an accurate comprehensive assessment for one (1) of twenty-four (24) residents reviewed. Resident #5 was inaccurately coded as edentulous. Resident identifier: #5. Facility census: 45. Findings include: a) Resident #5 A Stage 1 observation, on 11/09/15 at 3:24 p.m., revealed Resident #5 had gaps between his teeth with likely missing teeth. On 11/11/15 at 3:00 p.m., review of the most recent comprehensive admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 08/27/15, found a response of Yes for Section L, Item L0200B No natural teeth or tooth fragment(s) edentulous. Section L, Item L0200D - Obvious or likely cavity or broken natural teeth was not checked, indicating a response of No. Licensed Practical Nurse (LPN) #24, interviewed on 11/11/15 at 3:10 p.m., related the resident had his own teeth and said, I hope I have that many teeth when I am that old. MDS Coordinator #88, interviewed on 11/11/15 at 5:23 p.m., related she had coded the MDS Section L, Item L0200B as Yes, because the resident had likely cavities and tooth fragments, and indicated it was the correct response. At 5:31 p.m. on 11/11/15, a request was made for Section L of the Resident Assessment Instrument (RAI) Manual utilized for completion of the MDS. During a follow-up interview, at 6:08 p.m., MDS Coordinator #88 related the MDS was coded incorrectly. She confirmed the resident had teeth, and Section L, Item L0200 indicated the resident was edentulous (no natural teeth present).",2019-10-01
4511,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2015-11-12,278,D,0,1,YR5K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the individual completing and certifying the accuracy of Resident #6's quarterly minimum data set (MDS) assessment accurately assessed the status of one (1) of twenty-four (24) residents in Stage 2 of the Quality Indicator Survey (QIS). The assessment did not accurately reflect the resident's [MEDICAL CONDITION] disorder. Resident identifier: #6. Facility census: 45. Findings include: a) Resident #6 A review of the medical record for Resident #6 on 11/12/15 at 11:15 a.m., revealed the quarterly MDS assessment with an assessment reference date (ARD of 10/27/15, did not accurately reflect a [DIAGNOSES REDACTED]. During further review, it was noted the physician's orders [REDACTED].#6 had an order for [REDACTED]. An interview on 11/12/15 at 12:45 p.m., with the MDS coordinator verified Section I - Active Diagnoses, Item I3400 did not include the [DIAGNOSES REDACTED].#6.",2019-10-01
4512,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2015-11-12,323,E,0,1,YR5K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure the resident environment was as free of accident hazards as possible. The mechanical room door at the front of the 100 hallway was unlocked. This practice had the potential to affect more than a limited number of residents. Facility census: 45. Findings include: a) During an initial tour, on 11/09/15 at 11:16 a.m., when checking doors, the mechanical room door opened when the knob was turned. Upon inquiry, Housekeeper #53, who was in the area, related the door should have been locked. The housekeeper said he would find the maintenance man and let him know. Another observation, at 1:45 p.m. on 11/09/15, found the mechanical room unlocked. No one was in the area. Again at 3:30 p.m. and 5:25 p.m., the door was unlocked. At 5:25 p.m. on 11/09/15, the director of nursing (DON) related the door should have been locked. She said the door knob had been changed and should work properly. She checked the lock and said the door could be locked from the inside. The room contained an air compressor, a hot water heater, sprinkler system, electrical breaker boxes, hot water tank, a bed frame positioned on its side with a mattress floor, and telephone wires. An interview with Licensed Practical Nurse (LPN) #35 and LPN #24, on 11/09/15 at 5:41 p.m., revealed staff rarely entered the mechanical room, and it was kept locked. Upon inquiry, LPNs #35 and #24 related four (4) residents had a history of [REDACTED]. The residents were Residents #26, #12, #5 and #22. An interview and observation with Maintenance Director #48 and the administrator, on 11/11/14 at 4:31 p.m., again revealed the door was unlocked. He confirmed the room contained two (2) unlocked generators with multiple wires in each, six (6) electrical boxes, a sprinkler system, gas lines, and telephone lines. Additionally, a cart with an unlocked tool box was present in the room. The maintenance director related the door knob was just changed and the door should have been locked.",2019-10-01
4513,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2015-11-12,332,D,0,1,YR5K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and, review of Omnicell (an automated medication dispensing system) usage reports, and staff interview, the facility failed to ensure a medication error rate of less than five percent (5%). The medication error rate was 12.5 percent with four (4) errors in thirty-two (32) opportunities for error. A resident received the wrong dosage of aspirin, two (2) doses of medication would have been missed if not for surveyor intervention, and one (3) dose of medication was omitted. Resident identifiers: #50 and #88. Facility census: 45. Findings include: a) Resident #50 During a medication administration observation, on 11/11/15 at 8:14 a.m., Licensed Practical Nurse (LPN) #42 administered the following medications to Resident #50: [MEDICATION NAME] 25 milligrams (mg) orally (PO), Aspirin 81 mg PO, [MEDICATION NAME] 100 mg PO, [MEDICATION NAME] 0.6 mg PO, [MEDICATION NAME] 25 mg PO, and [MEDICATION NAME] 5 mg PO. Review of the medical record, at 10:00 a.m. on 11/11/15, revealed an order for [REDACTED].>A follow-up interview with LPN #42 at 10:30 a.m. on 11/11/15, confirmed [MEDICATION NAME] should have been administered with the medication administration at 8:14 a.m. The LPN reviewed the medications in the medication cart and related none was available to give. Upon inquiry, LPN #42 related [MEDICATION NAME] was available in the Omnicell emergency kit, and acknowledged she could have administered the dose. Upon inquiry regarding administration of the multivitamin, LPN #42 related she did not realize she had not administered the medication. Review of the Omnicell usage report, at 12:30 p.m., on 11/11/15 revealed LPN #42 removed four (4) [MEDICATION NAME] 5 mg tablets from the Omnicell machine at 11:45 a.m. for administration to Resident #88. b) Resident #88 During another medication administration pass with Licensed Practical Nurse (LPN) #42, on 11/11/15 at 8:20 a.m., the LPN administered Aspirin 81 milligrams (mg) orally (PO) to Resident #88. She related no [MEDICATION NAME] was available in the medication cart and would have to order it from the pharmacy. Review of the Medication Administration Record [REDACTED] A follow-up interview with LPN #42 at 9:45 a.m. revealed the Omnicell (automated dispensing system) contained medications which could be obtained and administered if not available in the medication cart. The nurse confirmed [MEDICATION NAME] was available for administration, and could have been obtained during medication administration. Upon request, LPN #42 identified the bottle utilized to administer Aspirin. The bottle was labeled Aspirin 81 mg. The nurse reviewed the physician's orders [REDACTED]. The LPN related Resident #88 should have received Aspirin 325 mg orally. Upon request, an Omnicell usage report was obtained from the pharmacy, and was reviewed on 11/11/15 at 12:30 p.m. The report confirmed [MEDICATION NAME] was pulled from the Omnicell at 9:43 a.m. and administered late. c) During a review of the medical records and the Omnicell report with the director of nursing (DON) on 11/11/15 at 12:45 p.m., the DON confirmed [MEDICATION NAME] was administered late to Resident #50, and [MEDICATION NAME] was administered late to Resident #88, but could have been administered timely if obtained from the Omnicell during the medication administration pass. The DON also acknowledged the medications would have been missed if not for surveyor intervention.",2019-10-01
4514,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2015-11-12,334,D,0,1,YR5K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .Based on medical record review, staff interview, review of the facility's pneumococcal vaccine (PV) policy, the facility failed to administer a PV to one (1) of five (5) residents reviewed under the mandatory facility task for infection control/immunization review. A PV was not administered after receiving a telephone verbal/consent from a resident's medical power of attorney (MPOA) upon admission to the facility. Resident identifier: #46. Facility census: 45. Findings include: a) Resident #46 Review of the resident's medical record, on 11/12/15 at 8:15 a.m., found the resident was admitted on [DATE]. The resident's consent for the flu (influenza) vaccine, pneumonia vaccine, and [MEDICATION NAME] (TB) skin testing noted a telephone verbal/consent with the date of 04/29/15. The consent was checked Yes, I give my permission for the [MEDICATION NAME] (pneumonia vaccine) (PV) if not previously taken. A review of Resident #46's [MEDICAL CONDITION] screen/influenza/ pneumonia vaccination record on 11/12/15 at 8:30 a.m. revealed the Resident #46 did not receive a PV. A review of the facility's PV policy, on 11/12/15 at 8:45 a.m., revealed prior to or upon admission, residents would be assessed for eligibility to receive the PV and when indicated they would be offered the vaccine within thirty (30) days of admission to the facility unless medically contraindicated or the resident had already been vaccinated. The assessment of pneumococcal vaccination status would be conducted within five (5) working days of the resident's admission if not conducted prior to admission. In an interview on 11/12/15 at 9:00 a.m., with Registered Nurse (RN) #16, the RN was asked if she received consent to administer a PV for Resident #46. The RN stated, No. The RN was then asked, When would you expect to administer the vaccine after you received permission to administer a PV if it has not previously given? The RN stated, She would give the vaccine within that week. The RN reviewed Resident #46's record and stated, This consent was obtained at the time of his admission, and we did not receive this form to review whether the resident should have received the pneumonia vaccine. The RN stated, I did not realize we had a problem with our newly admitted resident receiving vaccination until you asked me. The admission coordinator (AC) and the social worker (SW) had obtained Resident #46's consent, and they did not know to inform us. A review of Resident #46's consent for flu and pneumonia vaccine, and [MEDICATION NAME] (TB) skin testing on 11/12/15 at 9:15 a.m., revealed Social worker (SW) #34 was the facility staff member who obtained the telephone/verbal consent upon Resident #46 being admitted to the facility. In an interview on 11/12/15 at 10:20 a.m., with AC #5, and SW #34, the SW confirmed that she and the AC had completed Resident #46's admission paperwork. The AC acknowledged that she did not sign the consent that she was present when the MPOA gave verbal consent over the telephone for the flu, PV and TB skin testing form. AC #5 confirmed she was present when the telephone/verbal consent was given by Resident #46's MPOA. Both employees were asked what they did with this consent when the MPOA gave permission for Resident #46 to receive a PV. Both the AC and the SW confirmed they placed the consent in the Resident #46's chart. The AC and SW were then asked, Do you give a copy of this consent, or verbally inform a staff member of this consent.? Both employees stated, No, we just place the consent in the chart.",2019-10-01
4515,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2015-11-12,356,E,0,1,YR5K11,"Based on observation, review of the facility's staff tracking sheet, nursing schedule, staff interview, and the facility's posting of nurse staffing policy, the facility failed to accurately post the total number and the actual hours worked for the licensed practical nurses (LPNs) who were responsible for direct resident care per shift. This had the potential to affect more than a limited number of residents. Facility census: 45. Findings include: a) Staff tracking sheet Observation of the staff tracking sheet, on 11/09/15 at 11:45 a.m., found the facility had written on the staffing tracking sheet that two (2) LPNs were working the 6:00 a.m. to 6:00 p.m. shift, and the actual combined total hours for these LPNs was twenty-four (24). Observation of the LPNs present on 11/09/15 at 11:46 a.m., revealed LPN #78, LPN #24, LPN #89, and LPN #35 were directly responsible for the residents' care. The DON reviewed the staff tracking sheet on 11/09/15 at 11:50 a.m. When asked whether the number of LPNs was accurate, she stated, No. She marked through the number two (2) under LPNs, and wrote a three (3) in the section. She revealed the LPNs combined total hours were 36. A review of the facility's LPN schedule on 11/09/15 at 11:55 a.m., found for the date of 11/09/15, LPN #78, LPN #24, LPN #89, and LPN #35 were scheduled to work from six 6:00 a.m. to 6:00 p.m. On 11/09/15 at 11:56 a.m., LPN #35 and LPN #78 confirmed LPNs #78, #24, #89, and #35 were working. These two (2) LPNs stated, The staff tracking sheet is inaccurate, there are four (4) LPNs working. The DON on 11/11/15 at 6:00 p.m., confirmed the staff tracking sheet should have had four (4) LPNs, and the LPN's total hours were forty-eight (48), not twenty-four (24), or thirty-six (36). A review of the facility's nurse staffing policy, on 11/11/15 at 6:15 p.m. revealed the policy stated the following in regards to the nurse staff posting, 8.14.i.1. The current date; resident census; and 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, including: 8.14.i.1.A. Registered nurses; 8.14.i.1.B licensed practice nurses; and 8.14.i.1.C. Registered nurse aides.",2019-10-01
4516,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2015-11-12,366,D,0,1,YR5K11,"Based on observation and staff interview, the facility did not offer substitutes of similar nutritive value to two (2) of fourteen (14) residents served in the restorative dining room, and for one (1) randomly observed resident. Resident identifiers: #19 and #46. Facility census: 45. Findings include: a) Resident #46 A random observation of the lunch meal, on 11/09/15 at 12:05 p.m., revealed Resident #46 in his room with his lunch tray on the over-bed table in front of him. The resident was not eating. Another observation at 12:12 p.m. again revealed uneaten food. Nurse Aide (NA) #72 entered the room at 12:14 p.m. and asked Resident #46 if he was going to eat. The resident replied, I don't like it. The NA encouraged him to take a bite and he refused. NA #72 then removed the milk from his tray, placed it on the over-bed table and said, At least drink your milk. NA #72 did not offer the resident a substitute meal. b) Resident #19 During an observation of the dinner meal, Resident #19 related to Nurse Aide (NA) #68 he did not like his vegetable and removed it from his plate. NA #68 did not offer the resident a substitute. c) An interview with the director of nursing (DON), on 11/11/15 at 1:14 p.m., revealed staff should have offered substitutes of similar nutritive value when a resident refused a food item and/or meal. The DON further added, the facility always had items on hand such as soup and sandwiches.",2019-10-01
4517,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2015-11-12,371,E,0,1,YR5K11,"Based on observation and staff interview, it was determined the facility had not ensured foods were stored, distributed and served under sanitary conditions. The kitchen staff did not store dishware and serving utensils in a manner that utilized proper sanitation techniques. In addition, the Speech Language Pathologist and nurse aides did not serve food to residents under sanitary conditions. Facility census: 45. Findings include: a) During the initial dietary tour on 11/09/15, the following items were not stored in a sanitary manner: 1. Plastic cups were stored wet in a wooden cabinet. This procedure allowed the potential for bacteria to grow in a moist environment. 2. Serving utensils were stored in drawers in a haphazard manner, which could lead to staff touching the serving portion of the utensil with their bare hands when retrieving the handle of a device. 3. Dishware had some chipped areas on the edges. This created the potential for improper cleaning and sanitization. These items were discussed with the dietary manager on 11/11/15 at midmorning. She confirmed that she was trained to determine these were sanitation issued. b) Residents #35, #3, #10, #59, #47, #30, #43, #19, #22, #84, #50, #67, #23, and #12. During an observation of the lunch meal, from 11:15 a.m. to 12:00 p.m. on 11/09/15, Speech Language Pathologist (SLP) #91 set up the tray for Resident #35, touching the resident's bread with bare hands. The resident was not eating and the therapist returned to the table and said, I'm going to fold your bread in half, okay? The SLP then folded the bread with bare hands. Additionally, SLP #91 removed the paper from Resident #35's straw and held the area from which the resident drank in the palm of her hand. SLP #91 assisted Resident #23, folding her bread with bare hands and touched the food of Resident #22. Nurse Aide (NA) #12 removed the a of bread from the plastic sheath for Resident #67, touching it with her bare hands. She also peeled a banana for Resident #10, and then grasped the edible part of the banana in her palm, before serving to the resident. Additionally, the nurse aide touched the resident's waffle with bare hands. c) During a dining observation of the dinner meal, on 11/09/15 from 5:30 p.m. through 6:30 p.m., NA #72 touched the cornbread of Residents #22 and #10, with bare hands while setting up the trays. While feeding Resident #3, NA #72 broke the resident's cookie with the bare hands and fed it to him. d) An interview with the director of nursing (DON), on 11/09/15 at 6:30 p.m., confirmed staff should not touch food with bare hands, and related staff were to wear gloves when touching food. e) Review of the assistance with meals policy, on 11/10/15 at 10:00 a.m., revealed . All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. f) A follow-up interview with the DON, on 11/11/15 at 1:14 p.m. again confirmed staff should have washed hands and/or utilized hand sanitizer between residents, and should have worn gloves when touching residents' food.",2019-10-01
4518,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2015-11-12,441,D,0,1,YR5K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, and review of the Centers for Disease Control and Prevention Guidelines (CDC), the facility failed to maintain an effective infection control program to help prevent the development and transmission of disease and infection, to the extent possible. The facility did not ensure Personal Protective Equipment (PPE) was utilized when indicated, and/or did not ensure staff employed proper handwashing technique when performing a wound dressing change. These practices affected three (3) residents, but had the potential to affect more than a limited number of residents. Resident identifiers: #88, #50, and #5. Facility census: 45. Findings include: a) Resident #88 During an an Accucheck (fingerstick blood sugar), on 11/11/15 at 8:30 a.m., Licensed Practical Nurse (LPN) #42 entered the room of Resident #88 to complete the test. Without donning gloves, the nurse proceeded to complete the fingerstick blood sugar. After obtaining the blood sugar, the LPN wiped the excess blood from the resident's finger, still without donning gloves. b) Residents #88 and #50 When pouring medications for Resident #50 on 11/11/15 at 8:14 a.m., Licensed Practical Nurse (LPN) #42 placed each medication in her bare hand before placing it in the medication cup for administration. Medications included: [MEDICATION NAME] 25 milligram (mg) PO (by mouth), Aspirin 81 mg PO, [MEDICATION NAME] 100 mg PO, [MEDICATION NAME] 0.6 mg PO, [MEDICATION NAME] 25 mg PO, and [MEDICATION NAME] 5 mg PO. When completing the medication administration pass, on 11/11/15 at 8:20 a.m., LPN #42 poured Aspirin 81 mg, [MEDICATION NAME] 1 mg po, [MEDICATION NAME] 20 mg po, and [MEDICATION NAME] 2.5 mg po. The nurse placed each medication in her bare hand, and then dropped it into the medication cup. The medication was then administered to Resident #88. Aspirin, and [MEDICATION NAME] and were obtained from a bottle of medication utilized for all residents who received those medications. After allowing medications to touch her bare hand, the pills then were placed back into the bottle for administration to others. Upon inquiry, the director of nursing (DON) provided an order report, dated 10/11/15 - 11/11/15, which indicated ten (10) residents received Aspirin 81 mg from the medication cart. Residents included #54, #58, #26, #85, #32, #30, #22, #89, #66, and #29. During a follow-up interview, on 11/11/15 at 10:48 a.m., LPN #42 acknowledged she should not have touched the pills she administered to the residents, and should have worn gloves when completing the fingerstick blood sugar. On 11/11/15 at 11:10 a.m., review of the medication administration orals policy, section 7.5 of the Nursing Care Center Pharmacy policy and procedure manual - 2007 PharMerica Corp provided by the facility, revealed procedures included: Pour the correct number of tablets or capsules into the medication cup, taking care to avoid touching any of the medication unless wearing gloves. The director of nursing (DON), interviewed on 11/11/15 at 11:25 a.m., revealed LPN #42 should not have touched medication with her bare hands, and related gloves should always be worn when completing fingerstick blood sugars. The DON related gloves were required when having contact with blood or body fluids. Additionally, the Dressings/Soiled/Contaminated policy, reviewed on 11/11/15 at 6:00 p.m., revealed Gloves must be worn . when handling items contaminated with blood, body fluids, or potentially infective materials. c) Resident #5 During a pressure ulcer dressing change, on 11/11/15 at 3:25 p.m., Licensed Practical Nurse (LPN) #89, entered the room of Resident #5 and washed her hands for a count of ten (10) seconds. She donned gloves, established a clean field and arranged supplies. The LPN removed her gloves and washed her hands for a count of seven (7) seconds. The nurse then donned new gloves, removed the dressing from the resident's left heel which contained a moderate amount of creamy brownish colored drainage, removed her gloves, and again washed her hands for a count of seven (7) seconds. LPN #89 donned new gloves, cleansed the wound, and washed her hands for a count of seven (7) seconds. The nurse obtained a large magnifying glass from the treatment cart and placed it on the bed beneath the resident's heel. LPN #89 washed her hands for a count of 8 seconds, donned new gloves, measured the wound, applied a clean dressing, and washed her hands for a count of seven (7) seconds. LPN #89 donned gloves, cleansed and measured the pressure ulcer on Resident #5's right heel. She removed her gloves and washed her hands for a count of seven (7 seconds). Review of the hand hygiene policy and CDC guidelines, on 11/12/15 at 9:00 a.m., revealed Employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water An interview with the director of nursing (DON) on 11/12/15 at 9:30 a.m., confirmed LPN #89 utilized improper handwashing technique, and should have washed her hands for at least fifteen (15) seconds.",2019-10-01
4519,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2015-11-12,464,E,0,1,YR5K11,"Based on observation and staff interview, the facility did not furnish sufficient space to accommodate dining activities in the restorative dining room for fourteen (14) of fourteen (14) residents observed during the lunch meal. Resident identifiers: #35, #3, #10, #59, #47, #30, #43, #19, #22, #84, #50, #67, #23, and #12. Facility census: 45. Findings include: a) Resident #35, #3, #10, #59, #47, #30, #43, #19, #22, #84, #50, #67, #23, and #12. A lunch observation, on 11/09/15 from 11:15 a.m. until 12:00 p.m., revealed these fourteen (14) residents ate in the restorative dining room. Resident #59 was the last resident assisted into the dining room. All other residents had been served and were eating. Resident #59 was seated in a specialized recliner chair. Nurse Aide (NA) #30 attempted to position the resident at the far side of the first table to the left of the door upon entry of the dining room. The tables were positioned close together and residents were seated at each table. The NA was unable to position the chair due to the closeness of tables. After several attempts, and interrupting residents' dining, NA #30 removed Resident #59 from the dining room. She turned the chair around and entered again, once more disrupting residents' meals while positioning the resident at the table. An interview with the director of nursing (DON) on 11/11/5 at 1:14 p.m. confirmed the dining area was crowded. The DON related the facility was aware of the situation. Upon inquiry, the DON related the dining room had not been addressed in quality assurance, nor had an action plan had been developed to address the situation.",2019-10-01
4520,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2015-11-12,502,E,0,1,YR5K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain a laboratory test for one (1) of five (5) residents reviewed for unnecessary medications. A fecal occult stool test was not obtained for Resident #48. Resident identifier: #48. Facility census: 45. Findings include: a) Resident #48 A medical record review, on 11/11/15 at 9:31 a.m., revealed Resident #48 received celecoxib ([MEDICATION NAME]) 100 milligrams (mg) orally twice daily. physician's orders [REDACTED]. Further review, also revealed an order dated 05/23/15, for a Fecal Occult Stool. No evidence was present in the medical record to indicate the test had ever been completed. An interview with Licensed Practical Nurse (LPN) #25 on 11/11/15 at 2:50 p.m. revealed the facility had a book which contained laboratory (lab) tests. The LPN related she and Registered Nurse (RN) #73 developed a system to ensure all laboratory tests were completed as ordered. Upon inquiry, LPN #25 related Resident #48 would not defecate in a hat, and would throw it away, if placed on the toilet seat. An interview with Resident #48, on 11/12/15 at 10:24 a.m., revealed the resident took herself to the bathroom, and said she would let staff know if she had a bowel movement. The director of nursing (DON), interviewed on 11/12/15 at 10:43 a.m., revealed if a resident was continent, staff would place a hat in the commode to collect stool. She agreed resident #48 would throw away the hat. Progress notes, reviewed on 11/12/15 at 10:44 p.m., revealed no evidence the resident had refused to comply with the fecal occult stool test. Review of the admission minimum data set (MDS) with an assessment reference date (ARD) of 05/29/15, noted a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Additionally, Section [NAME] indicated the resident had exhibited no behaviors. Review of the care plan, on 11/12/15 at 11:00 a.m., revealed a focus related to [MEDICAL CONDITION], and another focus for pain management related to a [DIAGNOSES REDACTED]. Approaches included to administer the medication, monitor for side effects, and obtain lab/diagnostics as ordered. A follow-up interview with the DON on 11/12/15 at 1:30 p.m., confirmed no evidence was present in the medical record to indicate the facility attempted to obtain the fecal occult stool test or to indicate Resident #48 had refused to comply with the test.",2019-10-01
4859,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2016-07-29,157,D,1,0,G6NZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to notify the physician on two (2) incidents of improper medication administration for one (1) of six (6) residents reviewed. Resident identifier #52. Facility census 58. Findings include: a) Resident #52 A review of Resident #52's physician order [REDACTED]. A review of the Medication Administration Record [REDACTED] -- On 07/08/16, Resident #52 received her 9:00 a.m. dose of [MEDICATION NAME] at 2:57 p.m., due to waiting on tubing from the pharmacy. -- On 07/09/16, Residetn #52 received her 9:00 a.m. dose of [MEDICATION NAME] at 3:44 p.m., due to waiting for trough (laboratory results). Review of Resident #52's medical record, on 07/27/16 at 2:37 p.m., revealed Licensed Practical Nurse (LPN) #18 and LPN #80 did not notify the Resident's physician of the 9:00 a.m. dose of [MEDICATION NAME] 1,000 mg IV was not administered on 07/08/16 and 07/09/16 as ordered. In an interview with the Director of Nursing (DON), on 07/27/16 at 4:05 p.m., she stated, they ran out of of tubing on 07/08/16, and had to wait for the tubing to arrive from the pharmacy. The DON further stated the nursed had to do a trough (laboratory) level on 07/09/16, and had to wait on the results. The nurses. The DON revealed the nurses did not notifiy the physician the medication was administered late, nor did they receive a new physician order. The facility's policy for changing IV tubing revealed the intermittent administration set is change every twenty-four (24) hours.",2019-07-01
4860,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2016-07-29,225,D,1,0,G6NZ11,"> Based on record review, staff interview, resident interview, and policy review the facility failed to investigate and report an allegation of neglect for one (1) of six (6) residents reviewed. Resident Identifier: #52. Facility census: 58. Findings include: a) Resident #52 In an interview with Resident #52, on 07/28/16 at 10:17 a.m., she revealed a morning in (MONTH) (YEAR) she had rang her call light due to she was incontinent of bowel and bladder. Nursing Aide (NA) #97 entered her room to assist her with her care. The resident said the NA cleaned her and left. She stated that she did not feel like she was cleaned properly. The resident said she reached over and used one (1) of her wipes and wiped herself and she had bowel movement on the wipe. The resident said she saw NA #91 walking down the hall, and yell out to her to come into her room. She said she told NA #91, she was not cleaned properly. She said she showed her the wipe in which had bowel movement on the wipe. She said the NA reported this to the Licensed Practical Nurse (LPN) #18. LPN #18 came into her room and she showed her the wipe she used which had bowel movement present. The resident said she told LPN #18, I was not cleaned by NA #97 properly. The resident revealed LPN #18 told NA #91 to clean her up. During a record review on 07/25/16 at 3:00 p.m., the most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/15/16 found the resident scored a 15 on her brief interview for mental status (BIMS). The Brief BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding. A BIMS score of 13-15 indicates a resident is cognitively intact. In an interview with NA #91, on 07/28/16 at 10:30 a.m., revealed Resident #52 yelled for her as she walked by the resident's room. She further revealed the resident showed her a wipe with bowel movement on it. NA #91 stated the Resident told her NA #97 did not clean her after incontinence care. NA #91 revealed she reported this to LPN #81. She said LPN #81 asked her to clean Resident #52 and write up a statement on the alleged neglect. NA #91 revealed Resident #52 had feces caked up the front of her peri-area. NA #91 stated she gave a written statement to LPN #81. In an interview with the DON and the Administrator on 07/28/16 at 12:30 p.m., revealed they had no knowledge of Resident #52 allegation. The DON on 07/28/16 at 2:00 p.m., revealed that she spoke to LPN #18 and the LPN confirmed that she was aware of the allegation, and the LPN asked NA #91 to place the statement in the DON's box. The DON said she never received a written statement from either staff member, nor was called and informed about this situation. The DON said the LPN did not identify this situation as abuse or neglect. The DON confirmed that this allegation was not reported correctly, therefore no investigation was conducted or reported to the appropriate places. A review of the facility's policy on 07/28/16 at 3:00 p.m., found the staff are mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse. The staff are educated on how to identify abuse, reporting and filing of accurate documents relative to incident of abuse, and a thorough investigations of all reports and allegations of abuse. The facility should provide a written report of the results of all abuse investigation and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and other as may be required by state or local laws, within five (5) working days of the reported incident.",2019-07-01
4861,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2016-07-29,226,D,1,0,G6NZ11,"> Based on record review, staff interview, resident interview, and policy review the facility failed to implement their policy related to performing an investigate and report an allegation of neglect which had been brought to staff attention for one (1) of six (6) resident reviewed for allegation of neglect. Resident Identifier #52. Facility census 58. Findings include: In an interview with Resident #52, on 07/28/16 at 10:17 a.m., she revealed a morning in (MONTH) (YEAR) she had rang her call light due to she was incontinent of bowel and bladder. Nursing Aide (NA) #97 entered her room to assist her with her care. The resident said the NA cleaned her and left. She stated that she did not feel like she was cleaned properly. The resident said she reached over and used one (1) of her wipes and wiped herself and she had bowel movement on the wipe. The resident said she saw NA #91 walking down the hall, and yell out to her to come into her room. She said she told NA #91, she was not cleaned properly. She said she showed her the wipe in which had bowel movement on the wipe. She said the NA reported this to the Licensed Practical Nurse (LPN) #18. LPN #18 came into her room and she showed her the wipe she used which had bowel movement present. The resident said she told LPN #18, I was not cleaned by NA #97 properly. The resident revealed LPN #18 told NA #91 to clean her up. During a record review on 07/25/16 at 3:00 p.m., the most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/15/16 found the resident scored a 15 on her brief interview for mental status (BIMS). The Brief BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding. A BIMS score of 13-15 indicates a resident is cognitively intact. In an interview with NA #91, on 07/28/16 at 10:30 a.m., revealed Resident #52 yelled for her as she walked by the resident's room. She further revealed the resident showed her a wipe with bowel movement on it. NA #91 stated the Resident told her NA #97 did not clean her after incontinence care. NA #91 revealed she reported this to LPN #81. She said LPN #81 asked her to clean Resident #52 and write up a statement on the alleged neglect. NA #91 revealed Resident #52 had feces caked up the front of her peri-area. NA #91 stated she gave a written statement to LPN #81. In an interview with the DON and the Administrator on 07/28/16 at 12:30 p.m., revealed they had no knowledge of Resident #52 allegation. The DON on 07/28/16 at 2:00 p.m., revealed that she spoke to LPN #18 and the LPN confirmed that she was aware of the allegation, and the LPN asked NA #91 to place the statement in the DON's box. The DON said she never received a written statement from either staff member, nor was called and informed about this situation. The DON said the LPN did not identify this situation as abuse or neglect. The DON confirmed that this allegation was not reported correctly, therefore no investigation was conducted or reported to the appropriate places. A review of the facility's policy on 07/28/16 at 3:00 p.m., found the staff are mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse. The staff are educated on how to identify abuse, reporting and filing of accurate documents relative to incident of abuse, and a thorough investigations of all reports and allegations of abuse. The facility should provide a written report of the results of all abuse investigation and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and other as may be required by state or local laws, within five (5) working days of the reported incident.",2019-07-01
4862,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2016-07-29,280,D,1,0,G6NZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, resident and staff interview, the facility failed to revise a care plan to reflect a resident's status for the use of a Foley catheter, and ability to transfer for one (1) of six (6) resident reviewed. Resident identifier: #52. Facility census 58. Findings include: a) Mobility/Transfer Status In an interview on 07/25/16 at 11:00 a.m., with Resident #52. The resident revealed she transfers with the assistance of two (2) NAs and a gait belt. The resident said that she had previously used a Hoyer lift, but she now transfers with two (2) and a gait belt now. Record review for Resident #52, on 07/25/16 at 3:00 p.m., revealed a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/15/16. This MDS noted the resident scored a 15 on her brief interview for mental status(BIMS). The BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding. A BIMS score of 13-15 indicates a resident is cognitively intact. In an interview with Licensed Practical Nurse (LPN) #90, on 07/26/16 at 10:00 a.m., she stated, The resident does not use a lift. Record review of Resident #52's, on 07/27/16 at 3:23 p.m., found a care plan created on 11/19/15 related to inability to maintain health state independently due to generalized weakness and right knee replacement. The care plan was for the the resident to have the assistance of two (2) people, and a Hoyer lift. A review of Resident #52's Kardex (information NAs use in order to know how to care for residents) revealed the resident requires the use of a Hoyer lift with the assistance of two (2) people. Observation of the Resident #52 on 07/27/16 at 3:30 p.m., found NA #42 and #74 transfer the resident into her bed from her wheelchair. The resident tried to resist using a transfer belt while transferring. NA #74 asked resident if they could use the gait belt for safety and the resident allowed them to transfer her. The staff transferred the resident to the side of her bed and then each NA pick up one of her lower extremities each and turned her so she would be lying in her bed. The NA confirmed they transfer the resident with two (2) people and a gait belt. In an interview on 07/27/16 at 3:45 p.m., with Registered Nurse (RN) #89, she confirmed Resident #52 transfers with a gait belt and the assistance of two (2) people. The RN reviewed the care plan and confirmed the care plan needed to be updated to reflect the resident's actual transfer status. b) Foley Catheter Use In an interview with Resident #52, on 07/25/16 at 11:10 a.m., she revealed she had a Foley catheter a while back, but the catheter was removed. Record review for Resident #52, on 07/25/16 at 3:00 p.m., revealed a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/15/16. This MDS noted the resident scored a 15 on her brief interview for mental status(BIMS). The BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding. A BIMS score of 13-15 indicates a resident is cognitively intact. Record review for Resident #52, on 07/27/16 at 3:23 p.m., found a care plan related to potential for complication related to indwelling urinary catheter. The approach is to assess for patency and document daily, assess for urine characteristics (volume, color, clarity, odor) and document daily. Change bag every thirty days per facility protocol. Charge catheter whenever needed (PRN) for blockage or per facility protocol. Keep drainage bag off the floor and cover for dignity. Maintain closed drainage system, with drainage bag lower than bladder level at all times. This current care plan was created on 11/19/15, edited on 11/13/15. A review of Resident #52's Kardex (information NAs use in order to know how to care for residents), revealed the resident has an indwelling catheter and the approach is for the NA to keep drainage bag off of the floor and keep the bag covered for dignity. The NAs are also to maintain a closed drainage system, with the drainage bag lower than bladder level at all times. Observation of the Resident #52 on 07/27/16 at 3:30 p.m., found NA #42 and #74 transferring the resident into her bed from her wheelchair. This observation found the resident did not have a Foley catheter. In an interview with the NA #42 and #74 at this time they confirmed Resident #52 does not have a Foley catheter. Observation of NA # 91 perform peri-care to Resident #52, on 07/28/16 at 10:17 a.m., revealed the resident did not have a Foley catheter. The NA confirmed the Foley catheter had been removed a couple of months ago. A review of the physician order [REDACTED]. In an interview on 07/27/16 at 3:45 p.m., with Registered Nurse (RN) #89, she confirmed the Resident #52's Foley catheter had been removed. The RN reviewed the care plan and confirmed the care plan needed to be updated to reflect the resident's actual status.",2019-07-01
4863,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2016-07-29,309,E,1,0,G6NZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interview and policy review, the facilty failed to ensure each resident physician's orders were followed for four (4) out of six (6) residents reviewed for medication administration. Four residents were found to have numerous episodes of medication not being given in a timely manner as prescribed by the physician. Resident identifier: #52, #110, #43 and #49. Facility census: 58. Findings include: a) Resident #52 A review of Resident #52's Medication Administration Record [REDACTED]. Two (2) ouces of power pudding with medication administered once a day at 8:00 a.m.: --05/11/16 administered at 9:37 a.m. --05/13/16 administered at 9:02 a.m. --05/15/16 administered at 10:23 a.m. --05/16/16 administered at 9:24 a.m. --05/19/16 administered at 9:18 a.m. Aspirin delayed release 81 mg once a day at 8:00 a.m: --05/10/16 administered at 12:56 p.m. --05/11/16 administered at 9:37 a.m. --05/13/16 administered at 9:02 a.m. --05/15/16 administered at 10:23 a.m. --05/16/16 administered at 9:24 a.m. --05/18/16 administered at 10:04 a.m --05/19/16 administered at 9:18 a.m. --05/27/16 administered at 9:19 a.m. --05/28/16 administered at 10:16 a.m [MEDICATION NAME] 0.5 mg every twelve hours, give one (1) tablet by mouth twice daily at 7:00 a.m. and 7:00 p.m.: --05/27/16 administered the 7:00 a.m. dose at 9:19 a.m. --05/28/16 administered the 7:00 a.m. dose at 10:16 a.m. [MEDICATION NAME] 1 mg twice daily to be administered at 7:00 a.m. and 7:00 p.m.: --05/02/16 the 7:00 a.m. dose administered at 8:26 a.m. --05/03/16 the 7:00 a.m. dose administered at 8:39 a.m. --05/05/16 the 7:00 p.m. dose administered at 1:40 a.m. --05/06/16 the 7:00 p.m. dose administered at 8:57 a.m. --05/11/16 the 7:00 a.m. dose administered at 9:27 a.m. --05/12/16 the 7:00 a.m. dose administered at 8:50 a.m. --05/13/16 the 7:00 a.m. dose administered at 9:02 a.m. --05/15/16 the 7:00 a.m. dose administered at 10:23 a.m. --05/16/16 the 7:00 a.m. dose administered at 9:24 a.m. --05/18/16 the 7:00 a.m. dose administered at 10:04 a.m. --05/19/16 the 7:00 a m. dose administered at 9:18 a.m. --05/25/16 the 7:00 p.m. dose administered at 9:16 p.m. Benadry 25 mg three times a day at 6:00 a.m., 2:00 p.m., and 10:00 p.m.: --05/11/16 the 2:00 p.m. dose administered at 5:26 p.m. [MEDICATION NAME] 100 mg once a day at 8:00 a.m.: --05/11/16 medication administered at 9:37 a.m. --05/13/16 medication administered at 9:02 a.m. --05/15/16 medication administered at 10:23 a.m. --05/16/16 medication administered at 9:24 a.m. --05/18/16 medication administered at 10:04 a.m. --05/19/16 medication administered at 9:18 a.m. --05/27/16 medication administered at 9:19 a.m. --05/28/16 medication administered at 10:16 a.m. [MEDICATION NAME] 20 mg once a day at 8:00 a.m.: --05/10/16 medication administered at 12:56 p.m. --05/11/16 medication administered at 9:37 a.m. --05/13/16 medication administered at 9:02 am. --05/15/16 medication administered at 10:23 a.m. --05/16/16 medication administered at 9:24 a.m. --05/18/16 medication administered at 10:04 a.m. --05/19/16 medication administered at 9:18 a.m. --05/27/16 medication administered at 9:19 a.m. --05/28/16 medication administered at 10:16 a.m. [MEDICATION NAME] sulfate 325 mg three times a day at 8:00 a.m., 1:00 p.m., and 6:00 p.m.: --05/01/16 the 1:00 p.m. dose administered at 3:13 p.m. --05/04/16 the 1:00 p.m. dose administered at 5:04 p.m. --05/05/16 the 8:00 a.m., dose administered at 9:29 a.m. --05/07/16 the 1:00 p.m. dose administered at 2:22 p.m. --05/08/16 the 1:00 p.m. dose administered at 4:25 p.m. --05/10/16 the 8:00 a.m. dose administered at 12:56 p.m. --05/11/16 the 8:00 a.m. dose administered at 9:37 a.m. --05/12/16 the 1:00 p.m. dose administered at 2:17 p.m. --05/13/16 the 8:00 a.m. dose administered at 9:02 a.m. --05/15/16 the 8:00 a.m. dose administered at 10:23 a.m. --05/16/16 the 8:00 a.m. dose administered at 9:24 a.m. --05/17/16 the 1:00 p.m. dose administered at 2:16 p.m. --05/18/16 the 8:00 a.m. dose administered at 10:04 a.m. --05/18/16 the 1:00 p.m. dose administered at 2:08 p.m. --05/19/16 the 8:00 a.m. dose administered at 9:18 a.m. --05/19/16 the 1:00 p.m. dose administered at 2:42 p.m. --05/23/16 1:00 p.m. dose administered at 2:31 p.m. --05/23/16 the 6:00 p.m. dose administered at 7:33 p.m. --05/26/16 the 1:00 p.m. dose administered at 2:53 p.m. --05/26/16 the 6:00 p.m. dose administered at 7:21 p.m. --05/27/16 the 1:00 p.m. dose administered at 2:11 p.m. --05/27/16 the 6:00 p.m. dose administered at 7:13 p.m. --05/28/16 the 8:00 a.m. dose administered at 10:16 a.m. --05/28/16 the 1:00 p.m. dose administered at 3:47 p.m. [MEDICATION NAME] 20 mg twice a day at 7:00 a.m. and 4: 00 p.m.: --05/02/16 the 7:00 a.m. dose administered at 8:36 a.m. --05/03/16 the 7:00 a.m. dose administered at 8:39 a.m. --05/04/16 the 4:00 p.m. dose administered at 5:04 a.m. --05/06/16 the 7:00 a.m. dose administered at 8:57 a.m. --05/06/16 the 4:00 p.m. dose administered at 5:05 p.m. --05/07/16 the 4:00 p.m. dose administered at 5:31 p.m. --05/10/16 the 4:00 p.m. dose administered at 5:39 p.m. --05/11/16 the 7:00 a.m. dose administered at 9:37 a.m. --05/11/16 the 4:00 p.m. dose administered at 5:26 p.m. --05/12/16 the 7:00 a.m. dose administered at 8:50 a.m. --05/12/16 the 4:00 p.m. dose administered at 5:17 p.m. --05/13/16 the 7:00 a.m. dose administered at 9:02 a.m. --05/13/16 the 4:00 p.m. dose administered at 5:37 p.m. --05/15/16 the 7:00 a.m. dose administered at 10:23 a.m. --05/15/16 the 4:00 p.m. dose administered at 5:16 p.m. --05/16/16 the 7:00 a.m. dose administered at 9:24 a.m. --05/16/16 the 4:00 p.m. dose administered at 5:30 p.m. --05/18/16 the 7:00 a.m. dose administered at 10:04 a.m. --05/18/16 the 4:00 p.m. dose administered at 5:06 p.m. --05/19/16 the 7:00 a.m. dose administered at 9:18 a.m. --05/19/16 the 4:00 p.m. dose administered at 5:06 p.m. --05/22/16 the 4:00 p.m. dose administered at 5:25 p.m. --05/23/16 the 4:00 p.m. dose administered at 7:33 p.m. --05/25/16 the 4:00 p.m. dose administered at 6:07 p.m. --05/27/16 the 7:00 a.m. dose administered at 9:19 a.m. --05/27/16 the 4:00 p.m. dose administered at 6:26 p.m. --05/28/16 the 7:00 a.m. dose administered at 10:16 a.m. [MEDICATION NAME] 100 mg twice a day at 8:00 a.m. and 8:00 p.m.: --05/10/16 the 8:00 a.m., dose administered at 12:56 p.m. --05/11/16 the 8:00 a.m., dose administered at 9:37 a.m. --05/13/16 the 8:00 a.m., dose administered at 9:02 a.m. --05/14/16 the 8:00 p.m., dose administered at 9:29 p.m. --05/15/16 the 8:00 a.m., dose administered at 10:23 a.m. --05/16/16 the 8:00 a.m., dose administered at 9:24 a.m. [MEDICATION NAME] 100 mg three times a day at 8:00 a.m., 1:00 p.m., and 8:00 p.m.: --05/01/16 the 1:00 p.m., dose administered at 3:13 p.m. --05/04/16 the 1:00 p.m. dose administered at 5:04 p.m. --05/07/16 the 1:00 p.m. dose administered at 2:22 p.m. --05/08/16 the 1:00 p.m. dose administered at 4:25 p.m. --05/10/16 the 8:00 a.m. dose administered at 12:56 p.m. --05/11/16 the 8:00 a.m. dose administered at 9:37 a.m. --05/12/16 the 1:00 p.m. dose administered at 2:17 p.m. --05/13/16 the 8:00 a.m. dose administered at 9:02 a.m. --05/14/16 the 8:00 p.m. dose administered at 9:39 p.m. --05/15/16 the 8:00 a.m. dose administered at 10:23 a.m. --05/16/16 the 8:00 a.m. dose administered at 9:24 a.m. --05/17/16 the 1:00 p.m. dose administered at 2:17 p.m. --05/18/16 the 8:00 a.m. dose administered at 10:04 a.m. --05/18/16 the 1:00 p.m. dose administered at 2:08 p.m. --05/19/16 the 8:00 a.m., dose administered at 9:18 p.m. --05/19/16 the 1:00 p.m. dose administered at 2:42 p.m. --05/23/16 the 1:00 p.m. dose administered at 2:31 p.m. --05/24/16 the 8:00 p.m dose administered at 9:16 p.m. --05/26/16 the 1:00 p.m. dose administered at 2:53 p.m. --05/27/16 the 1:00 p.m. dose administered at 2:11 p.m. --05/28/16 the 8:00 a.m. dose administered at 10:16 a.m. --05/28/16 the 1:00 p.m. dose administered at 3:47 p.m. [MEDICATION NAME] extended release 30 mg once a day at 8:00 a.m.: --05/10/16 medication administered at 12:56 p.m. --05/11/16 medication administered at 9:37 a.m. --05/13/16 medication administered at 9:02 a.m. --05/15/16 medication administered at 10:23 a.m. --05/16/16 medication administered at 9:24 a.m. --05/18/16 medication administered at 10:04 a.m. --05/19/16 medication administered at 9:18 a.m. --05/27/16 medication administered at 9:19 a.m. --05/28/16 medication administered at 10:16 a.m. [MEDICATION NAME] -S 8.6-50 mg twice a day at 7:00 a.m., and 7:00 p.m.: --05/02/16 the 7:00 a.m. dose administered at 8:36 a.m. --05/03/16 the 7:00 a.m. dose administered at 8:39 a.m. --05/06/16 the 7:00 a.m. dose administered at 8:57 a.m. --05/13/16 the 7:00 a.m. dose administered at 9:02 a.m. --05/15/16 the 7:00 a.m. dose administered at 10:23 a.m. --05/16/16 the 7:00 a.m. dose administered at 9:24 a.m. --05/19/16 the 7:00 a.m. dose administered at 9:18 a.m. --05/24/16 the 7:00 p.m. dose administered at 9:16 p.m. --05/27/16 the 7:00 a.m. dose administered at 9:19 a.m. [MEDICATION NAME] XL extended release 24 hr 25 mg once a day at 8:00 a.m.: --05/10/16 medication administered at 12:56 p.m. --05/11/16 medication administered at 9:39 a.m. --05/13/16 medication administered at 9:02 a.m. --05/15/16 medication administered at 10:23 a.m. --05/16/16 medication administered at 9:24 a.m. --05/18/16 medication administered at 10:04 a.m. --05/19/16 medication administered at 9:18 a.m. --05/27/16 medication administered at 9:21 a.m. --05/28/16 medication administered at 10:16 a.m. [MEDICATION NAME] 150 mg twice a day at 7:00 a.m. and 7:00 p.m.: --05/02/16 the 7:00 a.m. dose administered at 8:36 a.m. --05/03/16 the 7:00 a.m. dose administered at 8:39 a.m. --05/06/16 the 7:00 a.m. dose administered at 8:57 a.m. --05/11/16 the 7:00 a.m. dose administered at 9:37 a.m. --05/13/16 the 7:00 a.m. dose administered at 9:02 a.m. --05/15/16 the 7:00 a.m. dose administered at 10:23 a.m. --05/16/16 the 7:00 a.m. dose administered at 9:24 a.m. --05/18/16 the 7:00 a.m. dose administered at 10:04 a.m. --05/24/16 the 7:00 p.m. dose administered at 9:16 p.m. --05/28/16 the 7:00 a.m. dose administered at 10:16 a.m. A review of the record also revealed for the month of (MONTH) (YEAR) the resident had the following medications administered late: [MEDICATION NAME] 1,000 milligram (mg) to be administered every twelve hours from 06/29/16 to 07/11/16. --07/01/16 the 5:00 a.m., dose was administered at 6:02 a.m. had to wait for labs to be drawn before intravenous mediation could be infused: --07/04/16 the 5:00 a.m. dose administered at 9:46 a.m. --07/06/16 the 9:00 a.m. dose administered at 10:18 a.m. --07/07/16 the 9:00 a.m. dose administered at 10:16 a.m. --07/08/16 the 9:00 a.m. dose administered at 2:57 p.m. --07/09/16 the 9:00 a.m. dose administered at 3:44 p.m. --07/11/16 the 9:00 a.m. dose administered at 10:12 a.m. Normal saline flush 0.9% - 10 mililiter (ml) twice a day between 10:00 a.m. - 12:00 p.m. and 10:00 p.m. - 1:00 a.m. --07/18/16 the 10:00 a.m. - 12:00 p.m. dose administered at 2:44 p.m. --07/20/16 the 10:00 a.m. - 12:00 p.m. dose administered at 12:47 p.m. --07/21/16 the 10:00 a.m. - 12:00 p.m. dose administered at 12:21 p.m. --07/23/16 the 10:00 a.m. -12:00 p.m. dose administered at 12:08 p.m. b) Resident #110 A review of Resident #110's Medication Administration Record [REDACTED]. [MEDICATION NAME] 0.5 mg twice a day at 9:00 a.m. and 8:00 p.m.: --05/04/16 the 9:00 a.m. dose administered at 5:00 p.m. --05/07/16 the 9:00 a.m. dose administered at 2:37 p.m. --05/09/16 the 9:00 a.m. dose administered at 12:37 p.m. --05/10/16 the 9:00 a.m. dose administered at 12:52 p.m. --05/14/16 the 9:00 a.m. dose administered at 10:18 a.m. --05/14/16 the 8:00 p.m. dose administered at 9:37p.m. --05/15/16 the 9:00 a.m. dose administered at 10:09 a.m. --05/18/16 the 9:00 a.m. dose administered at 10:02 a.m. --05/24/16 the 8:00 p.m. dose administered at 9:15 p.m. --05/26/16 the 9:00 a.m. dose administered at 11:39 a.m. [MEDICATION NAME] drops, one (1)% three drops sublingual three (3) times a day at 9:00 a.m., 3:00 p.m., and 8:00 p.m.: --05/02/16 the 3:00 p.m. dose administered at 4:45 p.m. --05/03/16 the 3:00 p.m. dose administered at 4:47 p.m. --05/04/16 the 9:00 a.m. dose administered at 5:00 p.m. --05/04/16 the 3:00 p.m. dose administered at 5:01 p.m. --05/07/16 the 9:00 a.m. dose administered at 2:27 p.m. --05/08/16 the 3:00 p.m. dose administered at 4:29 p.m. --05/09/16 the 9:00 a.m. dose administered at 12:37 p.m. --05/09/16 the 3:00 p.m. dose administered at 4:08 p.m. --05/10/16 the 9:00 a.m. dose administered at 12:52 p.m. --05/10/16 the 3:00 p.m. dose administered at 5:37 p.m. --05/11/16 the 3:00 p.m. dose administered at 5:07 p.m. --05/14/16 the 9:00 a.m. dose administered at 10:18 a.m. --05/14/16 the 8:00 p.m. dose administered at 9:37 p.m. --05/15/16 the 9:00 a.m. dose administered at 10:09 a.m. --05/16/16 the 3:00 p.m. dose administered at 5:21p.m. --05/18/16 the 9:00 a.m. dose administered at 10:02 a.m. --05/22/16 the 3:00 p.m. dose administered at 5:24 p.m. --05/24/16 the 8:00 p.m. dose administered at 9:15 p.m. --05/25/16 the 3:00 p.m. dose administered at 6:05 p.m. --05/26/16 the 9:00 a.m. dose administered at 11:39 a.m. [MEDICATION NAME] 10 mg every six (6) hours to be administered at 5:30 a.m., 11:30 a.m., 5:30 p.m., and 11:30 p.m.: --05/02/16 the 11:30 a.m. dose administered at 12:46 p.m. --05/04/16 the 11:30 a.m, dose administered at 5:00 p.m. --05/07/16 the 11:30 a.m. dose administered at 2:27 p.m. --05/09/16 the 11:30 a.m. dose administered at 12:37 p.m. --05/10/16 the 11:30 a.m. dose administered at 12:52 p.m. --05/14/16 the 5:30 p.m. dose administered at 6:53 p.m. --05/16/16 the 11:30 a.m. dose administered at 12:47 p.m. --05/23/16 the 11:30 a.m. dose administered at 2:29 p.m. --05/23/16 the 5:30 p.m. dose administered at 7:29 p.m. --05/25/16 the 11:30 a.m. dose administered at 12:32 p.m. --05/27/16 the 5:30 p.m. dose administered at 6:37 p.m. --05/28/16 the 11:30 p.m. dose administered at 2:11 p.m. [MEDICATION NAME] 10 mg once a day at 9:00 a.m.: --05/07/16 medication administered at 2:27 p.m. --05/09/16 medication administered at 12:37p.m. --05/10/16 medication administered at 12:52 p.m. --05/14/16 medication administered at 10:18 a.m. --05/15/16 medication administered at 10:09 a.m. --05/18/16 medication administered at 10:02 a.m. --05/26/16 medication administered at 11:39 a.m. Keflex 500 mg every six (6) hours four (4) times a day for ten (10) days at 5:00 a.m., 11:00 a.m., 5:00 p.m., and 11:00 p.m.: --05/04/16 the 11:00 a.m. dose was not administered, the next dose administered at 5:00 p.m. Multi-vitamin once a day at 9:00 a.m.: --05/04/16 medication administered at 5:00 p.m. --05/07/16 medication administered at 2:27 p.m. --05/09/16 medication administered at 12:37 p.m. --05/10/16 medication administered at 12:52 p.m. --05/14/16 medication administered at 10:18 a.m. --05/15/16 medication administered at 10:09 a.m. --05/18/16 medication administered at 10:02 a.m. --05/26/16 medication administered at 11:39 a.m. [MEDICATION NAME] 100 mg three (3) times a day at 9:00 a.m., 3:00 p.m., and 9:00 p.m.: --05/02/16 the 3:00 p.m. dose administered at 4:45 p.m. --05/03/16 the 3:00 p.m. dose administered at 4:47 p.m. --05/04/16 the 9:00 a.m. dose administered at 5:00 p.m. --05/04/16 the 3:00 p.m. dose administered at 5:01 p.m. --05/07/16 the 9:00 a.m. dose administered at 2:27 p.m. --05/08/16 the 3:00 p.m. dose administered at 4:29 p.m. --05/09/16 the 9:00 a.m. dose administered at 12:37 p.m. --05/09/16 the 3:00 p.m. dose administered at 4:08 p.m. --05/10/16 the 9:00 a.m. dose administered at 12:52 p.m. --05/10/16 the 3:00 p.m. dose administered at 5:37 p.m. --05/11/16 the 3:00 p.m. dose administered at 5:07 p.m. --05/14/16 the 9:00 a.m. dose administered at 10:18 a.m. --05/15/16 the 9:00 a.m. dose administered at 10:09 p.m. --05/16/16 the 3:00 p.m. dose administered at 5:21 p.m. --05/18/16 the 9:00 a.m. dose administered at 10:02 a.m. --05/22/16 the 3:00 p.m. dose administered at 5:24 p.m. --05/25/16 the 3:00 p.m. dose administered at 6:05 p.m. --05/26/16 the 9:00 a.m. dose administered at 11:39 a.m. [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME])10-325 mg twice a day at 9:00 a.m. and 8:00 p.m.: --05/04/16 the 9:00 a.m. dose administered at 5:00 p.m. --05/07/16 the 9:00 a.m. dose administered at 2:27 p.m. --05/09/16 the 9:00 a.m. dose administered at 12:37 p.m. --05/10/16 the 9:00 a.m. dose administered at 12:52 p.m. --05/14/16 the 9:00 a.m. dose administered at 10:18 a.m. --05/14/16 the 8:00 p.m. dose administered at 9:37 p.m. --05/15/16 the 9:00 a.m. dose administered at 10:09 a.m. --05/18/16 the 9:00 a.m. dose administered at 10:02 a.m. --05/24/16 8:00 p.m., dose administered at 9:15 p.m. --05/26/16 9:00 a.m., dose administered at 11:39 a.m. Pudding four (4) times a day 6 ounces (OZ) at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 8:00 p.m.: --05/01/16 the 1:00 p.m. pudding administered at 3:12 p.m. --05/04/16 the 9:00 a.m. pudding administered at 5:00 p.m. --05/04/16 the 1:00 p.m. pudding administered at 5:01 p.m. --05/07/16 the 9:00 a.m. pudding administered at 2:27 p.m. --05/07/16 the 1:00 p.m. pudding administered at 2:28 p.m. --05/08/16 the 1:00 p.m. pudding administered at 4:29 p.m. --05/09/16 the 9:00 a.m. pudding administered at 12:37 p.m. --05/10/16 the 9:00 a.m. pudding administered at 12:52 p.m. --05/14/16 the 9:00 a.m. pudding administered at 10:18 a.m. --05/14/16 the 5:00 p.m. pudding administered at 6:53 p.m. --05/14/16 the 8:00 p.m. pudding administered at 9:37 p.m. --05/15/16 the 9:00 a.m. pudding administered at 10:09 a.m. --05/17/16 the 1:00 p.m. pudding administered at 2:08 p.m. --05/18/16 the 9:00 a.m. pudding administered at 10:02 a.m. --05/23/16 the 1:00 p.m. pudding administered at 2:29 p.m. --05/23/16 the 5:00 p.m. pudding administered at 7:29 p.m. --05/24/16 the 8:00 p.m. pudding administered at 9:15 p.m. --05/25/16 the 5:00 p.m. pudding administered at 6:05 p.m. --05/26/16 the 9:00 a.m. pudding administered at 11:39 a.m. --05/26/16 the 1:00 p.m. pudding administered at 2:52 p.m. --05/28/16 the 1:00 p.m. pudding administered at 2:11 p.m. [MEDICATION NAME] 0.5 mg twice a day at 9:00 a.m. and 8:00 p.m.: --05/04/16 the 9:00 a.m. dose administered at 5:00 p.m. --05/07/16 the 9:00 a.m. dose administered at 2:27 p.m. --05/09/16 the 9:00 a.m. dose administered at 12:37 p.m. --05/10/16 the 9:00 a.m. dose administered at 12:52 p.m. --05/14/16 the 9:00 a.m. dose administered at 10:18 a.m. --05/14/16 the 8:00 p.m. dose administered 9:37 p.m. --05/15/16 the 9:00 a.m. dose administered at 10:09 a.m. --05/18/16 the 9:00 a.m. dose administered at 10:02 a.m. --05/24/16 the 8:00 p.m. dose administered at 9:15 p.m. --05/26/16 the 9:00 a.m. dose administered at 11:39 a.m. [MEDICATION NAME] Forte 1 mg twice ad ay at 9:00 a.m. and 8:00 p.m.: --05/04/16 the 9:00 a.m. dose administered at 5:00 p.m. --05/0716 the 9:00 a.m. dose administered at 2:27 p.m. --05/09/16 the 9:00 a.m. dose administered at 12:37 p.m. --05/10/16 the 9:00 a.m. dose administered at 12:52 p.m. --05/14/16 the 9:00 a.m. dose administered at 10:18 a.m. --05/14/16 the 8:00 p.m. dose administered at 9:37 p.m. --05/15/16 the 9:00 a.m. dose administered at 10:09 a.m. --05/18/16 the 9:00 a.m. dose administered at 10:02 a.m. --05/24/16 the 8:00 p.m. dose administered at 9:15 p.m. --05/26/16 the 9:00 a.m. dose administered at 11:39 a.m. [MEDICATION NAME] XL extended release 24 hr 12.5 mg once a day at 9:00 a.m.: --05/04/16 dose administered at 5:00 p.m. --05/07/16 dose administered at 2:27 p.m. --05/10/16 dose administered at 12:53 p.m. --05/14/16 dose administered at 10:18 a.m. --05/15/16 dose administered at 10:09 a.m. --05/18/16 dose administered at 10:02 a.m. --05/26/16 dose administered at 11:39 a.m. c.) Resident #49 A review of the Medication Administration Record [REDACTED] Vitamin D capsule given twice a day at 7:00 a.m. and 7:00 p.m --05/28/16 medication administered at 8:31 p.m. --05/29/16 medication administered at 8:02 p.m. d.) Resident #43 A review of the medication adminstration record for Resident #49 on 07/26/16 at 10:15 a.m. with the DON revealed the resident had received the following medication later than ordered by the physician: Aspirin, delayed release tablet 81 mg at 7:00 a.m : --05/28/16 medication administered at 9:25 a.m. [MEDICATION NAME] .5 mg. tablet to be given every 12 hours at 7:00 a.m. and 7:00 p.m.: --05/28/16 the 7:00 a.m. dose administered at 9:25 a.m. [MEDICATION NAME] capsule 100 mg. once a day at 8:00 a.m.: --05/28/16 medication administered at 9:25 a.m. [MEDICATION NAME] 6.25 mg tablet, twice a day, at 7:00 a.m. and 7:00 p.m. --05/28/16 the 7:00 a.m. dose administered at 9:25 a.m. Digon tablet 125 mcg. once a day at 8:00 a.m.: --05/28/16 medication administered at 9:25 a.m. Donepezil tablet 5 mg twice a day at 7:00 a.m. and 5:00 pm. --05/28/16 the 7:00 a.m. dose administered at 9:25 a.m. [MEDICATION NAME] sulfate tablet 325 mg twice a day at 7:00 a.m. and 5:00 p.m. --05/28/16 the 7:00 a.m. dose administered at 9:25 a.m. [MEDICATION NAME] tablet 20 mg. once a day at 7:00 a.m.: --05/28/16 medication administered at 9:25 a.m. [MEDICATION NAME] tablet 10 mg twice a day at 7:00 a.m. and 7:00 p.m.: --05/28/16 the 7:00 a.m. dose administered at 9:25 a.m. [MEDICATION NAME] 400 mg suspension once a day at 7:00 a.m.: --05/28/16 medication administration at 9:25 a.m. Memantine tablet. 5 mg twice a day at 7:00 a.m. and 7:00 p.m.: --05/28/16 the 7:00 a.m. dose administered at 9:25 a.m. [MEDICATION NAME] tablet 5-325 tablet twice a day at 7:00 a.m. and 7:00 p.m. --05/28/16 the 7:00 a.m. dose administered at 9:25 a.m. [MEDICATION NAME], drops 0.4-0.3% four times a day at 8:00 a.m., noon, 4:00 p.m. and 8 :00 p.m.\ --05/28/16 noon dose administered at 2:04 p.m. d) Policy Review and Interview with the Director of Nursing A review of the facility's policy on 07/25/16 at 4:40 p.m., found the nursing staff must administer medication within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). In an interview with the Director of Nursing (DON) on 07/25/16 at 4:43 p.m., she confirmed the medication given late for Resident #52 and #110 on numerous occasions.",2019-07-01
4864,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2016-07-29,312,D,1,0,G6NZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility did not ensured residents received activity of daily living (ADL) care as ordered. Resident were not given baths and/or showers according to bathing schedules as required. This was evident for two (2) of six (6) residents reviewed. Resident identifers: #43 and #52. Facility census: 58 Findings include: a.) Resident #43 A review of Resident #43's bathing record showed she did not receive a shower on her shower day as required. Review of the nursing shower list revealed the resident's shower days were Tuesday, Thursday and Saturday. Resident #43 did not receive a shower on 05/28/16 (Saturday) as required. Interview with Registered Nurse (RN) #89 and the Director of Nursing #21, on 07/27/16 at 2:00 p.m. verified the resident did not receive a shower on the assigned day. The facility did not have a shower team of staff working that day to complete showers. b) Resident #52 In an interview on 07/25/16 at 11:30 a.m., with Resident #52. The resident stated, I did not get my shower on Memorial Day weekend. I was to receive a shower on Saturday and I did not get my shower until Tuesday. A review of the resident's shower schedule, found Resident #52 receives her shower on Tuesday, Thursday, and Saturday. The schedule is revised if the shower team is not available. The resident resides in room [ROOM NUMBER]-B, and she would receive her shower from 2:00 p.m. - 10: 00 p.m. if the shower team is not available. The form stated, IF A RESIDNET'(sic)' ( REFUSES A SHOWER YOU MUST INFORM THE NURSES ON DUTY AT THAT TIME, NOT AT THE END OF YOU SHIFT, YOU MUST APPROVE IT WITH NURSES BEFORE A RESIDNET '(sic)' IS GIVEN A BEDBATH, SCHEDULED SHOWERS MUST BE GIVEN EVERYDAY, THIS IS MANDATORY, IF NOT FOLLOWED DISCIPLINARY ACTION WILL BE TAKEN. A review of the facility's shower list, on 07/26/16 at 12:50 p.m., found on 05/28/16 (Saturday), Resident #52 did not receive a shower. A review of the activity of daily living flow record for Resident #52, found no evidence the resident had received a shower on 05/28/16. In an interview on 07/26/16 at 11:30 a.m., the DON reviewed the shower schedule and confirmed they did not have a shower team on 05/28/16 and this resident did not receive her shower.",2019-07-01
4865,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2016-07-29,333,D,1,0,G6NZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, resident interview, staff interview, and review of the State Operations Manual Appendix PP, the facility failed to ensure that one (1) of six (6) residents reviewed were free of any significant medication errors. One (1) resident did not receive her antibiotic intravenous (IV) medication on time to maintain consistent blood levels while the resident was receiving the medication. Resident Identifier #52. Facility census 58. Findings include: a) Resident #52 Interview with Resident #52, on 07/28/16 at 10:17 a.m., she stated, I do not receive my IV as I should be. When asked what she meant, she said they do not give her antibiotic intravenous(IV)medication in the morning. She further stated the staff either gives her morning IV antibiotic late, or she will give the medication in the afternoon, and then later in the evening. She said they have to wait a long time on a trough (laboratory)level before they are able to give her medication. The resident said they just give my antibiotic medication at different times. A review of Resident #52's Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/15/16 found the resident scored a 15 on her brief interview for mental status (BIMS). The BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding. A BIMS score of 13-15 indicates a resident is cognitively intact. A review of Resident #52's Medication Administration Record [REDACTED]. [MEDICATION NAME] 1,000 milligram (mg) administered every twelve hours from 06/29/16- 07/11/16. A review of (MONTH) medication MAR found: --07/01/16 the 5:00 a.m. dose administered at 6:02 a.m., had to wait for labs to be drawn before intravenous medication could be infused. -07/04/16 the 5:00 a.m. dose administered at 9:46 a.m., awaiting for trough results. -07/06/16 the 9:00 a.m. dose administered at 10:18 a.m. -07/07/16 the 9:00 a.m. dose administered at 10:16 a.m. -07/08/16 the 9:00 a.m. dose administered at 2:57 p.m., awaiting for tubing from pharmacy. -07/09/16 the 9:00 a.m. dose administered at 3:44 p.m., awaiting for trough results. -07/11/16 the 9:00 a.m. dose administered at 10:12 a.m., late due to with physician. The State Operations Manual Appendix PP, guidance to surveyors for the long term care facilities finds, if the drug is from a category that usually requires the resident to be titrated to a specific blood level, a single medication error could alter that level and precipitate a reoccurrence of symptoms or toxicity. [MEDICATION NAME] is considered as a significant medication. This designation is based on expert opinion without regard to the status of the resident. Most experts concluded that the significance of these errors, in and of themselves, have a high potential for creating problems for the typical long term care facility resident. In an interview with the DON on 07/27/16 at 4:05 p.m., confirmed the time the [MEDICATION NAME] was administered were significant medication errors for Resident #52. The DON acknowledged that receiving the medication on time is essential in order to maintain consistent blood levels while the resident is receiving the medication. The DON said there were different reason for her staff not being able to administer the medication. She stated, My staff had changed the tubing every time they hanged another bag, and they should of only changed the tubing once a day, is the reason they ran out of tubing. Therefore the medication was not given on time. The DON said, Waiting on trough level to get back to us, and just not administering the medication on time or being with the physician seemed to be the reason why the medication was not administered. The DON acknowledged that the medication administered was too close to the next dose.",2019-07-01
4866,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2016-07-29,353,E,1,0,G6NZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interview and policy review, the facility failed to deploy their staff in a manner that ensured medication were not administered late due to assisting with resident care, assisting with lunch and not being able to document on the time appropriately four (4) of six (6) resident reviewed for medication being administered in a timely manner. These residents were found to have multiple episodes of medication not being given in a timely manner. Resident Identifier #52, #110, #43 and #49. Facility census 58. Findings include: a) Resident #52 A review of Resident #52's Medication Administration Record [REDACTED]. Two (2) ouces of power pudding with medication administered once a day at 8:00 a.m.: --05/11/16 administered at 9:37 a.m. --05/13/16 administered at 9:02 a.m. --05/15/16 administered at 10:23 a.m. --05/16/16 administered at 9:24 a.m. --05/19/16 administered at 9:18 a.m. Aspirin delayed release 81 mg once a day at 8:00 a.m: --05/10/16 administered at 12:56 p.m. --05/11/16 administered at 9:37 a.m. --05/13/16 administered at 9:02 a.m. --05/15/16 administered at 10:23 a.m. --05/16/16 administered at 9:24 a.m. --05/18/16 administered at 10:04 a.m --05/19/16 administered at 9:18 a.m. --05/27/16 administered at 9:19 a.m. --05/28/16 administered at 10:16 a.m [MEDICATION NAME] 0.5 mg every twelve hours, give one (1) tablet by mouth twice daily at 7:00 a.m. and 7:00 p.m.: --05/27/16 administered the 7:00 a.m. dose at 9:19 a.m. --05/28/16 administered the 7:00 a.m. dose at 10:16 a.m. [MEDICATION NAME] 1 mg twice daily to be administered at 7:00 a.m. and 7:00 p.m.: --05/02/16 the 7:00 a.m. dose administered at 8:26 a.m. --05/03/16 the 7:00 a.m. dose administered at 8:39 a.m. --05/05/16 the 7:00 p.m. dose administered at 1:40 a.m. --05/06/16 the 7:00 p.m. dose administered at 8:57 a.m. --05/11/16 the 7:00 a.m. dose administered at 9:27 a.m. --05/12/16 the 7:00 a.m. dose administered at 8:50 a.m. --05/13/16 the 7:00 a.m. dose administered at 9:02 a.m. --05/15/16 the 7:00 a.m. dose administered at 10:23 a.m. --05/16/16 the 7:00 a.m. dose administered at 9:24 a.m. --05/18/16 the 7:00 a.m. dose administered at 10:04 a.m. --05/19/16 the 7:00 a m. dose administered at 9:18 a.m. --05/25/16 the 7:00 p.m. dose administered at 9:16 p.m. Benadry 25 mg three times a day at 6:00 a.m., 2:00 p.m., and 10:00 p.m.: --05/11/16 the 2:00 p.m. dose administered at 5:26 p.m. [MEDICATION NAME] 100 mg once a day at 8:00 a.m.: --05/11/16 medication administered at 9:37 a.m. --05/13/16 medication administered at 9:02 a.m. --05/15/16 medication administered at 10:23 a.m. --05/16/16 medication administered at 9:24 a.m. --05/18/16 medication administered at 10:04 a.m. --05/19/16 medication administered at 9:18 a.m. --05/27/16 medication administered at 9:19 a.m. --05/28/16 medication administered at 10:16 a.m. [MEDICATION NAME] 20 mg once a day at 8:00 a.m.: --05/10/16 medication administered at 12:56 p.m. --05/11/16 medication administered at 9:37 a.m. --05/13/16 medication administered at 9:02 am. --05/15/16 medication administered at 10:23 a.m. --05/16/16 medication administered at 9:24 a.m. --05/18/16 medication administered at 10:04 a.m. --05/19/16 medication administered at 9:18 a.m. --05/27/16 medication administered at 9:19 a.m. --05/28/16 medication administered at 10:16 a.m. [MEDICATION NAME] sulfate 325 mg three times a day at 8:00 a.m., 1:00 p.m., and 6:00 p.m.: --05/01/16 the 1:00 p.m. dose administered at 3:13 p.m. --05/04/16 the 1:00 p.m. dose administered at 5:04 p.m. --05/05/16 the 8:00 a.m., dose administered at 9:29 a.m. --05/07/16 the 1:00 p.m. dose administered at 2:22 p.m. --05/08/16 the 1:00 p.m. dose administered at 4:25 p.m. --05/10/16 the 8:00 a.m. dose administered at 12:56 p.m. --05/11/16 the 8:00 a.m. dose administered at 9:37 a.m. --05/12/16 the 1:00 p.m. dose administered at 2:17 p.m. --05/13/16 the 8:00 a.m. dose administered at 9:02 a.m. --05/15/16 the 8:00 a.m. dose administered at 10:23 a.m. --05/16/16 the 8:00 a.m. dose administered at 9:24 a.m. --05/17/16 the 1:00 p.m. dose administered at 2:16 p.m. --05/18/16 the 8:00 a.m. dose administered at 10:04 a.m. --05/18/16 the 1:00 p.m. dose administered at 2:08 p.m. --05/19/16 the 8:00 a.m. dose administered at 9:18 a.m. --05/19/16 the 1:00 p.m. dose administered at 2:42 p.m. --05/23/16 1:00 p.m. dose administered at 2:31 p.m. --05/23/16 the 6:00 p.m. dose administered at 7:33 p.m. --05/26/16 the 1:00 p.m. dose administered at 2:53 p.m. --05/26/16 the 6:00 p.m. dose administered at 7:21 p.m. --05/27/16 the 1:00 p.m. dose administered at 2:11 p.m. --05/27/16 the 6:00 p.m. dose administered at 7:13 p.m. --05/28/16 the 8:00 a.m. dose administered at 10:16 a.m. --05/28/16 the 1:00 p.m. dose administered at 3:47 p.m. [MEDICATION NAME] 20 mg twice a day at 7:00 a.m. and 4: 00 p.m.: --05/02/16 the 7:00 a.m. dose administered at 8:36 a.m. --05/03/16 the 7:00 a.m. dose administered at 8:39 a.m. --05/04/16 the 4:00 p.m. dose administered at 5:04 a.m. --05/06/16 the 7:00 a.m. dose administered at 8:57 a.m. --05/06/16 the 4:00 p.m. dose administered at 5:05 p.m. --05/07/16 the 4:00 p.m. dose administered at 5:31 p.m. --05/10/16 the 4:00 p.m. dose administered at 5:39 p.m. --05/11/16 the 7:00 a.m. dose administered at 9:37 a.m. --05/11/16 the 4:00 p.m. dose administered at 5:26 p.m. --05/12/16 the 7:00 a.m. dose administered at 8:50 a.m. --05/12/16 the 4:00 p.m. dose administered at 5:17 p.m. --05/13/16 the 7:00 a.m. dose administered at 9:02 a.m. --05/13/16 the 4:00 p.m. dose administered at 5:37 p.m. --05/15/16 the 7:00 a.m. dose administered at 10:23 a.m. --05/15/16 the 4:00 p.m. dose administered at 5:16 p.m. --05/16/16 the 7:00 a.m. dose administered at 9:24 a.m. --05/16/16 the 4:00 p.m. dose administered at 5:30 p.m. --05/18/16 the 7:00 a.m. dose administered at 10:04 a.m. --05/18/16 the 4:00 p.m. dose administered at 5:06 p.m. --05/19/16 the 7:00 a.m. dose administered at 9:18 a.m. --05/19/16 the 4:00 p.m. dose administered at 5:06 p.m. --05/22/16 the 4:00 p.m. dose administered at 5:25 p.m. --05/23/16 the 4:00 p.m. dose administered at 7:33 p.m. --05/25/16 the 4:00 p.m. dose administered at 6:07 p.m. --05/27/16 the 7:00 a.m. dose administered at 9:19 a.m. --05/27/16 the 4:00 p.m. dose administered at 6:26 p.m. --05/28/16 the 7:00 a.m. dose administered at 10:16 a.m. [MEDICATION NAME] 100 mg twice a day at 8:00 a.m. and 8:00 p.m.: --05/10/16 the 8:00 a.m., dose administered at 12:56 p.m. --05/11/16 the 8:00 a.m., dose administered at 9:37 a.m. --05/13/16 the 8:00 a.m., dose administered at 9:02 a.m. --05/14/16 the 8:00 p.m., dose administered at 9:29 p.m. --05/15/16 the 8:00 a.m., dose administered at 10:23 a.m. --05/16/16 the 8:00 a.m., dose administered at 9:24 a.m. [MEDICATION NAME] 100 mg three times a day at 8:00 a.m., 1:00 p.m., and 8:00 p.m.: --05/01/16 the 1:00 p.m., dose administered at 3:13 p.m. --05/04/16 the 1:00 p.m. dose administered at 5:04 p.m. --05/07/16 the 1:00 p.m. dose administered at 2:22 p.m. --05/08/16 the 1:00 p.m. dose administered at 4:25 p.m. --05/10/16 the 8:00 a.m. dose administered at 12:56 p.m. --05/11/16 the 8:00 a.m. dose administered at 9:37 a.m. --05/12/16 the 1:00 p.m. dose administered at 2:17 p.m. --05/13/16 the 8:00 a.m. dose administered at 9:02 a.m. --05/14/16 the 8:00 p.m. dose administered at 9:39 p.m. --05/15/16 the 8:00 a.m. dose administered at 10:23 a.m. --05/16/16 the 8:00 a.m. dose administered at 9:24 a.m. --05/17/16 the 1:00 p.m. dose administered at 2:17 p.m. --05/18/16 the 8:00 a.m. dose administered at 10:04 a.m. --05/18/16 the 1:00 p.m. dose administered at 2:08 p.m. --05/19/16 the 8:00 a.m., dose administered at 9:18 p.m. --05/19/16 the 1:00 p.m. dose administered at 2:42 p.m. --05/23/16 the 1:00 p.m. dose administered at 2:31 p.m. --05/24/16 the 8:00 p.m dose administered at 9:16 p.m. --05/26/16 the 1:00 p.m. dose administered at 2:53 p.m. --05/27/16 the 1:00 p.m. dose administered at 2:11 p.m. --05/28/16 the 8:00 a.m. dose administered at 10:16 a.m. --05/28/16 the 1:00 p.m. dose administered at 3:47 p.m. [MEDICATION NAME] extended release 30 mg once a day at 8:00 a.m.: --05/10/16 medication administered at 12:56 p.m. --05/11/16 medication administered at 9:37 a.m. --05/13/16 medication administered at 9:02 a.m. --05/15/16 medication administered at 10:23 a.m. --05/16/16 medication administered at 9:24 a.m. --05/18/16 medication administered at 10:04 a.m. --05/19/16 medication administered at 9:18 a.m. --05/27/16 medication administered at 9:19 a.m. --05/28/16 medication administered at 10:16 a.m. [MEDICATION NAME] -S 8.6-50 mg twice a day at 7:00 a.m., and 7:00 p.m.: --05/02/16 the 7:00 a.m. dose administered at 8:36 a.m. --05/03/16 the 7:00 a.m. dose administered at 8:39 a.m. --05/06/16 the 7:00 a.m. dose administered at 8:57 a.m. --05/13/16 the 7:00 a.m. dose administered at 9:02 a.m. --05/15/16 the 7:00 a.m. dose administered at 10:23 a.m. --05/16/16 the 7:00 a.m. dose administered at 9:24 a.m. --05/19/16 the 7:00 a.m. dose administered at 9:18 a.m. --05/24/16 the 7:00 p.m. dose administered at 9:16 p.m. --05/27/16 the 7:00 a.m. dose administered at 9:19 a.m. [MEDICATION NAME] XL extended release 24 hr 25 mg once a day at 8:00 a.m.: --05/10/16 medication administered at 12:56 p.m. --05/11/16 medication administered at 9:39 a.m. --05/13/16 medication administered at 9:02 a.m. --05/15/16 medication administered at 10:23 a.m. --05/16/16 medication administered at 9:24 a.m. --05/18/16 medication administered at 10:04 a.m. --05/19/16 medication administered at 9:18 a.m. --05/27/16 medication administered at 9:21 a.m. --05/28/16 medication administered at 10:16 a.m. [MEDICATION NAME] 150 mg twice a day at 7:00 a.m. and 7:00 p.m.: --05/02/16 the 7:00 a.m. dose administered at 8:36 a.m. --05/03/16 the 7:00 a.m. dose administered at 8:39 a.m. --05/06/16 the 7:00 a.m. dose administered at 8:57 a.m. --05/11/16 the 7:00 a.m. dose administered at 9:37 a.m. --05/13/16 the 7:00 a.m. dose administered at 9:02 a.m. --05/15/16 the 7:00 a.m. dose administered at 10:23 a.m. --05/16/16 the 7:00 a.m. dose administered at 9:24 a.m. --05/18/16 the 7:00 a.m. dose administered at 10:04 a.m. --05/24/16 the 7:00 p.m. dose administered at 9:16 p.m. --05/28/16 the 7:00 a.m. dose administered at 10:16 a.m. A review of the record also revealed for the month of (MONTH) (YEAR) the resident had the following medications administered late: [MEDICATION NAME] 1,000 milligram (mg) to be administered every twelve hours from 06/29/16 to 07/11/16. --07/01/16 the 5:00 a.m., dose was administered at 6:02 a.m. had to wait for labs to be drawn before intravenous mediation could be infused: --07/04/16 the 5:00 a.m. dose administered at 9:46 a.m. --07/06/16 the 9:00 a.m. dose administered at 10:18 a.m. --07/07/16 the 9:00 a.m. dose administered at 10:16 a.m. --07/08/16 the 9:00 a.m. dose administered at 2:57 p.m. --07/09/16 the 9:00 a.m. dose administered at 3:44 p.m. --07/11/16 the 9:00 a.m. dose administered at 10:12 a.m. Normal saline flush 0.9% - 10 mililiter (ml) twice a day between 10:00 a.m. - 12:00 p.m. and 10:00 p.m. - 1:00 a.m. --07/18/16 the 10:00 a.m. - 12:00 p.m. dose administered at 2:44 p.m. --07/20/16 the 10:00 a.m. - 12:00 p.m. dose administered at 12:47 p.m. --07/21/16 the 10:00 a.m. - 12:00 p.m. dose administered at 12:21 p.m. --07/23/16 the 10:00 a.m. -12:00 p.m. dose administered at 12:08 p.m. Documentation was showing medication was late, but the reason or comments indicated the medication was given on time and charted late for the following medications. Two (2) ounces of power pudding with med pass at 8:00 a.m. --05/17/16, administered at 10:57 p.m., late administration: charted late, comment: administered on time. Ambien 10 mg at bedtime, 10:00 p.m. --05/01/16, charted at 11:18 p.m., late administration, charted late, comment: late entry. --05/02/16, charted at 11:15 p.m., late administration, charted late, comment: late entry. --05/04/16, charted at 11:50 p.m., late administration, charted late, comment: late entry. --05/05/16, charted on 05/06/16 at 1:40 a.m., late administration, charted late, comment: administered on time. --05/06/16, charted at 11:13 p.m., late administration, charted late, comment late entry. --05/10/16, charted on 05/11/16 at 3:14 a.m., late administration, charted late, comment: late entry. --05/21/16, charted on 05/22/16 at 12:44 a.m., late administration, charted late, comment: late entry. --05/23/16, charted 11:26 p.m., late administration charted late, comment: late entry. --05/25/16, charted 11:20 p.m., late administration, charted late, comment administered on time. --05/28/16, charted on 05/29/16 at 7:49 a.m., late administration, charted late, comment: administered on time. Aspirin 81 mg once a day at 8:00 a.m. --05/05/16, charted at 9: 29 a.m., late administration: charted late, comment: late entry. --05/17/16, charted at 10:57 a.m., late administration: other, comment: administered on time. --05/29/16, charted at 10:16 a.m. late administration: other comment: administered on time. [MEDICATION NAME] 0.5 mg every twelve hours at 7:00 a.m., and 7:00 p.m. --05/26/16, 7:00 p.m., charted 10:53 p.m., late administration, charted late, comment: late entry. --05/27/16, 7:00 p.m., charted at 10:31 p.m., late administration, charted late, comment: late entry. --05/28/16, 7:00 p.m., charted at 7:49 p.m., late administration, charted late, comment: administered on time. --05/29/16, 7:00 a.m., charted at 10:16 a.m., late administration, other , comment: administered on time. --05/30/16, 7:00 p.m., charted at 10:16 p.m., late administration, charted late, comment: late entry. [MEDICATION NAME] one (1) mg twice a day at 7:00 a.m. and 7:00 p.m. --05/02/16, 7:00 p.m., charted at 11:15 p.m., late administration, charted late, comment: late entry. --05/03/16, 7:00 p.m., charted at 8:21 p.m., late administration, charted late, comment: administered on time. --05/04/16, 7:00 p.m. charted at 11:50 p.m., late administration, charted late, comment: late entry. --05/05/16, 7:00 a.m., charted at 9:29 a.m., late administration, charted late, comment: late entry. --05/05/16, 7:00 p.m., charted at 1:40 a.m. on 05/06/16, late administration, charted late, comment: administered on time. --05/06/16, 7:00 p.m., charted at 11:13 p.m., late administration, charted late, comment: late entry. --05/07/16, 7:00 p.m., charted at 9:19 p.m., late administration, charted late, comment: administered on time. --05/08/16, 7:00 p.m., charted at 8:38 p.m., late administration, charted late, comment: administered on time. --05/09/16, charted at 8:24 p.m., late administration, charted late, comment: administered on time. --05/10/16, 7:00 p.m., charted at 3:14 a.m. on 05/11/16, late administration, charted late, comment late entry. --05/12/16, 7:00 p.m., charted at 10:52 p.m., late administration, charted late, comment: late entry. --05/13/16, 7:00 p.m., charted at 9:04 p.m., late administration, charted late, comment; administered on time. --05/16/16, 7:00 p.m., charted ate 10:32 p.m., late administration, charted late, comment: administered on time. --05/17/16, 7:00 a.m., charted 10:57 a.m., late administration, charted late, comment: administered on time. --05/17/16, 7:00 p.m., charted at 10:34 p.m., late administration, charted late, comment late entry. --05/20/16, 7:00 p.m., charted at 8:37 p.m., late administration, charted late, comment: late entry. --05/21/16, 7:00 p.m., charted on 05/22/16 at 12:44 a.m., late administration, charted late, comment late entry. --05/22/16, 7:00 p.m., charted at 10:42 p.m., late administration, charted late, comment: administered on time. --05/23/16, 7:00 p.m., charted at 11:26 p.m., late administration, charted late, comment late entry. [MEDICATION NAME] 25 mg three (3) times a day at 6:00 a.m., 2:00 p.m. and 10:00 p.m. --05/10/16, charted on 05/11/16 at 3:14 a.m., late administration, charted late, comment: late entry. [MEDICATION NAME] 100 mg once a day at 8:00 a.m., --05/05/16, charted at 9:29 a.m., late administration, charted late, comment: late entry. --05/29/16, 8:00 a.m., charted at 10:16 a.m., late administration, other, comment: administered on time. [MEDICATION NAME] 20 mg once a day at 8:00 a.m. --05/05/16, charted ate 9:29 a.m., late administration, charted late, comment late entry. --05/17/16, charted at 10:57 a.m., late administration, charted late, comment: administered on time. --05/29/16, charted at 10:16 a.m., late administration, other, comment: administered on time. [MEDICATION NAME] sulfate 325 mg three (3) times a day at 8:00 a.m., 1:00 p.m. and 6:00 p.m. --05/05/16, 8:00 a.m., charted at 9:29 a.m., late administration, charted late, comment: late entry. --05/17/16, 8:00 a.m., charted at 10:57 a.m., late administration, charted late, comment: administered on time. --05/29/16, 8:00 a.m., charted at 10:16 a.m., late administration, other, comment: administered on time. [MEDICATION NAME] 20 mg twice a day at 7:00 a.m. and 4:00 p.m. --05/05/16, 7:00 a.m., charted at 9:29 a.m., late administration, charted late, comment: late entry. --05/17/16, 7:00 a.m., charted at 10:57 a.m., late administration, charted late, comment: administered on time. --05/17/16, 4:00 p.m., charted at 5:23 p.m., late administration, charted late, comment late entry. --05/29/16, 7:00 a.m., charted at 10:16 a.m., late administration, other, comment; administered on time. --05/29/16, 4:00 p.m., charted at 5:30 p.m., late administration, charted late, comment: administered on time. [MEDICATION NAME] 100 mg twice a day at 8:00 a.m. and 8:00 p.m. --05/10/16, 8:00 p.m., charted at 3:14 a.m., late administration, charted late, comment: late entry. --05/12/16, 8:00 p.m., charted at 10:52 p.m., late administration, charted late, comment late entry. --05/13/16, 8:00 p.m., charted at 9:04 p.m., late administration, charted late, comment: administered on time. --05/16/16, 8:00 p.m., charted at 10:32 p.m., late administration, charted late, comment: administered on time. --05/17/16, 8:00 a.m., charted at 10:57 a.m., late administration, charted late, comment administered on time. --05/17/16, 8:00 p.m., charted at 10:34 p.m., late administration, charted late, comment: late entry. [MEDICATION NAME] 100 mg three (3) times a day at 8:00 a.m., 1:00 p.m., and 8:00 p.m. --05/01/16 8:00 p.m., charted at 11:18 p.m., late administration, charted late, comment: late entry. --05/0216, 8:00 p.m., charted at 11:15 p.m., late administration, charted late, comment: late entry. --05/04/16, 8:00 p.m., charted at 11:50 p.m., late administration, charted late, comment: late entry. --05/05/16, 8:00 a.m., charted at 9:29 a.m., late administration, charted late, comment: late entry. --05/06/16, 8:00 p.m., charted at 11:13 p.m., late administration, charted late, comment: late entry. --05/07/16, 8:00 p.m., charted at 9:19 p.m., late administration, charted late, comment: administered on time. --05/10/16, 8:00 p.m., charted on 05/11/16 at 3:14 p.m., late administration, charted late, comment; late entry. --05/12/16, 8:00 p.m., charted at 10:52 p.m., late administration, charted late, comment: late entry. --05/13/16, 8:00 p.m., charted at 9:04 p.m., late administration, charted late, comment: administered on time. --05/16/16, 8:00 p.m., charted at 10:32 p.m., late administration, charted late, comment: administered on time. --05/ 17/16, 8:00 a.m., charted at 10:57 a.m., late administration, charted late, comment; administered on time. --05/17/16, 8:00 p.m., charted at 10:34 p.m., late administration, charted late, comment: late entry. --05/21/16, 8:00 p.m., charted on 05/22/16 at 12:44 a.m., late administration, charted late, comment; late entry. --05/22/16, 8:00 p.m., charted at 10:42 p.m., late administration, charted late, comment: administered on time. --05/23/16, 8:00 p.m., charted at 11:26 p.m., late administration, charted late, comment: late entry. -05/2616, 8:00 p.m., charted at 10:53 p.m., late administration, charted late, comment: late entry. --05/27/16, 8:00 p.m., charted at 10:31 p.m., late administration, charted late, comment: late entry. --05/28/16, 8:00 p.m., charted on 05/29/16 at 7:49 a.m., late administration, charted late, comment: administered on time. -05/29/16, 8:00 a.m., charted at 10:16 a.m., late administration, other, comment; administered on time. --05/30/16 8:00 p.m., charted at 10:16 p.m., late administration, charted late, comment: late entry. [MEDICATION NAME] extended release 30 mg once a day at 8:00 a.m. --05/05/16, charted at 9:29 a.m., late administration, charted late, comment: late entry. --05/17/16, charted at 10:57 a.m., late administration, charted late comment: administered on time. --05/29/16, charted at 10:16 a.m., late administration, other, comment: administered on time. Remedy [MEDICATION NAME] skin paste cleanse with normal saline, pat dry, apply [MEDICATION NAME] cream every shift and prn for ten (10) days and re-evaluate. 6:00 a.m. - 6:00 p.m., 6:00 p.m. - 6:00 a.m. --05/28/16 day 6:00 p.m. - 6:00 a.m., administered at 7:49 a.m., late administrated charted late, comment: administered on time. [MEDICATION NAME]-S 8.6 -50 mg 2 tabs: twice a day. 7:00 a.m. and 7:00 p.m. --05/02/16, 7:00 p.m., charted at 11:15 p.m., late administration, charted late, comment: late entry. --05/03/16, 7:00 p.m., charted at 8:21 p.m., late administration, charted late, comment: administered on time. --05/04/16, 7:00 p.m., charted at 11:50 p.m., late administration, charted late, comment: late entry. --05/05/16, 7:00 p.m., charted at 1:40 a.m. on 05/06/16, late administration, charted late, comment: administered on time. --05/06/16, 7:00 p.m., charted at 11:13 p.m., late administration, charted late, comment: late entry. --05/07/16, 7:00 p.m., charted at 9:19 p.m., late administration, charted late, comment: administered on time. --05/08/16, 7:00 p.m., charted at 8:38 p.m., late administration, charted late, comment: administered on time. --05/09/16, 7:00 p.m., charted at 8:24 p.m., late administration, charted late, comment: administered on time. --05/10/16, 7:00 p.m., charted on 05/11/16 at 3:14 a.m., late administration, charted late, comment: late entry. --05/12/16, 7:00 p.m., charted 10:52 p.m., late administration, charted late, comment; late entry. --05/13/16, 7:00 p.m., charted at 9:04 p.m., late administration, charted late, comment: administered on time. --05/16/16, 7:00 p.m., charted at 10:32 p.m., late administration, charted late, comment: administered on time. --05/17/16, 7:00 p.m., charted at 10:34 p.m., late administration, charted late, comment: late entry. --05/21/16, 7:00 p.m., charted on 05/22/16 at 12:44 a.m., late administration, charted late, comment: late entry. --05/22/16, 7:00 p.m., charted at 10:42 p.m., late administration, charted late, comment: administered on time. --05/23/16, 7:00 p.m., charted at 11:26 p.m., late administration, charted late, comment: late entry. --05/26/16, 7:00 p.m., charted at 10:53 p.m., late administration, charted late, comment; late entry. --05/27/16, 7:00 p.m., charted at 10:31 p.m., late administration, charted late, comment: late entry. --05/28/16, 7:00 p.m., charted on 05/29/16 at 7:49 a.m., late administration, charted late, comment: administered on time. --05/30/16, 7:00 p.m., charted at 10:16 p.m., late administration, charted late, comment: late entry. [MEDICATION NAME] XL extended release 24 hours 25 mg once a day at 8:00 a.m. --05//5/16, charted late at 9:29 a.m. --05/17/16, charted late at 10:57 a.m. --05/29/16, charted late at 10:16 a.m. [MEDICATION NAME] 150 mg twice a day at 7:00 a.m. and 7:00 p.m. --05/02/15, 7:00 p.m., charted at 11:15 p.m., late administration charted late comment: late entry. --05/03/16, 7:00 a.m., charted at 8:21 p.m., late administration, charted late, comment: administered on time. --05/04/16, 7:00 p.m., charted at 11:50 p.m., late administration, charted late, comment: late entry. --05/05/16, 7:00 a.m., charted at 9:29 a.m., late administration, charted late, comment: late entry. --05/05/16, 7:00 p.m., charted on 05/06/16 at 1:40 a.m., late administration, charted late, comment: administered on time. --05/06/16, 7:00 p.m., charted at 11:13 p.m., late administration, charted late, comment: late entry. --05/07/16, 7:00 p.m., charted at 9:19 p.m., late administration, charted late, comment: administered on time. --05/08/16, 7:00 p.m., charted at 8:38 p.m., late administration, charted late, comment: administered on time. --05/09/16, 7:00 p.m., charted at 8:24 p.m., late administration, charted late, comment: administered on time. --05/10/16, 7:00 p.m., charted on 05/11/16 at 3:14 a.m., late administration, charted late, comment: late entry. --05/12/16, 7:00 p.m., charted on 10:52 p.m., late administration, charted late, comment: late entry. --05/13/16, 7:00 p.m., charted at 9:04 p.m., late administration, charted late, comment: administered on time. --05/16/16, 7:00 p.m., charted at 10:32 a.m., late administration, charted late, comment: administered on time. --05/17/16, 7:00 a.m., charted at 10:57 a.m., late administration, charted late, comment: administered on time. --05/17/16 7:00 p.m., charted at 10:34 p.m., late administration, charted late, comment: late entry. --05/20/16, 7:00 p.m., charted at 8:37 p.m., late administration, charted late, comment: late entry. --05/21/16, 7:00 p.m., charted on 05/22/16 at 12:44 a.m., late administration, charted late, comment: late entry. --05/22/16, 7:00 p.m., charted at 10:42 p.m., late administration, charted late, comment: administered on time. --05/23/16, 7:00 p.m., charted at 11:26 p.m., late administration, charted late, comment: late entry. --05/26/16, 7:00 p.m., charted at 10:53 p.m., late administration, charted late, comment: late entry. --05/27/16, 7:00 p.m., charted at 10:31 p.m., late administration, charted late, comment: late entry. --05/28/16, 7:00 p.m., charted at 7:49 p.m., late administration, charted late, comment: administered on time. --05/29/16, 7:00 a.m., charted at 10:16 a.m., late administration, charted late, comment: administered on time. --05/30/16 7:00 p.m., charted at 10:16 p.m., late administration, charted late, comment: late entry. b) Resident #110 A review of Resident #110's Medication Administration Record [REDACTED]. [MEDICATION NAME] 0.5 mg twice a day at 9:00 a.m. and 8:00 p.m.: --05/04/16 the 9:00 a.m. dose administered at 5:00 p.m. --05/07/16 the 9:00 a.m. dose administered at 2:37 p.m. --05/09/16 the 9:00 a.m. dose administered at 12:37 p.m. --05/10/16 the 9:00 a.m. dose administered at 12:52 p.m. --05/14/16 the 9:00 a.m. dose administered at 10:18 a.m. --05/14/16 the 8:00 p.m. dose administered at 9:37p.m. --05/15/16 the 9:00 a.m. dose administered at 10:09 a.m. --05/18/16 the 9:00 a.m. dose administered at 10:02 a.m. --05/24/16 the 8:00 p.m. dose administered at 9:15 p.m. --05/26/16 the 9:00 a.m. dose administered at 11:39 a.m. [MEDICATION NAME] drops, one (1)% three drops sublingual three (3) times a day at 9:00 a.m., 3:00 p.m., and 8:00 p.m.: --05/02/16 the 3:00 p.m. dose administered at 4:45 p.m. --05/03/16 the 3:00 p.m. dose administered at 4:47 p.m. --05/04/16 the 9:00 a.m. dose administered at 5:00 p.m. --05/04/16 the 3:00 p.m. dose administered at 5:01 p.m. --05/07/16 the 9:00 a.m. dose administered at 2:27 p.m. --05/08/16 the 3:00 p.m. dose administered at 4:29 p.m. --05/09/16 the 9:00 a.m. dose administered at 12:37 p.m. --05/09/16 the 3:00 p.m. dose administered at 4:08 p.m. --05/10/16 the 9:00 a.m. dose administered at 12:52 p.m. --05/10/16 the 3:00 p.m. dose administered at 5:37 p.m. --05/11/16 the 3:00 p.m. dose administered at 5:07 p.m. --05/14/16 the 9:00 a.m. dose administered at 10:18 a.m. --05/14/16 the 8:00 p.m. dose administered at 9:37 p.m. --05/15/16 the 9:00 a.m. dose administered at 10:09 a.m. --05/16/16 the 3:00 p.m. dose administered at 5:21p.m. --05/18/16 the 9:00 a.m. dose administered at 10:02 a.m. --05/22/16 the 3:00 p.m. dose administered at 5:24 p.m. --05/24/16 the 8:00 p.m. dose administered at 9:15 p.m. --05/25/16 the 3:00 p.m. dose administered at 6:05 p.m. --05/26/16 the 9:00 a.m. dose administered at 11:39 a.m. [MEDICATION NAME] 10 mg every six (6) hours to be administered at 5:30 a.m., 11:30 a.m., 5:30 p.m., and 11:30 p.m.: --05/02/16 the 11:30 a.m. dose administered at 12:46 p.m. --05/04/16 the 11:30 a.m, dose administered at 5:00 p.m. --05/07/16 the 11:30 a.m. dose administered at 2:27 p.m. --05/09/16 the 11:30 a.m. dose administered at 12:37 p.m. --05/10/16 the 11:30 a.m. dose administered at 12:52 p.m. --05/14/16 the 5:30 p.m. dose administered at 6:53 p.m. --05/16/16 the 11:30 a.m. dose administered at 12:47 p.m. --05/23/16 the 11:30 a.m. dose administered at 2:29 p.m. --05/23/16 the 5:30 p.m. dose administered at 7:29 p.m. --05/25/16 the 11:30 a.m. dose administered at 12:32 p.m. --05/27/16 the 5:30 p.m. dose administered at 6:37 p.m. --05/28/16 the 11:30 p.m. dose administered at 2:11 p.m. [MEDICATION NAME] 10 mg once a day at 9:00 a.m.: --05/07/16 medication administered at 2:27 p.m. --05/09/16 medication administered at 12:37p.m. --05/10/16 medication administered at 12:52 p.m. --05/14/16 medication administered at 10:18 a.m. --05/15/16 medication administered at 10:09 a.m. --05/18/16 medication administered at 10:02 a.m. --05/26/16 medication administered at 11:39 a.m. Keflex 500 mg every six (6) hours four (4) times a day for ten (10) days at 5:00 a.m., 11:00 a.m., 5:00 p.m., and 11:00 p.m.: --05/04/16 the 11:00 a.m. dose was not administered, the next dose administered at 5:00 p.m. Multi-vitamin once a day at 9:00 a.m.: --05/04/16 medication administered at 5:00 p.m. --05/07/16 medication administered at 2:27 p.m. --05/09/16 medication administered at 12:37 p.m. --05/10/16 medication administered at 12:52 p.m. --05/14/16 medication administered at 10:18 a.m. --05/15/16 medication administered at 10:09 a.m. --05/18/16 medication administered at 10:02 a.m. --05/26/16 medication administered at 11:3",2019-07-01
4867,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2016-07-29,356,D,1,0,G6NZ11,"> Based on staff posting and staff interview, the facility failed to accurately post the combined hours on the posting form for one (1) of three (3) days staffing was reviewed. Facility census 58. Findings include: a) Staff posting combined hours. A review of the staff posting for 05/28/16 - 05/29/16, finds three (3) licensed practical nurses (LPN) worked from 6:00 a.m. - 6:00 p.m. for the total combined hours are 36 hours. The staff posting also revealed there is five (5) Nurse Aides (NA) working from 6:00 a.m. to 2:00 p.m., for a combined total hours of 37.50. There were three (3) LPN working from 6:00 p.m. to 6:00 a.m., combined total hours of 36 hours. In an interview with the Director of Nursing (DON) on 07/27/16 at 2:00 p.m., she confirmed they wrote on the staff posting form there were three (3) LPN'S, but one (1) of these LPNs assisted the assistive living unit from 4:00 p.m. to 6:00 p.m. Another LPN also provide care to the assisted living area from 6:00 p.m. to 6:00 a.m. She did not know how much time to take off the staff posting for the hours the LPN goes and works upstairs. The DON confirmed that there were four (4) NAs that worked from 6:00 a.m. to 2:00 p.m., and one NA came on duty on 05/28/16 at 8:55 a.m. to 2:00 p.m. The DON confirmed the combined hours were not accurate for the LPN and the NA due to the NA did not work the whole shift on the first floor unit and they counted her for the whole shift. They only count 7.50 hour for each aide. The DON confirmed that she may not know the number of hours the nurse worked upstairs in the assisted living, section from 4:00 p.m., to 6:00 p.m. and from 6:00 p.m. to 6:00 a.m.",2019-07-01
4868,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2016-07-29,428,E,1,0,G6NZ11,"> Based on medical record review and staff interview, the pharmacist failed to identify medication errors for residents receiving medication late. The pharmacist also did not identify the medication were being administered too close to the next dose. There were no physician order to hold the medication or administer the medication at a later time. Resident identifiers: #52, #110, #43 and #49. Facility census: 58. Findings include: a) Resident #52 A review of Resident #52's Medication Administration Record [REDACTED]. A review of Resident #52's MAR for the month of (MONTH) (YEAR) found the resident received Vancomycin 1,000 milligram (mg) administered every twelve hours from 06/29/16 - 07/11/16. The medication was either administered late, held without a physician order, administered at a later date without a physician order, or administering medication too close to the next dose seven (7) times, on 07/01/16, 07/04/16, 07/06/16, 07/07/16, 07/08/16, 07/09/16, 07/11/16. The reason for the medication not being administered on time was due to waiting on labs, intravenous tubing from pharmacy, late due to being with physician. Interview with the Director of Nursing (DON) on 07/27/16 at 4:05 p.m., revealed The DON was asked whether the pharmacist had identified the medications were being administered late, or that staff have not been notifying the physician when they held mediation, administered medication at a later date, or administered medication too close to the next dose. The DON stated, No. The nurse provided evidence the consultant pharmacist did his monthly review for (MONTH) already, and he made no recommendation regarding any of the resident's medication being late, holding medication without an order, or administering medication without an order at a later date. b) Resident #110 A review of Resident #110's Medication Administration Record [REDACTED]. Resident #110 had 134 medications that was administered late due to assisting with a resident's care, or assisting with lunch meal. d) Resident #43 A review of the medical record for this resident on 07/27/16 at 11:10 a.m.revealed the registered pharmacist had not identified on monthly drug regimen reviews any medication irregularities when meds had been documented as being administered late due to various reasons such as not given timely due to assisting with resident care or assisting with lunch distribution. Also there was inaccurate notations about the timing being late but states was given on time. This was evident for thirteen (13) medications that were given on 05/28 and one time on 05/29/16. e.) Resident #49 Review of this resident's medical record on 07/26/16 at 10:10 a.m. indicated the registered pharmacist had not identifed on his monthly drug regimen reviews when medications were given late when medication history form documentation indicated they were given late due to various rationale, such as having to assist with resident care or lunch time and inaccurate documentation which stated the medication was given late but rationale stating given on time. Interview with the DON, on 07/27/16 at 2:00 p.m., confirmed the registered pharmacist had not identifed these issues as being irregularities when he completed his monthly reviews or on concern forms. On 07/28/16 at 11:00 a.m., attempted to notify the consultant pharmacist in regards of whether he identified the medication were being administered late, or that staff have not been notifying the physician when they held medication, administered medication at a later date, or administered medication too close to the next dose. The consultant pharmacist was unavailable. Left message for him to return my call. The consultant pharmacist never returned the call.",2019-07-01
4869,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2016-07-29,514,D,1,0,G6NZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to accurately document in the medical record a medication that had not been administered. Documentation showed a resident received an intravenous (IV) medication, but after counting the medication, pharmacy inventory revealed the medication could not have been administered. Resident #52. Facility census 58. Findings include: a) Resident #52 A review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. In an interview with the DON on 07/27/16 at 1:03 p.m., she was asked why the medication was not given on time. The DON stated the LPN that documented this evidence was not available, and I will have to call her at home. On 07/27/16, at 1:22 p.m. the DON stated LPN #18 confirmed she did not give the medication, due to waiting on a pharmacy to call with new dosing. The DON counted the [MEDICATION NAME] medication bags with the pharmacy inventory sheet and found the medication could not have been administered. She did confirm the written information in the MAR indicated [REDACTED].",2019-07-01
5298,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2015-06-24,258,E,0,1,FGRX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews and staff interviews the facility failed to provide comfortable sounds levels for five (5) of twenty-eight (28) residents on the B Unit. Resident identifiers: #10, #35, #37, #39, and #71. Facility census: 57. Findings include: a) Resident #10 During an interview, on 06/22/15 at 9:17 a.m., Resident #10 revealed it was loud in the facility in the evening. The resident stated some of the residents are loud and yell out in the evening. b) Resident #35 During an interview, on 06/22/15 at 9:48 a.m., Resident #35 stated the televisions were too loud after supper. c) On 06/23/15 at 6:50 p.m., the facility was entered to make observations of the noise levels in the facility. Upon entering the facility, a television on Unit B room [ROOM NUMBER] was playing extremely loud. d) An interview with Licensed Practical Nurse (LPN) #11, on 06/23/15 at 7:00 p.m., revealed the resident always turned the television up very loud every day, and they had to ask him to turn it down. LPN #11 stated the resident liked to listen to music loudly and liked to sing. e) Resident #37 During an interview, on 06/22/15 at 1:00 p.m., Resident #37 indicated it was noisy in the facility in the evenings and stated the televisions were loud. The resident stated she tells the staff, but they do not do anything. f) Resident #39 In an interview, on 06/23/15 at 7:11 p.m., the resident said staff were loud on the B Unit dining room in the evening and some of the resident ' s televisions were loud in the evening. g) Resident #71 During an interview, on 06/22/15 at 7:05 p.m., Resident #71 revealed it was very noisy in the facility in the evening. The resident stated she often heard small children yelling loudly and staff was loud at times. During the interview with Resident #71, children were heard yelling loudly from out in the hall. Upon observation, there were two (2) small children in the main dining room on the B Unit running and yelling loudly. Activity Staff #1 was in the dining area during this observation. h) An interview with Activity Staff #1, on 06/22/15 at 7:05 p.m., revealed she brought her children to the facility for about one (1) hour in the evenings, due to a scheduling conflict and there was no one at home to care for them. She stated an activity staff person quit and she was covering the evening activities. She stated she was not aware her children were loud and disturbing the residents. i) During an interview with Administrator #68, on 06/24/15 at 8:20 a.m., he said he received notification the previous day the children were being loud in the facility. He stated he was not previously aware the children were coming into the facility on a consistent basis with Activity Staff #1.",2019-01-01
5299,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2015-06-24,371,F,0,1,FGRX11,"Based on observations and staff interviews, the facility failed to store food under sanitary conditions to prevent, to the extent possible, the outbreak of foodborne illness. This practice had the potential to affect all residents who received nutrition from the kitchen. Facility census: 57. Findings include: a) The initial tour of the facility was conducted on 06/22/15 at 6:50 a.m. The following sanitation infractions were identified and discussed with staff as indicated: 1. The floors around the cove molding in the kitchen had a large build-up of a black substance. 2. The milk cooler did not contain a thermometer. Dietary Employees #8 and #9 verified the milk cooler did not have a thermometer. They stated the milk cooler was new and they were not sure where to locate the thermometer. 3. Observation of the walk-in freezer revealed bags of dough balls and frozen vegetables which were stored in boxes open to the air. Dietary Employee #9 verified this at 7:05 a.m. 4. The walk-in cooler had a cardboard carton of macaroni salad and a box of sausage patties open to air. 5. Observation of the walk-in cooler revealed a box of more than 20 Health Shakes. An interview with Dietary Employee #9, regarding the system to thaw, serve, and dispose of the Health Shakes, revealed the employee was not aware of any policy. Dietary Employee #9 deferred to Dietary Employee #8. Interview with Dietary Employee #8, on 06/22/15 at 7:10 a.m., revealed the Health Shakes were taken out of the walk-in freezer and placed in the walk-in cooler to thaw. He stated the shakes were usually gone within a week or so. Employee #8 said he was unaware of any policy for how long they could be thawed prior to disposal. An interview with Dietary Manager (DM) #32, on 06/22/15 at 1:45 p.m., revealed the shakes placed in the walk-in cooler (from the walk-in freezer) were usually all gone within a week or so. Observation with DM #32, on 06/23/15 at 12:48 p.m., revealed two (2) boxes of Health Shakes in the walk-in cooler. One (1) box had (MONTH) 1st written on the side. The DM #32 stated she puts the date on the outside of the box when she pulled them from the walk-in freezer. DM #32 verified the box with (MONTH) 1st written on it was pulled from the walk-in freezer on that date. She further verified the Health Shakes in the box had been thawed for 22 days. She verified the need for a system to not pull an entire box at one time because they do not always use the whole box within 14 days. The individual Health Shakes had written instructions on the container to discard after they had thawed for 14 days.",2019-01-01
5300,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2015-06-24,460,F,0,1,FGRX11,"Based on observations and staff interviews, the facility failed to provide full visual privacy in 15 resident rooms observed on the A and B Units. The Stage 2 Sample was 24. Facility census: 57. Findings include: a) Rooms B1, B2, and B3 Observations of these rooms, on 06/22/15 between 2:00 p.m. and 4:00 p.m., revealed each room held two (2) beds. -- The privacy curtain went across the foot of the bed for the bed nearest the door. -- A second curtain was located between the beds from the wall at the head of the bed to about 4 feet from the opposite wall. -- There was no curtain that went across the foot of the bed of the resident nearest the window. -- The common bathroom was at the foot of the bed for the resident nearest the window. There was also a common sink, with a mirror above it, on the wall at which the middle privacy curtain did not reach. With that curtain pulled, residents could see each other on the opposite side of the curtain. b) The facility also had twelve (12) additional rooms with the same floor plan and bed arrangements. The privacy curtains in those rooms also failed to allow for full visual privacy. c) Observation with the facility Administrator and the Maintenance Supervisor, on 06/24/15 at 8:55 a.m., verified the resident in the bed next to the window did not have visual privacy from a roommate or anyone using the sink or common bathroom. The Administrator said, We have extra track and curtains. We will get that fixed. I have never looked at the curtains that way.",2019-01-01
5301,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2015-06-24,469,F,0,1,FGRX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, staff interviews, and record reviews, the facility failed to maintain an effective pest control system to ensure the facility was free from pests. The facility was observed with small flying gnat-like insects in resident rooms, hallways, common areas, nurses ' stations, the elevator, dining room, and conference room. This practice had the potential to affect all facility residents. Facility census: 57. Findings include: a) Observations of the facility, from 06/22/15 through 06/24/15, revealed the continual presence of gnat-like insects in the conference room, common areas, hallways, nurse ' s station, elevator, and the dining room. b) Rooms B8, B10, and B12 Observations on the initial tour, on 06/22/15 from 7:00 a.m. to 7:30 a.m., revealed the presence of gnat-like insects in these rooms. During a follow up observation, on 06/23/15 at 3:20 p.m., gnat-like insects were seen again in room B12. Room B10 was having floor work done with the door closed so an observation was not possible. c) Resident #71 Interview with Resident #71, on 06/23/15 at 7:05 p.m., revealed there were a lot of small flying bugs of some kind in her room. She stated she swatted them away, but they always came back. She stated they had been bad for a few weeks, and she wished they would do something about them. d) Resident #39 Interview with Resident #69, on 06/23/15 at 7:09 p.m., revealed there were a lot of small flying insects around the facility. She stated they were in her room and in the dining room. She stated they fly around her food when she is eating and she wished the facility would get rid of them because they have been a problem for over a month. Interview with Resident #39, on 06/23/15 at 7:11 p.m., revealed there were several small flying bugs in her room. The resident indicated they were all over the facility in the halls and the dining room. She stated they got on her food when she ate. During the interview, the resident had a flying insect on her nose that she swatted away. She stated she reported the flying insects to the Director of Nursing (DON) #69. Resident #39 said staff told her the flying insects must have gotten into the facility when they installed the window air conditioners. The resident stated the flying insects had been a problem for about three (3) weeks, and were getting worse. e) On 06/23/15 at 10:00 a.m., the Director of Nursing (DON) #69 was interviewed. She swatted at gnat-like insects throughout the interview. f) During an interview with Licensed Practical Nurse (LPN) #11, on 06/23/15 at 12:08 p.m., she stated, These gnats are not usually this bad. This year they are a lot worse. g) During an interview with Social Worker (SW) #22, on 06/23/15 at 3:05 p.m., she stated a resident complained last week of bugs he thought were termites. She stated as a result, the pest control company completed an inspection and treatment. h) During an interview with the Administrator #68, on 06/24/15 at 8:12 a.m., he stated the pest control company treated the facility for ants and gnats on 06/19/15. He said they would usually see an increase, then a decrease, in the pests after the treatment. The administrator stated he called the pest control company the morning of 06/24/15 to see what more could be done to get the pests out quicker. He said the pest control company indicated they would try to get someone back out to the facility. He stated they had some residents who had food in their rooms, but they try to make sure they don't have fruit around. i) A review of the pest control company invoice, on 06/24/15 at 8:15 a.m., revealed the company treated the facility on 06/19/15. The invoice noted the treatment of [REDACTED]. There was no mention of any treatment for [REDACTED]. There was no evidence the pest company had actually completed a treatment to alleviate the problem of gnats in the facility. j) An interview with the Maintenance Supervisor #23, on 06/24/15 at 8:25 a.m. revealed the pest control company was out earlier in (MONTH) but the gnats had gotten worse since it had gotten warmer. He indicated the insects were much worse on the first floor.",2019-01-01
5522,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2017-11-09,241,D,0,1,FJSP11,"Based on observation and staff interview, the facility failed to provide a dining experience with dignity for one randomly observed resident, during a dinner time meal. One (1) nurse aid (NA) approached Resident #149 to set the resident up for the meal without speaking to the resident or letting the resident know what the NA was about to do. Resident identifier: #149 and #99. Facility census: 87. Findings include: a) Resident #149 Random observation during the dinner time meal, on 11/06/17 at 5:12 p.m., revealed Resident #149 was reclining in a geri chair beside a dinner table. Nurse Aide (NA) #44 came up behind Resident #149, and without saying anything to the resident or explaining what he was about to do changed the geri chair from a reclining position to a sitting position. The sudden quick movement from a reclining to a sitting position jarred the resident and caused the resident to scream out. b) Resident #99 Random observation during the dinner time meal, on 11/06/17 at 5:22 p.m., revealed NA #44 was feeding Resident #99 as she was leaning to the right side in her gerri-chair, with her head leaning forward. LPN #26 also in the dining room at the time and after observing NA #44 feeding Resident #99 agreed Resident #99 was not in good body alignment to promote feeding. LPN #26 proceeded to reposition the resident and prop the resident with folded blankets, after surveyor intervention, and instruct NA #44 on proper body alignment to promote feeding.",2018-11-01
5523,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2017-11-09,279,D,0,1,FJSP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a care plan had measurable and/or individualized objectives for a resident on anti-anxiety medication. This was evident for one (1) of five (5) residents reviewed for unnecessary medications, out of fifteen (15) Stage II sampled residents. Resident identifier: #88. Facility census: 87. Findings include: a) Resident #88 The medical record was reviewed on 11/09/17. Physician orders [REDACTED]. at bedtime daily for anxiety. Review of the care plan found it lacked individualized, measurable goals for the use of anti--anxiety medications. The care plan did not identify the behaviors the facility intended to treat with the anti-anxiety medication. The care plan did not include measurable goals set for the resident's emotional and/or behavioral condition. Rather, the care plan focus stated (name of resident) receives anti-anxiety medications ([MEDICATION NAME]) r/t (related to) anxiety disorder. The goals stated Patient will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Their only non-pharmacological interventions were to encourage him to vent his feelings, and listen to his concerns. On 11/09/17 at 9:58 a.m. an interview was conducted with the director of nursing (DON). She said this resident does have targeted behaviors, but they were not listed on the care plan. She acknowledged that there was no focus on the behaviors that caused him to need the [MEDICATION NAME]. She acknowledged that there were no individualized or measurable goals for any targeted behaviors they were treating. She said she would correct these issues right away.",2018-11-01
5524,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2017-11-09,371,E,0,1,FJSP11,"Based on observation and staff interview, the facility failed to maintain kitchen equipment in a sanitary manner. This practice has the potential to affect more than limited number Residents. Staff Identifiers: #66. Facility Census: 87. Findings include: On 11/06/17 at 2:40 p.m., inspection of the kitchen with the dietary assistant #66, revealed an observation of the food lid to hot bar was dirty. The dietary assistant #66 agreed the food lid to hot bar was dirty and should not have been.",2018-11-01
5525,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2017-11-09,431,D,0,1,FJSP11,"Based on observation and staff interview the facility failed to store and label medications. Resident: #48, #81 and #88. 11/08/2017 11:05:14 AM in medication room B and 2 medication carts, LPN #72 Levemir multi vail use wasn't labeled with opened date on vial for Resident #48, LPN #56 11/08/2017 11:15:31 AM Medication Room A and 2 medication carts, LPN #23 pens LPN #4 Humalog pen not labeled with opened date, Resident #81 Novolog pen not labeled with opened date, Resident #88 Based on observations and staff interview, the facility failed to collaborate with the pharmacist, to ensure safety and effective use of medications. An opened and partially used insulin vial was not dated when initially opened. This had the potential to negatively impact the safety and/or potency of the medication. This was evident for three (3) of thirty one (31) opened insulin vials and pens stored in two (2) of four (4) carts. Resident identifiers: #48, #81, #80. Findings include: a) Resident # 48 Observation on 11/08/2017 at 11:05 a.m., found a Levermir vial which belonged to resident # 48 was opened and partially used. There was no date indicating when the vial was intially opened, or the date it should be discarded. The Licensed Practical Nurse (LPN) #72 agreed the date that it was opened should have been on the vial. b) Resident #81 and #80 Observation on 11/08/2017 at 11:15 a.m. found a Humalog pen which belong to Resident # 81 was opened and partially used. There was no date indicating when the pen was was intially opened, or the date to discard. A novolog pen belonging to Resident #80 was opened and partially used. There was no date indicating when the pen was intially opened, or the date to discard. The LPN # 4 agreed that it should have been labeled when it was intially opened. There was a place on the pens to put the opened dates that were blank. Interveiw with the Director of Nursing was completed on 11/09/2017 at 10:30 a.m. she was aware of the findings of the insulin not being dated of when the medication was intially opened and/or to be discarded. She stated the policy required it to be labeled when it is first used with the discard date. The DON says that she has a plan to fix this problem.",2018-11-01
5570,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2015-10-16,309,D,1,0,ZDYQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and clinical record review, the facility failed to provide one (1) of six (6) sampled residents care and services to ensure the highest practicable well-being. The resident's blood glucose was not monitored as ordered by the physician. Resident identifier: #51. Facility census: 53. Findings include: a) Resident #51 Clinical record review on 10/14/15 at 10:00 a.m., revealed Resident #51 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On 09/23/15, the physician determined the resident had capacity to make health care decisions. The 09/23/15 physician's orders [REDACTED]. The 10/10/15 care plan goal for diabetes was Will remain free of signs/symptoms or complications related to diabetes as evidenced by labs and blood sugar checks will be in normal range. The clinical record contained no evidence staff performed the daily accu-checks as ordered. On 09/25/15, the resident's HB A1C ( laboratory test result for overall mean blood glucose) was 6.8. According to the providing laboratory standards, the normal range for HB A1C was 4.3 to 6.1. During an interview on 10/14/15 at 12:10 p.m., Director of Nursing (DON) #4 stated the facility failed to perform the accu-checks daily as ordered. The DON stated an accu-check was performed at 11:46 a.m. on 10/14/15. It was 262. On 10/14/15 at 12:45 p.m., Resident #51 confirmed the facility had not performed accu-checks daily. She said the first one was that day, on 10/14/15.",2018-10-01
6185,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2014-09-18,156,B,0,1,O60P11,"Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility Census: 55 Findings include: a) On 09/17/14 at 10:10 a.m., during an observation of the facility, it was discovered there was no written information posted in the facility to inform a resident about how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. An interview was conducted on 09/17/14 at 1:20 p.m., with the Nursing Home Administrator. She was unable to locate any information posted to inform residents on how to apply for and use Medicare and Medicaid benefits.",2018-05-01
6186,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2014-09-18,241,D,0,1,O60P11,"Based on observation and staff interview, the facility failed to provide care to Resident #17 in a manner that promoted the resident's dignity and respect. While providing assistance with toileting to this resident, the staff member pulled the seat of the resident's pants to assist her with standing. Additionally, a laundry staff member opened the door to the bathroom without knocking while the resident was being toileted. This affected one (1) of twenty (20) residents observed in Stage 2 of the Quality Indicator Survey. Resident #17. Facility Census: 55. Findings include: a) Resident #17 An observation of incontinence care was conducted on 09/18/14 at 11:30 a.m. The resident was taken to the combination shower room / bathroom in front of the nurses' station by a nursing assistant (Employee #67). The nursing assistant provided cueing to the resident to stand and at the same time assisted her to stand by pulling up on the seat of her pants to help her stand. The nursing assistant was questioned about the method of transfer and was asked if they used gait belts. She stated they had some (gait belts) for some people, but she did not use them for this resident. She verified this was not a dignified manner to transfer the resident. During this same observation, on 09/18/14 at 11:32, the bathroom door was opened by a laundry staff member (Employee #20) who started through the door without knocking or announcing herself. When she observed there were people in the restroom, she immediately went back out closing the door. Resident #17 was sitting on the commode within sight of the door when it opened and anyone outside the door could have seen this resident sitting on the toilet. The administrator was made aware of this observation on 09/18/14 at 3:30 p.m. She verified they had gait belts and the staff should be using them on the residents who required assistance with transfers. She was also made aware of the observation with the laundry employee walking in the bathroom without knocking. She agreed staff should knock before coming in the bathroom. .",2018-05-01
6187,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2014-09-18,247,D,0,1,O60P11,"Based on resident interview, staff interview, and record review, the facility failed to provide notice of a roommate change for two (2) of two (2) residents reviewed for admission, transfer and discharge. Resident identifiers: #75 and #41. Facility census: 55. Findings include: a) Resident #75 During a Stage 1 interview, on 09/16/14 at 11:16 a.m., Resident #75 related she had received a new roommate without notice. The resident said the facility transferred the new roommate from another part of the facility. An interview with the social worker (SW), on 09/17/14 at 1:48 p.m., revealed the facility's practice was for the resident, medical power of attorney, and/or health care surrogate to be notified prior to a room or roommate change. She reviewed the facility records and related the resident received a new roommate on 08/21/14. The social worker said the nursing staff usually notified a resident of roommate changes, but she had no evidence this resident was notified of the change. Employee #76, a registered nurse (RN), interviewed on 09/17/14 at 2:30 p.m., reviewed the chart of Resident #75 and the roommate. The nurse confirmed no evidence was present to indicate Resident #75 was notified she was receiving a roommate b) Resident #41 Resident #41, interviewed on 09/16/14 at 4:54 p.m., related she had received a roommate without notification. She said, They just brought her in. The social worker, interviewed on 09/17/14 at 1:55 p.m., reviewed facility records and confirmed the resident had received a new roommate on 09/05/14. She related the resident should have been notified prior to receiving a roommate and verified she had not notified Resident #41. Employee #76 (RN) reviewed the resident's medical record on 09/17/14 at 2:45 p.m., and confirmed no evidence was available to indicate Resident #41 was notified prior to receiving a new roommate.",2018-05-01
6188,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2014-09-18,253,E,0,1,O60P11,"Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services in order to provide a sanitary, orderly, and comfortable interior. Cove molding and tiles were stained, loose, and/or missing. Walls had gouges and paint was missing in areas, exposing bare drywall. Furniture in resident rooms was in need of repair. This had the potential to affect more than an isolated number of residents. Facility Census: 55 Findings include: a) Cove molding: -- Room 105 - The cove molding had rough edges on the wall by the bathroom. -- Resident shower room - The cove molding and tiles were stained with a brown substance. -- Room 110 - The molding underneath the window was stained and had a brown substance on the molding and along the edge of the cove molding. -- Room 112 - The molding in the bathroom was pulled away from the wall exposing the drywall. -- Room 114 - The cove molding was broken away and protruding from the wall by the closet. -- The cove molding in the bathroom between Room 114 and Room 116 was broken and pulled away from the wall. -- Room 121 - The cove molding in the bathroom was soiled. There were brown stained areas along the floor . -- Room 130 - The cove molding had brown stained areas along the floor. -- The cove molding in the bathroom between Room 130 and 132 was cracked, broken, and had brown stained areas along the floor. b) Clothes or linens found on the floor of the closet. -- Room 123 - Resident clothing and unused briefs were on the floor of the closet. -- Room 124 - Resident clothing was on the floor of the closet. -- Room 127 - Folded linens were on the floor of the closet. Employee #43 picked up the linens and took them from the room. She stated The CNAs (certified nursing assistants) help with keeping the closets cleaned up, but these shouldn't be here. -- Room 132 - Resident clothing was on the floor of the closet. During an interview with Employee #43 on 09/17/14 at 3:00 p.m., she confirmed the resident's clothing should not be on the floor. c) The sink front was broken and the sharp edges of the particle board were exposed in Room 126. d) The following rooms had gouged wall paper and wall board or had paint in poor repair. -- Room 101 - The area above the sink in the bathroom, where the mirror would usually be, had an area that was not painted like the rest of the room. -- Room 103 - The paint was chipped on the walls in the resident's room. -- Room 104 - There were two (2) large square areas behind both beds where the wall paper or paint was missing. -- Room 107 - Beside the door, there was an area where the wall was unpainted. -- Room 109 - The area around the outlet behind the bed closest to the door was cracked and broken. -- Room 110 - The paint beside the sink was cracked. -- Room 112 - There were holes in the drywall under the window. -- Room 114 - There was an area behind the bed closest to the window that was unpainted. -- Room 116 - Paint was chipped in the bathroom wall and the walls were gouged. -- Room 119 - The wall beside the closet had areas of chipped paint and gouged wall board. The wall behind the bed closest to the door was also chipped and gouged. -- Room 127 - The room door had gouges along the bottom. -- Room 130 - The wall behind the bed closest to the door had gouges. -- Room 131 - The paint on the wall beside the door was scuffed and soiled with black brown areas. -- Shower room B - There was an area on the left side of the room that was rectangular in shape that was not the same as the rest of the room. There was also a rectangular area on the wall facing the door that had small nail-like holes in it. e) Unfinished wooden surfaces -- Room 107 - There was a wooden platform under the chair of the resident closest to the window. The wood did not have varnish or finish applied. -- Room 128 - An unpainted wooden board had been used to replace a board below the sink. The wood did not have varnish or finish applied. f) Furniture -- Room 105 - The handle on the night stand was missing. g) The shower nozzle in Shower Room B was wrapped in a washcloth. In an interview with the Employee #43 on 09/17/14 at 3:15 p.m., she stated, They probably put that there because it was leaking. h) An observation of these rooms was completed with the administrator on 09/08/14 at 5:00 p.m. She said she had recently received approval for upgrading the facility.",2018-05-01
6189,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2014-09-18,272,D,0,1,O60P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to conduct a complete and accurate initial comprehensive assessment. A resident's initial minimum data set (MDS) comprehensive assessment did not provide a complete assessment of urinary incontinence for one (1) of two (2) Stage 2 sample residents whose assessments were reviewed for the area of urinary incontinence. The Care Area Assessment (CAA) was not completed to assess the cause and type of incontinence experienced. Resident identifier: #17 Facility Census: 55. Findings include: a) Resident #17 This resident was admitted to the facility on [DATE]. Her initial Minimum Data Set (MDS) assessment had an assessment reference date (ARD) of 11/25/13. This date was seven (7) days following her admission to the facility. The assessment identified the resident had no problems with her cognition. Section H0300 of the assessment, was coded 2, indicating the resident was frequently incontinent of bladder. According to the instructions provided on the MDS, this indicated there were seven (7) or more episodes of urinary incontinence, but at least one (1) episode of continent voiding in the last seven (7) days prior to the ARD. Section V of the MDS indicated the Care Area of Urinary Incontinence was triggered and needed to be assessed further. It stated the location and date of the CAA documentation was the Urinary CAA summary assessment dated [DATE]. Review of the Urinary CAA summary assessment found it did not provide a further assessment of this resident's incontinence. There was no assessment to indicate what type of urinary incontinence the resident was experiencing or any information to assist with identifying the cause of her incontinence. The analysis of findings stated she had decreased mobility and used a diuretic. Based on this inadequate assessment, the resident was never placed on any type of toileting program to see if she could improve in the area of incontinence. During an interview with Employee #76 (MDS Nurse) 09/18/14 at 3:00 p.m., she verified Resident #17's assessment was not completed to identify the causal factors of her incontinence. She confirmed the initial CAA form they used to further assess the urinary incontinence was not completed in the section provided to identify the type of Incontinence. She also confirmed there had been no toileting plan implemented for the resident since her admission, but she might be able to participate in one.",2018-05-01
6190,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2014-09-18,280,D,0,1,O60P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, and staff interview, the facility failed to review and revise a resident's care plan for one (1) of twenty (20) sample residents. The resident's care plan was not revised in the areas of dental status and pain management for a resident with no lower dentures and who complained of knee pain and cervical pain. Resident identifier: #6. Facility census: 55. Findings include: a) Resident #6 During a Stage 1 interview, on 09/16/14 at 9:28 a.m., Resident #6 related she had no lower dentures because she had become angry and had thrown them away. She said she was saving money to get new teeth. The resident also related she had received therapy related to pain in her cervical spine, and that hot packs were very effective. Resident #6 said only therapy had utilized hot packs. Upon inquiry, she related nursing staff did not provide nonpharmacologic interventions, only medication. She further added she now had pain in her knees. An interview with family representative #1, on 09/17/14 at 9:50 a.m., revealed she had spoken with facility staff, was informed the resident had just received teeth about a year before, and was not able to request them again. The representative also related she had advocated for treatment of [REDACTED]. Review of the medical record, on 09/17/14 at 10:15 a.m. revealed nutrition notes, dated 08/12/14, indicated the resident received a mechanical soft diet with ground meat because she had lost her dentures. Another note, dated 05/13/14, also indicated a loss of dentures. Therapy notes, dated August 2014, indicated the resident had received therapy for cervical pain. There was no evidence knee pain had been addressed. During an interview with Employee #75, a nursing assistant (NA) on 09/17/18 at 1:20 p.m., The NA related he/she did not know the resident's dentures were missing, or of the resident's complaints of knee pain. She indicated the resident had received treatment from therapy for cervical pain, but no interventions were required by NAs. Review of the resident's care plan and Kardex, on 09/17/14 at 5:00 p.m., revealed no evidence the care plan had been reviewed or revised to indicate Resident #6 no longer had lower dentures. There were no interventions to monitor for changes in nutrition related to her loss of teeth. Additionally, no evidence was present to indicate the care plan had been revised to reflect cervical or knee pain. Review of the quarterly minimum data set (MDS), with an assessment reference dated (ARD) of 08/05/14, indicated [DIAGNOSES REDACTED]. An interview with Employee #15, a licensed practical nurse, on 09/17/14 at 5:45 p.m., revealed the resident complained of back pain. The nurse was unsure, but thought it May be cervical pain. She was not aware of the resident's knee pain. The director of nursing (DON) interviewed at 6:02 p.m. on 09/17/14, related staff should have been aware of the resident's pain, because any time she is asked, she will have a list of things wrong. Upon inquiry, she related the resident had voiced cervical pain and knee pain. She reviewed the MDS and care plan and confirmed the care plan had not been reviewed and revised to address the cervical pain and knee pain. She also confirmed the care plan did not utilize non-pharmacological interventions and verified it should have. In addition, she confirmed the care plan did not address the loss of dentures.",2018-05-01
6191,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2014-09-18,282,D,0,1,O60P11,"Based on observation, policy review, medical record review, and staff interview, the facility failed to implement and follow the care plan for one (1) of two (2) Stage 2 sample residents reviewed for catheter use. The care plan indicated the resident's urinary catheter bag should be covered and kept off the floor. This had the potential to affect an isolated number of residents with a urinary drainage bag. Resident identifier: #91. Facility Census: 55. Findings include: a) Resident #91 Observations on 09/16/14 at 9:00 a.m., during an interview for Stage 1 of the Quality Indicator Survey, the resident's urinary catheter drainage bag lay on the floor in the resident's room. This was again observed at 2:02 p.m. and at 4:10 p.m. When Employee #37, the director of nursing, was shown the urinary drainage bag on the floor beneath the resident's chair at 9:10 a.m. on 09/17/14, she secured the urinary catheter bag to the bottom of the chair. Review of the resident's care plan, implemented on 08/17/14, found it included an approach of Keep drainage bag off the floor and covered for dignity.",2018-05-01
6192,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2014-09-18,309,D,0,1,O60P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, medical record review, and policy review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (1) of three (3) residents reviewed for pain. The facility failed to accurately assess and identify pain, and failed to provide non-pharmacological interventions for a resident who voiced pain. Resident identifier: #6. Facility census: 55. Findings include: a) Resident #6 During an interview on 09/16/14 at 9:25 a.m., Resident #6 related she had been having discomfort in her legs, and still had knee problems. The resident also related she had occasional neck pain. Resident #6 indicated therapy had utilized heat therapy which was effective. Upon further inquiry, she said licensed nurses and nursing assistants did not provide non-pharmacological interventions for any of her pain. An interview with family member #1, on 09/17/14 at 9:50 a.m., revealed she had to follow up with the facility to ensure they intervened, after she informed the facility of the resident's complaint of pain. Family member #1 related she had told a nurse about the resident's complaint of pain in her neck and was told she would refer the resident to therapy. She said she called back and spoke with therapy, and they said she had not been referred. She came to the facility and during follow up on that date, the nurse completed the referral while she was there. Review of the July and August 2014 medication administration records revealed no evidence [MEDICATION NAME] was administered as per the as needed physician's orders [REDACTED]. Review of the minimum data set (MDS), with an assessment reference date (ARD) of 08/05/14, indicated a resident interview was completed. It noted the resident voiced she had occasional pain which was rated as 05 during the five (5) day look back. Review of the care plan dated 02/09/12, with next review date of 11/12/14, revealed an alteration in comfort related to pain in her right wrist and right arm, for which she received [MEDICATION NAME] and [MEDICATION NAME], scheduled and as needed. The goal was to have no unrelieved pain within one hour of receiving medication. Interventions included: administer medication and observe for effectiveness and side effects. Further review of the medical record, revealed [MEDICATION NAME] had been discontinued related to a possibility of increasing serotonin levels. The psychosocial well-being focus indicated the resident was able to make needs known. An interview with Employee #75 (NA), on 09/17/14 at 1:20 p.m., indicated Resident #6 never complained of pain, and had no care plan related to pain. She related a book was available to let staff know how to care for the resident, but she did not read it because she was with the residents daily. Employee #77 (NA) related during an interview on 09/17/14 at 2:30 p.m., (Resident #6) don't hardly hear her complain at all. She said she had never heard the resident complain about cervical, neck, back, or knee pain. An interview with Employee #15, a licensed practical nurse (LPN), on 09/17/14 at 5:45 p.m., revealed the resident complained of back and neck pain, and had received therapy. She verified licensed staff did not implement the use of heat therapy or other non-pharmacological interventions. The nurse indicated the resident was asked about pain which was rated on a 1-10 scale. On 09/17/14 at 6:02 p.m., the director of nursing said staff should have been aware of the resident's pain, because any time she was asked, she would have a list of things wrong. She confirmed the care plan did not address cervical, back or knee pain, nor provide non-pharmacological interventions for potential pain. She verified the facility had not implemented a care plan with interventions which could be implemented consistently, due to it had not been revised to include cervical and knee pain. She confirmed the resident's care plan was not reviewed and revised with input from the resident and/or representative, to the extent possible to achieve desired outcomes. During an interview with Employee #32 (LPN), on 09/18/14 at 9:50 a.m., the nurse related he/she did not ask residents about pain, because they would all say yes. She indicated she would assess to see if they had signs of pain, and then she would give them medication. The LPN said she could tell if the resident had pain by looking at them and talking to them. Review of the pain clinical protocol, on 09/18/14 at 11:00 a.m., revealed staff would assess each individual's pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The MDS with an ARD of 08/05/14 revealed a BIMS score of 15, which indicated the resident did not have cognitive impairment.",2018-05-01
6193,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2014-09-18,314,D,0,1,O60P11,"Based on observation, a review of the Lippincott Nursing procedure manual, review of facility policy/procedure, and staff interview, the facility failed to provide treatment to a pressure ulcer in a manner to promote healing and prevent infection for one (1) of one (1) resident in the facility reviewed for the care area of pressure ulcers. The staff failed to ensure effective infection control techniques were employed while cleansing a wound creating a potential for the transfer of microorganisms into the wound. Resident identifier: #12. Facility Census: 55. Findings include: a) Resident #12 During a record review, it was identified Resident #12 had a Stage III pressure ulcer to her coccyx. Employee #50 (the treatment nurse) was observed providing treatment to this wound on 09/17/14 at 10:45 a.m. Employee #50 was observed to clean the wound after applying wound cleanser to a 4 x 4 dressing. She cleansed the outside around the wound first. Then, using the same 4 x 4 and the same area on the 4 x 4, the nurse wiped across the center of the wound. She did not use a different gauze for each cleansing stroke. The facility's policy and procedure for wound management titled Dressings. Dry/Clean last revised June 2005, was reviewed. The policy instructed in step #16 for cleansing the wound: If using gauze, use a clean gauze for each cleansing stroke. Clean from least contaminated area to the most contaminated area (usually from center outward). According to Lippincott Nursing Procedures (WOUND WISE: Basic wound cleaning step by step Nursing Made Incredibly Easy! September/October 2008 Volume 6 Number 5, Pages 30 - 31, found at www.nursingcenter.com/lnc/static?pageid= 4), to prevent contamination and potential infection when cleaning an open wound, such as a pressure ulcer, the area should be gently wiped in a circular motion starting directly over the wound and moving outward. Employee #50 was made aware of the observation of the technique used to clean the wound. She stated she was aware she cleaned the outside first but she was wiping around it in case there was any drainage. She agreed this was not the usual way to clean a wound.",2018-05-01
6194,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2014-09-18,315,D,0,1,O60P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide the appropriate treatment and services to restore as much normal bladder function as possible. There were no interventions to decrease incontinence episodes for one (1) of two (2) residents reviewed in Stage 2 of the Quality Indicator Survey (QIS) for the care area of urinary incontinence. The type and cause of the resident's urinary incontinence was not assessed. There was no toileting schedule or plan to decrease the episodes of incontinence for a resident who exhibited a potential for improvement. Resident identifier: #17. Facility Census: 55. Findings include: a) Resident #17 Resident #17 was admitted to the facility on [DATE]. Her initial Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/25/13, indicated the resident was frequently incontinent of bladder in Item H0300. According to the instructions provided on the MDS, this indicated there were seven (7) or more episodes of urinary incontinence, but at least one (1) episode of continent voiding in the last seven (7) days prior to the ARD. Section V of the MDS indicated the Care Area of Urinary Incontinence was triggered and needed to be reviewed further. It stated the location and date of the Care Area Assessment (CAA) documentation was the Urinary CAA summary assessment dated [DATE]. The Urinary CAA summary assessment was reviewed. The assessment did not provide a further assessment of this resident's incontinence. There was no assessment to indicate what type of urinary incontinence this resident was experiencing or any information to assist with identifying the cause of her incontinence. The analysis of findings stated only she had decreased mobility and received a diuretic. The most recent MDS, with an ARD date of 09/01/14, indicated the resident was frequently incontinent of bladder. Item H0200, regarding whether the resident was on a toileting program, was coded No. The care plan was reviewed and it was identified she had a history of [REDACTED]. There was also a problem related to incontinence in the care plan initially established 11/22/13. The care plan identified a problem of, Potential for altered skin integrity r/t (related to) incontinence. Receives a diuretic, requires extensive assist with bed mobility and toilet use, uses adult attends. The goal for the problem was, Will have intact skin free of redness, blisters or discoloration through review date. There was no goal or plan to decrease the resident's episodes of incontinence or to assess to see what type of incontinence this resident experienced. There was no [DIAGNOSES REDACTED]. The interventions for this resident included obtaining labs and diagnostic work up, observe document and notify physician of changes in skin status, body audits, notify nurse of breakdown, turn and reposition, keep bed as flat as tolerated, use lifting devise, dray sheet, encourage to use bed rails for turning, provide supplemental protein as ordered, notify family of any new skin breakdown, administer medications, Panacea mattress to maintain skin integrity, preventive skin care per protocol, Incontinence care q (every ) two (2) hours prn (as needed). The interventions did not include any toileting plan to promote continence. The care plan instructed only to provide incontinence care every two (2) hours as needed. Nursing assistant (NA) #67 was observed taking Resident #17 to the bathroom on 09/18/14 at 11:30 a.m. She stated she was going to do incontinence care. After assisting the resident to stand, she removed the resident's brief, which was wet with urine. The NA positioned the resident on the toilet and the resident voided in the commode. The nursing assistant then put a clean brief on the resident and did not provide incontinence care or wash the resident after her episode of incontinence. Employee #67 was interviewed about this resident's continence. She verified the resident was not on any kind of toileting program. She was questioned about the frequency of this resident's continence of urine and she stated, She usually goes in the toilet when I take her. She verified the resident's brief was wet at that time. A copy of the resident's bowel and bladder report was reviewed for the period between 09/01/14 and 09/18/14. It was noted the resident had several daily episodes of bladder continence. There were also daily episodes of incontinence. The MDS nurse (Employee #76) was interviewed 09/18/14 at 3:00 p.m. She verified Resident #17 was alert and oriented. She verified her assessment was not completed to identify the causal factors of the resident's incontinence. She also confirmed there had been no toileting plan implemented for this resident since her admission, but stated she may be able to participate in one. The nurse stated the resident had frequent urinary tract infections and had fallen in the past taking herself to the bathroom, but they had not attempted scheduled toileting or an individualized toileting program. She stated, That might work for her.",2018-05-01
6195,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2014-09-18,323,D,0,1,O60P11,"Based on record review, observation, and staff interview, the facility failed to ensure the environment, for one (1) of two (2) sample residents in Stage 2 of the Quality Indicator Survey (QIS) reviewed for accidents, remained as free of accident hazards as possible and the resident received adequate supervision to prevent accidents. The facility did not ensure the resident's chair alarm was functioning properly to alert staff of the resident's need for assistance. Resident identifier: #71. Facility Census: 55. Findings include: a) Resident #71 On 09/17/14 at 1:45 p.m., a review of this resident's current medication administration record (MAR) found it did not include monitoring of her chair alarm to see if it was functioning properly every shift. An observation of Resident #71's wheelchair on 09/18/14 at 2:15 p.m., verified this resident had a chair alarm in place. On 09/18/14 at 2:30 p.m., a staff interview was conducted with Employee #12, registered nurse (RN). She explained the functioning of a bed and chair alarm was monitored every shift to make sure they were operating properly and documented on the MAR. She reviewed Resident #71's MAR and verified there was no documentation to ensure the resident's chair alarm was being monitored for proper functioning.",2018-05-01
6196,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2014-09-18,329,D,0,1,O60P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident's medication regimen was free of unnecessary medications for one (1) of five (5) residents reviewed. A resident received duplicate medication therapy for [MEDICAL CONDITION] reflux disease without adequate indications for their use. Resident identifier: Resident #41. Facility census: 55. Findings include: a) Resident #41 The medical record, reviewed on 09/16/14 at 3:48 p.m., indicated Resident #41 was admitted on [DATE]. The resident received three (3) medications for [MEDICAL CONDITION] reflux disease (GERD): [MEDICATION NAME] 20 milligrams (mg) by mouth (po) daily at bedtime, [MEDICATION NAME] DR (long acting) 40 mg po once a day, and [MEDICATION NAME] 10 mg po once a day. Employee #15, a licensed practical nurse, interviewed on 09/17/14 at 5:30 p.m., indicated staff would tell the nurse if there were changes in the resident's condition, and licensed staff assessed/evaluated on rounds and medication pass. She also related the resident was able to express herself. The nurse related medications were assessed for effectiveness through pharmacy review on a monthly basis, and more often if needed. She indicated staff monitored effects of medication to determine appropriate dose along with guidelines for administration. Further review of the medical record, on 09/17/14, at 2:00 p.m., revealed a monthly pharmacy review. No evidence was present to indicated the pharmacist addressed the use of duplicate therapy for the [DIAGNOSES REDACTED]. An interview with Employee #32 (LPN), on 09/18/14 at 2:45 p.m., revealed she did not know why Resident #41 received [MEDICATION NAME] DR, [MEDICATION NAME] and [MEDICATION NAME]; and did not know if it had been addressed with the doctor. An interview with the executive director, a registered nurse (RN), on 09/18/14 at 3:00 p.m., revealed she did not know why the resident was on the three (3) medications for the same diagnosis. Said she would ask Employee #12 (RN). Employee #12 (RN), interviewed on 09/18/14 at 3:20 p.m., reviewed the record and determined Resident #41 was admitted on all three (3) medications. When inquired whether the pharmacist had identified the use of three (3) medications, the RN replied, To be honest, I'm surprised he didn't, he is usually really good about that. She further added, We usually try non-pharmacological interventions, like three (3) inch blocks or something like that. Employee #12 said she was going to ask the daughter about it. The RN returned about 3:35 p.m. and related the resident had previously been under the care of a [MEDICATION NAME], but had not followed up for a while. When asked if the physician had reviewed the medications or questioned the use of three (3)medications, she related, I would have expected him to. The nurse related she put it on the communication book for the doctor to review, and that she spoke with the daughter and the daughter agreed to reduce medication if the resident could tolerate it. She confirmed [MEDICATION NAME] and [MEDICATION NAME] were generally only used for short term due to significant side effects. After reviewing the record, Employee #12 confirmed the facility did not provide evidence to indicate objective findings such as [DIAGNOSES REDACTED]. (3) medications. In an interview with Employee #9 (RN), minimum data set (MDS) coordinator, on 09/18/14 at 3:30 p.m., she also was Surprised the pharmacist didn't catch it. The MDS coordinator said she was aware the resident received multiple medications for the same diagnosis, but did not mention it to the doctor or refer it to other staff for follow up. She confirmed medications were generally reviewed if a resident received multiple medications from the same class or for the same diagnosis. She also confirmed she had no evidence to indicate a clinical need justified the use of the three (3) medications utilized for GERD.",2018-05-01
6197,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2014-09-18,371,E,0,1,O60P11,"Based on observation, staff interview, and policy review, the facility failed to store, prepare, distribute and serve food under sanitary conditions. The facility failed to date and label food stored in the kitchen walk-in freezer; and a staff member did not properly sanitize her hands during the dining process in the day room. This had the potential to affect more than an isolated number of residents. Facility census: 55. Findings include: a) Food storage During the initial tour of the kitchen, on 09/15/14 at 4:44 p.m., an observation found three (3) plastic bags containing food in the walk-in freezer. The bags of food were not labeled or dated. An interview with Employee #49 (dietary supervisor), at the time of the observation, revealed the bags contained crab cakes, barbecue patties, and breaded steak patties. Upon inquiry as to how she knew when they were opened or when they expired, she replied, I don't. They should have been labeled. b) On 9/15/14 at 6:20 p.m., the director of nursing was helping to deliver trays during the evening meal in the day room. She pushed her hair back from her face, then delivered trays from the cart to residents without washing her hands.",2018-05-01
6198,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2014-09-18,428,D,0,1,O60P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based of medical record review and staff interview, the pharmacist failed to report a medication irregularity to the attending physician and the director of nursing for one (1) of five (5) residents reviewed. The pharmacist failed to identify and report duplicate medication therapy which did not have clinical justification. Resident identifier: Resident #41. Facility census: 55. Findings include: a) Resident #41 The medical record, reviewed on 09/16/14 at 3:48 p.m., indicated Resident #41 received was admitted on [DATE] and received three (3) medications for gastroesophageal reflux disease (GERD): Pepcid 20 milligrams (mg) by mouth (po) daily at bedtime, Protonix DR (long acting) 40 mg po once a day, and Reglan 10 mg po once a day, for Employee #15, a licensed practical nurse, interviewed on 09/17/14 at 5:30 p.m., indicated medications were assessed for effectiveness through pharmacy review on a monthly basis, and more often if needed. Further review of the medical record, on 09/17/14, at 2:00 p.m., revealed a monthly pharmacy review. No evidence was present to indicate the pharmacist addressed the use of duplicate therapy for the [DIAGNOSES REDACTED]. Employee #12 (RN), interviewed on 09/18/14 at 3:20 p.m., reviewed the record and determined Resident #41 was admitted on all three (3) medications. When asked whether the pharmacist had identified the use of three (3) medications, the RN replied, To be honest, I'm surprised he didn't, he is usually really good about that. She further added, We usually try non-pharmacological interventions, like three (3) inch blocks or something like that. Employee #12 said she was going to ask the daughter about it. The RN returned about 3:35 and related she had spoken with the daughter and the daughter agreed to a medication reduction if the resident could tolerate it. She confirmed the pharmacist did not report irregularities regarding the use of duplicate therapy and/or by excessive dose (used longer than recommended by manufacturer's recommendations), without clear clinical factors that would warrant the continued use of the medication. .",2018-05-01
6199,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2014-09-18,441,F,0,1,O60P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of disease and infection. Staff failed to perform hand hygiene when indicated and failed to follow isolation precautions consistent with accepted standards of practice. An ice scoop was placed inside cups in use by residents' during ice pass, and then stored the scoop in the ice chest. A staff member exited an isolation room while wearing personal protective equipment (PPE) and failed to adequately wash her hands. This had the potential to affect all residents. Facility census: 55. Findings include: a) Ice pass During a random observation on 09/16/14, between 10:15 a.m. and 10:45 a.m., Employee #3 (NA) passed ice to residents on the short hallway and the long hallway. The NA entered room [ROOM NUMBER], exited with the resident's drinking pitcher/drinking cup, opened the ice chest, removed the ice scoop from the ice and placed ice in the resident's cup, then placed the ice scoop into a holding container. She returned the water cup to the resident's room and exited again without sanitizing her hands. She passed ice in the same manner in Rooms #109 and #106. While passing ice for room [ROOM NUMBER], she placed the ice scoop inside of the resident's cup, then continued to use the scoop for other residents. While passing ice in room [ROOM NUMBER]b, Employee #3 added water to the pitcher before exiting the room to obtain ice. The NA turned the faucet on and off without utilizing a barrier, creating a potential for cross contamination. The resident in room [ROOM NUMBER]a required isolation precautions. The NA washed her hands, then turned off the faucet without utilizing a barrier, again creating a potential for cross contamination. Additionally, the NA only washed her hands about 10 seconds. Employee #3 entered room [ROOM NUMBER] and pulled up the left side rail. She washed her hands, and again for only 10 seconds. The NA again turned the faucet off without utilizing a paper towel. The NA continued passing ice to room [ROOM NUMBER]. Upon completion, she donned personal protective equipment (PPE) and at 10:31 a.m. entered room [ROOM NUMBER] which required contact precautions. She exited the room at 10:32 a.m., still wearing the PPE, and moved the ice cart to the door of room [ROOM NUMBER]. She placed ice in the cup retrieved from the resident's room and again placed the scoop inside the cup. When exiting the room, she was standing in the doorway removing the PPE. As the NA turned around, she was partially in the hallway and the back of the isolation gown swung over toward ice chest, and barely missed making contact. After removing the PPE, the NA did not wash her hands, but utilized hand sanitizer for a count of three (3) seconds. After passing ice to room [ROOM NUMBER], Employee #3 washed her hands for seven (7) seconds and turned off the faucet without utilizing a paper towel. The NA added water to the residents' cups in room [ROOM NUMBER] beds A and B, before adding ice. She did not utilize hand hygiene between residents, nor did she utilize a paper towel to turn the faucets on and off when obtaining water. Additionally, although the NA appeared to be careful, water sprayed upward when placing ice into the cups, creating another potential for cross contamination. b) During a random observation on 09/15/14 at 6:08 p.m., Employee #47, a registered nurse, washed her hands after preparing a tray for a resident in room [ROOM NUMBER]b. After washing her hands for eight (8) seconds, utilizing the one-one thousand, two- one-thousand method, the nurse turned off the faucet without utilizing paper towel or other barrier. At 6:12 p.m., the nurse entered the room again, and when exiting, washed her hands for an eight (8) second count. Again, the RN did not utilize paper towels to turn off the faucet. c) In an interview on 09/17/14 at 1:34 p.m., Employee #75 (NA) related the State standard of fifteen (15) seconds, and turn off the faucet with a paper towel was the facility's usual practice. Upon inquiry as regarding the practice for passing ice, the NA related staff utilized a scoop to dip ice. She related the scoop is never to be put inside the cup. When asked about procedures for passing ice to residents with isolation precautions, the NA indicated the ice cart was taken to the door of the isolation room, staff wore gloves,obtained the cup from the room, and dipped the ice. She further added, I always wondered about that. An interview with Employee #77 (NA) on 09/17/14 at 4:00 p.m. related staff filled up the cart, started at one end and worked the way down the hallways to the other end of the facility. She related staff should fill the resident's cup without touching it. Review of the facility's policy for ice chests and ice machines, on 09/17/14 at 4:15 p.m., revealed all ice handlers were to perform hand hygiene before obtaining ice. It also required staff to store the ice scoop in a container when not in use. d) Hand washing In addition to the deficits in hand hygiene observed during ice pass, Employee #51 (the treatment nurse), was observed on 09/17/14 at 10:45 a.m. washing her hands after she performed a pressure ulcer dressing change. She was observed to lightly rub her hands together for three (3) seconds. She then turned the faucet off using her hand directly on the faucet, re-contaminating her hand. The facility policy was reviewed for Hand washing/Hand Hygiene last Revised April 2010. This procedure for hand washing instructed to vigorously lather hands with soap and rub them together, creating friction to all surfaces for 15 seconds, the policy then instructed to turn off the faucets with a clean, dry paper towel. The nurse was questioned about the facility's hand washing procedure. She verified the facility uses the standard policy. She was made aware that she was observed to only wash her hands three (3) seconds and stated this was not the standard. She said the facility has been doing in-services on hand washing. The Director of Nursing was made aware of this observation on 09/17/14 at 1:00 p.m. She stated the facility has done hand washing teaching and have been monitoring the staff for the practice of inadequate hand washing. 2) In an interview on 09/17/14 at 5:21, Employee #37, the director of nursing (DON), p.m.,stated the infection control nurse had recently completed an in-service with staff, with return demonstrations. She related staff should wash their hands for a minimum of fifteen (15) seconds and turn off the faucet with a clean, dry paper towel. She also related staff should sanitize hands between residents' rooms. 3) During an interview with the infection control coordinator, Employee #47, on 09/18/14 at 1:00 p.m., regarding hand washing, she said, I messed up and did it wrong. She further added, I did it twice. She confirmed she did not wash her hands for the amount of time required (15 seconds), nor turn off the faucet with a paper towel. She said she had given an in-service to staff and was trying to get staff to comply. She confirmed staff should sanitize hands between residents when touching inanimate objects in the residents' rooms. She also related staff should sanitize hands after touching their person, such as hair. 4) Review of the hand washing/hand hygiene policy, dated April 2010, on 09/17/14 at 3:00 p.m., revealed Employees must wash their hands for at least fifteen (15) seconds using an antimicrobial soap or non-antimicrobial soap and water .before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); .before and after entering isolation precaution settings; before and after assisting a resident with meals; .after removing gloves . The hand washing procedure noted to vigorously lather hands with soap and rub them together, creating friction for at least fifteen (15) seconds .dry hands with a paper towel, and then turn off faucets with a clean, dry paper towel.",2018-05-01
6200,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2014-09-18,469,E,0,1,O60P11,"Based on observation and staff interview, the facility failed to ensure it maintained an effective pest control program so the facility was free of pests. Ant-like insects were observed in two (2) rooms during Stage 1 of the Quality Indicator Survey. This had the potential to affect more than a limited number of residents. Facility census: 55. Findings include: a) Ant-like insects During Stage 1 of the Quality Indicator Survey, the following were noted: -- Room 128 - Insects were crawling on the floor beside the bed closest to the window. -- Room 103 - Insects were crawling on the floor beside the bed closest to the window. b) During an interview with the housekeeping supervisor, Employee #43, on 09/17/14 at 3:10 p.m., she agreed the insects looked like ants and commented the residents often had food in their rooms. Employee #43 said a pest control service was provided by the facility and she would call them.",2018-05-01
6605,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2014-02-27,253,E,0,1,UM8N11,"Based on observation and staff interview, the facility failed to ensure effective maintenance services. The physical environment was in poor repair with issues such as holes in walls, stained ceiling tiles, scuffed furniture, rust in the shower room, and missing baseboard. In addition, a shower room wall had a black substance, which had the appearance of mold. This had the potential to affect more than an isolated number of residents. Facility census: 57. Findings include: a) Observation of the facility during Stage 1 of the Quality Indicator Survey (QIS) revealed the following concerns: 1) Room B-12 The corner of the wall beside the bathroom had missing plaster and was scuffed and scratched. The wall beside the bathroom had deep scratches in the plaster and the television stand had chipped and scratched areas. 2) Room A-6 In room A-6, there were observations of cracked ceiling tile. Behind bed (B), an observation revealed a cracked wall and uneven plaster. The ceiling tile was cracked and the wall behind the B-bed had cracked and uneven plaster. In addition, an observation revealed a round area big enough to insert a pencil beside the call light mounted on the wall behind bed B. The nightstand and the television stand was scuffed and had missing veneer. 3) Room A-1 The vent under the window in room A-1 was taped with plastic wrap. The room also had stained ceiling tile. 4) Room A-3 Observation revealed the room had stained ceiling tile. 5) Room A-20 The two (2) bottom drawers on the wardrobe were off track and did not close. The floor tile beside the wardrobe had an indented area and a crack. The ceiling tiles were discolored. 6) Hallway on B-Unit The cove base molding across from the nurses' station was missing between the soiled and clean linen rooms. 7) Room B-11 An observation revealed a visible hole in the floor below the window. 8) B-Unit shower room The doorframe had rust around the shower door. The maintenance director (Employee #29) observed the identified issues on 02/26/14 at 3:00 p.m. No further information was provided regarding the maintenance issues. b) During the initial tour of the building, at 11:23 a.m. on 02/24/14, an observation in the A unit shower room revealed a dark black substance, which had the appearance of mold. At 02/24/14 on 11:30 a.m., an interview with Employee #63 (environmental services assistant) revealed the employee did not know for sure what the black substance was. He indicated he would get the housekeeper to take some bleach and wipe down the surface to see if it would wipe off. At 11:39 p.m. on 02/24/13, Employee #28 (environmental services assistant) sprayed bleach on the dark black substance and wiped it with a cloth. As he wiped the substance, it went from a dark black color to a dark gray color. He stated, It is coming off a little, but it is not coming off completely. Further observations of the A unit shower room, at 1:00 p.m. on 02/16/13, revealed the substance was a light gray color. At that time, an interview with Employee #29, environmental service supervisor, revealed the staff continued to clean the substance, but it remained noticeable on the wall. He stated though it was still noticeable, it was a lot lighter than before they began cleaning it. He reported they had been scrubbing it with bleach. He stated he could not speculate as to what the substance was. He commented, This is an old building.",2017-12-01
6606,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2014-02-27,309,D,0,1,UM8N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of one (1) residents who received [MEDICAL TREATMENT] treatment received the necessary care and services to maintain the highest practicable physical well-being. The resident had an order for [REDACTED]. Resident Identifier: #8. Facility Census: 57. Findings Include: a) Resident #8 On 02/26/14 at 10:39 a.m., a review of Resident #8's medical record revealed a physician's orders [REDACTED]. The date on the physician order [REDACTED]. It contained an order, Nepro (nutritional supplement) 8 oz (ounces) daily 4 days per week on non-[MEDICAL TREATMENT] days please do not include in 1000 cc FR (Fluid Restriction) daily. Further review of the medical record revealed a physician order, dated 01/23/14, which stated, Nepro four (4) times a day every sun (Sunday), tues (Tuesday), thu (Thursday), sat (Saturday) for CKD ([MEDICAL CONDITION]) Give 8 oz on non [MEDICAL TREATMENT] days per [MEDICAL TREATMENT] do not include in fluid restriction. The order was discontinued on 02/04/13. The medical record also contained a physician order, dated 02/04/14, which stated One time a day every sun, mon wed, fri for ckd give 8 oz daily on non [MEDICAL TREATMENT] days per [MEDICAL TREATMENT] do not include in fluid restriction daily. This order remained as the active order in Resident #8's medical record. A review of the Medication Administration Record [REDACTED] - 1/23/14: 5:00 p.m. and 9:00 p.m. - 1/25/14, 1/26/14, and 01/28/14: 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m. - 02/1/14: 9:00 a.m., 5:00 p.m., and 9:00 p.m. - 02/02/14: 9:00 a.m., 1:00 p.m., 5:00 p.m. and 9:00 p.m. - 02/03/14: 9:00 a.m., 1:00 p.m., and 5:00 p.m. An interview, on 02/26/14 at 2:08 p.m., revealed Employee #50, director of nursing (DON), registered nurse (RN) confirmed the resident received 8 ounces of Nepro more often than she should have on 01/23/14, 01/25/14, 1/26/14, 1/28/14, 02/01/14, 02/02/14, and 02/03/14. She confirmed the order from [MEDICAL TREATMENT] indicated the resident was to receive Nepro 8 ounces once daily four (4) days a week. During an interview with Employee #31, (licensed practical nurse) on 02/26/14 at 2:50 p.m., she confirmed she received the order on 01/23/14 from the [MEDICAL TREATMENT] clinic. She stated she incorrectly entered the order dated 01/23/14, for Nepro as eight (8) ounces four (4) times a day, four (4) days a week. She stated she should have entered the order as, Nepro eight (8) ounces, once daily four (4) days a week. Employee #31 confirmed she entered the order incorrectly, which caused Resident #8 to receive the Nepro more often than ordered.",2017-12-01
6607,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2014-02-27,323,E,0,1,UM8N11,"Based on observation and staff interview, the facility failed to ensure the resident environment was as free of accident hazards as possible. The grab bar in the shower room on the A-hall was loose and moved easily with the slight touch of a hand. This had the potential to affect more than an isolated number of residents on the A-hall who used the shower room. Facility census: 57. Findings include: a) A-hall shower room Observation with the maintenance supervisor, Employee #29, at 3:00 p.m. on 02/26/14, found there was only one grab bar in the A-hall shower room. The grab bar was on the right side of the door leading out of the shower room. The grab bar was loose and moved up and down with the slight touch of a hand. Employee #29 said he would fix the bar.",2017-12-01
6608,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2014-02-27,463,D,0,1,UM8N11,"Based on observation and staff interview, the facility failed to ensure one (1) of thirty (30) residents had a means of directly contacting caregivers. Nursing staff received resident calls through a pager communication system from resident rooms and toilet and bathing facilities. This resident did not have a functioning call system in her bathroom. Resident identifier: #5. Facility census: 57. Findings include: a) Resident #5 On 02/24/14 at 10:40 a.m., an observation in Resident #5's bathroom revealed a call system that did not function properly. Employee #39 (nurse aide) verified this call system did not work. The nurse aide had a pager designed to beep when residents pulled their call cords or pushed their call buttons. A demonstration of pulling the call cord in Resident #5's bathroom revealed the nurse aide's pager did not beep. Employee #39 also confirmed Resident #5 used her bathroom and was capable of using the call light. Employee #39 said if her pager did not alarm then she did not know a call light needed answered. All nursing staff carried pagers to alert them when call lights needed answered. Employee #39 said she would inform her supervisor the resident's bathroom call system did not work.",2017-12-01
6609,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2014-02-27,468,E,0,1,UM8N11,"Based on observation and staff interview, the facility failed to ensure corridors were equipped with secured handrails. The A-Unit of the facility had handrails that were not securely affixed to the wall. This had the potential to affect more than an isolated number of residents. Facility census: 57. Findings include: a) Handrails on A-Unit Observation with the environmental services director, on 02/26/14, at approximately 3:00 p.m., found the handrail was loose between rooms A-17 and A-18 on the north hall, and the short hall on the A-unit.",2017-12-01
6610,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2014-02-27,514,D,0,1,UM8N11,"Based on record review and staff interview, the facility failed to ensure medical records were complete and accurately documented, for one (1) of forty-nine (49) Stage 2 sample residents. A hospital discharge summary, which did not belong to Resident #30, was found in the resident's medical record. Resident identifier: #30. Facility census: 57. Findings include: a) Resident #30 The medical record review, at 10:30 a.m. on 02/25/14, for Resident #30, a male resident, revealed a female resident's discharge summary from a local hospital had been scanned into Resident #30's electronic medical record. An interview with Employee #50, the director of nursing, at 11:06 a.m. on 02/25/14, confirmed the discharge summary did not belong in Resident #30's medical record.",2017-12-01
7317,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-04-18,156,D,0,1,KPNE11,"Based on record review and staff interview, the facility failed to ensure one (1) of three (3) residents selected for the liability notice and beneficiary appeal rights review were given information in writing when they were discharged from a skilled service covered by Medicare. Resident identifier: #20. Facility census: 51. Findings include: a) Resident #20 On 04/16/13 at 1:00 p.m., the billing clerk (Employee #74) assisted in a review of the liability notices and beneficiary appeal rights for three (3) residents. Two (2) of the three (3) residents selected for review were discharged to another skilled nursing facility. Resident #20 had refused to participate in the skilled therapy service. Employee #74 said the resident said she was too sick to participate. Employee #74 indicated she did not send the resident a written notice informing her of her discharge from a skilled service covered by Medicare. She said she did not think she had to send a written notice when the resident refused to participate. According to the Centers for Medicare and Medicaid Services (CMS) survey and certification letter 09-20: If a SNF provider believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable and necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services.",2017-06-01
7318,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-04-18,160,D,0,1,KPNE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of financial records and staff interview, the facility failed to convey the resident's funds, and/or a final accounting of those funds, after the resident's death, to the individual or probate jurisdiction administering the individual's estate as provided by State law. This was found for one (1) of four (4) records reviewed for residents with personal funds deposited with the facility. Resident identifier: #66. Facility census: 51. Findings include: a) Resident #66 A review of the facility's financial records showing the balance in the resident trust accounts at the end of [DATE] revealed an account for one (1) resident who had expired on [DATE]. During an interview with Employee #74, the Billing Clerk, at 1:50 p.m. on [DATE], she stated Resident #66 had expired on [DATE], and a check for the balance of her account ($200.59) had been issued to the funeral home on [DATE], and another check for ($20.02 ) was sent to the funeral home on [DATE]. There was no evidence to reflect the probate jurisdiction administering the individual's estate had been issued a final accounting of the resident's personal funds or had approved the payments made by the facility from the resident's account.",2017-06-01
7319,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-04-18,225,D,0,1,KPNE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, abuse/neglect policy review, and staff interview, the facility failed to ensure allegations of neglect were reported to the required entities, and investigated. One (1) of twenty-two (22) residents' medical records contained an allegation of neglect for which there was no evidence it had been thoroughly investigated or had been reported to the required State agencies. Resident identifier: #54. Facility census: 51. Findings include: a) On 04/18/13 at 10:00 a.m., a review of the medical record for Resident #54 revealed a skilled nursing note dated 01/26/13. The note included . Son states that he is not satisfied with care. States that physical therapy removed O2 (oxygen) NC (nasal cannula) and took resident to therapy. Son states that resident needs her O2. The medical record revealed the resident had a [DIAGNOSES REDACTED]. The director of nursing (Employee #47) indicated the facility had no documentation to show they had investigated or reported the allegation of neglect. The abuse policy procedure revealed the following statement The (facility name) will ensure that all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property are reported immediately to the appropriate authorities and to other officials in accordance with state law through established procedures (including to the state survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The facility did not have evidence of an investigation, nor did they have evidence the allegation was reported to the State survey and certification agency.",2017-06-01
7320,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-04-18,226,D,0,1,KPNE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and staff interview, the facility failed to ensure it implemented its abuse and neglect policy. The facility failed to investigate and report an allegation of neglect. Resident identifier: #54. Facility census: 51. Findings include: a) On 04/18/13 at 10:00 a.m., a review of the medical record for Resident #54 revealed a skilled nursing note dated 01/26/13. The note included . Son states that he is not satisfied with care. States that physical therapy removed O2 (oxygen) NC (nasal cannula) and took resident to therapy. Son states that resident needs her O2. The medical record revealed the resident had a [DIAGNOSES REDACTED]. The director of nursing (Employee #47) indicated the facility had no documentation to show they had investigated or reported the allegation of neglect. The abuse policy procedure revealed the following statement The (facility name) will ensure that all alleged violations involving mistreatment, neglect, or abuse including injuries of unknown source and misappropriation of resident property are reported immediately to the appropriate authorities and to other officials in accordance with state law through established procedures (including to the state survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The facility did not have evidence of an investigation, nor did they have evidence the allegation was reported to the State survey and certification agency as required by their policy.",2017-06-01
7321,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-04-18,272,D,0,1,KPNE11,"Based on medical record review and staff interview, the facility failed to ensure the minimum data set (MDS) assessments for one (1) of twenty-two (22) residents accurately reflected the resident's weight. Resident identifier: #35. Facility census: 51. Findings include: a) Resident #35 On 04/17/13 at 4:00 p.m., review of the minimum data set for a re-admission/return assessment, with an assessment reference date (ARD) of 12/15/12, found Section K (swallowing/nutritional status), item K0200 (weight) identified the resident weighed 168 lbs. The discharge/return not anticipated assessment, with an ARD of 12/22/13, also listed the resident's weight as 168. The dietitian (Employee #97) had completed a progress note for the resident on 12/10/12. The dietitian listed the resident's current body weight as 153.4 lbs. The weight record also listed the resident's weight as 153.4 on 12/10/12. On 04/17/13 at 5:00 p.m., Employee #1 (registered nurse) reviewed the above information and agreed the facility did not record the accurate weight on the two (2) MDS assessments. .",2017-06-01
7322,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-04-18,278,D,0,1,KPNE11,"Based on medical record review and staff interview, the facility failed to ensure one (1) of twenty-two (22) residents had a minimum data set (MDS) assessment that correctly documented the resident's weight. Two (2) MDS assessments did not reflect the resident's accurate weight. Resident identifier: #35. Facility census: 51. Findings include: a) Resident #35 On 04/17/13 at 4:00 p.m., review of the medical record for Resident #35 noted an MDS re-admission/return assessment, with an assessment reference date (ARD) of 12/15/12. Section K (swallowing/nutritional status), item K0200 (weight) identified the resident weighed 168 lbs. The discharge/return not anticipated assessment, with an ARD of 12/22/13, also listed the resident's weight as 168. The dietitian (Employee #97) completed a progress note for the resident on 12/10/12. The dietitian listed the resident's current body weight as 153.4 lbs. The weight record listed the resident's weight as 153.4 on 12/10/12. On 04/17/13 at 5:00 p.m., Employee #1 (registered nurse) reviewed the above information and agreed the facility did not record the accurate weight on the two (2) MDS assessments listed above. .",2017-06-01
7323,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-04-18,280,D,0,1,KPNE11,"Based on medical record review and staff interview, the facility failed to notify the resident and/or the resident's representative of a care plan meeting. One (1) of twenty-two (22) Stage 2 sample residents was affected. Resident identifier: #53. Facility census 51. Findings include: a) Resident #53 Medical record review, on 04/16/13 at 1:00 p.m., revealed the care plan meeting for Resident #53 was held on 02/26/13. No documentation was found to indicate the resident and/or the resident's representative had been invited and/or informed of the care plan meeting. During an interview with Employee #54, the social worker (SW), on 04/16/13 at 2:40 p.m., it was confirmed she had not notified the resident and/or the resident's representative of the care plan meeting scheduled on 02/26/13.",2017-06-01
7324,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-04-18,371,F,0,1,KPNE11,"Based on observation and staff interview, the facility failed to ensure the emergency food supply was stored under sanitary conditions. The ceiling of the room where the facility stored the food had sustained a water leak. This had the potential to affect all residents. Facility census: 51. Findings include: a) On 04/17/13 at 11:00 a.m., the dietary manager (Employee #27) accompanied a tour of the area where the emergency food supply was stored. The emergency food supply was stored on the first floor of the assisted living unit. Observations of the ceiling in the room where the food was stored revealed two (2) areas where the ceiling had leaked. One area was larger than the other area. This larger area surrounded a light fixture. The ceiling had turned yellow, brown and grey. Parts of the paint/plaster had fallen down. The paint/plaster was bubbled and cracked. A large section of the paint/plaster had fallen and exposed another layer of the ceiling, which appeared grey with black specs. On 04/17/13 at 11:15 a.m., the dietary manager indicated she had requested repairs for this area and agreed this did not provide the most sanitary environment for storing food.",2017-06-01
7325,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-04-18,428,D,0,1,KPNE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the pharmacist's recommendation for a dose reduction for Xanax, with which the physician had agreed, was acted upon. This affected one (1) of ten (10) residents reviewed for unnecessary medications. Resident identifier: #40. Facility census: 51 Findings include: a) Resident #40 A record review was completed for Resident #40 on 04/17/13 at 10:39 a.m. The review revealed the pharmacist had made a recommendation to evaluate the current dose of Xanax 0.5 milligrams 3 times daily on 03/11/13. The recommendation was to consider a gradual taper of this medication to ensure this resident was receiving the lowest possible effective and optimal dose. On 03/20/13, the attending physician agreed to the dose reduction of Xanax, but the response did not include an order for [REDACTED].>An interview was conducted, on 04/17/13 at 11:45 a.m., with Employee #40, the director of nursing. She reported the staff failed to carry out the recommended dose reduction of Xanax for this resident.",2017-06-01
7326,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-04-18,441,F,0,1,KPNE11,"Based on observation, staff interview, and policy review, the facility failed to store residents' respiratory equipment in a sanitary manner. This practice affected seven (7) of twelve (12) residents observed who had respiratory care needs. Resident identifiers: #8, #13, #33, #40, #41, #45, and #81. Facility census: 51. Findings include: a) Residents #8, #13, #33, #40, #41, #45 and #81 On 04/15/13 at 12:32 p.m., during the initial tour of the facility, it was discovered Residents #8, #13, #33, #40, #41, #45 and #81 had nebulizer mouthpieces improperly stored after their breathing treatments. The mouthpieces were observed lying uncovered on the residents' nightstands where they were potentially exposed to environmental contaminants and/or could transfer organisms from the resident's respiratory tract to other objects. An interview was conducted on 04/16/13 at 9:14 a.m. with Employee #76, a Registered Nurse (RN) and Infection Control Coordinator. She verified the staff failed to store the residents' nebulizer mouthpieces in a sanitary manner to prevent transmission of bacteria between uses. On 04/16/13, Employee #40, the Director of Nursing (DON) provided the procedure for administering medications through a small (handheld) nebulizer. The policy for handheld nebulizer units included instruction that after each breathing treatment, the nebulizer mouthpiece was to be stored in a plastic bag with the resident's name and date on the bag.",2017-06-01
7985,"MERCER NURSING AND REHABILITATION CENTER, LLC",515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2013-11-08,465,F,1,0,PPO411,"Based on observation, resident interview, and staff interview, the facility failed to provide a functional, sanitary, and comfortable environment for residents, staff and the public. Twenty-three (23) of twenty-three (23) residents' toilets observed were leaking and soiled around their bases. In addition, there was a lingering foul smelling odor in the toilet rooms which permeated throughout the building. This practice had the potential to affect all residents. Facility census: 59. Findings include: a) Upon entry into the facility, the purpose of the complaint investigation was discussed with the Administrator and the Home Office Environmental Coordinator (HOEC) They stated they were aware of the toilet issues. b) Observations of the toilets revealed they had been sealed at the base with silicone. The toilets were smaller than the hole cut out of the floor tile, creating a leveling problem. Some rooms had a black substance around the base of the toilet. The silicone was wet in some rooms. There was a consistent foul odor within the toilet rooms and throughout the facility. c) Rooms A02, A03 and A05, A04 and A06, A07 and A09, A08 and A10, A11, A12 and A14, A15, A16 and A17, A18 and A19, A20 and A21, A23 and A24, A25, B01 and B03, B02 and B04, B05 and B07, B06 and B08, B09 and B10, B11 and B12, B13 and B14, and B15: The twenty-one (21) toilets in the bathrooms used by residents in these rooms showed signs of leakage. The floor tile had heavy stains that appeared to permeate from below. The floor tile was cut to the outline of the toilet base instead of running tight to the toilet flange. The toilet base was sealed with silicone. The visual inspection revealed soiled tile, base and caulking. It could not be determined if this was from sewage leak, the result of poor housekeeping practices, or both. 2) Room A22 The toilet in the bathroom used by residents in this room showed signs of leakage. The floor tile had heavy stains that appeared to permeate from below. The floor tile was cut to the outline of the toilet base instead of running tight to the toilet flange. The toilet base was sealed with silicone. The visual inspection revealed soiled tile, base and caulking. It could not be determined if this was from sewage leak, the result of poor housekeeping practices, or both. An interview was conducted with a resident who resided in this room. He stated the toilet was still a problem, although it leaked less than it used to. c) Room A25 The toilet in the bathroom used by residents in this room showed signs of leakage. The floor tile had heavy stains that appeared to permeate from below. The floor tile was cut to the outline of the toilet base instead of running tight to the toilet flange. The toilet base was sealed with silicone. The visual inspection revealed soiled tile, base and caulking. It could not be determined if this was from sewage leak, the result of poor housekeeping practices, or both. The resident in this room asked what was being observed. Upon explaining the toilets were being checked, the resident stated the toilet was a problem.",2016-11-01
8018,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-11-19,225,D,1,0,OGFK11,"Based on a review of the abuse/neglect reportable allegations, the facility's abuse policy and procedure, and staff interview, the facility failed to ensure allegations of abuse/neglect were thoroughly investigated and reported to the appropriate State agencies. A review of six (6) allegations of abuse/neglect revealed the facility did not report or investigate one (1) allegation of neglect. Resident identifier: #5. Facility census: 48. Findings include: a) Resident #5 On 11/19/13 at 2:00 p.m., a review of the abuse/neglect reportable allegations revealed the facility had substantiated an allegation of neglect on 07/25/13. The facility determined Employee #86 (nurse aide) had neglected Resident #9 on 07/24/13. The facility terminated Employee #86 (nurse aide) because of this substantiation of neglect. A note dated 07/24/13, in the investigation file authored by the director of nursing (Employee #43), stated Employee #86 (nurse aide) was terminated on this day due to neglect of Resident care. Residents on her assigned list were found to be wet and uncared for from the oncoming shift. Social Worker had witnessed a resident in a social setting whose pants were saturated with urine at shift change and employee had already left. She was also informed by staff members of other Residents who had been neglected to be cared for by this c.n.a. (nurse aide). On 11/19/13 at 2:45 p.m., the social worker (Employee #53) was asked about the note she had written regarding neglect of residents by Employee #86. She said she had not reported the allegation of neglect to the State agencies and had not investigated any other residents who may have been neglected by Employee #86. At 3:00 p.m., the administrator (Employee #48) and director of nursing (Employee #43) said Employee #72 might have additional information related to the substantiated findings of neglect against Employee #86. An interview with Employee #72 (registered nurse), on 11/19/13 at 2:30 p.m., revealed she had worked on 07/24/13, the day of the incident. She said she was making rounds and checking to see that residents had received care. She noticed Resident #5 had feces on his bottom and in folds of his thigh. Employee #72 said she had confronted Employee #86 about not providing incontinence care for Resident #5. She indicated that she passed this information along to the director of nursing. The director of nursing said she did not collect statements or turn in the information as an allegation of neglect to the State agencies. The director of nursing and the administrator confirmed they did not report or thoroughly investigate the allegation of neglect regarding Resident #5. The facility had not thoroughly investigated to identify all residents who may have been neglected by Employee #86.",2016-11-01
8019,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-11-19,226,D,1,0,OGFK11,"Based on a review of the abuse/neglect reportable allegations, review of the facility's abuse policy and procedure, and staff interview, the facility failed to operationalize its abuse policy and procedure. The facility failed to ensure all allegations of abuse/neglect were thoroughly investigated and reported in accordance with its policy. A review of six (6) allegations of abuse/neglect revealed the facility did not report alleged neglect by a nurse aide. Additionally, the facility did not conduct a thorough investigation the alleged neglect. Resident identifier: #5. Facility census: 48. Findings include: a) Resident #5 On 11/19/13 at 2:00 p.m., a review of the abuse/neglect reportable allegations revealed the facility had substantiated an allegation of neglect on 07/25/13. The facility determined Employee #86 (nurse aide) had neglected Resident #9 on 07/24/13. The facility terminated Employee #86 (nurse aide) because of this substantiation. A note dated 07/24/13 in the investigation file authored by the director of nursing (Employee #43) stated Employee #86 (nurse aide) was terminated on this day due to neglect of Resident care. Residents on her assigned list were found to be wet and uncared for from the oncoming shift. The Social Worker had witnessed a resident in a social setting whose pants were saturated with urine at shift change and the employee had already left. She was also informed by other staff members of other Residents who had been neglected to be cared for by this c.n.a. (nurse aide). The social worker (Employee #53) was asked about this occurrence on 11/19/13 at 2:45 p.m. She said she had not reported or investigated any other residents who may have been neglected by Employee #86. At 3:00 p.m., the administrator (Employee #48) and director of nursing (Employee #43) said Employee #73 might have additional information related to the substantiated findings of neglect against Employee #86. An interview with Employee #73 (registered nurse) on 11/19/13 at 2:30 p.m. revealed, she worked on 07/24/13, the day of the incident. She said she was making rounds and checking to see that residents had received care. She noticed Resident #5 had feces on his bottom and in folds of his thigh. Employee #73 said she confronted Employee #86 about not providing incontinence care for Resident #5. She indicated that she passed this information along to the director of nursing. The director of nursing said she did not collect statements or turn in the information as an allegation of neglect. The facility abuse policy and procedure stated The (facility name) will ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the appropriate authorities and to other officials in accordance with state law through established procedures (including to the state survey and certification agency.) The director of nursing and the administrator confirmed they did not report or thoroughly investigate the allegation of neglect regarding Resident #5. The facility did not thoroughly investigate to identify all residents who may have been neglected by Employee #86.",2016-11-01
8020,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-11-19,253,E,1,0,OGFK11,"Based on observation and staff interview the facility failed to ensure it maintained a safe, sanitary environment for residents. Residents' furniture had scratches and areas where the finish had worn off exposing the wood surface. The exposed wood surfaces could not be sanitized effectively. Sixteen (16) of thirty-one (31) resident rooms had furnishings that could not be cleaned and sanitized. Room numbers: #131, #114, #118, #126, #104, #106, #116, #127, #129, #123, #121, #124, #119, #132, #122, and #128. Facility census: 48. Findings include: On 11/19/13 at 10:45 a.m., observations of furniture in resident rooms revealed the following issues: a) Room #131: The finish was off the wooden drawers at the sink. The drawers at the sink had many scratches and gouges. The wood surface was worn off on the footboard of one of the beds leaving particle board exposed. b) Room #118: Resident #48's over-bed-table had the finish worn off which left the particle board exposed. The sink had brown stains in the basin. The counter top around the sink had the finish worn off and was discolored. The drawers at sink had wood exposed from several scratches/gouges. The footboard of the bed had the wooden finish worn off which left the particle board exposed. Room #116: The footboard of the bed had the finish worn off with the wood/particle board exposed. Room #127: The wood finish was worn off the drawers at the sink. The drawers had several scratches and gouges. Room #129: The finish was worn off the wood on the drawers on the sink. This left the wood exposed. There was a chip out of the countertop, particle board exposed Room #123: The chair in the room had the finish worn off the arms. The drawers at the sink had the wood finish worn off. The drawers had scratches/gouges, which left the wood exposed. Room #121: The finish was worn off the wooden sink drawers. The wooden drawers had numerous scratches/gouges. Room #124: The finish was worn off the wooden drawers at the sink. The drawers had several scratches/gouges. Room #119: Resident #36's bed had the finish worn off footboard. This left the particle board exposed. There were many black marks along the lower wall near the closet. The finish was worn off the wood at the sink. Room #132: The footboard of Resident #24's bed had the finish worn off. Room #122: The finish was worn off the wooden drawers at the sink. There were several scratches/gouges in the wooden drawers. Room #128: The finish was off the wooden drawers at the sink Room #114: The footboard of both beds had the finish worn off. This left the particle board exposed. The drawers at the sink had the finish worn off. Room #126: The wood finish was worn off the drawers at the sink. Room #104: The covering on the side of the nightstand had pulled loose at bottom exposing particle board. This nightstand was outside of Room #104 and was used to hold isolation supplies. Room #106: Outside of Room #106, a nightstand had the finish off a section on the side. This left particle board exposed. At 11:45 a.m. on 11/19/13, the environmental issues were discussed with the maintenance director (Employee #31) and administrator (Employee #48). The administrator said the building was currently in the process of redoing their central bathrooms on all floors. She said she knew some of the drawers of the sinks were to be replaced. The administrator indicated they were trying to replace all of them. She said the company had plans to change the facility layout.",2016-11-01
8031,"MERCER NURSING AND REHABILITATION CENTER, LLC",515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2012-08-07,225,D,0,1,CCLH11,"Based on review of sampled personnel records, staff interview, and review of the facility's abuse policy and procedures, the facility failed to make reasonable efforts to uncover information that would indicate an individual was unfit for service as an employee of a nursing home. The facility failed to adequately screen individuals for adverse actions by applicable professional licensing boards, and/or findings entered into the State nurse aide registry concerning abuse, neglect, or misappropriation of resident property before hiring. This was true for two (2) of ten (10) employee personnel files reviewed. Employee identifiers: #27 and #35. Facility census: 53. Findings include: a) Employee #27 Review of the personnel record of Employee #35 found this individual was employed by the facility as a licensed practical nurse on 10/19/2010. An interview with the administrator and the business office assistant, Employee #40, on 08/07/12 at 11: 00 a.m., found the facility was unable to provide verification this employee had been checked through the State nurse aide registry for any potential history of abuse, neglect, or misappropriation of resident property. The administrator was also unable to provide evidence Employee #27's nursing license was in good standing before employment. b) Employee #35 Employee #35 was employed by the facility, on 05/07/12, as an environmental service assistant. An interview with the administrator and the business office assistant, Employee #40, on 08/07/12 at 11:00 a.m., found the facility was unable to provide verification this employee had been checked through the State nurse aide registry for any past history of abuse, neglect, or misappropriation of resident property. c) Review of the facility's policy for, Abuse, Neglect and Misappropriation of Resident Property: Protection of Resident's/Reporting and investigation, found, section D, Procedures: The facility will screen potential new employees for a history of abuse, neglect or mistreating resident. This includes checking with the appropriate licensing boards and registries .",2016-10-01
8032,"MERCER NURSING AND REHABILITATION CENTER, LLC",515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2012-08-07,241,D,0,1,CCLH11,"Based on observations, the facility failed to maintain dignity during the dining experience for one (1) of three (3) residents. A resident had to sit and watch while the other residents at the table were fed by staff. Resident identifiers: #19, #37, and #20. Facility census: 53. Findings include: a) Resident #19 Observation of the noon meal, on 07/30/12, found Residents #19, #37, and #20 seated at the same table. Each resident had a tray, but Resident #19 was not being fed. Employee #41 (nurse aide) was feeding Residents #37 and #20. Residents #37 and #20 consumed their entire meal before another employee came in to feed Resident #19. Resident #19's tray was sitting in front of her during this time, but she had no assistance with her meal until the second aide came into the dining area.",2016-10-01
8033,"MERCER NURSING AND REHABILITATION CENTER, LLC",515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2012-08-07,253,E,0,1,CCLH11,"Based on observations and staff interview, the facility failed to ensure the floor tiles were in good repair in the A-hall shower room. This had the potential to affect more than a limited number of residents on A Floor who used this shower room. Facility census: 53. Findings include: a) On 07/31/12 at 11:15 a.m., observations of the A Hall shower room revealed severely cracked and missing tile work in the entryway and throughout the shower room floor. This would inhibit effective cleaning and sanitization of the area. On 08/01/12 at 1:45 p.m., Employee #16, the unit charge nurse, verified the cracked tile work and missing tiles.",2016-10-01
8034,"MERCER NURSING AND REHABILITATION CENTER, LLC",515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2012-08-07,257,E,0,1,CCLH11,"Based on observation, resident interview, and staff interview, the facility failed to ensure comfortable and safe environmental temperatures were maintained in resident rooms on the B wing of the facility. During the initial tour of the facility, rooms were observed to be very warm. Residents stated they were not comfortable with the room temperatures. Resident identifiers: Residents #64, #28, #30, and #84. Facility census: 53. a) Resident #64 During the initial tour of the facility, on 07/30/12 at 12:50 p.m., it was noted the hallways and resident rooms on B wing were very warm. The afternoon sun was coming in the windows at that time. In the hallway, a thermostat was observed with a reading of eighty degrees (80). Resident #64 was observed in her room awake. With resident permission the room was entered and the resident was questioned regarding the environmental temperature. This resident stated she was very hot. She also voiced having a red rash on her back which started when it got hot in the facility a couple weeks ago. b) Resident #28 This resident was also interviewed regarding the environmental temperatures. She commented, at 2:28 p.m. on 07/30/12, she was too hot, and added, the fan don't help, it's been hot awhile. c) Resident #30 At 2:22 p.m. on 07/30/12, when asked about the environmental temperatures, this resident said she was burning up. d) Resident #82 At 2:30 p.m. on 07/30/12, this resident also voiced being too hot. The resident stated it had been that way awhile. e) At 2:40 p.m., Employee #60 (Environmental Supervisor), was asked to obtain environmental (air) temperatures. This employee, used an infrared gun device to measure the temperature in Resident #64's room. A reading of 89.4 degrees was obtained. (Infrared gun devices measure surface temperatures which may or may not coincide with ambient temperatures.) This employee confirmed this device was being the device used to check temperatures. On 07/31/12, in the morning, during a random tour of B wing, it was observed that all resident rooms mentioned previously had been equipped with portable air conditioners. Resident #64 was interviewed again. At that time, she said that after the air conditioner was installed she was breathing easier and was able to sleep the best she had since the weather had been hot.",2016-10-01
8035,"MERCER NURSING AND REHABILITATION CENTER, LLC",515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2012-08-07,323,D,0,1,CCLH11,"Based on observation and staff interview, the facility failed to ensure residents were provided an environment free of accident hazards. Observations found the grab bars were loose in two (2) resident bathrooms. Resident identifiers: #52 and #37. Facility census : 53. Findings include: a) Residents #52 and #37 During Stage 2 of the survey, observations were made in room A-8A and room A-21A. Both Residents #52 and #37 used the grab bars to assist themselves in transferring on and off of the toilet. The grab bars next to the toilets were found to be loose and unstable. On 08/07/12, at approximately 9:15 a.m., Employee #63 (administrator) and Employee #60 (environmental supervisor) also observed both sets of grab bars. Employee #60 stated, they are all flexible, this is how they come from the manufacturer. She further added only two (2) rooms had grab bars in the facility. On 08/07/12, at approximately 9:45 a.m., Employee #60 was asked for the manufacturer's instructions for the grab bars. At approximately 3:00 p.m., on 08/07/12, the information requested still had not been provided by the facility.",2016-10-01
8358,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-08-16,441,D,1,0,2RNY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure staff practiced infection control techniques to prevent the spread of disease and infection. Staff failed to perform handwashing and glove changes when indicated during dressing changes on residents with wounds and infections. Additionally, a nurse put clean gloves in her potentially contaminated pocket, then used them during a dressing change. Additionally, the gloves were retrieved from her pocket which was underneath an isolation gown, potentially transferring pathogens to her uniform pocket. Two (2) of the seventeen (17) residents on the sample, chosen from the fifty-two (52) residents in the facility, were affected. Resident identifiers: #22 and #11. Facility census: 52. Findings include: a) Resident #22 During a treatment observation, on 08/14/13 at 10:10 a.m., Employee #63, a licensed practical nurse, and Employee #21, a licensed practical nurse (LPN), performed the dressing change on a resident in contact isolation for Clostridium difficile. Employee #63 gathered the dressing supplies from the treatment cart in the hallway outside of the resident's room and donned a pair of gloves and personal protective equipment and entered the resident's room. Employee #63 was observed placing gloves into her uniform top under her isolation gown. The dressing supplies were then placed on the bedside table without cleaning the area or placing a barrier. Employee #63 proceeded to remove a soiled dressing from Resident #22's left ankle that was visibly soiled with stool. She then cleaned the area with normal saline and dried it with a gauze pad. The LPN continued the dressing change with the same pair of gloves and reapplied a clean dressing to the ankle. This created a potential for transfer of microorganisms from the soiled dressing to the wound and to the clean dressing. After finishing the dressing to the ankle, the LPN then picked the call light up from the floor and place it on the resident's bed and began changing the soiled underpad of the resident that was visibly covered with stool. Employee #63 then changed her gloves and donned a clean pair that she had removed from her uniform pocked under the isolation gown. She did not wash her hands prior to donning the clean gloves. The LPN then applied [MEDICATION NAME] cream to the resident's peri area, and while wearing the same pair of gloves, applied [MEDICATION NAME] cream. Employee #63 and Employee #21 then removed their soiled gloves and donned a clean pair without washing their hands. Employee #21 donned a new pair of gloves from the bedside table while Employee #63 removed a pair from her uniform top pocket. Employee #21 then removed the soiled dressing from the resident's coccyx and then removed her soiled gloves, washed her hands and donned a clean pair of gloves to measure the wound to the resident's coccyx, after which she proceeded to redress the wound with the same pair of gloves. After the dressing was completed both LPNs removed their gloves and washed their hands. The pockets of a nurse's uniform are considered unclean. By placing the clean gloves in her pocket, any microorganisms deposited there from other activities during the course of the day would be transferred to the gloves. Those microorganisms could then be transferred from the gloves to the resident's wounds. Likewise, by the nurse putting her unclean hand into her pocket underneath the isolation gown, she created a potential for transfer of Clostridium difficile, and its spores, into her pocket. This would create a potential for spread of this disease to others. b) Resident #11 A treatment observation was done on 08/14/13 at 1:05 p.m. with licensed practical nurses (LPN), Employee #21 and Employee #63. Employee #63 gathered the dressing supplies from the treatment cart in the hall and entered the resident's room. She placed the dressing supplies on the bedside table without cleaning the surface or placing a barrier on the table. Employee #63 did not wash her hands prior to beginning the dressing change. The resident's soiled brief was then removed. With the same pair of gloves on, the LPN measured the coccyx wound, cleaned the area and inserted packing into the wound. She then removed her gloves and washed her hands and donned a clean pair of gloves to apply the [MEDICATION NAME] cream to the resident's buttocks and coccyx area. c) An interview was conducted with the director of nursing (DON) on 08/14/13 at 2:00 p.m. regarding the infection control and handwashing . When asked if the area the wound care supplies were placed should be cleaned or have a barrier put in place, the DON stated the area should be a clean surface. She was asked about when handwashing and changing gloves should be done. She stated the nurses should wash their hands with each dressing change. She stated the facility had recently had an inservice regarding handwashing and glove use. And interview was conducted with Employee #63, a licensed practical nurse, on 08/14/13 at 1:20 p.m. She stated she knew she should have changed her gloves and washed her hands between dirty and clean procedures. She stated she was nervous and that today was unusual finding her residents in a mess. She stated she was just learning how to do the treatments for the facility. A review of the facility's infection control policy, on 08/14/13 at 3:30 p.m., revealed under the section titled General Guidelines #3 were guidelines as to when staff were to wash their hands. The line numbered 3 a. was before and after direct contact with residents, c. was after contact with blood, body fluids, secretions, mucous membranes, or intact skin, d. was After removing gloves:, and g. When there is likely exposure to spores (i.e., [DIAGNOSES REDACTED]icile or Bacillus anthracis) (Note: Alcohol based hand rubs are inactive against spores. For effective mechanical removal of spores, wash hands for 30-60 seconds with soap and water or 2% [MEDICATION NAME].)",2016-07-01
9116,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,156,E,0,1,REFP12,Deficiency Text Not Available,2016-02-01
9117,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,170,B,0,1,REFP11,"Based on an interview with the president of the resident council (Resident #1) and staff interview, the facility failed to afford residents with the right to promptly receive mail. The facility did not distribute resident mail on Saturdays, although mail was available for delivery to the facility on this day of the week. This deficient practice had the potential to affect more than an isolated number of residents. Facility census: 50. Findings include: a) An interview with the president of the resident council (Resident #1), on the afternoon of 09/14/11, elicited that the residents did not receive mail on Saturdays. An interview with the facility's bookkeeper (Employee #22), on the morning of 09/15/11, confirmed the facility does not distribute mail to residents on Saturdays. Employee #22 stated they have the post office hold the mail until Monday, in case the mail contains any money. According to Employee #22, the facility has both delivery at the facility and a post office box, and they do not check the post office box for mail on Saturdays. Mail is delivered to the front office, sorted, and given to the activity director to distribute to the residents. An interview with the activities director (Employee #38), at 9:25 a.m. on 09/15/11, revealed she does not go to the post office on Saturdays and mail is not delivered to the facility due to no one being in the front office to receive it. She agreed she did not check the post office box on Saturdays.",2016-02-01
9118,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,225,E,0,1,REFP11,"Based on review of sampled employees' personnel records, review of facility documents, and staff interview, the facility failed, for two (2) of five (5) sampled employees, to make reasonable efforts to screen for criminal convictions in other states in which they had lived and/or worked, to ensure these individuals were not unfit for employment in a nursing facility. Employee identifiers: #16 and #75. Additionally, the facility failed to immediately report (to State officials in accordance with State law), thoroughly investigate, and/or take appropriate corrective action for four (4) of twelve (12) allegations of abuse / neglect. Resident identifiers: #64, #30, #16, and #22. Facility census: 50. Findings include: a) Employees #16 and #75 Review of sampled employees' personnel files, with Employee #55 on the afternoon of 09/19/11, found the facility failed to conduct criminal background checks in the previous states where Employees #16 and #75 had previously worked. -- b) Resident #64 Review of facility documents found that, on 06/15/11, three (3) nursing assistants were overheard discussing Resident #64's genitals in a public area of the facility. The staff members were alleged to have identified the resident by name and make explicit and embarrassing remarks about his penis within the hearing range of other residents and staff members. Further review found the facility failed to report this allegation of abuse, failed to conduct a thorough investigation to identify the individuals involved, and failed to take corrective action to assure this abusive behavior did not continue. -- c) Resident #33 Review of facility documents found that, on 05/12/11, a nursing assistant (Employee #52) was alleged to have tilted Resident #33's wheelchair backwards and frightened her. Resident #33 reported the nursing assistant scared her and she (the resident) thought she was going to fall out of her chair. Further review found no evidence the facility reported this incident as required by State law, nor was a thorough investigation conducted. -- d) Resident #16 According to facility documents, on 08/09/11, Resident #16's daughter alleged that an antique ring belonging to the resident was missing. The daughter made the statement that she wanted staff to realize she knows there may be a thief. The facility did not report this allegation of misappropriation of property as required. An interview with the director of nursing (DON - Employee #44), on the afternoon of the document review, confirmed the above allegation was not reported. -- e) Resident #22 On 09/14/11 at approximately 9:00 a.m. (during the Stage I resident interview portion of the survey), Resident #22 stated someone working at the facility had yelled at him. During a subsequent interview to further explore this issue on 09/15/11 at approximately 9:30 a.m., the resident did not know the name of individual who yelled and him but knew it was a female. - On 09/14/11 at approximately 10:00 a.m., Employee #10 (a licensed practical nurse - LPN) said she knew about the resident making this allegation. She said she had informed a registered nurse (RN - Employee #2) about the situation. - On 09/14/11 at approximately 10:30 a.m., Employee #44 (the director of nursing - DON), Employee #63 (an RN), and Employee #2 were interviewed regarding their knowledge of the above situation. The DON said the facility did not have any documentation to show they had investigated the resident's allegation. She said the resident knew the race and gender of the alleged perpetrator and that the incident occurred in late August 2011 on night shift. She verified there were no supporting documentation showing the facility had conducted an investigation into this allegation of verbal abuse or reported this allegation to the State agencies. The DON said the facility had recently sent their social worker to training on abuse / neglect reporting, because they realized they needed additional education on the State and Federal requirements for reporting allegations of abuse / neglect.",2016-02-01
9119,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,246,D,0,1,REFP12,"Based on observation, resident interview, and staff interview, the facility failed to ensure one (1) of twelve (12) residents resided in an environment that provided reasonable accommodations of individual needs and preferences. One (1) of twelve (12) residents had bedroom furnishings that were arranged in a manner that did not allow for independent functioning based on the resident's own needs and preferences. Resident #34 did not have access to her chest of drawers where many of her personal belongings and snacks were kept. Resident identifier: #34. Facility census: 50. Findings include: a) Resident #34 On 12/12/11, at approximately 2:00 p.m., a tour of the facility revealed Resident #34's bed was pushed up against her chest of drawers. The bed had wheels and had been pushed up against the chest and the wheels locked. The bed was positioned to face towards the window in the room. The resident's roommate had a bed that was positioned facing the sink and closet door. The director of nursing (DON) Employee #46 said Resident #34's bed was positioned by the wall, facing out toward the window to make more space in the room. The DON said Resident #34 did store personal items and snacks in the chest. On 12/12/11, at approximately 2:00 p.m., Resident #34 sat facing her bed watching her television. She said she could not get into her chest of drawers. Employee #18 (nurse aide) said the resident's bed was positioned against the chest of drawers because the resident might injure herself getting into the chest. On 12/12/11, at approximately 3:00 p.m., an observation of Resident #34's room revealed the bed had been moved to face in the same direction as the roommate's bed and the chest was moved against the wall which allowed the resident access to the items stored in the chest. On 12/12/11, at approximately 3:15 p.m., Employee #35 (laundry/housekeeping) said the nurse aide had brought the issue to her attention and they had moved the room around to give the resident access to her chest of drawers. Employee #35 said the nurse aides should not have pushed the bed up against the chest.",2016-02-01
9120,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,250,D,0,1,REFP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and family interview, the facility failed to provide medically-related social services to one (1) of forty-five (45) Stage II sampled residents. The facility failed to offer provision of assistance to Resident #66 and her family in attending the funeral the resident's spouse. Additionally, the facility failed to conduct a thorough social history for one (1) of forty-five (45) Stage II sample residents in order to identify and assist in meeting unmet social service needs. Resident identifiers: #66 and #22. Facility census: 50. Findings include: a) Resident #66 On [DATE] at 11:50 a.m., observations were made of the difficulties family members experienced when attempting to transfer Resident #66 from a wheelchair to the front seat of a passenger car. The son was observed to struggle to lift his mother into the car. The resident's husband, who had shared a room in the facility with Resident #66, had died on [DATE], and family members were transporting her to his funeral. No staff members were present to assist the family in transferring the resident into the car. An interview with Family Member #1 revealed the facility had offered no assistance with arrangements in assuring Resident #66 was able to attend her husband's funeral. The family member stated Resident #66 was paralyzed on one (1) side and was very heavy. According to this family member, the facility offered no assistance other than getting the resident dressed, and the family had to buy a transport chair in order to wheel the resident into the church for the funeral. - Review of Resident #66's medical record found a quarterly minimum data set assessment (MDS), with an assessment reference date (ARD) of [DATE], identified the resident required the extensive assistance of two (2) or more staff for transfers, she had limited voluntary range of motion in the upper and lower extremities on one side, and she weighed 174 pounds. - During an interview on [DATE] at 11:50 a.m., the facility's social worker (Employee #43) was asked what assistance had been offered to the resident or her family with transportation to the funeral. The social worker was unable to provide any evidence that medically-related social services were offered to meet the needs of this resident in attending her husband's funeral. - In an interview with the director of nursing (DON - Employee #44), conducted on [DATE] at 12:11 p.m., when asked what assistance the facility offered to the resident or the family members in arranging transportation or other medically-related social services, the DON stated the family brought in the clothing they wanted the resident to wear. To her knowledge, the facility didn't offer any additional assistance, as it was implied that the family didn't need anything. -- b) Resident #22 During an interview on [DATE] at approximately 11:00 a.m., Resident #22 revealed his birthplace and other personal information, such as his favorite sports team and past military experience. The resident was alert and could answer questions about his past. He had no family / friend involvement; therefore, the only personal information obtained must come from the resident himself. He presented as very quiet, but he answered questions when asked. - On the afternoon of [DATE], several nurses (Employees #72, #44, and #6) shared additional information they personally knew about the resident, such as Resident #22 had extensive military service, he was a former Navel SEAL, and that they knew he had earned several prestigious military honors, including a Purple Heart. - A review of the resident's medical record, on [DATE] at approximately 10:00 a.m., revealed his social history did not mention his extensive military past. The social history form was blank in the following sections: specialized training, retirement / most recent employment, military rank, and birthplace. Additionally, the support system section of the social service assessment listed Resident #22's former health care surrogate as a person who provided formal support. - On [DATE] at approximately 12:00 p.m., the DON said Resident #22's physician had appointed a new health care surrogate (WV Department of Health and Human Resources - WVDHHR). The new health care surrogate's name had not been included in this assessment. The DON commented that the new health care surrogate showed great interest in the resident's past military career and had made a point to mention to the facility staff how prestigious the resident's career had been. This had not been documented in the record. - The last update on the resident's social history was dated [DATE]. The [DATE] entry stated, Reviewed and continued. A previous update dated [DATE] stated, Reviewed and continue. Other social service entries mainly re-stated the resident's cognitive status and summarized the current plan of care. - On [DATE] at approximately 10:30 a.m., the facility's social worker (Employee #43) stated she did not work at the facility when the resident was admitted ; therefore, she did not complete the social history assessment. - Neither the current social worker or any other licensed staff member had not added the pertinent information they had gathered into the resident's social history and social assessment or any other social service related documentation.",2016-02-01
9121,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,253,D,0,1,REFP11,"Based on observation and staff interview, the facility failed to ensure resident furnishings were in good repair. The wood finish of the sink / vanity in Room #125 was stripping off / coming loose, which rendered the surface unable to be effectively cleaned and sanitized, and the drawers were scratched. This affected one (1) of thirty-two (32) resident rooms reviewed. Facility census: 50. Findings include: a) Room #125 On 09/14/11 at approximately 2:00 p.m., the life safety code (LSC) surveyor observed the wood finishing coming off of the sink / vanity in one (1) of thirty-two (2) resident rooms (Room #125). The wood finish on the top of the vanity area had begun to strip and peel away, rendering the surface unable to effectively cleaned and sanitized. Additionally, the drawers down the side of this fixture were scratched / not in good repair. On 09/14/11, the LSC surveyor brought this to the attention of the maintenance staff person (Employee #64) and explained the reason for his concern, which Employee #64 acknowledged. The LSC surveyor also brought this to the attention of the administrator (Employee #21) and the director of nursing (DON - Employee #44) during an exit conference regarding his findings at approximately 1:00 p.m. on 09/15/11.",2016-02-01
9122,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,272,D,0,1,REFP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete assessments to accurately reflect the resident's health status and condition for one (1) of forty-five (45) Stage II sample residents. The facility failed to conduct a complete and accurate assessment of the resident's ability to regain normal bladder function and/or for the continued need of an indwelling urinary catheter. Facility census: 50. Findings include: a) Resident #25 Review of Resident #25's medical record revealed she was admitted from the hospital to the nursing facility with an indwelling urinary catheter in place. - The facility completed the Care Area Assessment Urinary Incontinence and Indwelling Catheter Worksheet on 08/10/11. Review of this worksheet found the supporting documentation for the continued use of the indwelling catheter was: While in hospital. see D/C (discharge) summary. Review of the hospital discharge summary found no documentation to support the continued use of an indwelling catheter. - During an interview on 09/20/11 at 2:05 p.m., a licensed practical nurse (LPN - Employee #70) stated, It was my understanding that the catheter was related to [MEDICAL CONDITION]. A registered nurse (RN - Employee #6) stated, I thought it was for multiple wounds. - On 09/20/11 at 2:30 p.m., the director of nursing (DON - Employee #44) stated, I don't know why she had it, unless the surgeon wanted it. Her wounds were not bad enough. The family was planning on taking her home soon. We may have left it in, so they would have it when she went home. - Extensive review of her medical record found no evidence that the facility had assessed the resident's ability to have the urinary catheter removed or normal bladder function restored.",2016-02-01
9123,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,279,E,0,1,REFP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to develop a comprehensive care plan for four (4) of forty-five (45) Stage II sample residents with measurable objectives and timetables to meet each resident's physical and psychosocial needs. Resident identifiers: #78, #29, #86, and #25. Facility census: 50. Findings include: a) Resident #78 Review of the medical record found Resident #78 sustained falls on 07/20/11 and 08/06/11. On 08/10/11, the physician ordered the application of an alarming seatbelt for safety. Review of the current care plan, dated 07/21/11, found a handwritten note under interventions related to falls which merely stated: W/c (wheelchair) seatbelt alarm for safety. The care plan did not provide instructions to staff as to when this seatbelt alarm was to be utilized, for what time frame the seatbelt was to be utilized, what interventions to provide to prevent the development of pressure ulcers, how often the seatbelt was to be removed for toileting and pressure relief, etc. The care plan did not include measurable objectives and timetables to meet this resident's needs. -- b) Resident #29 Review of the medical record revealed this resident was admitted on [DATE] with orders for [MEDICATION NAME] (an antipsychotic drug) 50 mg at bedtime. Review of the current care plan found the facility failed to address the use of this antipsychotic drug in the comprehensive care plan. An interview with one (1) of the minimum data set (MDS) coordinators (Employee #2), on the afternoon of 09/20/11, confirmed no care plan had been developed to address this resident's use of an antipsychotic drug. -- c) Resident #86 Review of the medical record found this male resident was admitted to the facility on [DATE] with an indwelling urinary catheter. Review of the resident's care plan found an episodic care plan, dated 09/13/11, addressing a urinary tract infection. Further review found the goal included pain-free voiding. One (1) of the approaches included: Assist / remind to void every 1-3 hours as need & to completely empty bladder. Not only did this resident's care plan not address the medical and nursing needs associated with this resident's catheter, the facility developed a care plan with goals and approaches for a resident who did not have an indwelling catheter in place. The care plan was signed by Employee #63, a registered nurse (RN). -- d) Resident #25 Review of the facility's wound assessment and progress review found Resident #25 developed an unstageable wound measuring 5.7 cm in length and 3 cm in width. A licensed practical nurse (LPN - Employee #73) identified the wound on 08/18/11, documenting, Noted bruised area admission on 08/03/11 developed into unstageable wound at present necrotic blackish green length 5.7 width 3. On 08/24/11, another LPN (Employee #70) described the area to the left posterior calf as being 90% black necrosis with a 10% area of red granulation to the upper portion of wound. - Review of the plan of care for Resident #25 found no evidence the facility identified the presence of this wound to the left posterior calf. The care plan identified the presence of three (3) Stage II pressure ulcers that were present on admission, but there was no mention of the wound on her posterior calf. - During an interview with the other MDS coordinator (Employee #39) on 09/21/11 at 10:48 a.m., she stated, We don't do another care plan when they develop a new pressure ulcer. If they already had pressure ulcers, we wouldn't add it. - On 09/22/11 at 9:49 a.m., another RN (Employee #6) stated, We go through the pink slips and we do an interim care plan. Sometimes they slip through the cracks.",2016-02-01
9124,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,280,E,0,1,REFP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to revise the care plan when changes occurred in the status of five (5) of forty-five (45) Stage II sample residents. Resident identifiers: #82, #66, #78, #42, and #22. Facility census: 50. Findings include: a) Resident #82 Review of the medical record found this female resident was admitted to the facility on [DATE]. The nursing admission assessment identified reddened areas to her inner buttocks. A care plan was developed to address these reddened areas. On [DATE], the resident developed a Stage II pressure ulcer to her inner sacrum which required assessment / monitoring and dressing changes. The care plan was not revised to address this change in the resident's status. An interview with one (1) of the minimum data set (MDS) coordinator (Employee #39), on [DATE] at 10:30 a.m., confirmed the care plan was not revised to meet this resident's needs related to the development of a pressure ulcer. -- b) Resident #66 Review of the medical record found Resident #66 resided in the facility and had shared a room with her spouse prior to his death on [DATE]. Review of the care plan found the facility did not revise the resident's care plan to address her psychosocial needs after the death of her spouse. -- c) Resident #78 Observations, conducted on [DATE] at 5:40 p.m., noted this resident's wheelchair was equipped with an alarming seat belt. Review of the medical record found Resident #78 sustained falls on [DATE] and [DATE]. The treating physician ordered an alarming seatbelt to be utilized to prevent falls on [DATE]. Review of the current care plan found the facility failed to revise the care plan to include measurable goals and interventions to meet this resident's needs associated with the use of the alarming seatbelt. Review of the care plan found the facility had merely written: ,[DATE] w/c (wheelchair) seatbelt alarm for safety. -- d) Resident #42 Review of Resident #42's medical record found she had joint contractures of the hips, knees, and lower leg. An interview with Resident, #42 on [DATE], revealed she did have contractures and particular concerns about her knees and inability to walk. She expressed some desire to walk again. Observations of the resident, from [DATE] through [DATE], found she did not want to get out of bed and preferred to stay in bed in her room all of the time. At most, she would sit in her wheelchair in the doorway of her room. In an interview on [DATE], Employee #6 (a registered nurse - RN) reported the resident came to the facility with severely contracted hips and knees. Employee #6, who had known the resident for the duration of the time she had lived at the facility, stated the resident never expressed a desire to work with therapy services or having range of motion exercises to the affected areas. On [DATE] at approximately 4:30 p.m., Employee #82 (a certified occupational therapy assistant - COTA) stated she had worked with Resident #42. She said the resident did not have much interest in participating in therapy services. She also knew the resident came into the facility with severely contracted hips, which would have made walking again almost impossible. Review of the resident's care plan found the resident was to have physical and occupational therapy evaluations per physician's orders [REDACTED]. On [DATE] at approximately 9:30 a.m., Employee #6 stated the facility would revise the care plan to reflect the resident's desire to not actively participate in therapy and range of motion exercises to her hips, knees, and lower leg. -- e) Resident #22 The medical record review for Resident #22, conducted on [DATE] beginning at approximately 10:00 a.m., revealed the following physician's orders [REDACTED].* [DATE] Resident to have right foot pillow when AFO (ankle foot orthoses) not used to prevent skin breakdown. - On [DATE] at approximately 11:20 a.m., Employee #6 explained the resident did not comply with wearing the foot pillows. On [DATE] at approximately 11:10 a.m., Resident #22 sat in his room without these foot pillows in place. The nurse aide (Employee #66) said the resident did not like to wear the boots on his feet. Employee #70 (a licensed practical nurse - LPN) came down the hall with the resident's foot pillows. She said he often kicked these boots off and did not like to wear them. On various other occasions between [DATE] and [DATE], observation found the resident did not have the foot pillows in place while he sat in his wheelchair watching television in his room. - The resident's current care plan, when reviewed [DATE] at approximately 2:00 p.m., contained the following problem statement: At risk for injury R/T (related to): history of falls. Resident has had [MEDICAL CONDITION] with right [MEDICAL CONDITION], right ankle has slight contracture, ambulatory at present time with restorative to bathroom, requires extensive assistance of two with transfers and poor vision. The goal for this problem was: Resident will remain free of injury R/T falls through next review date. The interventions to achieve this goal included: Ensure that resident is wearing appropriate footwear bedroom type slippers with socks when up in w/c (wheelchair) with heel pillows when will allow. Non-ambulatory at this time unless assisted. - On [DATE] at approximately 11:30 a.m., the director of nursing (Employee #44) and both minimum data set nurses (Employees #39 and #2) were informed the care plan did not reflect the resident's refusal to wear the foot pillows.",2016-02-01
9125,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,282,D,0,1,REFP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure one (1) of forty five (45) residents had access to thickened water in accordance with this care plan. Resident #22 required thickened liquids, and on several occasions the resident either had no thickened water available or had the liquids available but not within his reach. Resident identifier: #22. Facility census: 50. Findings include: a) Resident #22 On 09/14/11 at approximately 9:00 a.m., upon entering Resident #22's room, he asked this surveyor for water. Observation found he did not have a water pitcher in his room. Employee #6 (a registered nurse - RN) said the resident required thickened liquids. She said he normally takes cartons of thickened water from his breakfast or lunch tray and stores them in the drawers in his room. Employee #6 went into the resident's room, and he had no water cartons stored in his room. The RN then said staff typically keeps a lunch box with an ice pack to keep the water cartons cool. Observation revealed Resident #22 did not have a lunch box in his room. The RN said perhaps the staff had washed the lunch box and forgot to put it back in his room. The RN said she would take care of the situation and assure the resident had water to drink. - On 09/15/11 at approximately 11:20 a.m., Resident #22 could not reach the lunch box that contained his cartons of thickened water. A nurse aide came in and moved the lunch box to the bedside table, where the resident could reach it. - On 09/19/11 at 12:15 p.m., Resident #22's lunch box did not have any water cartons in it. He said he would like to have some water. Employee #6 said the facility had received some new ice packs and she would give the resident some water. - On 09/21/11 at approximately 5:00 p.m., Resident #22's water was sitting behind his television out of reach. Employee #52 (a nurse aide) said she would move the water to where the resident could reach it. - A review of the resident's care plan revealed the following problem: Alteration in ADLs (activities of daily living) self-care deficit r/t (related to)[MEDICAL CONDITION] with right sided [MEDICAL CONDITION], weakness requires limited to extensive assistance with ADL's, Speech disturbance and weakness. Resident is able to propel his wheelchair and feeds himself after his tray set up. An intervention to reach one of the care plan goals stated: Pre Packaged thickened liquid to be at bedside. - Resident #22 sat in his wheelchair most of the days between 09/12/11 and 09/22/11 and watched television. Due to a [MEDICAL CONDITION], he could not independently get up from the wheelchair to walk around his room to access things. He could only access what he was able to reach from his wheelchair. On multiple occasions during this survey event, the resident did not have access to thickened liquids and expressed a desire for something (such as water) to drink. Several staff members, including Employee #6 and Employee #72 (a licensed practical nurse - LPN), commented the resident would rarely ask for anything and that staff must anticipate his needs.",2016-02-01
9126,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,285,D,0,1,REFP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, minimum data set review, and staff interview the facility failed to ensure they completed a new Pre Admission Screening (PAS) evaluation for one (1) of forty five (45) residents after the resident significantly improved in the self-performance of activities of daily living (ADLs) to the point that he was independent with all ADLs. Resident identifier: #121. Facility census: 50. Findings include: a) Resident #121 Record review revealed Resident #121 was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. On 09/13/11, an interview with the resident and observations revealed he assisted other residents to and from activities. He had a very active role in the resident council and conducted a bible study for the residents. He said he had improved significantly since he came to the facility. He talked about how ill he had become in 2009 prior to this admission to the facility. In an interview on 09/15/11 at approximately 11:45 a.m., the administrator (Employee #21) reported she had tried to get Resident #121 to move to the facility's assisted living area (lesser level of care), but he had refused. She said the resident had always approached the idea of moving a lesser level of care with resistance. According to the administrator, Resident #121 began digressing in areas such as continence and mobility / ambulation whenever the facility approached this idea. Interviews with various nursing staff (including the director of nursing), between 09/15/11 and 09/20/11, revealed Resident #121 had excessive health complaints and he went to outside appointments with a variety of specialists to address this various health complaints. -- A review of Resident #121's minimum data set (MDS) assessments for the time period of 09/04/09 through 06/17/11 found the following: 1. Admission MDS with an assessment reference date (ARD) of 09/04/09 - Cognitive skills for daily decision making: 0 (independent) - Bed mobility: 2/2 (limited assistance / one person) - Transfer: 2/2 - Walk in room: 2/2 - Walk in corridor: 8/8 (activity did not occur) - Locomotion on unit: 0/0 (independent / no staff assistance needed) - Locomotion off unit: 4/2 (total dependence / two plus persons) - Dressing: 2/2 - Eating: 0/1 (independent / setup help only) - Toilet use: 3/2 (extensive assist / one person) - Personal hygiene: 0/1 - Bathing: 3/2 - Bowel continence: 3 (incontinent 2-3 times per week) - Bladder continence: 3 (tended to be incontinent daily) 2. Annual MDS with an ARD of 12/15/10 - Bed mobility: 0/0 - Transfer: 0/0 - Walk in room: 0/0 - Walk in corridor: 0/0 - Locomotion off unit: 0/0 - Dressing: 0/0 - Eating: 0/0 - Toilet use: 0/0 - Personal hygiene: 0/0 - Bathing: 1/2 (supervision / setup help only) - Bowel continence: 0 (completely continent) - Bladder continence: 0 3. Abbreviated quarterly MDS with an ARD of 06/17/11 - Bed mobility: 0/0 - Transfer: 0/0 - Walk in room: 0/0 - Walk in corridor: 0/0 - Locomotion off unit: 0/0 - Dressing: 0/0 - Eating: 0/1 - Toilet use: 0/0 - Personal hygiene: 0/0 - Bathing: 1/2 Review of his medical record revealed the resident began to demonstrate improvements in self-performance of ADLs in March 2010 and continued to make significant improvements to the point of being independent with most ADLs (requiring only setup help with bathing). Further medical record review, conducted on 09/20/11, revealed the West Virginia Department of Health and Human Resources (WV DHHR) completed a Pre-Admission Screening (PAS) for long term care placement on 08/25/09. At that time, a determination was made that he needed nursing home care with no anticipation for discharge / return home. The MDS data review revealed the resident had improved significantly since his admission to the facility in 2009. - An interview with the social worker revealed the facility had not completed any additional PAS evaluations for the resident, even though he was no longer physically dependent on staff for the performance of ADLs. The social worker stated she did believe the resident would benefit from a lesser level of care. She said that, in the past, the resident had resisted this change. - On 09/21/11, the social worker said she spoke with the resident and explained the deficits that he would have to have in order to remain on the long term care unit. She said he expressed understanding and agreed to move to the assisted living.",2016-02-01
9127,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,309,G,0,1,REFP11,"**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 assure one (1) of forty-five (45) Stage II sample residents received the care and services necessary for an effective pain management program, resulting in actual harm to this resident due to untreated pain. Resident identifier: #85. Facility census: 50. Findings include: a) Resident #85 During an interview with Resident #85, she was asked (as part of the Stage I survey protocol) if she was experiencing any pain. Resident #85 stated she had pain in her legs and that they don't give her pain pills anymore. She stated she used to get a pain pill when she first got up and a pain pill when she went to bed. She stated she was in a wheelchair because of my legs hurting so bad. Resident #85 triggered in the Stage II sample due to experiencing pain. A review of her medical record found she was prescribed [MEDICATION NAME] 5/500 mg every four (4) hours as needed (PRN) for pain. She was further ordered to be observed or questioned for pain every four (4) hours while awake. Review of the Medication Administration Record [REDACTED]. The resident was visited in her room at 8:30 a.m. on 09/21/11. Observation found she was rubbing her left leg. When asked by this surveyor if she was experiencing any pain, Resident #85 stated, Yes, my legs. and continued rubbing her left leg. When asked how much pain she was having on a scale of 1 to 10 (with 1 being, Oh, it doesn't hurt much and 10 being, OH MY GOD THAT HURTS!), the resident stated her pain was a 10. When asked if her nurse had asked her if she was having any pain when she received her medications this morning, Resident #85 stated the nurse did not ask her anything about having pain. An immediate review of the resident's MAR, on 09/21/11 at 8:34 a.m., found the licensed practical nurse (LPN - Employee #53) had documented having observed or questioned the resident for pain at 8:00 a.m. on 09/21/11. It was further noted that this nurse had already documented asking the resident about pain at 12:00 p.m. on 09/21/11. Employee #53 was then asked about her documentation of observing or questioning the resident about pain during the morning medication pass at 8:00 a.m. The nurse stated she asks her residents about pain but may have forgotten to ask Resident #85. When asked why she had already documented having assessed the resident for pain at 12:00 p.m., she stated that all those lines got her confused. The director of nursing (DON - Employee #44) was immediately informed, at 8:35 a.m. on 09/21/11, of the resident's complaints of pain and the LPN's failure to assess the resident for pain. She was also informed that the nurse had already documented assessing the resident for pain at 12:00 p.m. on 09/21/11. She agreed that this was a problem.",2016-02-01
9128,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,312,D,0,1,REFP11,"Based on observation, staff interview, and review of the floor assignment sheet, the facility failed to assure one (1) of forty-five (45) Stage II sample residents received the necessary care and services to maintain good nutrition. Staff left Resident #29's evening meal tray sitting on the bedside table for forty (40) minutes with no attempts to assist the resident in eating. Resident identifier: #29. Facility census: 50. Findings include: a) Resident #29 Random observation of the evening meal service, at 6:10 p.m. on 09/12/11, found Resident #29's evening meal tray was sitting on her bedside table. Continued observations noted facility staff passed by this resident's room, including the director of nursing and the charge nurse, without offering assistance for the resident to eat. At 6:47 p.m., a nursing assistant (Employee #11) was picking up trays of residents who had finished eating when she reached Resident #29's room. She entered the room and noted the resident's tray had not been set up. She returned to the hallway and asked another nursing assistant to finish picking up trays, as she needed to feed Resident #29. At 6:50 p.m., Resident #29 was asked if she was hungry. The resident replied in a affirmative. It was noted that Employee #11 did not reheat the resident's tray prior to feeding her. A review of the evening shift assignment sheet found another nursing assistant (Employee #47) was assigned to feed residents on the short hall. At 6:55 p.m. on 09/12/11, Employee #47 was observed to be assisting another nursing assistant to pick up trays from the long hall. When asked in an interview if she was assigned to the short hall, she confirmed she was assigned the short hall. When asked why she did not feed Resident #29, she replied that she guessed she just forgot about her.",2016-02-01
9129,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,323,E,0,1,REFP11,"Based on observation, review of facility documents, review of manufacturer's information, and staff interview, the facility failed to apply WanderGuard signaling devices in accordance with manufacturer's instructions for five (5) of seven (7) Stage II sampled residents. This failure to follow manufacturer's instructions for the application of the WanderGuard signaling device placed these residents at risk of unrecognized elopement. Resident identifiers: #71, #41, #59, #82, and #78. Facility census: 50. Findings include: a) Residents #71, #41, #59, #82, and #78. Random observations, beginning upon entrance to the facility on the afternoon of 09/12/11, noted various residents who had WanderGuard signaling devices attached to their wheelchairs. - Review of a facility document found that, on 07/04/11, Resident #59 went out the front door and the WanderGuard on her wheelchair failed to activate the alarming system. The document detailed that another resident's wheelchair, also equipped with a WanderGuard device, was tested on the door and it also failed to activate the alarm. - Review of the manufacturer's user manual, on page 25, found the section entitled Wheelchair Placement which stated: Facilities often ask about attaching the signaling device to a wheelchair. If attempts to use wrist or ankle placement (see above) have failed, mount the signaling device away from the metal frame of a wheelchair at a height of approximately 3' (feet) from the floor (in the center of the back of the wheelchair). Use only plastic clips or plastic tape to attach the device. DO NOT use a metal safety pin to attach the device . - A registered nurse (RN - Employee #6) was asked to provide a list of all residents with orders for WanderGuard signaling devices. At 3:30 p.m. on 09/20/11, Employee #6 assisted this surveyor in identifying the placement of the WanderGuard devices for the identified residents. Observation found the WanderGuard devices for the following residents were not applied in accordance with manufacturer's instructions and were attached directly to the metal frames of their wheelchairs: Residents #71, #41, #59, #82, and #78.",2016-02-01
9130,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,371,F,0,1,REFP11,"Based on observation and staff interview, the facility did not ensure the kitchen was operated under clean and sanitary conditions. This practice had the potential to affect more than an isolated number of residents. Facility census: 50. Findings include: a) On 09/12/11 at approximately 3:00 p.m., a tour of the dry storage area revealed canned foods and dry food goods stored in this area. A vent in the ceiling of this room was without a cover; this left the dry food area exposed to lint, dust, and other debris that blew through this vent. The dietary manager (Employee #29) reported she would have this repaired. b) On 09/21/11 at approximately 11:00 a.m., an observation of the kitchen revealed the floors behind the stove and the vegetable sink had white flaky debris on them. The dietary manager said she did not know what the substance was, but she agreed it needed to be cleaned up and out of the floor.",2016-02-01
9131,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,441,D,0,1,REFP11,"Based on observation and interview with contracted oxygen therapy personnel, the facility failed to assure that outdated and contaminated oxygen concentrator bottles were properly disposed of, to prevent the ingestion of their contents by one (1) of three (3) residents with orders for oxygen therapy. Resident identifier: #46. Facility census: 50. Findings include: a) Resident #46 During random observations of the noon meal service on 09/14/11 at 11:50 a.m., Resident #46 was noted to be seated in her room with her lunch tray on an overbed table positioned in front of her. She was noted to be drinking from an odd looking water bottle. The resident's roommate was overheard to yell, Don't drink that! That's for your oxygen! Resident #46's room was entered, and she was noted to be holding a used oxygen concentrator humidifier bottle with a date of 09/07/11. She handed the bottle to this surveyor and stated, This bottle is too hard to drink from. The bottle was then given to staff members at the nursing station. An interview was conducted with the contracted oxygen employee following this observation. He apologized for leaving the used bottle in the resident's room.",2016-02-01
9132,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,514,D,0,1,REFP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure the medical records for two (2) of forty-five (45) Stage II sample residents were complete and accurately documented. The physician's orders [REDACTED].#85's Medication Administration Record [REDACTED]. Resident identifiers: #86 and #85. Facility census: 50. Findings include: a) Resident #86 Record review revealed Resident #86 was admitted to the facility on [DATE] with orders for an indwelling Foley urinary catheter. Review of the admission orders [REDACTED]. physician's orders [REDACTED].#__ to bedside drainage. (The size of catheter to be utilized was left blank.) Review of the MAR found that it also did not specify what size of indwelling Foley catheter was to be utilized when changing the catheter. An interview with registered nurses (RN) #39 and #2 on 09/21/11 at 10:30 a.m. confirmed that the medical record did not contain clear and specific orders for the size of the indwelling Foley catheter to be utilized for Resident #86. -- b) Resident #85 Review of the medical record found Resident #85 was prescribed [MEDICATION NAME] 5/500 mg every four (4) hours as needed (PRN). Nursing staff was to observe and/or question the resident for pain every four (4) hours. Review of the resident's MAR found the documentation portion of the order merely allowed nursing staff to document the time of the assessment by use of initials and whether the resident was awake. The MAR indicated [REDACTED].",2016-02-01
9133,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-02-06,157,E,1,0,EVNT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review, review of facility policy for notification of changes, and staff interview, the facility failed to notify the responsible parties for three (3) residents, who had been determined to lack capacity to make medical decisions, when the residents' treatments were altered due to changes in the resident's condition or when there was a medication change. This was true for three (3) of ten (10) sampled residents. Resident identifiers: #11, #43, and #40. Facility Census: 54. Findings Include: a) Resident #11 A medical record review, conducted at 9:10 a.m. on 02/06/13, revealed Resident #11 had been determined to lack the capacity to make health care decisions since 06/03/12. Further review of the medical record found a Medical Power Of Attorney (MPOA) was completed by the resident on 08/14/98. The medical record review, conducted at 1:30 p.m. on 02/05/13, revealed the resident had a [MEDICATION NAME] time and international normalized ratio (PT/INR) laboratory test completed on 01/28/13. Based on the results of this test, on 01/30/13, the resident's physician ordered, D/C (discontinue) [MEDICATION NAME] 2 MG (milligrams) and start [MEDICATION NAME] 1 MG. There was no evidence the resident's MPOA was notified of this medication change. This medical record review also revealed a new order dated 12/03/12 for [MEDICATION NAME] to the resident's peri-area due to redness X (for) 14 days. There was no evidence the resident's MPOA was notified of this treatment change. On 12/03/12, a nurse documented this resident had experienced a fall. A new order was written for neurochecks to be done. There was no further documentation to indicate the resident's MPOA was informed of the resident's fall or of the new order for neurochecks. In an interview with the Director of Nursing (DON), Employee # 62, at 11:00 a.m. on 02/06/13, the DON confirmed there was no evidence the MPOA was notified of the changes in the resident's care and her fall. b) Resident #43 Medical record review, conducted at 4:00 p.m. on 02/05/13, revealed Resident #43 had been determined to lack capacity to make health care decisions since 06/30/10. Further review of the medical record found a Medical Power Of Attorney (MPOA) which had been completed by the resident on 09/07/06. A nursing entry, dated 11/22/12, noted the resident's wife had reported his urine was foul smelling and he had painful urination. The nurse obtained an order for [REDACTED]. A nurse's note, dated 11/25/12, revealed the physician had come to the facility and given an order for [REDACTED]. There was no evidence the MPOA was notified of the initiation of this new treatment. On 12/17/12, a nurse documented the physician was in to see Resident #43. During the visit, the resident complained of left lower chest pain, so the physician ordered a chest x-ray. The physician reviewed the resident's X-ray on 12/18/12 and wrote an order for [REDACTED]. Further review of the medical record revealed the resident had a PT/INR laboratory test completed on 12/24/12. As a result of this test, a new order was obtained on 12/24/12 for D/C (discontinue) [MEDICATION NAME] 6 MG (and start) [MEDICATION NAME] 7 MG. There was no evidence contained in the medical record to indicate the MPOA was made aware of this new order. The resident had another PT/INR test completed on 01/07/13. The physician gave a new order as a result of this test. The order was given by the physician on 01/07/13 which read as follows: D/C [MEDICATION NAME] 7 MG (and start) [MEDICATION NAME] 4 MG daily on 01/09/13. There was no evidence the MPOA was notified about this medication change. Resident #43 had another PT/INR collected on 01/14/13. As a result of this lab report, the physician gave another [MEDICATION NAME] order. The physician order [REDACTED]. There was no indication the MPOA was notified of this medication change. The medical record review also revealed the resident had another PT/INR lab test on 01/28/13. This lab result also resulted in another physician order [REDACTED]. On 01/30/13, the physician ordered D/C [MEDICATION NAME] 5 MG (and start) [MEDICATION NAME] 6 MG daily. There was no evidence the resident's MPOA was notified of this change in medication. The medical record also contained a nurse's note, dated 02/02/13, which revealed the resident had a fall while attempting to transfer from his bed to his wheelchair. As a result of this fall, a standing order to begin neurochecks was initiated and the neurochecks were started. There was no evidence which indicated the resident's MPOA was notified of this fall or the initiation of the neurochecks. An interview with the DON, Employee #62, at 11:00 a.m. on 02/06/12, confirmed the documentation of the notification of the MPOA for this resident was not contained on the order or the nurse's notes related to these changes in his plan of care. The facility's policy titled, Change in a Resident's condition or status, directed the facility's staff to notify the resident's family of changes with in twenty-four hours of a change occurring in the resident's mental/medical condition or status. c) Resident #40 Medical record review, on 02/04/13, found a nurse's note, dated 12/21/12 at 11:55 a.m., (name of physician) in facility. See new order for chest x-ray d/t (due to) chest congestion. Further review of the medical record found the chest x-ray was completed on 12/21/12 as ordered. The results of the chest x-ray found, Since 11/08/12, worsening bibasilar lung infiltrates, right greater than left. The physician was contacted by telephone on 12/21/12 and made aware of the results of the x-ray. The physician ordered [MEDICATION NAME] 500 milligrams, daily, for ten (10) days for a [DIAGNOSES REDACTED]. On 12/04/07, a Health Care Surrogate was appointed for this resident due to the resident's inability to process information related to a [DIAGNOSES REDACTED]. Subsequent evaluations found the resident continued to lack capacity to make health care decisions. The administrator, Employee #47, was interviewed at 12:59 p.m. on 02/04/13. The administrator was unable to provide evidence the resident's health care surrogate was notified of the resident's change in condition and the addition of the new antibiotic on 12/21/12.",2016-02-01
9134,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-02-06,280,D,1,0,EVNT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to update the resident's plan of care when the resident was readmitted to the facility with orders to receive two (2) anticoagulants for the treatment of [REDACTED]. This was true for one (1) of ten (10) residents whose medical records were reviewed. Resident identifier: 55. Facility census: 54. Findings include: a) Resident #55 Medical record review found the resident was admitted to a local hospital on [DATE] . The resident received treatment for [REDACTED]. The resident returned to the facility with new orders to receive two anticoagulants for the treatment of [REDACTED]. -- [MEDICATION NAME] 5 mg. by mouth, daily, and -- [MEDICATION NAME] 65 g. (grams), subcutaneous, every 12 hours, stop on December 13, 2012 or once the INR is between 2-3. The admitting physician's orders [REDACTED]. Review of the current care plan, on 02/06/13, found the care plan was not updated to include the change in condition and the new physician's orders [REDACTED]. Employee #1, the care plan coordinator, was interviewed on 02/06/13 at 3:49 p.m. She verified she failed to update the existing care plan when the resident returned from the hospital.",2016-02-01
9135,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-02-06,309,G,1,0,EVNT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Based on medical record review, review of hospital records, staff interview, and review of the facility's corrective actions after discovery, the facility failed to ensure physician's orders were followed regarding obtaining weekly [MEDICATION NAME] Time and International Normalized Ratio (PT/INR) for a resident receiving two (2) anticoagulants. The facility discontinued one anticoagulant, [MEDICATION NAME] without confirmation of the results of the PT/INR. The physician assessed the resident during this time period and failed to recognize lab orders were not completed as ordered. The failure to monitor and identify serious adverse reactions due to the failure to collect the ordered PT/INRs resulted in a critically elevated INR which lead to the resident's hospitalization . The resident expired within twenty-four hours of admission to the hospital. Resident identifier: #55. Facility census: 54. This deficient practice was determined to constitute past non-compliance, as it occurred after the last standard survey and before the start of this complaint investigation on [DATE]. The facility administrator was informed of the past non-compliance on [DATE] at 3:45 p.m. Findings include: a) Resident #55 Medical record review found the resident was transferred from the facility to an area hospital on [DATE]. According to facility records, the resident was transferred due to a decline in mental status. The resident was admitted to the area hospital on [DATE]. Review of the hospital's discharge summary, dated [DATE], found the resident was treated for [REDACTED]. The resident returned to the facility on [DATE] with new orders to receive two (2) anticoagulants: [MEDICATION NAME] 5 mg. by mouth, daily and [MEDICATION NAME] 65 g. (grams), subcutaneous, every 12 hours, stop on [DATE] or once the INR is between ,[DATE]. The admitting physician's orders directed a PT/INR be obtained weekly. The physician completed the resident's history and physical on [DATE] and noted the resident was receiving [MEDICATION NAME] 5 mg. daily and [MEDICATION NAME] 65 mg. every 12 hours pending stabilization of her [MEDICATION NAME]. On [DATE], the physician documented he saw the resident at the facility for an acute visit. The resident's daughter approached the desk today indicating that her mother was having persistent dry cough. A chest x-ray was ordered. At the time of this physician's visit, three ([DATE], [DATE], and [DATE]) of the ordered PT/INRs had not been obtained. There was no documentation the physician was aware the PT/INR's had not been obtained as ordered. Review of the Medication Administration Record [REDACTED]. The facility did not obtain the PT/INR as directed by the physician. There was no evidence the physician was aware the facility had discontinued the [MEDICATION NAME]. Further review of the medical record found the first PT/INR would have been due on [DATE]. Additional PT/INRs should have been completed on the following Mondays: [DATE], [DATE], [DATE], and [DATE]. The administrator, Employee #47, was interviewed on [DATE] at 1:00 p.m. She verified all weekly labs were obtained on Mondays. At that time, the administrator verified the PT/INRs were not obtained as ordered, and she verified the facility discontinued the [MEDICATION NAME] without confirming the INR was between 2.0 and 3.0. According to the medical record, on [DATE], the physician was notified of dried blood in the resident's brief, no active bleeding was noted. A urinalysis with culture and sensitivity (UA/C&S) was ordered but never obtained. On [DATE] at 1:00 p.m., the administrator confirmed the UA/C&S was never obtained as ordered by the physician. A nurse's note, dated [DATE], revealed the . resident was experiencing bright red blood in brief and a nose bleed. The physician was contacted and a new order was written to Hold [MEDICATION NAME] until Labs seen by (name of physician). At 10:00 a.m. on [DATE], the family was advised of the resident's change in condition, but the family did not want the resident sent to the hospital. Results of the first PT/INR, obtained by the facility on [DATE] at 11:50 a.m., found the PT was 76.0 and the INR was greater than 8.0. An interview with the facility's contracted laboratory supervisor, on [DATE] at 10:00 a.m., found the laboratory could only guarantee the accuracy of the INR results to be greater than eight (8). According to the target range on the laboratory report, the PT should have been between 10.1 - 11.6 and the INR should have been between 2.0 and 3.0. The result of the lab testing was reported to the facility by the laboratory on [DATE] at 2:51 p.m. On Wednesday [DATE] at 3:05 p.m. the physician ordered, Discontinued the [MEDICATION NAME] 5 mg. Start Vitamin K, one (1) 5 mg (milligrams) by mouth, daily. Dx. (diagnosis) elevated PT/INR. Obtain PT/INR on Friday. The facility immediately contacted the pharmacy to obtain the Vitamin K. The facility was notified by the pharmacy, at 4:00 p.m. on [DATE], Vitamin K was not available for immediate delivery. At 4:45 p.m. on [DATE], the pharmacy notified the facility the Vitamin K was not available from five (5) back up pharmacies and it could take 3.5 hours to get the medication to the facility. The nurse on duty spoke with family members at 7:40 p.m. on [DATE]. The nurse once again asked for permission to send the resident to the hospital. At that time the family agreed. The resident was discharged to the hospital at 8:00 p.m. on [DATE]. (The vitamin K arrived at the facility at 9:00 p.m. on [DATE], after the resident was discharged .) The hospital was visited on [DATE], where it was found the resident's INR had been greater than 15 when she was admitted on [DATE]. The hospital documents indicated she had been brought in as she had increased bleeding from her nose and she was not responding normally. The emergency room physician noted she was bleeding a large amount from her vagina. He ordered a catheter be inserted. A very large amount of bright red blood was seen in the urine draining from the resident ' s bladder. It was also noted the resident ' s right arm was still bleeding from the site where blood had been drawn six (6) hours earlier. A central line was discussed, but the physician wanted a surgeon to do the insertion because of the bleeding. The resident ' s daughter decided she only wanted her mother kept comfortable. The resident was place on hospice in the hospital. The resident expired at the hospital on [DATE], at approximately 12:05 p.m. Review of the current care plan, on [DATE], found the care plan was not updated to include the change in the resident's condition and the new physician's orders when the resident returned from the hospital on [DATE]. Employee #1, the care plan coordinator, was interviewed on [DATE] at 3:49 p.m. She verified she failed to update the existing care plan to include the use of [MEDICATION NAME] and the weekly PT/INRs when the resident returned from the hospital. Review of the physician's hospital discharge summary, dictated on [DATE], found the following: .In June of 2012 because of her overall decline, the Resident was moved from Assisted Living to the Health Care area. There, she seemed to do well for a brief interval. Late in her course the Resident began experiencing episodes of some vaginal bleeding. The Resident had been on [MEDICATION NAME] with a weekly order for PT/INR but the Resident had gone for an interval of about four weeks with no PT/INR being obtained. When these were finally obtained in conjunction with additional laboratory studies the Resident was found to have an INR greater than 8. At that point, she was also found to have a degree of azotemia with an increase in her BUN. Interestingly, her hemoglobin was stable at 12 grams. She did have an increased white count. The Resident had an order given for PO (by mouth) [MEDICATION NAME] 5 mg. daily, as the family at that point declined hospital transfer, but because of the development through the day of recurrent bleeding and lethargy the Resident was transported from the facility to the emergency room at (name of area hospital.) The Resident apparently declined and ultimately expired there. Final Diagnosis: [REDACTED]. [MEDICATION NAME] Induced [MEDICATION NAME] (abnormally low levels of [MEDICATION NAME] in the blood, characterized by poor clot formation, longer bleeding times, and a potential for hemorrhage) 2. [MEDICAL CONDITION] 3. [MEDICAL CONDITION] Reflux Disease 4. [MEDICAL CONDITION] 5. Essential Hypertension 6. [MEDICAL CONDITION] 7. [MEDICAL CONDITION]. II. Due to the finding of past non-compliance related to care regarding residents who received blood thinners, the medical records for six (6) additional residents who were ordered [MEDICATION NAME] were reviewed. This included Residents #9, #12, #11, #19, #40 and #43. Lab work, as ordered, was obtained for each of these residents, except Resident #40. a) Resident #40 Medical record review found the resident was admitted to the facility on [DATE]. The physician ordered [MEDICATION NAME] 5 mg., by mouth daily, for a [DIAGNOSES REDACTED]. Further orders required a [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) to be completed weekly to ensure the [MEDICATION NAME] dosage was within therapeutic ranges. On [DATE], the physician ordered electrolytes, blood urea nitrogen (BUN), and Creatinine to be obtained monthly for a [DIAGNOSES REDACTED]. The administrator, when interviewed on [DATE], stated the facility obtained labs on Mondays. Review of the medical record found the facility failed to obtain a PT/INR on the following seven (7) Mondays in [DATE] and [DATE] : [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. On [DATE] at 1:00 p.m., the administrator confirmed the PT/INRs were not obtained on the above dates, as ordered by the physician. A PT / INR was obtained on [DATE]. The INR was 2.3, within the normal range. b) The facility pharmacist also failed to recognize the PT/INRs were not completed as ordered when he completed his monthly drug regimen reviews on [DATE] and [DATE]. Both pharmacy reviews reported no irregularities. c) The facility physician saw Resident #40 on [DATE] and again on [DATE]. There was no evidence the physician recognized the PT/INR's were not completed as ordered. d) Based on review of the facility's [DATE] corrective actions, which included an internal investigation of a resident's untimely death. The investigation resulted in a review of all orders to ensure all lab orders were completed as ordered, adding a line on the medication administration records which required the results of PT/INRs be documented each time the test was ordered, adding a bright pink sticker to the chart to indicate the resident was at risk for bleeding, education of all LPNs and RNs which included the new facility protocol for notification of the physician if a lab was not completed, new lab protocols, and critical thinking in the presence of bleeding and signs and symptoms to look for. All nursing staff were educated between [DATE] and [DATE], on the implementation of the new policy and procedures to ensure all orders were transcribed and carried out. The facility implemented disciplinary actions for the nurses involved. A monitoring system was established to ensure completion of all lab orders in a timely manner. The facility identified and corrected the deficits in care related to Resident #55 and Resident #40, and implemented corrective actions to prevent reoccurrence as of ,[DATE]-,[DATE]. The sample was expanded and records were review to ascertain the corrective actions were effective. No additional deficient practices were identified. Therefore, this citation constitutes past noncompliance with the requirements at 483.25 - Quality of Care.",2016-02-01
9136,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-02-06,425,E,1,0,EVNT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to have physician ordered medications available for two (2) of ten (10) sampled residents. Each resident was ordered medication by their physician. The medications were not obtained from the pharmacy prior to the first dosage being due; therefore, the residents missed doses of their medication because they were not available at the facility. Facility Identifiers: #37 and #10. Facility Census: 54. Findings Include: a) Resident # 37 A medical record review was completed at 12:20 p.m. on 02/04/13. The record contained a physician's orders [REDACTED]. The medication administration record (MAR) for Resident #37, for the month of January 2013, revealed the resident did not receive her first dose of Flagyl until 2:00 p.m. on 01/29/13. The MAR also revealed the medication was to be given at 6:00 a.m., 2:00 p.m., and 10:00 p.m. daily. The resident missed the 10:00 p.m. dose on 01/28/13 and the 6:00 a.m. dose on 01/29/13. The pharmacy delivery sheet for this medication was reviewed at 11:00 a.m. on 02/06/13. This review revealed the medication was delivered to the facility at 5:38 a.m. on 01/29/13. An interview was conducted at 11:05 a.m. on 02/06/13 with Employee #62, the director of nursing (DON). The DON reported the night shift nurse completes the 6:00 a.m. medication pass and she was likely finished with this medication pass when the medication was received by the pharmacy at 5:38 a.m. on 01/29/13. She confirmed the first dose of the Flagyl was not given to Resident #37 until 2:00 p.m. on 01/29/13. b) Resident #10 Review of the medical record on 02/06/13 found the resident was admitted to the facility on [DATE]. 1) Review of the admitting physician's orders [REDACTED]. The MAR was reviewed, and noted the first dose of Robitussin with Codeine 5 ml was not given until 10:00 p.m. on 01/24/12 - three (3) days after the medication was ordered. According to the MAR, the resident should have received the first dose of the cough medicine on 01/21/13 at 10:00 p.m On 01/22/13 the resident should have received the medication at 6:00 a.m., 2:00 p.m., and 10:00 p.m. On 01/23/13 the resident should have received the cough medicine at 6:00 a.m., 2:00 p.m. and 10:00 p.m. On 01/24/13 the resident should have received the cough medicine at 6:00 a.m. and 2:00 p.m. Nursing staff initialed and circled the above missed doses of Robitussin with Codeine on the MAR. Only one (1) explanation was provided on the MAR, on 01/23/13 at 2:00 p.m., regarding the failure to administer the medication. It was, Reordered cough syrup. 2) Further review of the medical record found Doxycycline 100 mg by mouth, BID, (twice a day) at 8:00 a.m. and 8:00 p.m. for ten (10) days was ordered by the resident's physician. Review of the MAR found the Doxycycline was not given on 01/22/13 at 8:00 p.m. as indicated by the circling of the nurse's initials There was no explanation as to why the medication was not given. The DON was interviewed on 02/06/13 at 8:39 a.m. She stated the cough syrup with codeine was not ordered and she had no explanation as to why the Doxycycline was not given, but stated she would investigate the situation. On 02/06/13 at 10:21 a.m., the DON explained the first two (2) doses of Doxycycline were taken from the emergency drug box. The third dose of Doxycycline, due on 01/22/13 at 8:00 p.m., was not available at the facility as the Doxycycline had been depleted in the emergency drug box. Further investigation found the medications, Robitussin with Codeine and Doxycycline were not ordered when the resident was admitted to the facility on [DATE]. Review of the facility's, Nursing Services Policy and Procedure Manual found, . If drug is withheld, refused or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose . If a dose of a regular drug is withheld or regurgitated, the appropriate markings should be entered in the MAR and an explanation should be entered in the nurses notes describing the circumstances. On 02/06/13, the administrator, Employee #47, verified the facility's policy was not followed.",2016-02-01
9137,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-02-06,428,D,1,0,EVNT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's drug handbook, staff interview, and interview with the facility pharmacist, the pharmacist failed to recognize laboratory tests (Prothrombin Time and International Normalized Ratio (PT / INR) had not been obtained as ordered for a resident receiving Coumadin. The resident had orders to receive weekly PT / INRs. The facility failed to obtain a PT / INR for seven weeks. This was true for one (1) of ten (10) residents reviewed. Resident identifier: #40. Facility census: 54. Findings include: a) Resident #40 Medical record review found the resident was admitted to the facility on [DATE]. The physician ordered Coumadin 5 mg. by mouth daily for a [DIAGNOSES REDACTED]. Further orders were written for a Prothrombin Time/International Normalized Ratio (PT/INR) to be completed weekly to ensure the Coumadin dosage was within therapeutic range. The administrator was interviewed on 02/04/13. She stated the facility obtained all labs on Mondays. Further review of the medical record found the facility failed to obtain a PT/INR on the following Mondays in November 2012 and December 2012: 11/19/12, 11/26/12, 12/03/12, 12/10/12, 12/17/12, 12/24/12, 12/31/12. Seven (7) PT/INRs were not obtained as ordered. On 02/04/13 at 1:00 p.m., the administrator, Employee #47, confirmed the PT/INRs were not obtained as ordered by the physician. Review of the facility's, Nursing 2013 Drug Handbook, found, Warfarin / Coumadin has a black box warning and . can cause major or fatal bleeding, which is more likely to occur during the starting period with a higher dose. Regularly monitor INR in all patients. Consider more frequent INR monitoring in those at high risk for bleeding. Further alerts associated with usage of Warfarin / Coumadin specify, Elderly patients and patients with renal or hepatic failure are especially sensitive to drug's effect. Resident #40 had a current [DIAGNOSES REDACTED]. Review of the pharmacist's drug regimen review found the resident's medications were reviewed on 12/07/12 and again on 01/14/13 by the facility pharmacist. On both occasions the pharmacist reported no irregularities. The facility's contracted pharmacist was interviewed on 02/06/13 at 4:00 p.m. The pharmacist verified he failed to recognize the PT / INRs were not completed as ordered. He further agreed weekly monitor of PT / INRs was recommended for residents receiving Coumadin.",2016-02-01
9138,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-02-06,497,F,1,0,EVNT11,"br>Based on employee file reviews and staff interview, the facility failed to complete a performance review of every nurse aide at least once every 12 months. The performance evaluations are necessary to ensure deficient care practices are identified and appropriate in-service education is provided which addresses the identified areas of weakness. Twenty-one (21) of twenty-one (21) nurse aides currently employed by the facility had no performance evaluation. This practice had the potential to affect the care of all residents. Facility census: 54. Findings include: a) A review of all twenty-one (21) nurse aide employee files was conducted on 02/06/13 at 9:00 a.m. No evidence of any performance evaluations were found in any file for any nurse aide. During an interview with Employee #47, the Administrator, on 02/06/13 at 10:00 a.m., it was confirmed that no performance evaluations would be found in any nurse aides' file. The Administrator revealed the facility had not been completing performance evaluations for nurse aides.",2016-02-01
9139,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-02-06,498,F,1,0,EVNT11,"br>Based on employee file review and staff interview, the facility was unable to provide evidence eighteen (18) of twenty-one (21) currently employed nurse aides were competent in the skills and techniques necessary to care for residents' needs, as identified through resident assessments, and as described in the plan of care. The competency of nurse aides is essential to ensure each resident receives optimum care and services. This practice had the potential to affect the care of all residents. Facility Census: 54. Findings include: a) A review of all nurse aide files was conducted on 02/06/13 at 9:00 a.m. Competency skills checklists were discovered for Employee #4, Employee #15, and Employee #57. All other nurse aide files did not contain competency skills checklists. During an interview with Employee #47, the Administrator, on 02/06/13 at 10:30 a.m., it was confirmed that no competency skills checklists were completed other than those for Employee #4, Employee #15, and Employee #57.",2016-02-01
9978,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-12-14,246,D,0,1,REFP12,". Based on observation, resident interview, and staff interview, the facility failed to ensure one (1) of twelve (12) residents resided in an environment that provided reasonable accommodations of individual needs and preferences. One (1) of twelve (12) residents had bedroom furnishings that were arranged in a manner that did not allow for independent functioning based on the resident's own needs and preferences. Resident #34 did not have access to her chest of drawers where many of her personal belongings and snacks were kept. Resident identifier: #34. Facility census: 50. Findings include: a) Resident #34 On 12/12/11, at approximately 2:00 p.m., a tour of the facility revealed Resident #34's bed was pushed up against her chest of drawers. The bed had wheels and had been pushed up against the chest and the wheels locked. The bed was positioned to face towards the window in the room. The resident's roommate had a bed that was positioned facing the sink and closet door. The director of nursing (DON) Employee #46 said Resident #34's bed was positioned by the wall, facing out toward the window to make more space in the room. The DON said Resident #34 did store personal items and snacks in the chest. On 12/12/11, at approximately 2:00 p.m., Resident #34 sat facing her bed watching her television. She said she could not get into her chest of drawers. Employee #18 (nurse aide) said the resident's bed was positioned against the chest of drawers because the resident might injure herself getting into the chest. On 12/12/11, at approximately 3:00 p.m., an observation of Resident #34's room revealed the bed had been moved to face in the same direction as the roommate's bed and the chest was moved against the wall which allowed the resident access to the items stored in the chest. On 12/12/11, at approximately 3:15 p.m., Employee #35 (laundry/housekeeping) said the nurse aide had brought the issue to her attention and they had moved the room around to give the resident access to her chest of drawers. Employee #35 said the nurse aides should not have pushed the bed up against the chest. .",2015-08-01
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
10129,"MERCER NURSING AND REHABILITATION CENTER, LLC",515052,PO BOX 410,BLUEFIELD,WV,24701,2012-02-09,250,D,1,0,MC4611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure medically-related social services were provided to one (1) of four (4) residents on the sample. Resident #55 left the facility against medical advice (AMA) with his family on 10/28/12. The resident experienced aggressive behaviors related to a [DIAGNOSES REDACTED]. The facility had planned to transfer him to an inpatient psychiatric unit. The resident's family did not want the facility to seek this type of medical intervention to try and stabilize these behaviors. The family at one time asked to come to the facility and restrain the resident. The facility did not contact adult protective services to make them aware of the situation. Resident identifier: #55. Facility census: 52. Findings include: a) Resident #55 The medical record review for Resident #55 revealed he came to the facility from home on 09/28/11. He had a [DIAGNOSES REDACTED].). The resident's care plan addressed issues such as impaired cognitive function and impaired thought processes due to the dementia. It also addressed the resident's physical behaviors (kicking, hitting, scratching) related to dementia. The following progress notes related to the resident's behaviors and the family's resistance to inpatient psychiatric care. -10/01/11 2:45 p.m. ""Resident has been at nurses station with staff; has had 1:1 all day without success. As staff attempted to reposition resident in his wheelchair to keep him from falling, he punched the nurse in the stomach, pulled back his fist and said (cursing) 'I'll punch your nose' resident then grabbed nurses arm and twisted it tightly. Haldol 5 mg po (by mouth) x 1 dose now and Ativan 1 mg IM x 1 dose now. Daughter notified that if behavior continues resident will most likely be transferred OOF (out of facility) for eval (evaluation) of behaviors. She replied 'oh try to hold off, we could come see him but it probably wouldn't do any good ... he's done me like that before.'"" - 10/04/11 ""Resident awake the entire night hollering 'HELP ME, HELP ME,' and attempting to get out of the bed. Resident also made a fist and attempted to hit staff while providing care."" - 10/09/11: ""Resident family in to visit with resident. Family concerned about 'psych' meds being too strong for resident. Spoke with MPOA in length about resident need for medicine in order for facility to be able to meet resident's needs. Resident family concerned that resident did not need appointment with psychiatrist. Explained to MPOA that the psychiatrist would be more able to better manage behavior meds. "" - 10/10/11 ""RUE (right upper extremity) completed earlier today at (local hospital) radiology dept. physician's orders [REDACTED]. Ambulance staff stated that resident became combative with radiology staff while being filmed."" - 10/10/11 ""(Daughter) has called facility several times today to check on her father. When she was informed that resident had been combative this am she replied 'I'm sorry, I know how he is ... we were up there this weekend and he tried to beat us up too.'"" - 10/11/11 ""Residents' daughter still concerned regarding resident's medications. Daughter states resident is 'always sleepy.' Attempted to explain that resident's meds had been adjusted yesterday and that the effects had not had time to be visualized; also explained that resident had been OOF for a procedure this morning and could be sleepy from that. Explained that the physician would be in the facility later and that we would have him review his meds further."" - 10/12/11 ""Resident continued on Augmentin 875/125 mg bid x 14 days for pneumonia."" - 10/13/11 2:29 p.m. ""MPOA (medical power of attorney) concerned that residents' psych meds are too strong, resident seen by (facility physician) and has an appointment to see (psychiatrist) on 10/19/11 at 1:45 p.m. MPOA also concerned that we are unable to physically restrain resident and asked if she could come in and restrain him herself."" - 10/16/11 5:21 p.m. ""Resident is up to chair several hours out of the day and night d/t agitation from dementia."" -10/19/11 6:11 p.m. ""Attending physician notified of resident's return to facility with new orders from (psychiatrist) office. Dementia with Levy (Lewy) Body disease; behaviors worse at night, frequent falls and combative at times. New orders received to decrease Seroquel to 100 mg bid (twice a day); decrease Remeron to 15 mg qhs (at night); continue Klonopin as ordered; and discontinue Haldol."" -10/21/11 5:54 p.m. Resident was started on Augmentin (antibiotic) 875 mg bid (twice per day) due to pneumonia. - 10/22/11 11:44 a.m. ""Resident was combative with CNA this morning while she was attempting to give him a shower, he attempted kicking, biting, and wrapped his legs around her body."" - 10/22/11 1:20 p.m. ""Staff attempted to calm resident without success. Resident continued to be combative while nurse was dressing wounds, attempting to hit the CNA with the bed control, bite the nurse, and was kicking both legs. Physician gave ok for transfer to (local hospital psychiatric unit)."" - 10/22/11 1:32 p.m. ""(family member) has called the facility and ask to speak with me, RD (registered dietitian) had answered the phone, and (family member) became extremely rude with the RD, yelling and stating that 'I'm leaving the house now and he better be there when I get there.'"" - 10/22/11 3:45 p.m. ""Resident has left the facility AMA (against medical advice); resident's daughter arrived at the facility, yelling 'All I said was that I didn't want him sent to (local hospital name), I never said anything about anywhere else. Explained that we had attempted to reach her on her cell phone to inquire about another suggestion, even though (local hospital) is the preference d/t (due to) the psych expertise as well as geriatric expertise. Informed her that we had attempted to reach her to inform her of the physician's orders [REDACTED]. Discussed that resident is a threat to the well-being of himself as well as staff and other residents. Daughter asked 'Did you give him the injection already?' Informed her at that time we had. She demanded 'Why?' Informed her that we were unable to reach her on the cell number that was given to us, and that it was the only option since she refused transfer. Family agitated; stating 'We are taking him home now ... we took care of him for three years and you all couldn't handle him for three weeks' adding that 'You all are supposed to be professionals, and be able to handle Alzheimer's patients.' Resident left the facility AMA with the family. Explained that resident is likely to be combative with them at home. ... "" On 02/08/12, at approximately 3:00 p.m., the social worker (Employee #47) and the executive director (Employee #66) confirmed the resident's responsible party had resistance to any psychiatric treatment for [REDACTED]. Based on comments the family made about him beating them up too, it was apparent the behaviors displayed at the facility were not new. During a telephone interview with the responsible party, on 02/09/12, at approximately 10:00 a.m., she indicated she had needed to tie her father in the bed before because she feared he would fall and hit his head as he had in the past. The social worker and executive director indicated they did not feel a contact to adult protective services was necessary when the resident's family took him from the facility against medical advice. They commented he never seemed fearful of the family when they visited. They stated they did not have knowledge the responsible party restrained the resident at home, but they did have documentation the responsible party had requested to come in and restrain him at the facility. The social worker and executive director indicated the responsible party adamantly did not want the resident sent to an inpatient psychiatric hospital. They were unable to determine why she did not want this type of care for the resident. The social worker said prior to admission the responsible party had cared for the resident at home. The responsible party told her the resident received medical care from a small community clinic. The facility knew the resident needed an inpatient psychiatric evaluation due to his aggressive behaviors, and made a referral to a local in-patient psychiatric unit. He was going to be transferred there on the day his family removed him from the nursing facility against medical advice (AMA). The responsible party's unwillingness to seek needed psychiatric evaluation and treatment, the family's removal of the resident from the nursing facility AMA, and knowledge the family wanted the resident restrained in the nursing facility, all created the necessity to refer the case to adult protective services. .",2015-06-01
10214,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2012-02-07,496,E,1,0,T47911,". Based on personnel file review and staff interview, the facility failed to ensure they received registry verification, for one (1) of eleven (11) nurse aides, prior to hiring the individual to perform work as a nurse aide. The employee could not prove she had successfully completed a training and competency evaluation program approved by the State of West Virginia. Employee #85 (nurse aide) came to work at the facility in November 2011 without a West Virginia nurse aide registration. The employee had completed a nurse aide training program in (other state) but had not completed the nurse aide competency examination in (other state) or applied for reciprocity in the State of West Virginia. This issue had the potential to affect more than an isolated number of residents. Employee identifier: #85. Facility census: 47. Findings include: a) Employee #85 On 02/06/12, at approximately 12:00 p.m., the receptionist (Employee #51) provided the personnel files for employees hired from October 2011 through January 2012. A total of eleven (11) files were reviewed. The file review revealed Employee #85 (nurse aide) had started to work at the facility on 11/14/11. Her personnel file showed she had completed her nurse aide training course in another state. Before hiring her, the facility did not verify she had successfully completed the nurse aide competency evaluation in that state, or if she had requested reciprocity for West Virginia. On 02/06/12, at approximately 1:00 p.m., the director of nursing (Employee #42) confirmed the facility hired Employee #85 without verification she was eligible to work as a nursing assistant. She said the facility should have verified the employee met the requirements to work as a nursing assistant before they offered her employment. At approximately 5:00 p.m. on 02/06/12, the social worker (Employee #40) said the facility became aware Employee #85 did not have a valid nurse aide registration on 12/14/11, when the employee became involved in an allegation of neglect. Employee #40 (social worker) provided a copy of the report the facility sent to the state agencies regarding an incident involving Resident #18. The report, which was filed on 12/15/11, stated (typed as written) ""Resident was in wheel chair, but seatbelt alarm did not go off when she fell out of the wheelchair when she tried to take herself to the bathroom. (Employee #85) stated that 5 minutes prior she had taken resident to the bathroom and turned off seat belt alarm. (Employee #85) obviously did not turn the seat belt alarm back on. Resident fell and broke her wrist. Upon start of investigation it was found that (Employee #85) had never gotten WV reciprocity, nor even her (other state) license. She had told staff that she was going to test in next 2 weeks. To date (Employee #85) has not test for (other state) CNA, so she is unable to apply for WV reciprocity. She is scheduled to test in (other state) in January 2012 and was told by her nursing teacher that she was able to work 180 days after her hire date in any state. She is not able to work in West Virginia and upon finding out that (Employee #85) was not licensed as a CNA in West Virginia, she was immediately terminated until she had a WV CNA license."" .",2015-06-01
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
11166,"MERCER NURSING AND REHABILITATION CENTER, LLC",515052,PO BOX 410,BLUEFIELD,WV,24701,2011-03-03,463,E,1,0,3LVK11,". Based on performance testing and staff interview, the facility failed to maintain all portions of the nurse call system operable as designed / required. This deficient practice affected seventeen (17) of forty (40) resident rooms and toilet rooms. Facility census: 55. Findings include: a) During tour of the facility on 02/28/11 at approximately 11:30 a.m., the nurse call system failed to operate as designed / required, when tested , in seventeen (17) of forty (40) resident rooms and toilet rooms. The rooms were identified as B1, B2, B3, B4, B5, B6, B7, B8, B9, B10, B11, B12, B13, B14, and B15. Also, at approximately 12:15 p.m. on this same date, the nurse call system at the bed was not operable in rooms A12 and A20, when tested . b) During tour of the facility on 02/28/11 at approximately 11:30 a.m., cow bells were observed at the resident beds in fifteen (15) of fifteen (15) resident rooms and ten (10) of fifteen (15) toilet rooms on the ""B"" floor. A cow bell was not observed to be available for use in the toilet rooms for B1, B3, B9, B10, and B12. c) On 03/01/11 at approximately 3:45 p.m., an interview with the administrator revealed that, due to the failure of the nurse call system on the entire ""B"" floor, the facility purchased cow bells on 11/12/10 for the ""B"" floor residents to use. This interview also revealed that, as of this date (03/01/11), there was no specific date set to start installation of a new nurse call system. Also, there was no documentation evidence available to indicate that a set of plans for the new nurse call system had been submitted to the Office of Health Facility Licensure and Certification for review and approval.",2014-07-01
11167,"MERCER NURSING AND REHABILITATION CENTER, LLC",515052,PO BOX 410,BLUEFIELD,WV,24701,2011-03-03,246,E,1,0,3LVK11,". Based on observation, resident interview, and staff interview, the facility failed to provide reasonable accommodations of individual resident needs for twelve (12) of nineteen (19) sampled residents, by failing to provide a means by which they may summon staff for assistance in the absence of a fully functional nurse call system. Resident identifiers: #25, #17, #30, #10, #6, #12, #15, #18, #28, #36, #41, and #42. Facility census: 55. Findings include: a) During tour of the facility on 02/28/11 at approximately 11:30 a.m., the nurse call system failed to operate as designed / required, when tested , in seventeen (17) of forty (40) resident rooms and toilet rooms. (See also citation at F463.) 1. Resident #25 During tour of the facility on 02/28/11 at 12:00 p.m., observation found Resident #25 did not have a cow bell in her room. The resident said, ""I don't know where it is."" This surveyor stepped outside of the room next to the dining room and could hear Resident #25 hollering that she was thirsty. At 12:05 p.m., a nurse aide (Employee #29) was passing by the room and went to see what the resident wanted. At 2:00 p.m., this surveyor again checked on Resident #25, and she still did not have a cow bell. At 3:40 p.m., this surveyor observed Resident #25 again and she still did not have a cow bell in her room. The above findings were then reported to the unit charge nurse (Employee #42), and this surveyor asked Employee #42 for assistance in locating Resident #25's cow bell. Employee #42 looked and could not find it; she said, ""I will have to get her another one."" - 2. Resident #17 During a random observation on 02/28/11 at 3:35 p.m., Resident #17 was in a geri chair in the middle of her room; her bed was to the left of her, and her cow bell was placed on the bedside table (which was also to the left of her bed). She had no way to reach the cow bell. Her roommate was not in the room at the time. This surveyor asked the resident how she let staff know when she needed assistance. She stated, ""I ring the cow bell when I can reach it."" This finding was reported to the interim director of nursing (DON - Employee #68). - 3. Residents #30 and #10 Residents #30 and #10 occupied rooms located on A floor. During tour of the facility with the administrator (Employee #67) on 02/28/11, the nurse call system at the bedside in these rooms did not function when tested . The administrator stated, ""These may be the ones they worked on last week."" She then confirmed this with another staff member. No cow bells had been provided to these residents. - 4. Residents #6, #12, #15, #18, #28, #36, #41, and #42 Observations, during tour of the facility with the administrator on 02/28/11 at 12:00 p.m., found eight (8) toilet rooms on the B floor without any type of call system (including no cow bells available for use). These toilet rooms were used by Residents #6, #12, #15, #18, #28, #36, #41, and #42. When asked how she would summon staff assistance if needed, Resident #6 stated, ""I just holler when I need help."" On 02/28/11 at 12:15 p.m., the administrator stated, ""There is supposed to be a cow bell in every bathroom."" -- b) On 03/01/11 at 1:30 p.m., the administrator and the maintenance supervisor (Employee #41) were asked how long the nurse call system on B floor had been out of service. Employee #41 could not remember. On 03/01/11 at approximately 3:45 p.m., an interview with the administrator revealed that, due to the failure of the nurse call system on the entire B floor, the facility purchased cow bells on 11/12/10 for the B floor residents to use. .",2014-07-01
241,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2020-02-13,558,D,0,1,G76I11,"Based on observation and interview, the facility failed to ensure a call light and bed controller was accessible and within reach for two (2) residents. This was a random opportunity for discovery. Resident identifiers: #26 and #313. Facility census: 62. Findings included: a) Resident #26 On 02/10/20 at 3:02 PM, Resident #26's call light and bed controller were not in reach. The call light and bed controller were located at the head of the bed, behind the headboard on the left side of the headboard. Resident #26 was lying across the middle of the bed. Resident #26's feet were on the floor, body angled across the bed, and her head lying near the wall. Resident #26 had a nutritional shake in her hand and was yelling, I can't get up, I can't drink my milk. On 02/10/20 at 3:04 PM, Employee #[AGE], Nursing Assistant (NA), entered the room when asked by the surveyor. On 02/10/20 at 3:06 PM, Employee #6, NA, entered Resident #26's room to assist NA #[AGE]. On 02/10/20 at 3:09 PM, Employee #6, Nursing Assistant, placed the call light and bed controller after the surveyor asked where the call light and bed controller were located. On 02/12/20 at 3:13 PM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided prior to the end of the survey on 0[DATE]20. b) Resident #313 On 02/11/20 at 8:53 AM, Resident #313's bed controller was observed to be located behind the headboard, on the right side of the bed. Resident #313, who has capacity to make medical decisions, was asked if he could adjust his bed. Resident #313 stated that the did not know where the controller was located. On 02/11/20 at 9:01 AM, Employee #96, Clinical Quality Consultant, placed the bed controller in reach of Resident #313. On 02/12/20 at 3:13 PM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided prior to the end of the survey on 0[DATE]20.",2020-09-01
242,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2020-02-13,583,D,0,1,G76I11,"Based on observation and staff interview, the facility failed to ensure resident privacy. This was a random opportunity for discovery. This failed practice had the potential to affect a limited number of residents. Resident identifier: #26. Facility census: 62. Findings included: a) Resident #26 During the initial tour of the facility on 02/10/20 at 11:18 AM, Resident #26's window blinds handle, used to opening and closing the blinds, was observed to be off of the blinds and lying in the windowsill. On 02/10/20 at 11:22 AM, Employee #51, Maintenance Assistant, entered the room. Employee #51 examined the window blinds and attempted to place the handle back on the window blinds. Employee #51 stated that the window blinds were broken. Employee #51 stated that she would have someone repair the window blinds that day. Employee #51 was asked if the blinds could be pulled to allow the resident privacy since Resident #26's bed was against the wall as well as located on the side of the room with the window. Employee #51 stated that the blinds could not be closed. On 02/10/20 at 3:02 PM, the window blind was still broken and the handle to the window blind was still lying in the windowsill. Employee #[AGE], Nursing Assistant (NA), was asked to enter the room since Resident #26 was calling for help. On 02/10/20 at 3:06 PM, Employee #6, NA, entered the room to assist NA #[AGE] with providing care for Resident #26. On 02/10/20 at 3:09 PM, after Resident #26 was transferred to her wheelchair, the surveyor asked NA #6 and NA#[AGE] what do they do when providing personal care to Resident #26 since the window blinds do not close. NA #6 and NA #[AGE] stated that Resident #26 takes herself to the bathroom. When NA #6 and #[AGE] were asked how do staff members ensure privacy when assisting Resident #26 with changing clothes, assisting with bathing, or any other aspect of care, NA #6 and NA #[AGE] did not provide an answer. On 02/11/20 at 9:04 AM, the window blinds for Resident #26 were still broken, with the handle lying in the windowsill. On 02/11/20 at 9:06 AM, the Director of Nursing (DON), was asked to enter Resident #26's room. The DON examined the window and window blinds, stating that the blinds could not be adjusted, nor opened and / or closed, and she would have someone fix the blinds. On 02/12/2020 at 3:13 PM, the findings were discussed with the Administrator and the DON. No further information was provided prior to the end of the survey on 0[DATE]20.",2020-09-01
243,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2020-02-13,684,D,0,1,G76I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice. This was a random opportunity for discovery. Resident identifier: #26. Facility census: 62. Findings included: a) Resident #26 During the initial tour of the facility on 02/10/20 at 11:18 AM, a fall mat was observed to be propped up against the exterior wall of Resident #26's room. The fall mat was located between the exterior wall and the tv cabinet. On 02/10/20 at 11:22 AM, Employee #52, Maintenance Assistant, observed the fall mat leaning against wall. On 02/10/20 at 3:02 PM, Resident #26 was lying across the middle of the bed. Resident #26's feet were on the floor, body angled across the bed, and her head lying near the wall. The fall mat was laying on the floor beside of Resident #26's bed. Employee #[AGE], Nursing Assistant (NA) entered Resident #26's room on 02/10/20 at 3:04 PM and NA #6 entered Resident #26's room at 3:06 PM. Both NA #6 and NA #[AGE] noted that the fall mat was located beside Resident #26's bed. A review of Resident #26's physician orders [REDACTED].#26 did not have an order for [REDACTED]. On 02/11/20 at 9:06 AM, the Director of Nursing (DON) entered Resident #26's room with the surveyor. The DON noted that the fall mat was against the exterior wall, between the wall and the tv cabinet. In an interview with the DON on 02/11/20 at 2:10 PM, the DON stated Resident #26 did not have an order for [REDACTED]. The findings were discussed with the Administrator and the DON on 02/12/2020 at 3:13 PM. No further information was provided prior to the end of the survey on 0[DATE]20.",2020-09-01
244,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2020-02-13,812,E,0,1,G76I11,"Based on observations and interviews with facility staff, the facility failed to maintain kitchen appliances in a sanitary manner. Equipment was found to be in need of cleaning. This practice has the potential to affect more than a limited number of residents who receive food served from this central location. Facility census: 62. Findings included: a) During the initial tour of the dietary department on 02/10/20 prior to lunch revealed the dietary staff had not followed proper sanitary techniques. The tour was performed with the Assistant Food Service Director, Employee #26, The following issues were noted at the time: 1. A reach-in freezer did not contain an internal thermometer which would allow the staff to determine if the unit was keeping the correct temperature. This is to ensure the food items are maintained in safe temperatures levels for consumption. 2 The milk cooler located near the serving line was found to have many spills in the bottom of the unit and to be in need of cleaning. 3. Drip pans under the range top had a large accumulation of food debris and in need of cleaning. 4. Oven doors had a greasy buildup both on the inside and outside the unit that needed cleaned. The handles of the doors were found to need cleaning as they were greasy and sticky to the touch. 5. The toaster was noted to have a large accumulation of crumbs and debris This was after the unit had been used for breakfast and had not been cleaned as yet.",2020-09-01
245,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2020-02-13,867,D,0,1,G76I11,"Based on record review and staff interview, the facility failed to ensure the Quality Assessment and Assurance (QA&A) committee corrected quality deficiencies it had or should have had knowledge of. This practice has the potential to effect all residents currently residing in the facility. Facility census: 62. Findings included: a) Cross reference deficiency cited at F 8[AGE] During an interview on 0[DATE] at 8:44 AM with the Administrator, the findings related to Quality Assurance were discussed with the Administrator. The Administrator stated that they are currently reviewing the action steps related to the deficient practice. The Administrator discussed future ways that they would track and trend with regard to the pneumococcal vaccinations. No further information was provided prior to the end of the survey on 0[DATE]20.",2020-09-01
246,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2020-02-13,880,E,0,1,G76I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was a random opportunity for discovery. Resident identifiers: #62 and #25. Facility census: 62. Findings included: a) Resident #62 On 02/11/20 at 11:34 AM, surveyor entered Resident's room with Registered Nurse (RN) #32 to observe wound care. Upon entering the room, observation was made of contracted hospice nurse assistant (HNA) providing incontinence care to the Resident #62. The HNA tossed the soiled wash clothes and towels smeared with dark brown substance that appeared to be stool over her shoulder onto the floor on top of a pile of existing dirty linens. The soiled linens were noted not to be in a bag or have any barrier between them and the floor. The dirty pile of linens created by the HNA was approximate two (2) feet into the doorway of the resident's room, and surveyor had to step over the dirty linens in order to enter room. RN# 32 was asked if she agreed with the procedure the HNA used for handling and disposing of the soiled linens, and RN#32 stated, No way, I saw that, they should have been placed in bag and not just tossed in the floor. At 11:49 AM on 02/11/20, surveyor informed Infection Control Nurse RN# 66 of surveyor's observation that occurred for Resident #62. RN #66 stated, Oh no, that's not our staff but they still should know better. During an interview at 12:35 PM on 2/11/20, the Director of Nursing (DON) stated, I have a call out the hospice agency the nursing assistant works for and will address her performance issues with the way she handled the soiled linens, and will be providing education all staff. b) Resident #25 During the initial tour of the facility on 02/10/20 at 11:19 AM, Resident #25's oxygen tubing was observed to be lying on the floor. Resident #25's nebulizer was observed sitting on the nebulizer machine. On 02/10/20 at 11:20 AM, Employee #47, Nursing Assistant (NA), was asked if the oxygen tubing was supposed to be on the floor. NA #47 stated the tubing was supposed to be in a bag. NA #47 stated that she would go get a nurse. On 02/10/20 at 11:24 AM, Employee #9, Licensed Practical Nurse (LPN), entered Resident #25's room. LPN #9 stated the oxygen tubing was supposed to be placed in a bag. LPN #9 further stated the nebulizer was supposed to be stored in a bag. A review of Resident #25's medical record noted a physician order [REDACTED]. On 02/12/ at 3:13 PM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided prior to the end of the survey on 0[DATE]20. c) room [ROOM NUMBER] During the initial tour of the facility on 02/10/20 at 11:36 AM, soiled towels were observed in the floor of room [ROOM NUMBER]. These linens appeared to be wet, discolored, and gray smudges, roughly a quarter size in diameter, on them. The towels were found outside of the bathroom in room [ROOM NUMBER], near the closet area of room [ROOM NUMBER]. Employee #14, Housekeeping, stated she would remove the towels and place them in the soiled linen. A review of the facility's policy entitled, Infection Prevention and Control Program revealed the following: 10. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens so as to prevent spread of infection. d. Soiled linen shall be collected at the beside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen shall not be kept in the resident's room or bathroom. e. Environmental services staff shall not handle soiled linen unless it is properly bagged. Unless resident and / or family representative prefers; soiled linen may be kept in resident room and / or bathroom if kept in an enclosed container. A review of the facility's policy entitled, Handling Soiled Linen, noted the following: 3. Guidelines for handling, storage, processing, and transporting linens include, but are not limited to, the following: a. Linen should not be allowed to touch the uniform or floor. e. Used or soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. Soiled linen should not be kept in the resident's room or bathroom unless resident and / or family representative prefers otherwise, in which case soiled linen may be kept in resident's room and / or bathroom in an enclosed container. On 02/12/2020 at 3:13 PM, the findings were discussed with the Administrator and the Director of Nursing (DON). No further information was provided prior to the end of the survey on 0[DATE]20.",2020-09-01
247,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2020-02-13,883,D,0,1,G76I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop, maintain and follow policies and procedures for immunization of residents against pneumococcal disease in accordance with national standards of practice for two (2) of five (5) residents reviewed for the provision of immunizations. Resident identifiers: #62, #20. Facility census: 62. Findings included: a) Resident #62 Record review indicated Resident #62, [AGE] years of age, was administered 13-valent pneumococcal conjugate vaccine (PCV13) vaccine on 08/17/16. No documentation was found to indicate the resident either received the 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23) or did not receive the vaccine due to medical contraindications, previous vaccination, or refusal. During an interview on 02/12/20 at 10:05 AM, Infection Control Nurse (ICN) #66 verified there was no evidence to indicate the facility made an attempt to determine if the Resident had been offered or administered the PPSV23 vaccine. ICN #66 stated the facility had no process or procedure in place for monitoring the provision of both vaccines (PPSV23 and PCV13 vaccines) and said, I didn't know there were two vaccines and they both had to be given. Review of the facility's Pneumococcal Vaccine (Series) policy implemented on 11/27/17, stated the type of pneumococcal vaccine will be offered to Residents in accordance with current CDC guidelines and recommendations. The policy further stated: Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. b) Resident #20 Record review indicated Resident #20, [AGE] years of age, was administered 13-valent pneumococcal conjugate vaccine (PCV13) vaccine on 08/17/16. No documentation was found to indicate the resident either received the 23-valent pneumococcal [MEDICATION NAME] vaccine (PPSV23) or did not receive the vaccine due to medical contraindications, previous vaccination, or refusal. During an interview on 02/12/20 at 10:05 AM, Infection Control Nurse (ICN) #66 verified there was no evidence to indicate the facility made an attempt to determine if the Resident had been offered or administered the PPSV23 vaccine. ICN #66 stated the facility had no process or procedure in place for monitoring the provision of both vaccines (PPSV23 and PCV13 vaccines) and said, I didn't know there were two vaccines and they both had to be given. Review of the facility's Pneumococcal Vaccine (Series) policy implemented on 11/27/17, stated the type of pneumococcal vaccine will be offered to Residents in accordance with current CDC guidelines and recommendations. The policy further stated: Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received.",2020-09-01
248,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,552,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview the facility failed to ensure Resident #50 was afforded the opportunity to be informed of, and participate in, his treatment while a resident at the facility. This was true for one (1) of two (1) residents reviewed for the care area of Language and communication during the long-term care survey process. Resident identifier: #50. Facility census: 65. Findings included: a) Resident #50 A review of Resident #50's medical record, at 8:27 a.m. on 02/26/19, found Resident #50 had two (2) admissions to the facility since 05/01/18. Resident #50 was admitted to the facility on [DATE] and was discharged to home on 08/06/18. He was then readmitted to the facility on [DATE] and is currently still residing in the facility at the time of this review. Further review of the record found two (2) physician's determination of capacity forms. The first form was completed by Resident #50's attending physician on 05/18/18 and was the capacity form in effect from 05/18/18 until his discharge home on 08/06/18. Review of this form found Resident #50's attending physician indicated Resident #50 lacked capacity to make medical decisions. The reason given for this decision by the attending physician read as follows, Significant barrier to communication d/t (due to) thick accent/limited English use. The second capacity statement was completed by Resident #50's attending physician on 01/04/19 and was the current capacity statement in effect at the time of this review it indicated Resident #50 lacked capacity to make medical decisions due to inability to process information, delusions, hallucinations, and dementia secondary to Parkinson disease. Further review of Resident #50's medical record found Resident #50 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated he was cognitively intact. The medical record contained no indication he had a [DIAGNOSES REDACTED]. A review of a physician's progress note completed on 01/4/19, the same day the physician completed the capacity statement found the following, Orientation: Normal - Alert and orientated X 2. Affect is broad. Thought processes are intact. No visible signs of anxiety or depressed state. An interview with the Social Worker at 9:24 a.m. on 02/26/19 confirmed Resident #50 scored a perfect score on the BIMS. She stated, There is nothing wrong with his memory. She stated, I can understand him, and he can understand me. Some people have trouble understanding him, but I don't. She indicated, she did not know why the physician had taken his capacity to make medical decisions away from him and felt it should be reevaluated. She stated, He is sharp as a tack and does not appear to have any dementia problems. She indicated she was not aware that he could not make his own medical decisions. An interview with the Director of Nursing (DON), at 1:14 p.m. on 02/26/19, confirmed Resident #50 was deemed incapacitated by the attending physician on 05/18/18 and again on 01/04/19. She indicated she did not know why the attending physician completed the capacity statements in this manner and indicated she would have him to review Resident #50 for capacity. An interview with the Nursing Home Administrator, on 02/27/19 at 7:45 a.m., confirmed Resident #50's attending physician was at the facility on 02/26/19 in the evening hours and evaluated Resident #50's capacity status. She stated, He (referring to the attending physician) stated Resident #50 had capacity and that he had just made a mistake because it was hard for him to understand Resident #50 due to the fact Resident #50 spoke Spanish. She later provided a new completed capacity form completed by the attending physician on 02/27/19 that indicated Resident #50 had capacity to make medical decisions.",2020-09-01
249,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,561,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff interview and family interview, the facility failed to ensure one (2) of two (2) residents reviewed for the care area of choices, had the opportunity to participate in their usual daily routine for dining. Resident #6 was not offered a choice to get up in chair and attend lunch in the atrium. Resident #47 did not get the choice to sleep in and have breakfast served at her preferred time. Resident identifiers: #6, #47. Facility census: 65. Findings included: a) Resident #6 On 02/25/19 at 12:30 PM Resident was observed setting in bed eating lunch. Resident's Medical Power of Attorney (MPOA) was present at bedside and stated that Resident was usually up in chair by now and eats her lunch in the dining hall. MPOA said she had just questioned Nurse Aide (NA) #12 as to why Resident was not up in a chair or eating in dining hall. NA #12 informed MPOA that she did not have enough help to get Resident up with lift. During an interview with Resident #6, on 02/25/19 at 12:35 PM, Resident #6 expressed her personal preference was to be up in chair after breakfast and to go to the atrium to eat her lunch. Resident stated it took two (2) people to get her up, and this morning they were too busy to get her up. At 11:08 AM on 02/26/19 during an interview NA #12 stated, When I have hall 26-30, I never have help, restorative was supposed to help but they usually don't. Yesterday I couldn't find anybody to help me get her (Resident #6) up and it takes two people for the lift. She is usually up in chair by 10:00 and goes to dining hall for lunch. When I work that hallway (Rooms 26-30) I am usually by myself. NA #12 verified that being up chair by mid-morning prior to lunch was the Resident's personal preference and part of her usual daily routine. During an interview, on 02/27/19 at 8:26 AM, Director of Nursing (DON) stated that NA #6, who was assigned to care for Resident #6 was assigned with a restorative aid for assistance. DON specified NA #6 should have found the restorative aide and asked for her for help with resident transfer from bed to chair, and that not having anyone to help her should not have made this an issue. Record Review revealed pulmonology consult dated 01/16/19 listed an intervention in Resident #6's plan of care for her to be out of the bed to the chair every day. b) Resident #47 During an interview with the resident's responsible party (RP) at approximately 3:15 PM on 02/25/19, the RP said the resident always liked to sleep in and have breakfast around 10:00 AM when she was at home. The RP felt staff woke the resident up too early which made her combative. The RP said, Staff don't listen to me when I try to tell them to give her breakfast at 10:00 and don't wake her up so early. Staff want to get her up at 5:00 AM so she can eat at 7:00 AM. Review of the nursing notes found the following entry: 2/15/2019 08:21 Care Plan Note: Annual Care conference held on 2/13/19. No Nursing concerns noted. Nursing reports that Medication review by pharmacy was completed in (MONTH) 2019 with no medication recommendations. No Activity concerns noted, Resident continues to participate well and remains very social. Discussed information provided by Director of Dietary, (name of dietary manager); Resident is currently on a mechanical soft diet eating an average of 76-100% of meals with her weight remaining stable. Reviewed CNA (certified nursing assistant) Reports: Resident does not like to get up in the mornings and can be quite grumpy at times and at times refusing her breakfast tray, but once up she is pleasant. Resident's POA (power of attorney) states that all you can do is encourage her to get up and eat breakfast say that she can lay back down when finished if she wants. She also states that Resident prefers to not get up until around 10 am. Social Worker reviewed advance directives, preferences for care. No issues or concerns noted. Care Plan reviewed. Review of the Resident's current care plan found the problem: Risk of altered nutrition/hydration status related to cognitive deficits related to dementia and [DIAGNOSES REDACTED]. A goal associated with the problem was: Resident will consume 51% or greater at most meals through next review. Interventions included: Resident prefers to wait until 10:00 AM or after for breakfast. At 8:36 AM on 02/26/19 08:36 AM, the resident's nursing assistant (NA) #12 was interviewed. NA #12 said the breakfast trays came out around 7:00 AM. She said the resident was served breakfast, but she didn't eat anything. NA #12 said the trays have already been picked up. Observation of the resident at 10:00 AM on 02/26/19, found she was in her room sitting in her wheelchair watching television. Continued observation of the resident found she did not receive a tray. At 10:19 AM on 02/26/19, the food service director, (FSD) #39 was asked if Resident #47 received a tray at 10:00 AM. FSD replied, We don't cook a meal at 10:00 AM. She said if the resident was hungry, she could ask for some food items from the, always available menu, and the kitchen staff would get her something to eat. Review of the resident's most recent minimum data set (MDS), an annual, with an assessment reference date (ARD) of 01/21/19 found the resident scored a 7 on her brief interview for mental status (BIMS). A score of 7 indicates the resident's cognition is severely impaired. At 11:15 AM on 02/26/19, the administrator said the resident can have a tray at 10:00 AM if she wants one. The resident's BIMS score was discussed with the administrator. The administrator verified that most likely the resident could not advise staff it was 10:00 AM and she wanted a breakfast tray with a BIMS score of 7. The administrator said she would take care of the situation and the resident could receive breakfast at 10:00 AM from now on.",2020-09-01
250,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,576,C,0,1,DBDN11,"Based on resident interview and staff interview, the facility failed to ensure residents had the right to receive mail on Saturdays when delivery was available through the postal service. This had the potential to affect all residents residing at the facility. Facility census: 65. Findings included: a) Resident council meeting At 2:15 PM on 02/26/19, residents attending the council meeting were asked the question, is mail delivered unopened and on Saturdays? The residents agreed their mail was unopened, but they didn't know if mail was delivered on Saturdays. The activity director (AD) #10 attended the meeting. The AD said the facility did not get mail on Saturdays. She did not know if the mail could be delivered. On 02/27/19 at 3:46 PM, the administrator said the mail hadn't been delivered on Saturdays. The administrator contacted the postal carrier who can deliver mail on Saturdays and mail delivery has been arranged.",2020-09-01
251,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,622,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure documentation regarding the specific reason for the transfer on the Notice of Discharge or Transfer was provided to the guardian and ombudsman for one (1) of one (1) residents reviewed for the care area of hospitalization . Additionally, the physician did not document the reason for the resident's transfer. Resident identifier: #70. Facility census: 65. Findings included: a) Resident #70 Review of Resident #70's medical records revealed an emergency transfer to the hospital on [DATE] at 2:15 AM. The reason for the transfer according to the medical records was, Resident physically struck roommate, causing unsafe environment. A Notice of Transfer of Discharge was completed on 12/31/18. The Notice of Transfer or Discharge stated, Due to the reason indicated below a discharge or transfer from this center will be necessary. - The transfer or discharge is appropriate because your health has improved sufficiently that you no longer need the services provided by this center. - The transfer or discharge is necessary for your welfare and your needs cannot be met in this center. - The safety of other individuals in this center is endangered. - The health of other individuals in this center is endangered. Each of the discharge or transfer reasons had a box before the item that could be checked as appropriate. None of the reasons for discharge or transfer had been checked. The Notice of Transfer or Discharge stated Resident #70's guardian was verbally notified on 12/31/18. The time of notice was not given. A facsimile communication report showed the Notice of Transfer or Discharge was sent to the ombudsman on 01/18/19. No physician documentation regarding the reasons for Resident #70's transfer was in the medical records. The resident was ultimately not permitted to return to the facility. During an interview, on 02/27/19 at 12:21 PM, the Director of Nursing (DoN) agreed the reason for Resident #70's transfer or discharge was not indicated on the Transfer or Discharge form. The DoN was also unable to locate documentation by the resident's physician regarding the reason for transfer. During an interview, on 02/27/19 at 3:45 PM, the facility administrator was informed the reason for Resident #70's transfer or discharge was not indicated on the Transfer or Discharge form. She was also informed the physician did not document the reasons for the resident's transfer. She had no further information regarding the matter. No further information was received through the completion of the survey.",2020-09-01
252,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,626,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure physician documentation regarding the reason the resident was not permitted to return to the facility for one (1) of one (1) residents reviewed for the care area of hospitalization . Additionally, the facility failed to provide written notice to the resident's guardian and to the ombudsman specifically stating the resident would not be permitted to return to the facility. Resident identifier: #70. Facility census: 65. Findings included: a) Resident #70 Review of Resident #70's medical records revealed an emergency transfer to the hospital on [DATE] at 2:15 AM. The reason for the transfer according to the medical records was, Resident physically struck roommate, causing unsafe environment. A nursing note written at 12/31/2018 at 12:45 PM stated, This nurse called facility medical director, (physician name) regarding resident's status in facility pending return from hospital. (Physician name) expressed to this nurse that he did not feel comfortable accepting him back because he felt that the resident has had an increase in combative behavior and feels that we have to take into consideration our other resident's well-being. He feels that this resident may be a danger to other resident's going forward. It is also his belief that he requires more care than we are able to provide. At this time, we are unable to meet his needs and he will not accept him back in facility as a resident. A nursing note, written on 12/31/2018 at 1:20 PM stated, (Guardian name), guardian notified by this nurse that (physician name) has decided to not accept this resident back into this facility as he feels that this resident requires more care than we can provide. (Resident's name's) ongoing increase in behaviors towards staff and other resident's places the safety of our resident's at risk. It was explained that we had to take into account the safety of all residents at this time and in doing so, he cannot return. A Notice of Transfer of Discharge was completed on 12/31/18. The Notice of Transfer or Discharge stated, Due to the reason indicated below a discharge or transfer from this center will be necessary. - The transfer or discharge is appropriate because your health has improved sufficiently that you no longer need the services provided by this center. - The transfer or discharge is necessary for your welfare and your needs cannot be met in this center. - The safety of other individuals in this center is endangered. - The health of other individuals in this center is endangered. Each of the discharge or transfer reasons had a box before the item that could be checked as appropriate. None of the reasons for discharge or transfer had been checked. The Notice of Transfer or Discharge gave the effective date of transfer as 12/31/18. The destination of transfer was a local hospital's emergency room . The Notice of Transfer or Discharge stated Resident #70's guardian was verbally notified on 12/31/18 the time of notice was not given. A facsimile communication report showed the Notice of Transfer or Discharge was sent to the ombudsman on 01/18/19. During an interview, on 02/27/19 at 10:52 AM, Medical Records Clerk #35 stated she was unable to locate written information to Resident #70's guardian or to the ombudsman specifically stating the resident would not be permitted to return to the facility. Medical Records Clerk #35 was also unable to locate physician documentation regarding the reason Resident #70 would not be permitted to return to the facility. She stated no physician discharge summary was completed because Resident #70 was transferred to the hospital instead of discharged . During an interview on 02/27/19 at 12:21 PM, the Director of Nursing (DoN) stated the only notice provided to Resident #70's guardian and the ombudsman was the afore-mentioned Notice of Transfer or discharge date d 12/31/18. The DoN was unable to locate written information to the guardian and ombudsman specifically stating the resident would not be permitted to return to the facility. She was also unable to locate documentation by Resident #70's physician stating the reasons the resident would not be permitted to return to the facility. During an interview, on 02/27/19 at 3:45 PM, the facility administrator was informed Resident #70's guardian and the ombudsman were not provided written information specifically stating the resident would not be returning to the facility. The administrator was also informed Resident #70's physician did not document the reasons the resident would not be permitted to return to the facility. The administrator had no further information regarding the matter. No further information was received through the completion of the survey.",2020-09-01
253,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,641,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observation, the facility failed to ensure the accurate completion of the Minimum Data Set (MDS) for Resident #69 in the area of prognosis, for Resident #23 in the area of dental and prognosis, and Resident #68 in the area of discharge/return to the community. This was true for three (3) of 16 MDSs reviewed during the long term care survey. Resident Identifiers: #69, #23, and #68. Facility Census: 65. Findings included: a) Resident #69 A review of Resident #69's medical record, on 02/26/18 at 10:32 AM, found Resident #69 was admitted to hospice services on 09/25/18. A review of a signficant change MDS with an Assessment Reference Date (ARD) of 09/29/18 found Section J1400 Prognosis was marked to indicate Resident #69 did not have a condition or chronic disease that would result in a life expectancy of less than 6 months. This was not accurate considering Resident #69 was admitted to hospice services on 09/25/18. An interview with the MDS Coordinator Registered Nurse (RN) #66, at 3:00 PM on 02/27/19, confirmed this section was coded incorrectly. She stated, Since she was a hospice resident this should have ben marked yes not no. b) Resident #23 1. Dental Observations of Resident #23, on 02/25/19 at 1:58 PM, found Resident #23 was edentulous. She was observed sitting in her Geri- Chair in her with her mouth open. Her entire mouth could be observed and there were no teeth in her mouth. A review of Resident #23's medical record, at 1:12 PM on 02/26/19, found on 08/27/18 Resident #23 was assessed as having no natural teeth. Review of a Signficant Change MDS with an Assessment reference date (ARD) 09/18/18 found Section L Oral/Dental Status L Dental was marked Z. None of the above were present. This indicated Resident #23 had no dental problems. This was inaccurate and should have been marked B. No natural teeth or tooth Fragments (edentulous) . An interview with the MDS Coordinator Registered Nurse (RN) #66, at 3:00 PM, on 02/27/19 confirmed this section was coded incorrectly. She agreed B should have been marked since Resident #23 was edentulous. 2. Prognosis A review of Resident #23's medical record at 1:12 p.m. on 02/26/19 found Resident #23 was admitted to hospice services on 09/14/18. Review of a Signficant Change MDS with an ARD 09/18/18 found section J1400. Prognosis was marked to indicate Resident #23 did not have a condition or choric disease that may result in a life expectancy of less than 6 months. This was not accurate considering Resident #23 was admitted to hospice services on 09/14/18. An interview with the MDS Coordinator Registered Nurse (RN) #66 at 3:00 p.m. on 02/27/19 confirmed this section was coded incorrectly. She stated, Since she was a hospice resident this should have ben marked yes not no. c) Resident #68 Record review found Resident #68 was admitted to the facility on [DATE]. Upon admission, he expected to return home and discharge planning was initiated. The resident returned home on 12/15/18. Review of the resident's admission MDS with an ARD of 11/7/18, found the resident expected to return to the community after his nursing home stay. The MDS indicated the resident participated in answering questions regarding discharge to home and his expectations. A question on the MDS asks if the resident wanted to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community. The question was to be answered by checking one of the following: Yes, no, or unknown or uncertain. The facility checked unknown or uncertain. Directions from the ARI Manual: Code 0, No: if the resident (or family or significant other, or guardian or legally authorized representative) states that he or she does not want to talk to someone about the possibility of returning to live and receive services in the community. Code 1, Yes: if the resident (or family or significant other, or guardian or legally authorized representative) states that he or she does want to talk to someone about the possibility of returning to live and receive services in the community. Code 9, Unknown or uncertain: if the resident cannot understand or respond and the family or significant other is not available to respond on the resident ' s behalf and a guardian or legally authorized representative is not available or has not been appointed by the court. Resident #68 was alert, oriented, and had capacity to make medical decisions. The resident scored a 15 on his brief interview for mental status (BIMS). A score of 15 is the highest score obtainable and indicates the resident has cognition is intact. On 02/26/19 at 4:00 PM, the facility social worker, the author of the MDS, verified the MDS was coded incorrectly.",2020-09-01
254,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,656,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to implement a care plan for one (1) of sixteen (16) residents whose care plans were reviewed. Resident #47's care plan regarding her morning meal preference time was not implemented. Resident identifier: #47. Facility census: 65. Findings included: a) Resident #47 During an interview with the resident's responsible party (RP), at approximately 3:15 PM on 02/25/19, the RP said the resident always liked to sleep in and have breakfast around 10:00 AM when she was home. The RP felt staff woke the resident up too early which made her combative. The RP said, Staff don't listen to me when I try to tell them to give her breakfast at 10:00 and don't wake her up so early. Staff want to get her up at 5:00 AM so she can eat at 7:00 AM. Review of the nursing notes found the following entry: 2/15/2019 08:21 Care Plan Note Note : Annual Care conference held on 2/13/19. No Nursing concerns noted. Nursing reports that Medication review by pharmacy was completed in (MONTH) 2019 with no medication recommendations. No Activity concerns noted, Resident continues to participate well and remains very social. Discussed information provided by Director of Dietary, (name of dietary manager); Resident is currently on a mechanical soft diet eating an average of 76-100% of meals with her weight remaining stable. Reviewed CNA (certified nursing assistant) Reports: Resident does not like to get up in the mornings and can be quite grumpy at times and at times refusing her breakfast tray, but once up she is pleasant. Resident's POA (power of attorney) states that all you can do is encourage her to get up and eat breakfast say that she can lay back down when finished if she wants. She also states that Resident prefers to not get up until around 10am. Social Worker reviewed advance directives, preferences for care. No issues or concerns noted. Care Plan reviewed. Review of the Resident's current care plan found the problem: Risk of altered nutrition/hydration status related to cognitive deficits related to dementia and [DIAGNOSES REDACTED]. A goal associated with the problem was: Resident will consume 51% or greater at most meals through next review. Interventions included: Resident prefers to wait until 10:00 AM or after for breakfast. At 8:36 AM on 02/26/19 08:36 AM, the resident's nursing assistant, (NA) #12 was interviewed. NA #12 said the breakfast trays came out around 7:00 AM. She said the resident was served breakfast but she didn't eat anything. NA #12 said the trays had already been picked up. Observation of the resident at 10:00 AM on 02/26/19, found she was in her room sitting in her wheelchair watching television. Continued observation of the resident found she did not receive a tray. At 10:19 AM on 02/26/19, the food service director, (FSD) #39 was asked if Resident #47 received a tray at 10:00 AM. FSD replied, We don't cook a meal at 10:00 AM. She said if the resident was hungry she could ask for some food items from the, always available menu, and the kitchen staff would get her something to eat. Review of the resident's most recent minimum data set (MDS), an annual, with an assessment reference date (ARD) of 01/21/19 found the resident scored a (7) on her brief interview for mental status (BIMS). A score of 7 indicated the resident's cognition was severely impaired. At 11:15 AM on 02/26/19, the administrator said the resident could have a tray at 10:00 AM if she wanted one. The resident's BIMS score was discussed with the administrator. The administrator verified that most likely the resident could not advise staff it was 10:00 AM and she wanted a breakfast tray with a BIMS score of 7. The administrator said she would take care of the situation and the resident could receive breakfast at 10:00 AM from now on.",2020-09-01
255,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,684,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to administer medication in accordance with physician orders. This was a random opportunity for discovery. The facility did not obtain the resident's pulse or systolic blood pressure before administering the beta-blocker, [MEDICATION NAME]. Resident identifier: #47. Facility census: 65. Findings included: a) Resident #47 Medical record review found a physician's orders [REDACTED]. Systolic is the first number of the resident's blood pressure. Systolic blood pressure, measures the pressure in your blood vessels when your heart beats. The order was effective on 12/29/18. [MEDICATION NAME] is a beta-blocker. Beta-blockers affect the heart and circulation. [MEDICATION NAME] is used to treat heart failure and hypertension. Review of the resident's medication administration (MAR) for (MONTH) (YEAR), (MONTH) 2019, and (MONTH) 2019, found the medication was given daily; however, there was no evidence staff obtained the resident's pulse or blood pressure before administering the medication. On 02/26/19 at 9:05 AM, the director of nursing (DoN) verified staff would not know if the resident's medication should be held if pulse and systolic blood pressure were not obtained before administration. The DoN said staff should record the pulse on the MAR. The DoN was unable to provide verification the physician's orders [REDACTED].",2020-09-01
256,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,745,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #50 was provided medically-related social services to enable him to attain and/or maintain his highest practicable physical, mental and psychosocial well-being. This was true for one (1) of two (2) residents reviewed for the care area of communication during the long-term care survey. Resident identifier: #50. Facility census: 65. Findings included: a) Resident #50 A review of Resident #50's medical record at 8:27 a.m. on 02/26/19 found Resident #50 had two (2) admissions to the facility since 05/01/18. Resident #50 was admitted to the facility on [DATE] and was discharged to home on 08/06/18. He was then readmitted to the facility on [DATE] and is currently still residing in the facility at the time of this review. Further review of the record found two (2) physician's determination of capacity forms. The first form was completed by Resident #50's attending physician on 05/18/18 and was the capacity form in effect from 05/18/18 until his discharge home on 08/06/18. Review of this form found Resident #50's attending physician indicated Resident #50 lacked capacity to make medical decisions. The reason given for this decision by the attending physician read as follows, Significant barrier to communication d/t (due to) thick accent/limited English use. The second capacity statement was completed by Resident #50's attending physician on 01/04/19 and was the current capacity statement in effect at the time of this review it indicated Resident #50 lacked capacity to make medical decisions due to inability to process information, delusions, hallucinations, and dementia secondary to Parkinson disease. Further review of Resident #50's medical record found Resident #50 had a Brief Interview of Mental Status (BIMS) score of 15 which indicates he is cognitively intact. The medical record contained no indication he had a [DIAGNOSES REDACTED]. In fact, a review of a physician's progress not completed on 01/4/19 the same day he completed the capacity statement found the following, Orientation: Normal - Alert and orientated X 2. Affect is broad. Thought processes are intact. No visible signs of anxiety or depressed state. An interview with the Social Worker at 9:24 a.m. on 02/26/19 confirmed that Resident #50 scored a perfect score on his brims. She stated, There is nothing wrong with his memory. She stated I can understand him, and he can understand me. Some people have trouble understanding him, but I don't She indicated, she did not know why the physician had taken his capacity to make medical decisions away from him and felt it should be reevaluated. She stated, He is sharp as a tack and does not appear to have any dementia problems. She indicated she was not aware that he could not make his own medical decisions. An interview with the Director of Nursing (DON) at 1:14 p.m. on 02/26/19 confirmed Resident #50 was deemed incapacitated by the attending physician on 05/18/18 and again on 01/04/19. She indicated she did not know why the attending physician completed the capacity statements in this manner and indicated she would have him to review Resident #50 for capacity. An interview with the Nursing Home Administrator on 02/27/19 at 7:45 a.m. confirmed Resident #50's attending physician was at the facility on 02/26/19 in the evening hours and evaluated Resident #50's capacity status. She stated, He (referring to the attending physician) stated Resident #50 has capacity and that he had just made a mistake because it was hard for him to understand Resident #50 due to the fact Resident #50 spoke Spanish. She later provided a new completed capacity form completed by the attending physician on 02/27/19 that indicated Resident #50 had capacity to make medical decisions.",2020-09-01
257,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,757,D,0,1,DBDN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #62's drug regimen was free from unnecessary medications. Resident #62 received three (3) excessive doses of an antibiotic. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications during the long term care survey process. Resident identifier: 62. Facility census: 65. Findings included: a) Resident #62 A review of Resident #62's medical record, at 9:21 AM on 02/27/19, found a physician's orders [REDACTED]. This order had a start date of 02/04/19. A review of Resident #62's Medication Administration Record [REDACTED]. Resident #62 was only prescribed 20 doses by her attending physician. An interview with the Director of Nursing (DoN), at 11:16 a.m. 02/27/19, confirmed Resident #62 received three (3) extra doses of Cipro. She stated, It looks like they took the first three (3) doses from the Emergency box and then gave the 20 doses that were ordered from the pharmacy also.",2020-09-01
258,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-02-27,842,D,0,1,DBDN11,"Based on record review, observation, and staff interview the facility failed to ensure Resident #23's medical record was complete and accurate. Resident #23 had multiple dental assessments contained in her record that were not accurately completed. This was true for one (1) of 16 sampled residents. Resident identifier: 23. Facility census: 65. Findings included: a) Resident #23 An observation of Resident #23, at 1:58 PM, on 02/27/19 found she edentulous. She was observed sitting in her Geri Chair. Her mouth was opened and could be easily observed. This observation revealed Resident #23 had no teeth. A review of Resident #23's medical record, at 1:12 PM on 02/26/19, found the following dental assessments which were inaccurately completed: 12/18/18 Indicated Resident #23 had no dental problems. 04/01/18 Indicated Resident #23 had no dental problems. 04/26/18 Indicated Resident #23 had no dental problems. 09/23/16 Indicated Resident #23 had no dental problems. An interview with the Director of Nursing on 02/26/19 at 01:50 PM confirmed Resident #23 was edentulous and the above mentioned assessments should have been marked to indicate this, but they were not.",2020-09-01
259,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,565,E,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident interview, record review and staff interview, the facility failed to respond to a group grievance concerning the water pitches in a timely manner. This failed practice had the potential to affect more than an isolated number. Facility census: 56. Finding included: a) Resident council meeting On 11/21/17 the resident council filed a Concern/Grievance Form concerning the water pitchers not returned to them in a timely manner. The investigation completed on 11/27/18 stated, Audit was done to see if all residents had water pitchers. We noted during audit that there was a shortage of water pitchers. This was taken care of immediately. Extra water pitchers were ordered by dietary department. The date of the complaint resolution as left blank. During an interview on 03/12/18 at 10:49 AM, Resident # 28 said, We don't have anyway to keep ice and water in the rooms, we used to. It stopped when a new company took over and they stopped using the plastic pitchers and now are using these old Styrofoam cups. They don't hold much or keep the water very cold long, plus it is hard to hold. She demonstrated that she can not hold the cup very easy. She said she and others have request to get the pitchers back sometime ago but they did not get them back. On 03/13/18 at 01:30 PM, DON said about two weeks ago they started using Styrofoam cups, but have already ordered new pitchers to replace the others because they kept disappearing. She said the Food Service Manager had ordered some new ones. She was shown the resident council meeting minutes, which was in (MONTH) 21, (YEAR) concerning a complaint about not having any pitchers, she said they had not been worried about because they were worried about getting ready for the surveyors. During an interview on 03/13/18 at 01:45 PM, Food Service Manager #20 said about a month ago nursing asked if they could change from the pitchers to throw cups. No order order has been made because he was unaware of the change back to pitcher. He state he was not sure if he knew about the the complaints in (MONTH) council meeting about the pitchers. On 03/13/18 at 03:45 PM, the Administrator said the pitcher thing is a miscommunication between dietary and nursing. They ordered new pitchers in (MONTH) when the residents complained, but had a flu problem in January, so for infection control they were using disposable cups. Records indicated that the residents were given [MEDICATION NAME] on 01/28/18. She said she could provide a receipt to show the pitches were ordered in November, but the only receipt that was shown was dated 03/13/18 at 02:18 PM, for new pitchers. On 03/13/18 at 04:10 PM, she said they found 60 pitchers and all residents will have a water pitcher in the morning.",2020-09-01
260,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,641,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of four (4) resident's reviewed for the care area of nutrition had an accurate and complete minimum data set (MDS). This failed practice had the potential to affect a limited number of residents. Resident identifier: #40. Facility census: 56. Findings included: a) Resident #40 Record review on 03/13/18 at 11:00 AM, found the resident was admitted to the facility on [DATE]. The residents first weight was recorded as 271.3 pounds on 10/06/17. A significant change in status MDS with an assessment reference date (ARD) of 02/01/18, noted the resident's current weight was 221 pounds. The MDS coded the resident as having no weight loss, (5% or more in the last month or loss of 10% or more in last 6 months.) An interview with the dietary manager (DM) #20, at 12:14 PM on 03/13/18, confirmed the resident had an actual weight loss of 18.54 % as calculated by dietary manager at the time of the MDS with an ARD of 02/01/18. The DM verified the MDS was coded incorrectly.",2020-09-01
261,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,656,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for the care area of nutrition had a measurable care plan to address fluid intake. In addition, one (1) of three (3) residents reviewed for pressure ulcers failed to have interventions in place, as directed by the care plan, to promote healing of existing pressure ulcers and/or prevent the development of new pressure ulcers. Resident identifiers: #40 and #26. Facility census: 56. Findings included: a) Resident #40 Review of the resident's current care plan, dated 01/03/18, found the following focus/problem: --Risk of altered nutrition/hydration status related to inadequate intake of food and fluids. A goal associated with the problem was: --Resident will remain free of sign/symptoms of dehydration such as sunken eyes, decreased urine output, dry mucous membranes, daily through next review. A second care plan focus/problem, dated 03/12/18: --Resident has a urinary tract infection. The goal associated with the problem: --Resident's urinary tract infection will resolve with no complication. Interventions included: --Encourage fluids as tolerated. A comprehensive nutritional assessment, completed by the registered dietician on 01/26/18, noted the resident required 2070 milliliters of fluid a day. At 2:45 PM on 03/14/18, the director of nursing (DON) verified the facility did not keep any records to determine how much fluids any residents may or may not have consumed during the day. The facility only records the percent of food consumed by residents in a day. She was unable to verify how the facility determined the resident had an inadequate intake of fluids as specified on the care plan or how the facility would monitor daily fluid intake to ensure the resident consumed the required milliliters of daily fluid. The resident also had a urinary tract infection and the DON confirmed the facility could not verify fluids were encouraged as stated on the care plan. b) Resident #26 Review of the care plan, dated 02/12/18, found the current problem/focus: --Resident has or was admitted with pressure injuries to left inner foot, right gluteal fold, unstageable to right outer foot, and blanchable reddened area to right lateral foot, Deep tissue pressure injury to left inner heel. Potential for further pressure injury related to diabetes mellitus, [MEDICAL CONDITION] with bilateral leg contractures, recurrent hip dislocation, chronic pain, [MEDICAL CONDITION] requiring transfusion, hypertension, [MEDICAL CONDITION], dry skin and scalp, [MEDICAL CONDITION] and muscle wasting. Including the following pressure ulcers: --Stage 4 pressure ulcer to the right (middle) outer foot --Stage 2 pressure ulcer to the left buttock --Resolved Stage 2 pressure ulcer to the left elbow --Unstageable pressure ulcer to the right outer foot (distal, below little toe) The goal associated with the focus/problem: --Resident will have no further pressure ulcer formation noted through next review period. Interventions included: --May use knee/ankle abductor cushion between knees to help prevent further skin breakdown, --Resident will have elbows heels floated as allowed by the resident while in bed. Observation of the resident with the director of nursing (DON) at 1:57 p.m. on 03/13/18, found the resident did not have the abductors on and did not have elbows/heels floated as directed by the care plan. When asked why he did not have the abductors on, the resident said, I had them on earlier, they took them off when they pulled me up in the bed and didn't put them back on. At 2:06 p.m. on 03/13/18, the DON confirmed the resident's care plan addressing pressure ulcers was not followed as written.",2020-09-01
262,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,657,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the comprehensive care plan was revised in the area of nutrition for one (1) of four (4) residents reviewed for the care area of nutrition. This failed practice had the potential to affect a limited number of residents. Resident identifier: #5. Facility census: 56. Findings included: a) Resident #5 Resident #5 had an order written [REDACTED]. This order was discontinued on 10/25/17 because the resident preferred a different nutritional supplement. Review of Resident #5's comprehensive care plan on 03/13/18 revealed the focus of Risk of altered nutrition/hydration status related to inadequate intake of food and fluids contained the intervention of 2-cal, 60 ml, twice a day. During an interview on 03/13/18 at 1:07 PM, the Director of Nursing (DON) was informed Resident #5's comprehensive care plan continued to include the intervention of 2-cal, 60 ml, twice a day even though this nutritional supplement had been discontinued 10/15/17. The DoN had no further information regarding this matter.",2020-09-01
263,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,684,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to follow physician orders [REDACTED]. This failed practice had the potential to affect a limited number of residents. Resident identifier: #5. Facility census: 56. Findings included: a) Resident #5 Resident #5 had an order written [REDACTED]. Medication side effects were ordered to be monitored. Review of Resident #5's Medication Administration Record [REDACTED]= SE and 2 = No SE. However, side effects had not been monitored. Resident #5 was also prescribed another medication, [MEDICATION NAME], for depression and appetite stimulation. The resident was also to be monitored for side effects of [MEDICATION NAME]. The MAR indicated [REDACTED]. However, the MAR indicated [REDACTED]. During an interview on 03/13/18 at 1:07 PM, the Director of Nursing (DoN) was informed physician's orders [REDACTED].#5 for side effects of [MEDICATION NAME] was not followed in March, (YEAR). The DoN had no further information regarding this matter.",2020-09-01
264,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,686,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review and staff interview, the facility failed to provide care and services to promote the healing of existing pressure ulcers and prevent development of additional pressure ulcers for one (1) of three (3) residents reviewed for the care area of pressure ulcers. Resident #26 did not have pressure relieving devices in place as directed by the care plan. Resident identifier: #26. Facility census: 56. Findings include: a) Resident #26 Review of the care plan, dated 02/12/18, found the current problem/focus: --Resident has or was admitted with pressure injuries to left inner foot, right gluteal fold, unstageable to right outer foot, and blanchable reddened area to right lateral foot, Deep tissue pressure injury to left inner heel. Potential for further pressure injury related to diabetes mellitus, [MEDICAL CONDITION] with bilateral leg contractures, recurrent hip dislocation, chronic pain, [MEDICAL CONDITION] requiring transfusion, hypertension, [MEDICAL CONDITION], dry skin and scalp, [MEDICAL CONDITION] and muscle wasting. Including the following pressure ulcers: --Stage 4 pressure ulcer to the right (middle) outer foot --Stage 2 pressure ulcer to the left buttock --Resolved Stage 2 pressure ulcer to the left elbow --Unstageable pressure ulcer to the right outer foot (distal, below little toe) The goal associated with the focus/problem: --Resident will have no further pressure ulcer formation noted through next review period. Interventions included: --May use knee/ankle abductor cushion between knees to help prevent further skin breakdown, --Resident will have elbows heels floated as allowed by the resident while in bed. Observation of the resident with the director of nursing (DON) at 1:57 PM on 03/13/18, found the resident did not have the abductors on and did not have elbows/heels floated as directed by the care plan. When asked why he did not have the abductors on the resident said, I had them on earlier, they took them off when they pulled me up in the bed and didn't put them back on. At 2:06 pm on 03/13/18, the DON confirmed the resident's care plan was not being followed as written. On 03/14/18 at 12:56 PM the absence of the devices, knee/ankle abductor and the floating of the elbows and heels were again discussed with the DON. The resident has a history of pressure ulcer development and healing since his admission to the facility on [DATE]. The DON confirmed these devices were implement to prevent future skin breakdown and promote the healing of existing pressure ulcers.",2020-09-01
265,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,692,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, observation, and staff interview, the facility failed to recognize, evaluate, and address the nutritional needs of one (1) of four (4) residents reviewed for the care area of nutrition. In addition, the facility failed to to ensure proper hydration was provided to one resident during a random opportunity for discovery. Resident identifiers: #40 and #30. Facility census: 56. Findings included: a) Resident #40 During an interview with the resident on 03/12/18 at 10:12 AM, she said, I get mashed potatoes for every meal, I don't know why they can't fortify something else-like some macaroni and cheese for a change. The resident said she was losing weight because she can not eat and the food is not good. Record review found the resident was admitted to the facility on [DATE]. The resident's weight was recorded as 271.3 pounds on 10/06/17. The last weight recorded was 219 pounds on 03/12/18. A 19.28% weight loss since admission. Review of the resident's current care plan, dated 01/03/18, found the following focus/problem: Risk of altered nutrition/hydration status related to inadequate intake of food and fluids. A goal associated with the problem was: --Resident will remain free of sign/symptoms of dehydration such as sunken eyes, decreased urine output, dry mucous membranes, daily through next review. Interventions included: --Dietary to provide fortified foods one item per tray, initiated on 01/24/18, --Honor food preferences, --Dietary to provide 8 ounces of whole milk with meals, yogurt at 2pm and 1/2 sandwich hs (at night time) Two comprehensive nutritional assessments were completed by the registered dietician (RD) since the resident's admission. On on 10/07/17 and 01/29/18. On 10/07/17, the nutrition summary noted: --New admission. [AGE] year old female .BMI (body mass index) indicates obesity; no interventions warranted due to diagnosis. Will allow resident time to adjust to facility, encourage po (by mouth) intake, and monitor weights per policy .Weight fluctuations may occur due to diuretic . Weight loss meetings were held, on 12/01/17 and 01/12/18. --12/01/17, Weight meeting held with IDT (interdisciplinary team) members. Weight loss trend continues. PO intake 51-75% of most meals. RD recommendations reviewed 11/30/17 and new order received for house shake BID. Currently receiving whole milk with meals, yogurt daily and 1/2 sandwich at QHS. Resident has a [DIAGNOSES REDACTED]. --01/12/18, Weight meeting held with IDT members. Resident has [DIAGNOSES REDACTED].Several interventions in place including whole milk with meals, yogurt daily at 2 pm per request. HS snack of choice, handmade chocolate milkshakes BID (twice a day), one fortified food item per tray . Review of the hospital discharge summary, dated 10/05/17 found the resident has a surgical history of, Laparoscopic gastric banding surgery. (Laparoscopic gastric banding is surgery to help with weight loss. The surgeon places a band around the upper part of your stomach to create a small pouch to hold food. The band limits the amount of food you can eat by making you feel full after eating small amounts of food.) Normally a person with this surgery would need to eat several small meals daily, instead of three (3) large meals per day. The facility physician also noted the resident had Laparoscopic gastric banding surgery on the, New Patient History and Physical. Observation of the resident's noon meal on 03/12/17 found she had chicken and dumplings and mashed potatoes. Observation of the noon meal again on 03/13/17 found the resident had roast beef and mashed potatoes. At 12:14 PM on 03/13/18, the dietary manager verified the resident does have mashed potatoes for every lunch and supper meal-that is the food we fortify. He confirmed the resident only receives fortified oatmeal for breakfast and fortified mashed potatoes with every lunch and supper. He was not aware the resident had said she was tired of mashed potatoes and could no longer eat them. He said he could fortify some macaroni and cheese as requested by the resident. The DM said he is also unaware the resident had lap band surgery and did not know what kind of a diet the resident should receive after having the surgery. He confirmed the facility had never considered the lap band surgery as contributing to the resident's weight loss. At 8:20 AM on 03/14/18, the resident said she was unable to eat large meals at one setting because of her surgery. She said, If I had the right foods, I could eat more. She said she just requested a hot bowl of chicken noodle soup for lunch. That's all I want and it can even be from a can, just a bowl of hot chicken noodle soup. At 8:57 AM on 03/14/18, the resident's weight loss was discussed with the administrator. She was asked if anyone had every considered the resident's Laparoscopic gastric banding as contributing to her weight loss? The administrator was also advised the resident had been receiving mashed potatoes for every lunch and supper since 01/24/18 because the DM said this was the only food item his staff fortified. A third observation of the resident's noon meal at 12:20 PM on 03/14/18, with nursing assistant, NA #91, found the resident received mashed potatoes again. (She did have chicken noodle soup). At 1:16 PM on 03/14/18, the dietary manager was asked why the resident had mashed potatoes again. He stated, my staff only knows how to fortify mashed potatoes, I have to train them to fortify other food items, like the macaroni and cheese-I don't want them to do it the wrong way. Review of the facility's document entitled, Increasing the calorie content of a meal pattern, was reviewed with the DM. Lunch and dinner meals can be [MEDICATION NAME]/fortified with: --Extra margarine to vegetables and starches, serve cheese, cheese sauce, margarine, sour cream on meats, vegetables, or starches; --Offer fortified soup, fortified mashed potatoes or fortified pudding with meals; offer [MEDICATION NAME] milk as a beverage with meals. The DM said those were good ideas for fortifying foods and he would train his staff. At the close of the survey on 03/15/18 at 6:00 PM the facility provided no further information on Resident #40. No information was provided the facility staff addressing the resident's weight loss was aware of the Laparoscopic gastric banding surgery or considered this surgery as contributing to weight loss and attempted to provide a diet that could be tolerated by the resident. b) Resident #30 A random observation of Resident #30 on 03/12/18 at 12:10 PM, found there was no drinks with her lunch and no water pitcher on table or in the room. Resident #30 said, I would like to have had something to drink with my lunch, all I have had today to drink was a shake drink in that little box. On 03/13/18 at 10:00 AM, the director of nursing (DON) was notified about Resident # 30 not having any drinks with the her lunch yesterday. She was asked if she could find her fluid intake for yesterday. She said do not document fluid intake only meal percentages. During an observation on 03/13/18 at 10:24 AM, Resident #30 had a drink on her table. On 03/13/18 at 10:40 AM, the DON said yesterday Resident # 30 didn't get drinks on her tray because her tray was sent to the atrium and the drinks are put on the table not on the tray, but not sure why she was not given anything to drink in her room.",2020-09-01
266,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,757,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure Resident #62's medication regimen was free from unnecessary medication. Resident #62 was administered an antihypertensive ([MEDICATION NAME]) medication outside of the physician prescribed parameters. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #62. Facility census: 56. Findings included: a) Resident #62 Review of Resident #62's medical records found a physician order [REDACTED]. Review of Resident #62's Medication Administration Record [REDACTED] --11/26/17- blood pressure was 118/68. --11/27/17- blood pressure was 118/78. --12/05/17- blood pressure was 118/70. --12/11/17- blood pressure was 118/74. --12/13/17- blood pressure was 118/68. Interview with the Director of Nursing (DON) on 03/13/18 at 11:30 AM found after review of the MARs for (MONTH) and (MONTH) (YEAR). Resident was administered [MEDICATION NAME] when the medication should have been held as directed by the physician prescribed parameters.",2020-09-01
267,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,758,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure [MEDICAL CONDITION] medications prescribed on an as needed basis or PRN were limited to a 14 day order, nor did the facility address non-pharmacological interventions prior to the administration of as needed, PRN [MEDICAL CONDITION] medications for one (1) of five (5) residents reviewed for unnecessary medications. This failed practice had the potential to affect more than a limited number of residents. Resident identifier: #61. Facility census: 56. Findings include: a) Resident #61 Record review for Resident #61 found physician order [REDACTED].>--[MEDICATION NAME], give 0.25 mg (milligrams) by mouth every 12 hours as needed for anxiety. Order date 11/02/17 and start date 11/03/17. Review of the MAR indicated [REDACTED] --11/03/17 at 8:13 a.m. --11/05/17 at 10:30 p.m. --11/06/17 at 7:30 p.m. --11/07/17 at 7:49 p.m. --11/08/17 at 8:15 p.m. --11/12/17 at 7:59 p.m. Interview with the Director of Nursing (DON) on 03/15/18 at 11:45 AM confirmed non-pharmacological interventions were not implemented prior to the administration of PRN [MEDICAL CONDITION] medications. Facility failed to attempt non pharmalogical interventions prior to the administration of an anti anxiety medication. ([MEDICATION NAME]) Resident #61",2020-09-01
268,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,803,E,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review and staff interview, the facility failed to make a reasonable effort to assure menus were prepared to meet resident's choices for one (1) of four (4) residents reviewed for the care area of nutrition. Resident #40 received mashed potatoes every day for 49 days in a row. In addition, the facility failed to consider a menu/diet appropriate for a resident after having Laparoscopic gastric band surgery. Resident identifier: #40. Facility census: 56. Findings included: a) Resident #40 During an interview with the resident on 03/12/18 at 10:12 AM., she said, I get mashed potatoes for every meal, I don't know why they can't fortify something else-like some macaroni and cheese for a change. The resident said she was losing weight because she can not eat and the food is not good. Record review found the resident was admitted to the facility on [DATE]. The resident's weight was recorded as 271.3 pounds on 10/06/17. The last weight recorded was 219 pounds on 03/12/18. A 19.28% weight loss since admission. Review of the resident's current care plan, dated 01/03/18, found the following focus/problem: --Risk of altered nutrition/hydration status related to inadequate intake of food and fluids. A goal associated with the problem was: --Resident will remain free of sign/symptoms of dehydration such as sunken eyes, decreased urine output, dry mucous membranes, daily through next review. Interventions included: --Dietary to provide fortified foods one item per tray, initiated on 01/24/18, --Honor food preferences, --Dietary to provide 8 ounces of whole milk with meals, yogurt at 2pm and 1/2 sandwich hs (at night time) Two comprehensive nutritional assessments were completed by the registered dietician (RD) since the resident's admission. On on 10/07/17 and 01/29/18. On 10/07/17, the nutrition summary noted: --New admission. [AGE] year old female .BMI (body mass index) indicates obesity; no interventions warranted due to diagnosis. Will allow resident time to adjust to facility, encourage po (by mouth) intake, and monitor weights per policy .Weight fluctuations may occur due to diuretic . Two weight loss meetings were held, one on 12/01/17 and one on 01/12/18. --12/01/17, Weight meeting held with IDT (interdisciplinary team) members. Weight loss trend continues. PO intake 51-75% of most meals. RD recommendations reviewed 11/30/17 and new order received for house shake BID. Currently receiving whole milk with meals, yogurt daily and 1/2 sandwich at QHS. Resident has a [DIAGNOSES REDACTED]. --01/12/18, Weight meeting held with IDT members. Resident has [DIAGNOSES REDACTED].Several interventions in place including whole milk with meals, yogurt daily at 2 pm per request. HS snack of choice, handmade chocolate milkshakes BID (twice a day), one fortified food item per tray . Review of the hospital discharge summary, dated 10/05/17 found the resident has a surgical history of, Laparoscopic gastric banding surgery. (Laparoscopic gastric banding is surgery to help with weight loss. The surgeon places a band around the upper part of your stomach to create a small pouch to hold food. The band limits the amount of food you can eat by making you feel full after eating small amounts of food.) Normally a person with this surgery would need to eat several small meals daily, instead of three (3) large meals per day. The facility physician also noted the resident had Laparoscopic gastric banding surgery on the, New Patient History and Physical. Observation of the resident's noon meal on 03/12/17 found she had chicken and dumplings and mashed potatoes. Observation of the noon meal again on 03/13/17 found the resident had roast beef and mashed potatoes. At 12:14 PM on 03/13/18, the dietary manager verified the resident does have mashed potatoes for every meal-that is the food we fortify. He confirmed the resident only receives fortified oatmeal for breakfast and fortified mashed potatoes with every lunch and supper. He was not aware the resident had said she was tired of mashed potatoes and could no longer eat them. He said he could fortify some macaroni and cheese as requested by the resident. The DM said he is also unaware the resident had lap band surgery and did not know what kind of a diet the resident should receive after having the surgery. He confirmed the facility had never considered the lap band surgery as contributing to the resident's weight loss. At 8:20 AM on 03/14/18, the resident said she was unable to eat large meals at one setting because of her surgery. She said, If I had the right foods, I could eat more. She said she just requested a hot bowl of chicken noodle soup for lunch. That's all I want and it can even be from a can, just a bowl of hot chicken noodle soup. At 8:57 AM on 03/14/18, the resident's weight loss was discussed with the administrator. She was asked if anyone had every considered the resident's Laparoscopic gastric banding as contributing to her weight loss? The administrator was also notified the resident had been receiving mashed potatoes for every lunch and supper since 01/24/18 because the DM said this was the only food item his staff fortified. (The resident has received mashed potatoes for 49 days in a row for 98 meals.) A third observation of the resident's noon meal at 12:20 PM on 03/14/18, with nursing assistant #91 found the resident received mashed potatoes again. (She did have her chicken noodle soup). At 1:16 PM on 03/14/18, the dietary manager was asked why the resident had mashed potatoes again. He stated, my staff only know how to fortify mashed potatoes, I have to train them to fortify other food items, like the macaroni and cheese-I don't want them to do it the wrong way. Review of the facility's document entitled, Increasing the calorie content of a meal pattern, was reviewed with the DM. Lunch and dinner meals can be [MEDICATION NAME]/fortified with: --Extra margarine to vegetables and starches, serve cheese, cheese sauce, margarine, sour cream on meats, vegetables, or starches; --Offer fortified soup, fortified mashed potatoes or fortified pudding with meals; offer [MEDICATION NAME] milk as a beverage with meals. The DM said those were good ideas for fortifying foods and he would train his staff. At the close of the survey on 03/15/18 at 6:00 PM the facility provided no further information on Resident #40. No information was provided the facility staff addressing the resident's weight loss was aware of the Laparoscopic gastric banding surgery or considered this surgery as contributing to weight loss and attempted to provide a diet that could be tolerated by the resident.",2020-09-01
269,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,804,E,0,1,YXUB11,"Facility failed to provide palatable, attractive and appetizing and proper temperature of food with complaints from 12 anonymous residents. This failed practice had the potential to affect more than a limited number of residents. Facility census: 56. Finding included: a) Anonymous resident statements, from resident council and resident interviews Statements from random residents during resident interviews and resident council meeting. --The bread is always dry like it's been frozen. --Food is cold and mashed potatoes everyday sometimes twice a day --Too many potatoes --The food is either over cooked or under cooked, potatoes every day, the bread is always dried out. --Sometimes I don't even know what the food is. --Today the chicken and dumplings were cold. --They run out of things a lot, the orange juice don't even taste like juice, the vegetables are either over cooked or under cooked. We have told them in resident council, several of us we don't like that old black gravy on everything. --We have a lot of chicken with fancy names, but it ain't good. Sundays pork chop was so tough you can't cut it. --I eat in my room and the food is cold even though it is in a warmer. --I couldn't eat my lunch dried up lima beans and old chicken again. We all agree that we don't like that old brown goo stuff on our food. My meat needs to be cooked good and done. The chicken and dumplings only had 1 piece of meat in it the size of my finger the rest was dough. b) Temperature check on test tray, On 03/13/18 at 11:28 AM, trays arrived on the floor for the Short hall. Many staff members arrive to dispatch trays. They were asked to get a temperature on the last tray to be served on this food cart. Food Service Manager #20 arrived on the floor with thermometer on 03/13/18 at 11:39 AM, to check temperatures of a test tray. Roast beef 108 degrees Fahrenheit. Food Service Manager #20 agreed the temperature of the roast beef was not high enough to meet safe and palatable standards. c) Interviews with Food Service Manager (FSM) and Administrator: On 03/13/18 at 12:00 PM, the Administrator was informed about the food and temperature complaints, and the temperature of the test tray. She said they are working on the food problem and they have food committee. During an interview with FSM#20 on 03/14/18 at 01:35 PM, he was informed the residents had complained about the bread tasting like it was frozen he said, yes it is. Also the lack of variety. He confirmed there was a food committee. During record review the food committee minutes revealed discussion about table clothes and center pieces more then about food. He said they talked about the meal of the month at the beginning of the Resident Council Meeting. On 03/14/18 at 01:50 PM, the FSM #20 confirmed the food committee was more about fine dinning than the food is served. While he was still in the room the administrator was asked what she thought the food committee was about. She said to discuss the likes and dislikes of the kind of food that the residents prefer. She was surprised to know that it was geared more towards the fine dining experience than the food.",2020-09-01
270,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2018-03-14,842,D,0,1,YXUB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, facility failed to ensure each resident's medical records was complete and accurate. Resident #62 had an inaccurate lab value, International normalized ratio (INR) documented on the resident's anticoagulant ([MEDICATION NAME]) flow record. For Resident #29, the resident's weekly wound/pressure ulcer flow sheets were blank and/or inaccurate. Resident identifiers: #62 and #29. Facility census: 56. Findings included: a) Resident #62 Review of Resident #62's medical records found a [MEDICATION NAME] (anticoagulant) Flow sheet in which read: INR 15.1, normal range is 2.0 to 3.0. Interview with the Director of Nursing (DON) on 0n 03/13/18 at 11:30 AM, confirmed the lab was documented in error. This error was confirmed by Resident #62's physician at 3:47 PM on 03/13/18. b) Resident #29 Resident #29 had pressure ulcers on the right upper/inner posterior thigh and the left outer ankle. Resident #29's right thigh pressure ulcer had been present since (YEAR). Despite the presence of pressure ulcers, Resident #29's Weekly Licensed Nurse Skin Evaluations indicated No for the question Any existing ulcers (previously identified)? for the following dates: --03/02/18 --02/16/18 --01/26/18 --01/19/18 A Weekly Wound Evaluation for Resident #29 on 01/05/18 indicated a left ankle wound was identified on 01/05/18. Weekly Wound Evaluations on 01/12/18, 01/19/18, and 01/26/18 also indicated Resident #29's left ankle wound was identified on 01/05/18. However, Weekly Wound Evaluations on 01/29/18, 02/05/18, and 02/12/18 indicated Resident #29's left ankle wound was identified on 01/05/16. A Weekly Wound Evaluation on 02/14/18 indicated Resident #29's left ankle wound was identified on 01/05/18. Weekly Wound Evaluations on 02/23/18 and 03/09/18 indicated Resident #29's left ankle wound was identified on 01/05/16. Additionally, during review of Resident #29's medical records, Weekly Wound Evaluations for Resident # 29's left ankle wound and right thigh wounds could not be located for the time period between 02/23/18 and 03/09/18. During an interview on 03/14/18 at 12:06 PM, the Director of Nursing (DoN) was informed about the following issues: --Resident #29's Weekly Licensed Nurse Skin Evaluations which indicated No for the question Any existing ulcers (previously identified)? even though the resident did have pre-existing skin ulcers. The DON had no additional information regarding this matter. --The discrepancies on the Weekly Wound Evaluations which indicated Resident #29's left ankle wound was identified on 01/05/18 and 01/05/16. The DoN stated the 01/05/16 dates had been entered in error. --The absence of Weekly Wound Evaluations for Resident's left ankle and right thigh wounds for the week between 02/23/18 and 03/09/18. On 03/14/18 at 1:21 PM, the DON confirmed no Weekly Wound Evaluations had been performed between 02/23/18 and 03/09/18.",2020-09-01
271,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2019-11-06,609,D,1,0,L1WQ11,"> Based on policy review, record review, and staff interview, the facility failed to report allegations of abuse and neglect within the required timeframe. This deficient practice was found for three (3) of four (4) residents reviewed for the care area of abuse. Resident identifiers: #65, #26, #40. Facility census: 65. Findings included: a) Policy Review A review of the facility's abuse policy titled, Abuse, Neglect and Exploitation, implemented on 11/27/17 and last revised on 02/01/19 abuse and neglect are to be reported to the required agencies within specified time frames. b) Resident #65 Per a review of the facility's abuse and neglect logs during the survey, Resident #65 was noted to have an incidence of abuse and/or neglect in (MONTH) 2019. Resident #65's abuse/neglect investigation with an incident date of 08/29/19 was reviewed on 11/05/19 at 12:16 PM. According to the investigation, the incident occurred between 11:00 AM and 4:00 PM on 08/29/19. Per the fax sheets attached to the investigation, the incident was reported to Adult Protective Services (APS), the Nurse Aide Registry, and the Office of Health Facility Licensure and Certification (OHFLAC) on 08/30/19 at 4:25 PM, more than 24 hours after the incident occurred. The Ombudsman was faxed on 08/30/19 at 4:26 PM, more than 24 hours after the incident occurred. c) Resident #26 Per a review of the facility's abuse and neglect logs during the survey, Resident #26 was noted to have had two (2) incidences of abuse and/or neglect in (MONTH) 2019. Resident #26's abuse/neglect investigation with an incident date of 09/10/19 was reviewed on 11/05/19 at 10:50 AM. According to the investigation, the incident occurred on 09/10/19 at 9:00 AM. Per the fax sheets attached to the investigation, the incident was reported to APS on 09/11/19 at 5:21 PM, more than 24 hours after the incident occurred. OHFLAC was notified on 09/11/19 at 5:22 PM, more than 24 hours after the incident occurred. The Ombudsman was notified on 09/11/19 at 5:27 PM, more than 24 hours after the incident occurred. Resident #26's abuse/neglect investigation with an incident date of 09/26/19 was reviewed on 11/05/19 at 11:20 AM. According to the investigation, the incident occurred on 09/26/19 at 11:00 AM. Per the fax sheets attached to the investigation, the incident was reported to APS on 09/27/19 at 4:22 PM, more than 24 hours after the incident occurred. The Nurse Aide Registry and OHFLAC were notified on 09/27/19 at 4:23 PM, more than 24 hours after the incident occurred. The Ombudsman was notified on 09/27/19 at 4:24 PM, more than 24 hours after the incident occurred. d) Resident #40 Per a review of the facility's abuse and neglect logs during the survey, Resident #40 was noted to have had an incidence of abuse and/or neglect in (MONTH) 2019. Resident #40's abuse/neglect investigation with an incident date of 08/17/19 was reviewed on 11/05/19 at 12:52 PM. According to the investigation, the incident occurred on 08/17/19 at 5:30 PM. A documented entitled, Employee Disciplinary Form found in the investigation report listed the signatures of both the alleged perpetrator and the alleged perpetrator's supervisor, along with the date of the incident (08/17/19) and indicated that the alleged perpetrator was to be suspended pending a full investigation. Per the fax sheets attached to the investigation, the incident was reported to APS on 08/19/19 at 4:42 PM, more than 24 hours after the incident occurred. The Nurse Aide Registry and OHFLAC were notified on 08/19/19 at 4:43 PM, more than 24 hours after the incident occurred. The Ombudsman was notified on 08/19/19 at 4:44 PM, more than 24 hours after the incident occurred. e) Staff Interview An interview was conducted with the facility's Social Worker (SW) on 11/06/19 at 9:07 AM regarding the delay in reporting the abuse/neglects for Residents #65, #26, and #40. She stated that she reports incidents of abuse and/or neglect within 24 hours of when she is made aware of them, but sometimes events occur on the weekends or at other times she is not in the facility, so she is notified late. She agreed that the above incidences were not reported timely and added that she has been working on some education for other nursing home staff so that they can report abuse in her (the SW's) absence. An interview with the facility's Administrator on 11/06/19 at 9:55 AM also confirmed that the above incidences were not reported timely. On 11/06/19 at 12:19 PM the Administrator provided a copy of an inservice given to all staff on the premises that day regarding the proper procedures for reporting abuse and/or neglect.",2020-09-01
3334,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-01-25,609,D,0,1,K2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to immediately report (within 2 hours) of discovery, an alleged violation of possible neglect involving serious bodily injury to Resident #52 to the proper State authorities. This was true for one (1) of two (2) residents reviewed for the care area of hospitalization . Resident identifier: 52. Facility census: 112. Findings include: a) Resident #52 Review of the facility's, Resident Incident Report, form, dated 11/07/17 at 10:15 a.m. found the following narrative of the incident and description of injuries: Called to resident's room by CNA (certified nursing assistant) while providing ADL (activities of daily living) and dressing resident. Resident was sat up on bed to have shirt put on and CNA and resident heard a loud Pop. CNA called directly to get this nurse. Resident assessed stated she thought it was her back and she felt fine. Resident is a paraplegic and has contractures to bilateral lower legs. Resident is alert and oriented x 3. When assisting resident with another nurse resident right leg observed to straighten out more in the abduction position. The Resident was assessed, vital signs obtained, and sent to the emergency room of a local hospital for X-rays. A nurses' note written at 2:52 p.m. on 11/07/17, noted the resident was admitted to the hospital with [REDACTED]. Review of the Resident's last minimum data set (MDS) with an (ARD) assessment reference date of 09/05/17 found the resident required extensive assistance of two (2) staff members for dressing. At 11:36 a.m. on 01/24/18, the director of nursing (DON) confirmed the incident was not reported. The DON said the resident is alert and oriented and the resident said nothing happened. At 1:41 p.m. on 01/24/18, the DON, administrator and the social worker discussed the incident report. The DON verified the facility did not obtain any statements from the staff regarding the incident. The DON confirmed the incident report listed only 1 nursing assistant as being a witness to the incident. She did not know if any other staff were with the nursing assistant. In addition the DON confirmed there was no information obtained at the time of the incident to support 2 staff members were dressing the resident when the incident occurred. The social worker (SW) said, Just talking to (name of resident) I didn't feel like it was reportable. The SW also said the resident had a [DIAGNOSES REDACTED]. (This [DIAGNOSES REDACTED].) The administrator said the incident was cut and dry. The resident said she wasn't hurt. Review of the medical record found the resident does have a [DIAGNOSES REDACTED]. At the time of the injury, only 1 nursing assistant was reported on the incident report as being a witness. Documentation of the MDS noted the resident required 2 nursing assistants for dressing. In addition, the age related [MEDICAL CONDITION] with current pathological fracture was not added to the resident's list of [DIAGNOSES REDACTED].",2020-09-01
3335,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-01-25,623,D,0,1,K2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to provide Resident #116 with a discharge notice upon discharge from the facility. This failed practice had the potential to affect an isolated number of residents. Resident identifier: #116. Facility census: 112. Findings include: a) Resident #116 Record review revealed Resident #116 was discharged from the facility to the hospital on [DATE] with return to the facility anticipated. The facility provided the resident with a bed hold notice and a transfer notice on 11/08/17. Further record review found on 11/14/17, the facility refused to re-admit Resident #116 due to the resident having a [DEVICE]. The legal representative was notified the facility could not accept residents with [DEVICE] on the south halls, nor did they have an available bed for a female on the north halls. The facility did not issue a discharge notice, not offer the resident appeal rights for this discharge from the facility on 11/14/17. The resident never returned to the facility, and was admitted to another nursing home in the county. The medical record listed the discharge date as 11/14/17. On 01/24/18 at 3:13 PM, interview of the legal representative confirmed the facility refused to re-admit the resident following a brief hospitalization . The refusal was verbally stated due to the facility could not accommodate residents on the south halls with [DEVICE] and the facility did not have a bed available for a female on the north halls. The legal representative said Resident #116 really wanted to return to the facility because she had many friends that she missed. Even after moving to another facility, Resident #116 had talked about the friends she missed at her former facility. During an interview with Registered Nurse (RN) #42 on 01/25/18 at 10:43 AM, she stated the facility did not provide any additional notices following the 11/08/17 bed hold and transfer notices. No further information was provided.",2020-09-01
3336,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-01-25,626,D,0,1,K2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to provide Resident #116 the next available bed upon discharge from the hospital. This failed practice had the potential to affect an isolated number of residents. Resident identifier: #116. Facility census: 112. Findings include: a) Resident #116 Record review revealed Resident #116 was discharged from the facility to the hospital on [DATE] with return to the facility anticipated. The facility provided the resident with a bed hold notice and a transfer notice on 11/08/17. Further record review found on 11/14/17, the facility refused to re-admit Resident #116 due to the resident having a [DEVICE]. The legal representative was notified the facility could not accept residents with [DEVICE] on the south halls, nor did they have an available bed for a female on the north halls. The facility did not issue a discharge notice, not offer the resident appeal rights for this discharge from the facility on 11/14/17. The resident never returned to the facility, and was admitted to another nursing home in the county. The medical record listed the discharge date as 11/14/17. On 01/24/18 at 3:13 PM, interview of the legal representative confirmed the facility refused to re-admit the resident following a brief hospitalization . The refusal was verbally stated due to the facility could not accommodate residents on the south halls with [DEVICE] and the facility did not have a bed available for a female on the north halls. The legal representative said Resident #116 really wanted to return to the facility because she had many friends that she missed. Even after moving to another facility, Resident #116 had talked about the friends she missed at her former facility. During an interview with Registered Nurse (RN) #42 on 01/25/18 at 10:43 AM, she stated the facility did not provide any additional notices following the 11/08/17 bed hold and transfer notices. No further information was provided.",2020-09-01
3337,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-01-25,637,D,0,1,K2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a significant change Minimum Data Assessment (MDS) in (MONTH) (YEAR). Resident #51 experienced a major decline in bed mobility, transfers, dressing, eating, toilet use, personal hygiene, bladder incontinence, decline in oral intake, weight loss and documented resident/family declined of hospice services and chose palliative care. Resident identifier: #51. Facility census: 112. Findings include: a) Resident #51 Resident #51's medical record found the resident was readmitted on [DATE]. Review on 01/23/18 at 10:15 a.m., found Resident #51's medical records found two (2) quarterly MDS with assessment reference dates (ARDs)of 08/30/17 and 11/29/17. Further review found the resident had experienced a major decline in bed mobility, transfers, dressing, eating, toilet use, personal hygiene, bladder incontinence, decline in oral intake, weight loss and documented resident/family declined of hospice services and chose palliative care with an expected prognosis of six months or less to live. An interview, with the Director of Nursing (DON) on 01/24/18 at 11:15 a.m. Resident #51's two quarterly MDSs with ARD of 08/30/17 and 11/29/17 were reviewed together. The DON confirmed the Quarterly MDS with ARD of 11/29/17 should be a significant change MDS and not a quarterly MDS.",2020-09-01
3338,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-01-25,641,E,0,1,K2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, facility failed to accurately complete the Minimum Data Set (MDS) to reflect each resident's status. This was true for seven (7) of twenty-five (25) sampled residents. Resident #56, #71, #106, #62, #64 MDS was inaccurate in area of restraints (side rails). Resident #75's MDS was inaccurate in area of medication. Resident #27's MDS was inaccurate in area of skin tear. Resident identifiers: #56, #71, #106, #62, #64, #75 and #27. Facility census: 112. Findings include: a) Resident #56 Review of Resident #56's medical records found a quarterly MDS with an assessment reference date (ARD) of 12/05/17. This MDS found the resident required extensive assistance of two for bed mobility and transfers. Additionally, the MDS indicated the resident had side rails which was restraints. Observation of Resident #56's found resident had bilateral less than 1/4 side rails which held the bed controls. The side rails did not restrict the residents movements. b) Resident #71 Review of Resident #71's medical records found a quarterly MDS with an assessment reference date (ARD) of 12/13/17. This MDS found the resident required extensive assistance of two for bed mobility and transfers. Additionally, the MDS indicated the resident had side rails which was restraints. Observation of Resident #71's found resident had bilateral less than 1/4 side rails which held the bed controls. The side rails did not restrict the residents movements. c) Resident #106 Review of Resident #106's medical records found an admission MDS with an assessment reference date (ARD) of 01/05/18. This MDS found the resident required extensive assistance of two for bed mobility and transfers. Additionally, The MDS indicated the resident had side rails which was restraints. Observation of Resident #106's found resident had bilateral less than 1/4 side rails which held the bed controls. The side rails did not restrict the residents movements. d) Resident #62 Review of Resident #62's medical records found a quarterly MDS with an assessment reference date (ARD) of 12/06/17. This MDS found the resident required limited assistance of one for bed mobility and transfers. Additionally, the MDS indicated the resident had side rails which was restraints. Observation of Resident #62's found resident had bilateral less than 1/4 side rails which held the bed controls. The side rails did not restrict the residents movements or her ability to get out of bed as desired. e) Resident #64 Review of Resident #64's medical records found a quarterly MDS with an assessment reference date (ARD) of 12/06/17. This MDS found the resident required extensive assistance of two for bed mobility and transfers. Additionally, the MDS indicated the resident had side rails which was restraints. Observation of Resident #64's found resident had bilateral less than 1/4 side rails which held the bed controls. The side rails did not restrict the residents movements. f) Interview Interview with Employee #166, registered nurse (RN) MDS coordinator on 01/24/18 at 8:55 a.m. She confirmed the MDSs for Residents #56, #71, #106, #62 and #64 was inaccurate in the area of side rails being restraint. She agreed that the side rails did not restrict the residents movement and/or ability to get out of bed if desired. Director of Nursing (DON) agreed the MDSs were inaccurate. She confirmed the facility did not have any restraints in use in the facility. g) Resident #75 Resident #75 had an order for [REDACTED]. The drug classification of Brilinta (Ticagrelor) is platelet aggregation inhibitor. Resident #75's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 11/18/17, Section N, Medications, stated the resident received seven (7) days of anticoagulant therapy during the last 7 days. The Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual stated, Do not code antiplatelet medications . During an interview on 01/24/18 at 9:28 AM, Registered Nurse Case Manager #135 agreed Brilinta was not supposed to be coded as an anticoagulant because it is a platelet aggregation inhibitor. The MDS was corrected on 01/24/18 to reflect zero (0) days of anticoagulant therapy received by Resident #75. h) Resident #27 Review of the residents incident reports noted the resident received a 2 centimeter by 1 centimeter skin tear to the right forearm on 11/13/17 at 9:47 a.m. Review of the resident's most recent MDS, an annual with an ARD of 11/15/17, with Registered Nurse, #166, at 10:04 a.m. on 01/24/18, confirmed the MDS did not code the resident as having a skin tear. RN #166 said she would complete a correction MDS.",2020-09-01
3339,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-01-25,656,E,0,1,K2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop non-pharmacological interventions for antianxiety care plan goals for 4 out of 25 residents reviewed for unnecessary medications. The failed practice had the potential to affect more than a limited number of residents. Residents: #48, 23, 61, and #53. Facility census: 112. Findings include: a) Resident #48 Record review for Resident #48 revealed two orders for as needed or PRN [MEDICATION NAME] ([MEDICATION NAME]): --[MEDICATION NAME] Gel, apply 1 mg/ml gel topically every 6 hours as needed, order date 04/04/17, start date 04/04/17 (administered 3 x in (MONTH) (YEAR)) --[MEDICATION NAME], 1 mg tablet, give one tablet by mouth every 6 hours as needed, order date 08/15/17 and start date same for anxiety disorder (administered 8 times (MONTH) (YEAR)) Further record review found the following associated Diagnoses: [REDACTED]. --Major [MEDICAL CONDITION], recurrent, severe w/ psych symptoms; --Restlessness and agitation; --Dementia in other diseases classified elsewhere with behavioral disturbances; and --[MEDICAL CONDITION] with late onset. Record review found a care plan for the use of anti-anxiety medication with an onset date of 04/04/17: --(Resident Name) is at risk for side effects from antianxiety medication use. (Resident Name) will have no injury related to medication usage/side effects. --Administer (Resident Name) medication as ordered by physician --Observe (Resident Name) for adverse side effects. Document and report to physician --Monitor and record (Resident's Name) behaviors --Observe (Resident's Name) for signs of extrapyramidal sumptoms and document. --Resident is prescribed [MEDICATION NAME] The care plan did not address the use of non-pharmacological interventions for Resident #48 prior to the use of as needed [MEDICAL CONDITION] medication. From (MONTH) 1, (YEAR) through (MONTH) 23, (YEAR), Resident #48 was administered PRN [MEDICATION NAME] 31 times without any non-pharmacological interventions attempted prior to administration. Interview with the DON and Administrator on 01/25/18 at 11:45 AM confirmed non-pharmacological interventions were not addressed by the care plan, nor implemented prior to the administration of PRN [MEDICAL CONDITION] medications. b) Resident #23 Record review for Resident #23 found physician orders [REDACTED]. --[MEDICATION NAME] 0.5 mg tablet, give one tablet by mouth at bedtime for unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition (Order date 10/23/15 and Start date 10/23/15) --[MEDICATION NAME] 2 mg/ml oral concentrate, give 1 mg (0.5 ml) by mouth or [MEDICATION NAME] 3 times a day and up to every four hours as needed for anxiety disorder, unspecified. (HAS SCHEDULED ORDER). Order date 06/25/14 and start date 05/22/17 --[MEDICATION NAME] 2 mg/ml vial, give 1 mg intramuscular every 2 hours as needed, order date 02/17/17, start date 02/20/17 for anxiety disorder --[MEDICATION NAME] 2 mg/ml oral concentrate, give 1 mg (0.5 ml) by mouth or [MEDICATION NAME] 3x a day and up to every four hours as needed for anxiety disorder, unspecified. Order date 06/08/14 and start date 05/22/17 Further record review for Resident #23 found the following associated Diagnoses: [REDACTED]. --Anxiety disorder, unspecified; --Dementia in other diseases classified elsewhere with behavioral disturbances; --Restlessness and agitation; and --[MEDICAL CONDITION] with late onset. Record review found the following current care plan for the use of antianxiety medications: [REDACTED] --(Resident's Name) is at risk for side effects from antianxiety medication use. --(Resident's Name) will have no injury related to medication usage/side effects. --Administer (Resident's Name) medication as ordered by physician --Observe (Resident's Name) for adverse side effects. Document and report to physician --Monitor and record (Resident's Name) behaviors --Pharmacy consultant review of (Resident's Name) medication monthly --Resident is prescribed [MEDICATION NAME] The care plan did not address the use of non-pharmacological interventions for Resident #23 prior to the use of as needed [MEDICAL CONDITION] medication. Interview with the DON and Administrator on 01/25/18 at 11:45 AM confirmed non-pharmacological interventions were not addressed by the care plan for the use of PRN [MEDICAL CONDITION] medication. The DON stated the resident was on hospice and non-pharmacological interventions were not required. Review of the medical record did not identify Resident #23 as receiving hospice. Resident #23 had a hospice care plan to experience a peaceful, dignified death and to maintain comfortable hospice care. The onset date for this care plan goal was 04/07/14 with an achieved date of 04/22/15. Resident #23 was not a current hospice resident. c) Resident #61 Review of the medical record for Resident #61 found physician orders [REDACTED]. --[MEDICATION NAME] 0.5 mg tablet, give one tablet by mouth every six hours as needed with order/start date of 05/14/17. Further review of the medical record for Resident #61 found the following associated diagnoses -Anxiety disorder, unspecified; --Dementia in other diseases classified elsewhere with behavioral disturbances; --Major [MEDICAL CONDITION], recurrent, unspecified; and --[MEDICAL CONDITION] with late onset. Record review found the following care plan for the use of as needed antianxiety medication with an onset date of 02/26/14 for potential alteration in behaviors related to history of being resistive to care. --(Resident's Name) is at risk for side effects from antianxiety medication use. --(Resident's Name) will have no injury related to medication usage/side effects. --Observe (Resident's Name) for adverse side effects. Document and report to physician --Monitor and record (Resident's Name) behaviors --Pharmacy consultant review of (Resident's Name) medication monthly --Monitor (Resident's Name) for signs of extrapyramidal symptoms and document --Psych evals as ordered with (Doctor's Name) --Administer (Resident's Name) medication as ordered by physician --[MEDICATION NAME] 0.5 mg tablet, give one tablet by mouth every six hours as needed The care plan did not address the use of non-pharmacological interventions for Resident #61 prior to the use of as needed [MEDICAL CONDITION] medication. From (MONTH) 1, (YEAR) through (MONTH) 23, (YEAR), Resident #61 was administered PRN [MEDICATION NAME] 74 times without any non-pharmacological interventions attempted prior to administration. Interview with the DON and Administrator on 01/25/18 at 11:45 AM confirmed non-pharmacological interventions were not addressed by the care plan, nor implemented prior to the administration of PRN [MEDICAL CONDITION] medications. d) Resident #53 Review of the resident's care plan found the resident had a history of [REDACTED]. Past care plans addressed the following pressure areas: --A stage 2 to the right buttock, care plan, archived on 10/04/17. --Stage 2 pressure ulcer to her sacrum, archived 11/02/17 --Stage 2 pressure ulcer to the coccyx, archived 05/26/16 --Stage 2 pressure ulcer to the right buttock, and the left buttock, archived 05/09/17. --Stage 1 pressure ulcer to the right and left sacrum, now Stage 2 to sacrum and 2 areas to the right side of the sacrum, archived on 12/28/17. --A Stage 2 to the coccyx, archived 02/16/17, etc. Currently the resident has a Stage 2 pressure ulcer to the sacrum. A current physician's orders [REDACTED]. Review of the current care plan found the problem: --(Name of Resident) has a Stage 2 pressure ulcer Sacrum The goals associated with the problem were: --(Name of Resident) area will be healed by 3/6/18, --(Name of Resident) area will decrease in size by 50%, --(Name of Resident) area will remain free of infection. Approaches included: --Reposition (Name of Resident) every 2 hours and as needed, --(Name of Resident) needs wound care as ordered by physician, --Needs assistance with repositioning to avoid skin friction/shearing, --(Name of Resident) needs a referral to a dietician to evaluate resident nutritional status, --Encourage (Name of Resident's) good nutritional intake for healing, --(Name of Resident) needs weekly evaluation of wound healing, --(Resident of Resident) needs a daily observation of skin with routine care, --Adjust (Name of Resident's) treatment plan if no healing within 2-4 weeks, --Monitor for changes in (Name of Resident's) skin status that may indicate worsening of pressure ulcer and notify the physician. The resident also has a current [DIAGNOSES REDACTED]. At 12:09 p.m. on 01/23/18, Registered Nurse, #166, confirmed the wheelchair cushion was an approach to prevent pressure ulcers and should be on the resident's current care plan.",2020-09-01
3340,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-01-25,657,D,0,1,K2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. ased on medical record review and staff interview, the facility failed to revise the care plan after Resident #51 experienced a major decline in bed mobility, transfers, dressing, eating, toilet use, personal hygiene, bladder incontinence, decline in oral intake, weight loss and documented resident/family declined of hospice services and chose palliative care. Resident identifier: #51. Facility census: 112. Findings include: a) Resident #51 Resident #51's medical record found the resident was readmitted on [DATE]. Review on 01/23/18 at 10:15 a.m., found Resident #51's medical records found two (2) quarterly MDS with assessment reference dates (ARDs)of 08/30/17 and 11/29/17. Further review found the resident had experienced a major decline in bed mobility, transfers, dressing, eating, toilet use, personal hygiene, bladder incontinence, decline in oral intake, weight loss and documented resident/family declined of hospice services and chose palliative care with an expected prognosis of six months or less to live. Review of current comprehensive care plan found no revision after Resident #51 experienced a major decline. An interview, with the Director of Nursing (DON) on 01/24/18 at 11:15 a.m. Resident #51's care plan was reviewed together. The DON confirmed the care plan had not been revised after Resident #51 had experienced a major decline.",2020-09-01
3341,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-01-25,684,D,0,1,K2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to identify and provide treatment and care needed in accordance with professional standards of practice to meet the physical, mental and psychological needs of residents concerning weight loss and neurological checks following an unwitnessed fall. Resident identifiers: #13 and #91. Facility Census: 112. Findings include: a) Resident #13 Review of facility Weights Policy with a revision date of 03/20/15 revealed the following: --It is the policy of the facility to assist all residents to reach or maintain their optimal nutritional parameters. To identify factors contributing to weight changes and intervene as appropriate to resolve the problem and avoid further weight changes and complications related to a nutritional deficiency unless the resident's clinical condition demonstrates that it is not possible. --Significant weight loss means a 5% weight loss in 30 days, 7.5% weight loss in 90 days, and 10% weight loss within 180 days, or a five (5) pound weight loss or gain within one (1) week. --Residents will be weighted on a monthly basis, unless otherwise not requested, such as hospice request, physician order, family or resident choice. This will be documented in the medical record. All monthly weights will be obtained by the fifth of every month. All weights will be obtained by same method if available. --Re-weights: A re-weight will be obtained within 24 hours of previous weight if resident shows a 5# or more gain or loss. Monthly Weights, Weekly Weights and Re-Weights will be placed in the computer and can be found under the Vital Tab. After weights and re-weights have been obtained, Dietary Manager or Designee will form a monthly RD referral list that will include the following: a 5% gain or loss in 30 days; and/or a 10% gain or loss in 180 days. Record review of Resident # 13 medical record, on 01/24/18 at 11:15 AM, revealed a physician's orders [REDACTED]. 11.6 lb. weight loss in a 180-day period (10%) 2. Dietary Referral. Upon further record review, a dietary referral was not found in Resident #13's record for (MONTH) (YEAR). Additional record review revealed the last Dietary Progress note was dated 11/15/17 at 11:35 AM, and stated, Nutrition follow up re: weight. Wt at 101.8#. Stable in the last month. She has lost 13# total in the last 6 months though. Meal intake remains par for resident. 61% avg of meals with 1100 ml avg fluids. Staff reports she is not a big eater. Supplement recently changed to Two Cal for med pass. Receives super cereal at b'fast. B'fast continues to be her best meal. Meds noted. (11/6) GFR 49, H/H 11.3/34.1. Continue supplements. Liberalized diet to regular puree. Remove no added salt restriction. Signed Employee #127, Dietician. An interview and medical record review on 01/24/18 at 1:00 PM, was completed with Dietary Manager, Employee #62, and confirmed the above physician's orders [REDACTED].#13. Employee #62 stated, As soon as I receive a Notice to Dietary, I immediately, forward it to our Registered Dietician (RD), for her review and follow-up. There isn't even a 'Notice to Dietary' dated 12/09/17 under the 'Dietary' tab for this resident. The last dietary consults I received for this resident was on 11/15/17 and 11/06/17. At that time, Employee #62 formally asked the Licensed Practical Nurse (LPN) #148 to complete a Notice to Dietary for Resident #13's physician's orders [REDACTED].#148, Employee #62 stated, I will send this to the RD immediately, and I'll bring you a copy of her dietary note as soon as I receive it. The Dietary note, dated 01/24/18 at 2:28 PM stated, Nutrition referral re: significant wt. loss in the last 6 month. 11# loss in 180 days total, however weight has been stable within 1# since October. CW: 100.6#. BMI=18.4. Recent meal avg at 56% with 980 ml fluid. She gets super cereal at b'fast and Two Cal TID with med (consumes per nursing documentation in EMAR.) Plan appropriate. Continue supplement. Add to hydration program. Encourage increase in oral fluids-offer nutritious beverage option. Signed Employee #127, Dietician. b) Resident #91 1. Weight loss On 12/09/17, Resident #91 had a verbal order from his attending physician for a dietary referral due to a thirteen (13) pound weight loss in a 180-day period, or a nine (9) percent weight loss during this period. On 12/28/17 at 8:21 AM, Resident #91 was evaluated by Certified Dietary Manager (CDM) #62. The evaluation reported the resident triggered for a thirteen (13) pound or nine (9) percent weight loss during a 180-day period. According to the evaluation on 12/28/17, Resident #91's weight had stabilized since then. During an interview on 01/24/18 at 10:00 AM, the Director of Nursing (DoN) was asked if Resident #91 had received a dietary referral following the verbal order on 12/09/17. The DoN stated Resident #91 was evaluated by the CDM on 12/28/18, the Interdisciplinary Team (IDT) on 01/04/18, and the Registered Dietician (RD) on 01/11/18. However, there was not a dietary referral immediately following the 12/09/17 verbal order for a dietary referral. On 01/24/18, a dietary referral was reordered for Resident #91. 2. Neurological checks following an unwitnessed fall Resident #91 is a [AGE] year-old man. According to the Minimum Data Set (MDS) with Assessment Reference Date (ARD) 10/02/17, Resident #91's Brief Interview for Mental Status (BIMS) score was 4. On 11/17/17 at 10:22 AM, Resident #91 was found sitting on the floor of his room between the beds. The Resident Incident Report stated, Resident able to move all extremities without difficulty. No redness or bruising noted. Resident denies pain. Resident assisted up without difficulty. No injury observed. Resident stated I did not hit my head. No red area or bruising noted to head. The incident level was determined to be Non-witnessed. According to the facility's Policy and Procedure for unwitnessed falls, It is the policy of PHCC to perform head injury checks for unwitnessed falls. A head injury check sheet following Resident #91's unwitnessed fall on 11/17/17 could not be located in the medical records. On 01/25/18, at 10:02 AM, the Administrator confirmed a head injury check sheet was not initiated for Resident #91 following his unwitnessed fall on 11/17/17. On 01/25/18 at 10:49 AM, the Director of Nursing (DoN) was informed a head injury check sheet was not initiated for Resident #91 following his unwitnessed fall on 11/17/17. She was informed Resident #91 could not be relied upon to accurately state whether he hit his head during the fall due to his low BIMS score. The DoN provided no additional information for this matter.",2020-09-01
3342,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-01-25,686,D,0,1,K2BO11,"**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 five (5) resident's reviewed for pressure ulcers had interventions in place to promote the healing of pressure ulcers. Resident identifier: #53. Facility census: 112. Findings include: a) Resident #53 Review of the resident's care plan found the resident had a history of [REDACTED]. Past care plans addressed the following pressure areas: --A stage 2 to the right buttock, care plan, archived on 10/04/17. --Stage 2 pressure ulcer to her sacrum, archived 11/02/17 --Stage 2 pressure ulcer to the coccyx, archived 05/26/16 --Stage 2 pressure ulcer to the right buttock, and the left buttock, archived 05/09/17. --Stage 1 pressure ulcer to the right and left sacrum, now Stage 2 to sacrum and 2 areas to the right side of the sacrum, archived on 12/28/17. --A Stage 2 to the coccyx, archived 02/16/17, etc. Currently the resident has a Stage 2 pressure ulcer to the sacrum. The resident also has a [DIAGNOSES REDACTED]. A current physician's orders [REDACTED]. At 12:19 p.m. on 01/23/18, observation with Registered Nurse (RN) #10 found the resident did not have a wheelchair cushion in her chair according to the physician's orders [REDACTED]. In addition observation of the resident on 01/23/18 at 8:10 a.m., found the wheelchair cushion was not present.",2020-09-01
3343,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-01-25,692,D,0,1,K2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of five (5) residents who receives enteral feedings consistently maintained acceptable parameters of nutritional status. Due to the inconsistency of the resident's daily oral intake, the facility could not ensure the resident received the daily caloric and fluid intake recommended by the Registered Dietician. Resident identifier: #21. Facility census: 112. Findings include: a) Resident #114 Record review found the resident was originally admitted to the facility on [DATE] with a gastrostomy tube. According to the care plan the resident was admitted with Hospice services which were later discontinued on 05/03/17. Pallative services were started on 07/09/17. On 03/19/18, the resident's weight was 161.3 pounds. On 01/01/18, the resident's weight was 153.2 pounds. Original admission orders [REDACTED] --[MEDICATION NAME] 240 milliliters (ml) by gastrostomy tube 5 times a day. 12:00 a.m., 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m. --Flush 200 ml's of H2O (water) by gastrostomy tube after each feeding --Flush gastrostomy tube with 30 ml water before and after medications. The time for these flushes were 10:00 a.m. and 10:00 p.m. The only nutritional assessment was completed on 03/23/17. The assessment noted the following daily requirements for the resident: --1852.0 calories per day, --74.0 total protein requirement --2220.0 ml's fluid requirement. The dietary assessment noted the resident NPO, (no food or liquids by mouth). A registered dietician note, dated 05/09/17, noted the resident was eating well. At this time, recommended to hold all peg tube feeding of [MEDICATION NAME]. The physician discontinued all tube feedings on 05/09/17. A registered dietician note, dated 06/08/17, Resident with recent weight loss. Current weight 169.4 pounds. She originally gained a lot of weight after admission and has since started losing. BMI still high at 25.8. Concern at this time is decrease in oral intake and refusal of medications. In the last 3 days, resident as refused 6 meals. Oral fluids low at 613 ml average. At this time need to resume enteral nutrition. She needs 5 cans [MEDICATION NAME] daily if she does not eat anything. Give 240 ml [MEDICATION NAME] every night. Give additional 240 ml [MEDICATION NAME] when she refuses meal tray. Flush with 180 ml free water per can of tube feeding. Give additional water flush with meds. Continue Juven two times a day. A registered dietician note, dated 01/05/18, Nutrition follow up to check weight, wound and tube feeding. Weight this month at 153.2 pounds-weight has been stable for the last 3 months, but overall loss in six (6) months. Oral intake remains par for resident. 3 day average at 22% (4 refusals). Overall fluid intake 2630 ml oral and tube. Currently the resident receive a meal tray and a bolus tube feeding. Review of the January, (YEAR) treatment administration record (TAR) found the current orders: [MEDICATION NAME], give 240 ml bolus by syringe through gastrostomy tube four (4) times a day at 10:00 a.m., 2:00 p.m., 6:00 p.m., and 10:00 p.m. Flush with 180 ml water by syringe through gastrostomy tube four (4) times a daily after tube feeding. Flush gastrostomy tube with 30 ml water before and after medications at 10:00 a.m. and 10:00 p.m. The 10:00 a.m. bolus feeding was observed by the nurse survey with licensed practical nurse (LPN) # 54 at 10:15 on 01/24/18. LPN #54 bolus fed the resident with a carton of [MEDICATION NAME]. The carton noted the feeding had 355 calories for 8 ounces. The carton contained 8 ounces of feeding (237 ml). The total daily calorie count for [MEDICATION NAME] daily is 1420 calories. The fluid provided by the nursing staff was 120 ml with medications and 720 ml's of fluid for a total of 840 ml's of fluid. Although the resident received food and fluid by mouth, there was no guarantee the resident would receive the additional calories and fluid from her meal trays. At 11:39 a.m. on 01/24/18, the director of nursing (DON) and the administrator were asked how the facility would ensure the resident received the daily calories and fluid need daily. At 2:41 p.m. on 01/24/18, the dietary manager verified the resident had lost weight and the resident was a poor eater. The DM said she would have to get the assessments from the registered dietician. At the close of the survey at 5:30 p.m. on 01/25/18, the only Registered Dietician assessment provided was the initial assessment, dated 03/23/17.",2020-09-01
3344,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-01-25,693,E,0,1,K2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and staff interview, the facility failed to ensure residents who was fed by enteral (tube feeding) means receives the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers. The facility failed to ensure the licensed nursing staff labeled each eternal feedings when administered, (i.e. type of feeding, amount to be instilled, date and time, and initials of nurse administering. Additionally, the facility failed to ensure a resident is receiving nutrition via a feeding tube, the practitioner and the interdisciplinary team identify the resident's nutritional needs and facility procedures that direct staff in providing care and services to the resident. The practitioner's orders related to tube feeding typically include the following components: kind of feeding and its caloric value; volume, duration, and mechanism of administration (e.g., gravity or pump); and frequency and total amount of flush. This was true for four (4) of four(4) residents receiving tube feedings using a pump. Resident identifiers: #104, #20, #51 and #30. Facility census: 112. Findings include: a) Resident #104 Observation on 01/22/18 at 10:25 a.m., found eternal feeding bag full of formula labeled Two-cal and date of 01/22/18 and a separate hanging bag of a clear substance with no label. Review of Resident #104's physician orders [REDACTED]. --Two cal- Administer 240 milliliters (ml) by gastrostomy tube and pump (3) three times daily. --NPO- (nothing by mouth) --Flush gastrostomy tube with 30 ml. of H2O (water) before and after medication. --240 ml. free H2O four times (4) daily after tube feeding by gastrostomy tube and pump. --Keep HOB ( head of bed) up greater than 45 degrees during tube feedings and for two (2) hours after tube feedings are stopped. This order failed to have the caloric value of the tube feeding formula. b) Resident #20 Observation on 01/22/18 at 11:00 a.m., found eternal feeding bag full of formula labeled [MEDICATION NAME] and date of 01/22/18 and a separate hanging bag of a clear substance with no label. Review of Resident #20's physician orders [REDACTED]. --[MEDICATION NAME] 1.5 cal (calories)- Administer 240 milliliters (ml) by gastrostomy tube and pump (4) four times daily. --Flush gastrostomy tube with 30 ml. of H2O (water) before and after medication. --240 ml. free H2O four times (4) daily after tube feeding by gastrostomy tube and pump. --Keep HOB ( head of bed) up greater than 45 degrees during tube feedings and for two (2) hours after tube feedings are stopped. This order failed to have the caloric value of the tube feeding formula. c) Resident #51 Observation on 01/22/18 at 11:15 a.m., found eternal feeding bag full of formula labeled Ensure [MEDICATION NAME] and date of 01/22/18 and a separate hanging bag of a clear substance with no label. Review of Resident #51's physician orders [REDACTED]. --Ensure [MEDICATION NAME]- Administer 240 milliliters (ml) by gastrostomy tube and pump (4) four times daily. --NPO- (nothing by mouth) --Flush gastrostomy tube with 30 ml. of H2O (water) before and after medication. --240 ml. free H2O four times (4) daily after tube feeding by gastrostomy tube and pump. --Keep HOB ( head of bed) up greater than 45 degrees during tube feedings and for two (2) hours after tube feedings are stopped. This order failed to have the caloric value of the tube feeding formula. d) Resident #30 Observation on 01/22/18 at 2:00 p.m., found eternal feeding bag full of formula labeled [MEDICATION NAME] amount and date of 01/22/18 and a separate hanging bag of a clear substance with label, which read H2O. No nurse's initials could be found. Review of Resident #30's physician orders [REDACTED]. --[MEDICATION NAME] 1.5- Administer 240 milliliters (ml) by gastrostomy tube and pump (3) three times daily. --NPO- (nothing by mouth) --Flush gastrostomy tube with 30 ml. of H2O (water) before and after medication. --200 ml. free H2O four times (4) daily after tube feeding by gastrostomy tube and pump. --Keep HOB ( head of bed) up greater than 45 degrees during tube feedings and for two (2) hours after tube feedings are stopped. This order failed to have the caloric value of the tube feeding formula. e) Observations and Interviews On 01/22/18 at 12:00 p.m., observation and interview with the Director of Nursing (DON), found the feedings for Resident #104, #20, #51, not labeled appropriately with type of feedings, amount and frequency of feedings, nurses initials. Also, the bags of feeding were full instead of adding just the amount needed at times administered. Unable to determine if the appropriate amount of feeding and free water was administered. On 01/23/18 at 10:00 a.m. observation of Resident #104, #20, #51 and #30's tube feeding bags of formula and water was labeled appropriately. Additionally, the amount of formula was only added at appropriate time of feeding administration. The DON also provided an in-service initiated for all of the licensed nursing staff on 01/22/18 for the care of the tube feedings and syringe usage. Review of the Guidance to Surveyors reads: Nutritional Aspects of Feeding Tubes --When a resident is receiving nutrition via a feeding tube, the practitioner and the interdisciplinary team identify the resident's nutritional needs and facility procedures that direct staff in providing care and services to the resident. The practitioner's orders related to tube feeding typically include the following components: kind of feeding and its caloric value; volume, duration, and mechanism of administration (e.g., gravity or pump); and frequency of flush. --Flow of feeding. Direction for staff regarding how to manage and monitor the rate of flow, such as: --Use of gravity flow; --Use of a pump; --Periodic evaluation of the amount of feeding being administered for consistency with practitioner's orders; --Calibration of enteral feeding pumps to ensure that pump settings accurately provide the rate and volume consistent with the resident's care plan; and --Periodic maintenance of feeding pumps consistent with manufacturer's instructions to ensure proper mechanical functioning.",2020-09-01
3345,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-01-25,756,E,0,1,K2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to conduct monthly medical regimen review (MRR) for 5 out of 25 residents reviewed for unnecessary medications. Resident #6, 110, 48, 23, and 61 the facility's consultant pharmacist did not conduct the required monthly medication regimen review for the residents prescribed medications, including [MEDICAL CONDITION] medications. The practice had the potential to affect more than a limited number of residents. Resident identifiers: #6, 110, 48, 23, and 61. Facility census: 114. Findings include: a) Facility Medication Regimen Review Policy Review of the facility policy for Medication Regimen Review with an implementation date of 12/09/16 has the following relevant Policy Explanation and Compliance Guidelines: --Medication Regimen Review (MRR) is a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication. The review includes preventing, identifying, reporting, and resolving medication-related problems, medication errors, or other irregularities, and collaborating with other members of the interdisciplinary team. --The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist to include residents that 1) are receiving respite care; 2) are at the end of life or have elected the hospice benefit and re receiving respite care; 3) have an anticipated stay of less than 90 days; or 4) have experienced a change in condition. --A licensed pharmacist will perform the medical record review for long term and short term residents, make recommendations if applicable, and communicate to the facilty verbally or in writing. Review of the facility's MMR policy did not find language pertaining the the federal regulation at 483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist. The policy fails to address the the required monthly review of all residents. b) Resident #48 Record review for Resident #48 revealed physician orders for the following medication regimen: --[MEDICATION NAME], 10 mg tablet, give one tablet by mouth once daily --Rulox Suspension, give 20 cc by mouth every four hours as needed --SM Anit-Diarrheal, 2 mg caplet, give one caplet by mouth after each loose stool as needed --[MEDICATION NAME] ER, 5 mg tablet, give 3 tablets by mouth every thrid day as needed for constipation --Milk of Magnesia Concentrated, give 30 cc by mouth once in 24 hour period as needed for constipation --[MEDICATION NAME], 10 mg tablet, give one tablet by mouth once daily --Ensure, give 240 ml by mouth when refuses meal --[MEDICATION NAME], 1 mg/1ml oral syrup, give 1 mg/ml by mouth at bedtime --[MEDICATION NAME] Gel, apply 1 mg/ml gel topically every 6 hours as needed --[MEDICATION NAME], 1 mg tablet, give one tablet by mouth every 6 hours as needed --[MEDICATION NAME], 5-325 mg tablet, give one tablet by mouth every four hours as needed --[MEDICATION NAME], 5-325 mg tablet, give one tablet by mouth every eight hours and up to every four hours as needed Review of the Consultant Pharmacist Notes revealed the following month notes from (MONTH) (YEAR) - (MONTH) (YEAR): --01/08/18 at 9:32 AM- On [MEDICATION NAME]. Dx = Alzheimers with behavioral disturbances. Ensure documentation of behaviors. --12/06/17 at 5:25 PM - ok with med review --11/06/17 at 2:07 PM - No problems noted The documentation presented did not support a thorough monthly MMR by the consultant pharmacist to identify irregularities in a written report to the physician. Further review of the medical record revealed a Medication Regimen Review Form for Resident #48 dated 02/23/17. The form noted the resident was a new admission. Interview with the DON on 01/25/18 at 9:27 AM was asked to review this form. Upon inquiry the DON revealed the consultant pharmacist only uses this form for new admissions, readmissions and acute change of condition. She further confirmed this form nor one similar to it were not used by the consultant pharmacist to conduct monthly MRR. c) Resident #23 Record review for Resident #23 found physician orders for the following medication regimen: --[MEDICATION NAME], 0.004% eye drop, administer one drop to both eyes at bedtime --Rolux Suspension, give 20 cc by mouth every four hours as needed --Tylenol 325 mg tablet, give 2 tablets by mouth every 4 hours as needed for fever higher than 101.1 F --Immodium A-D, 2 mg caplet, give one caplet by mouth after each loose stool as needed for diarrhea --Milk of Magnesia Concentrated, give 30 cc by mouth once in 24 hours as needed for constipation --[MEDICATION NAME] EC, 5 mg tablet, give three tablets every third day as needed for constipation --[MEDICATION NAME], 0.5 mg tablet, give one tablet by mouth at bedtime --[MEDICATION NAME] 2 mg/ml oral concentrate, give 1 mg (0.5 ml) by mouth or [MEDICATION NAME] 3 times a day and up to every four hours as needed for anxiety disorder, unspecified. (HAS SCHEDULED ORDER) --[MEDICATION NAME] 2 mg/ml vial, give 1 mg intramuscular every 2 hours as needed --[MEDICATION NAME] 2 mg/ml oral concentrate, give 1 mg (0.5 ml) by mouth or [MEDICATION NAME] 3x a day and up to every four hours as needed for anxiety disorder, unspecified Review of the Consultant Pharmacist Notes revealed the following month notes from (MONTH) (YEAR) - (MONTH) (YEAR): --01/08/18 - Dx (diagnosis) = [MEDICAL CONDITION]. GDR attempted Nov (November) (YEAR). ok --12/06/17 - [MEDICATION NAME] GDR enated Nov (November) (YEAR) --11/06/17 - Per staff (2 nurses and one tech), only behavior is loud vocalizations at certain times. Is (Resident) a candidate for a GDR? The documentation presented did not support a thorough monthly MMR by the consultant pharmacist to identify irregularities in a written report to the physician. d) Resident #61 Review of the medical record for Resident #61 found physician orders for the following medication regimen: --[MEDICATION NAME] 0.5 mg tablet, give one tablet by mouth every six hours as needed --[MEDICATION NAME] 40 mg tablet, give one tablet by mouth daily --[MEDICATION NAME] 15 mg tablet, give one tablet by mouth at bedtime --[MEDICATION NAME] 400 mg capsule, give one capsule by mouth three times daily --Loratab 10-325 mg tablet, give one tablet by mouth every eight hours and up to every four hours as needed --Loratab 10-325 mg tablet, give one tablet by mouth every four hours as needed --[MEDICATION NAME] 40 mg tablet, give one tablet by mouth once daily --[MEDICATION NAME] 100 units/ml vial, give 8 units subcutaneously at bedtime --[MEDICATION NAME] 5T units/0.1 ml vial, give 0.1 ml intradermally to forearm --[MEDICATION NAME] 25 mg tablet, giveone tablet by mouth once daily --[MEDICATION NAME] Sodium 20 mg tablet, give one tablet by mouth daily at bedtime --[MEDICATION NAME] DR 40 mg capsule, give one capsue by mouth twice daily --[MEDICATION NAME] 25 mg tablet, give one tablet by mouth once daily --Folate 1 mg tablet, give one tablet my mouth once daily --Potassium CL ER 20 meq tablet, give one tablet by mouth once daily --[MEDICATION NAME] 5 mg tablet, give one tablet by mouth once daily --[MEDICATION NAME] ER 10 mg tablet, give one tablet by mouth daily --[MEDICATION NAME], 25 mg tablet, give one tablet by mouth at bedtime --[MEDICATION NAME] 5-160 mg tablet, give one tablet by mouth daily --[MEDICATION NAME] 100 mg capsule, give 2 capsules by mouth once daily --[MEDICATION NAME] 500 mg tablet, give one tablet by mouth twice daily --[MEDICATION NAME] 2.5 - 0.025 mg tablet, give one tablet b mouth twice daily --[MEDICATION NAME] 10 mg, tablet, give one tablet by mouth at bedtime --Cholestryamine Light Packet, give one packet in 240 ml of fluids by mouth at bedtime --Tylenol 325 mg tablet, give two tablets by mouth every four hours as needed for fever --Tylenol 325 mg tablet, give two tablets by mouth every four hours as needed for pain --[MEDICATION NAME]-DM Syrup, give 10 cc by mouth every four hours as needed for cough --Immodium A-D 2mg caplet, give one caplet by mouth after each loose stool as needed --[MEDICATION NAME][MEDICATION NAME] mg tablet, give one tablet by mouth every six hours as neede for nausea --Vitamin D3 50,000 units capsule, give one capsule by mouth weekly on Saturdays --Magnesium 400 mg tablet, give one tablet by mouth twice daily --[MEDICATION NAME] 325 mg tablet, give one tablet by mouth twice daily --Vitamin C 500 mg tablet, give one tablet by mouth twice dialy Review of the Consultant Pharmacist Notes revealed the following month notes from (MONTH) (YEAR) - (MONTH) (YEAR): --01/05/18 - No suggestions --12/04/17 - No problems noted --11/03/17 - Please reschedule Vitamin C so that it is given at the same time as iron (to increase iron absorption) The documentation presented did not support a thorough monthly MMR by the consultant pharmacist to identify irregularities in a written report to the physician. e) Resident #6 Review of Resident #6's medical record revealed the following Consultant Pharmacy Notes for (MONTH) (YEAR) through (MONTH) (YEAR): --01/08/18 - On AP ([MEDICATION NAME]). Ok .dx = delusions and dementia with behavioral disturbances. --12/08/17 - NO suggestions --11/07/17 - Resident is combative with some staff. (MONTH) need medication intervention. Thanks for evaluating. The documentation presented did not support a thorough monthly MMR by the consultant pharmacist to identify irregularities in a written report to the physician. c) Resident #110 Review of Resident #110's medical record revealed the following Consultant Pharmacy Notes for (MONTH) (YEAR) through (MONTH) (YEAR): --01/08/18 - Dx = dementia with behavioral disturbances. OK for AP use. Will follow for potential GDRs. --12/06/17 - No med changes noted. --11/06/17 - No suggestions The documentation presented did not support a thorough monthly MMR by the consultant pharmacist to identify irregularities in a written report to the physician. g) Staff Interviews Interview with the DON and Administrator on 01/25/18 at 11:45 AM confirmed the consultant pharmacist did not complete a thorough Monthly Medication Regimen reviews to address irregularities including a thorough record review. An earlier interview, on 01/25/18 at 9:27 AM, the DON confirmed the MMR form used for new admissions, readmissions, and acute change in condition was not used, nor one similar to it was not used by the consultant pharmacist to conduct monthly MMR.",2020-09-01
3346,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-01-25,758,E,0,1,K2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure [MEDICAL CONDITION] medications prescribed on an as needed basis or PRN were limited to a 14 day order, nor did the facility address non-pharmacological interventions prior to the administration of as needed, PRN [MEDICAL CONDITION] medications for 4 out of 8 residents reviewed for unnecessary medications. In addition, the facility failed to document the reason for the use of the PRN [MEDICAL CONDITION] medication. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #48, 23, 61, and #17. Facility census: 114. Findings include: a) Facility policy review Review of the facility's policy for Medication Regimen Review with an implementation date of 12/09/16 revealed the following: --Residents do not receive [MEDICAL CONDITION] drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. --PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, then he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. -PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluate the resdient fo the appropriateness of that medication. b) Resident #48 Record review for Resident #48 revealed two orders for as needed or PRN [MEDICATION NAME] ([MEDICATION NAME]): --[MEDICATION NAME] Gel, apply 1 mg/ml gel topically every 6 hours as needed, order date 04/04/17, start date 04/04/17. --[MEDICATION NAME], 1 mg tablet, give one tablet by mouth every 6 hours as needed, order date 08/15/17 and start date same for anxiety disorder. The medication order date for these psyhcotropic PRN medications is well beyond the required 14-day limited pursuant to 483.45(e) of the federal regulations and the facility's policy. Further record review found the following associated Diagnoses: [REDACTED]. --Major [MEDICAL CONDITION], recurrent, severe w/ psych symptoms; --Restlessness and agitation; --Dementia in other diseases classified elsewhere with behavioral disturbances; and --[MEDICAL CONDITION] with late onset. Record review found a care plan for the use of anti-anxiety medication with an onset date of 04/04/17: --(Resident Name) is at risk for side effects from antianxiety medication use. (Resident Name) will have no injury related to medication usage/side effects. --Administer (Resident Name) medication as ordered by physician --Observe (Resident Name) for adverse side effects. Document and report to physician --Monitor and record (Resident's Name) behaviors --Observe (Resident's Name) for signs of extrapyramidal sumptoms and document. --Resident is prescribed [MEDICATION NAME] Review of the Medication Administration Record [REDACTED]. October (YEAR): --10/01/17 at 10:08 AM --10/05/17 at 6:18 PM --10/09/17 at 10:23 AM --10/15/17 at 10:18 AM November (YEAR): --11/01/17 at 9:00 AM --11/02/17 at 6:59 AM --11/10/17 at 6:33 AM --11/11/17 at 9:24 AM --11/13/17 at 8:52 AM --11/16/17 at 11:16 AM --11/24/17 at 8:14 AM --11/26/17 at 6:59 AM --11/28/17 at 11:12 AM --11/29/17 at 6:37 AM --11/29/17 at 4:02 PM December (YEAR): --12/05/17 at 7:26 PM --12/08/17 at 1:44 PM --12/30/17 at 8:20 PM January (YEAR): --01/02/18 at 10:08 AM --01/05/18 at 6:18 PM --01/09/18 at 10:23 AM --01/15/18 at 10:18 AM Review of the Medication Administration Record [REDACTED]. October (YEAR): --10/03/17 at 9:01 AM --10/05/17 at 9:13 AM --10/10/17 at 8:44 AM --10/14/17 at 9:55 AM --10/23/17 at 9:31 AM --10/24/17 at 10:16 AM --10/28/17 at 10:57AM --10/29/17 at 9:00 AM November (YEAR): --11/03/17 at 10:55 AM --11/05/17 at 9:43 AM --11/06/17 at 8:53 AM --11/07/18 at 8:56 AM --11/13/17 at 2:30 PM --11/15/18 at 9:01 AM --11/20/17 at 9:17 AM --11/21/17 at 9:35 AM --11/25/17 at 9:11 AM December (YEAR): --12/09/17 at 8:54 AM --12/10/17 at 9:21 AM --12/19/17 at 8:49 AM --12/22/17 at 8:51 AM --12/23/17 at 9:45 AM --12/24/17 at 9:22 AM --12/27/17 at 10:23 AM --12/28/17 at 10:19 AM January (YEAR): --01/03/18 at 9:01 AM --01/05/18 at 9:13 AM --01/10/18 at 8:44 AM --01/14/18 at 9:55 AM --01/23/18 at 9:31 AM --01/29/18 at 9:00 AM From (MONTH) 1, (YEAR) through (MONTH) 23, (YEAR), Resident #48 was administered PRN [MEDICATION NAME] Gel 22 times without any non-pharmacological interventions attempted prior to administration. From (MONTH) 1, (YEAR) through (MONTH) 23, (YEAR), Resident #48 was administered PRN [MEDICATION NAME] 31 times without any non-pharmacological interventions attempted prior to administration. Interview with the DON and Administrator on 01/25/18 at 11:45 AM confirmed non-pharmacological interventions were not addressed by the care plan, nor implemented prior to the administration of PRN [MEDICAL CONDITION] medications. In addition, they verified the physician order [REDACTED]. b) Resident #23 Record review for Resident #23 found physician orders [REDACTED]. --[MEDICATION NAME] 0.5 mg tablet, give one tablet by mouth at bedtime for unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition (Order date 10/23/15 and Start date 10/23/15) --[MEDICATION NAME] 2 mg/ml oral concentrate, give 1 mg (0.5 ml) by mouth or [MEDICATION NAME] 3 times a day and up to every four hours as needed for anxiety disorder, unspecified. (HAS SCHEDULED ORDER). Order date 06/25/14 and start date 05/22/17 --[MEDICATION NAME] 2 mg/ml vial, give 1 mg intramuscular every 2 hours as needed, order date 02/17/17, start date 02/20/17 for anxiety disorder --[MEDICATION NAME] 2 mg/ml oral concentrate, give 1 mg (0.5 ml) by mouth or [MEDICATION NAME] 3x a day and up to every four hours as needed for anxiety disorder, unspecified. Order date 06/08/14 and start date 05/22/17 The medication order date for these psyhcotropic PRN medications is well beyond the required 14-day limited pursuant to 483.45(e) of the federal regulations and the facility's policy. Further record review for Resident #23 found the following associated Diagnoses: [REDACTED]. --Anxiety disorder, unspecified; --Dementia in other diseases classified elsewhere with behavioral disturbances; --Restlessness and agitation; and --[MEDICAL CONDITION] with late onset. Record review found the following current care plan for the use of antianxiety medications: [REDACTED] --(Resident's Name) is at risk for side effects from antianxiety medication use. --(Resident's Name) will have no injury related to medication usage/side effects. --Administer (Resident's Name) medication as ordered by physician --Observe (Resident's Name) for adverse side effects. Document and report to physician --Monitor and record (Resident's Name) behaviors --Pharmacy consultant review of (Resident's Name) medication monthly --Resident is prescribed [MEDICATION NAME] Review of the MAR indicated [REDACTED] October (YEAR): --Administered every day at 6:00 AM, 2:00 PM, 10:00 PM November (YEAR): --Administered every day at 6:00 AM, 2:00 PM, 10:00 PM December (YEAR): --Administered every day at 6:00 AM, 2:00 PM, 10:00 PM January (YEAR): ----Administered every day at 6:00 AM, 2:00 PM, 10:00 PM Review of the MAR indicated [REDACTED]. October (YEAR): --Administered 0 times November (YEAR): --Administered 0 times December (YEAR): --Administered 0 times January (YEAR): --Administered 0 times Review of the MAR indicated [REDACTED]. October (YEAR): --Administered 0 times November (YEAR): --Administered 0 times December (YEAR): --Administered 0 times January (YEAR): --Administered 0 times Review of the MAR indicated [REDACTED]. October (YEAR): --Administered 0 times November (YEAR): --Administered 0 times December (YEAR): --Administered 0 times January (YEAR): ----Administered 0 times Interview with the DON and Administrator on 01/25/18 at 11:45 AM confirmed non-pharmacological interventions were not addressed by the care plan, nor implemented prior to the administration of PRN [MEDICAL CONDITION] medications. The DON stated the resident was on hospice and non-pharmacological interventions were not required. Review of the medical record did not identify Resident #23 as receiving hospice. Resident #23 had a hospice care plan to experience a peaceful, dignified death and to maintain comfortable hospice care. The onset date for this care plan goal was 04/07/14 with an achieved date of 04/22/15. Resident #23 was not a current hospice resident. Interview with the DON and Administrator further confirmed non-pharmacological interventions were not addressed by the care plan, nor implemented prior to the administration of PRN [MEDICAL CONDITION] medications. In addition, they verified the physician order [REDACTED]. d) Resident #61 Review of the medical record for Resident #61 found physician orders [REDACTED]. --[MEDICATION NAME] 0.5 mg tablet, give one tablet by mouth every six hours as needed with order/start date of 05/14/17. The medication order date for this psyhcotropic PRN medication is well beyond the required 14-day limited pursuant to 483.45(e) of the federal regulations and the facility's policy. Further review of the medical record for Resident #61 found the following associated diagnoses -Anxiety disorder, unspecified; --Dementia in other diseases classified elsewhere with behavioral disturbances; --Major [MEDICAL CONDITION], recurrent, unspecified; and --[MEDICAL CONDITION] with late onset. Record review found the following care plan for the use of as needed antianxiety medication with an onset date of 02/26/14 for potential alteration in behaviors related to history of being resistive to care. --(Resident's Name) is at risk for side effects from antianxiety medication use. --(Resident's Name) will have no injury related to medication usage/side effects. --Observe (Resident's Name) for adverse side effects. Document and report to physician --Monitor and record (Resident's Name) behaviors --Pharmacy consultant review of (Resident's Name) medication monthly --Monitor (Resident's Name) for signs of extrapyramidal symptoms and document --Psych evals as ordered with (Doctor's Name) --Administer (Resident's Name) medication as ordered by physician --[MEDICATION NAME] 0.5 mg tablet, give one tablet by mouth every six hours as needed Review of the MAR indicated [REDACTED]. October (YEAR): --10/02/17 at 10:04 PM --10/09/17 at 9:33 AM --10/12/17 at 10:06 PM --10/13/17 at 9:47 AM --10/14/17 at 9:30 AM --10/17/17 at 8:49 PM --10/20/17 at 8:45 PM --10/23/17 at 9:31 AM --10/25/17 at 9:03 PM --10/26/17 at 9:37 PM --10/30/17 at 10:35 AM --10/30/17 at 9:18 PM November (YEAR): --11/03/17 at 10:08 AM --11/04/17 at 10:23 AM --11/04/17 at 5:41 PM --11/05/17 at 9:45 AM --11/07/17 at 9:13 AM --11/08/17 at 9:49 AM --11/09/17 at 9:38 AM --11/10/17 at 9:42 AM --11/13/17 at 10:11 AM --11/14/17 at 9:44 AM --11/17/17 at 9:55 AM --11/17/17 at 10:35 PM --11/18/17 at 9:56 AM --11/20/17 at 9:46 AM --11/23/17 at 9:09 AM --11/25/17 at 9:49 AM --11/27/17 at 10:05 AM --11/28/17 at 9:37 AM --11/29/17 at 10:33 AM --11/30/17 at 9:28 AM December (YEAR): --12/01/17 at 9:32 AM --12/02/17 at 9:53 AM --12/03/17 at 9:53 AM --12/06/17 at 9:56 AM --12/07/17 at 9:55 AM --12/07/17 at 10:13 PM --12/11/17 at 9:23 AM --12/12/17 at 9:32 AM --12/13/17 at 11:40 AM --12/14/17 at 9:51 AM --12/15/17 at 10:12 AM --12/16/17 at 9:35 AM --12/16/17 at 9:10 PM --12/17/17 at 10:12 AM --12/18/17 at 9:47 AM --12/20/17 at 9:57 AM --12/21/17 at 8:48 AM --12/22/17 at 9:54 AM --12/23/17 at 10:10 AM --12/26/17 at 9:39 AM --12/27/17 at 11:31 AM --12/28/17 at 11:29 AM --12/29/17 at 10:52 AM --12/30/17 at 10:32 AM --12/31/17 at 10:22 AM January (YEAR): --01/01/18 at 12:01 PM --01/03/18 at 9:52 AM --01/04/18 at 9:28 AM --01/06/18 at 12:30 PM --01/07/18 at 9:16 AM --01/07/18 at 9:30 PM --01/08/18 at 9:57 PM --01/10/18 at 10:27 AM --01/11/18 at 10:02 AM --01/12/18 at 9:42 AM --01/13/18 at 9:40 AM --01/14/18 at 9:46 AM --01/15/18 at 9:41 AM --01/16/18 at 8:34 AM --01/17/18 at 10:44 PM --01/18/18 at 9:27 AM --01/23/18 at 9:43 PM From (MONTH) 1, (YEAR) through (MONTH) 23, (YEAR), Resident #61 was administered PRN [MEDICATION NAME] 74 times without any non-pharmacological interventions attempted prior to administration. Interview with the DON and Administrator on 01/25/18 at 11:45 AM confirmed non-pharmacological interventions were not addressed by the care plan, nor implemented prior to the administration of PRN [MEDICAL CONDITION] medications. In addition, they verified the physician order [REDACTED]. e) Resident #17 Resident #17 had an order for [REDACTED]. The indication for the order was Anxiety disorder, unspecified. Resident #17 received [MEDICATION NAME] on the following dates and times for the month of January, (YEAR): --01/01/18, 9:34 AM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/01/18 at 11:13 AM. --01/01/18, 8:05 PM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/01/18 at 10:05 PM. --01/02/18, 8:27 PM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/02/18 at 9:13 PM. --01/03/18, 9:17 PM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The effectiveness of the medication was not documented. --01/04/18, 8:18 PM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The effectiveness of the medication was not documented. --01/05/18, 8:47 AM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/05/18 at 11:34 AM. --01/05/18, 9:13 PM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/05/18 at 10:27 PM. --01/06/18, 9:03 AM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/06/18 at 11:49 AM. --01/06/18, 9:12 PM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/06/18 at 10:19 PM. --01/07/18, 11:40 AM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/07/18 at 4:14 PM. --01/07/18, 8:22 PM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/07/18 at 10:50 PM. --01/08/18, 8:50 AM: There was no note specifying the behaviors that required the PRN medication, other than Anxiety and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/08/18 at 9:51 AM. --01/08/18, 9:08 PM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The effectiveness of the medication was not documented. --01/09/18, 8:44 PM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The effectiveness of the medication was not documented. --01/10/18, 10:00 AM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/10/18 at 1:19 PM. --01/10/18, 9:44 PM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/10/18 at 1:25 AM. --01/11/18, 10:02 AM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/11/18 at 4:46 PM. --01/11/18, 9:40 PM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/11/18 at 10:15 PM. --01/12/18, 9:00 PM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The effectiveness of the medication was not documented. --01/13/18, 8:26 AM: There was no note specifying the behaviors that required the PRN medication, other than Anxiety and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/13/18 at 9:06 AM. --01/13/18, 8:40 PM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The effectiveness of the medication was not documented. --01/15/18, 9:09 AM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/15/18 at 11:09 AM. --01/15/18, 9:37 PM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/15/18 at 10:36 PM. --01/16/18, 8:48 AM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/16/18 at 10:39 AM. --01/17/18, 8:48 PM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The effectiveness of the medication was not documented. --01/18/18, 9:02 PM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The effectiveness of the medication was not documented. --01/19/18, 9:03 AM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/19/18 at 11:05 AM. --01/19/18, 9:07 PM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/19/18 at 10:04 PM. --01/21/18, 11:47 PM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The medication was assessed as effective on 01/22/18 at 4:14 AM. --01/22/18, 9:51 PM: There was no note specifying the behaviors that required the PRN medication and the non-pharmacological interventions attempted. The effectiveness of the medication was not documented. During an interview on 01/25/18 at 9:58 AM, the Administrator was informed PRN orders for [MEDICAL CONDITION] drugs are limited to fourteen (14) days. If a PRN [MEDICAL CONDITION] medication is extended beyond fourteen (14) days, the prescribing practitioner must document the rationale to extend the PRN order and must indicate the duration of the PRN order. The Administrator was also informed the specific behaviors that required PRN medications were not documented for Resident #17 and non-pharmacological interventions attempted to alievate the behaviors were not documented for Resident #17. The Administrator had no further information regarding this matter. During an interview on 01/25/18 at 10:47 AM, the Director of Nursing (DoN) was also informed the specific behaviors that required PRN medications were not documented for Resident #17 and non-pharmacological interventions attempted to alievate the behaviors were not documented for Resident #17. The DoN had no further information regarding this matter.",2020-09-01
3347,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-01-25,880,D,0,1,K2BO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain an effective infection control program for the proper use of a syringe used for tube feedings. This was true for one (1) of five (5) residents receiving tube feedings. Resident identifier: #20. Facility census: 112. Findings include: a) Resident #20 Observation on 01/22/18 at 11:00 a.m., found eternal feeding bag full of formula labeled [MEDICATION NAME], date of 01/22/18,and a separate hanging bag of a clear substance with no label. Additionally, the tube feeding syringe was lying uncovered on Resident #20's bedside table. On 01/22/18 at 11:02 a.m., the Director of Nursing (DON) verified the tube feeding syringe should not be lying on the bedside table uncovered. She immediately removed that syringe and replaced it with a new covered syringe.",2020-09-01
3348,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-11-12,550,E,0,1,2C7711,"Based on observation and staff interview the facility failed to ensure Residents #60, #86, #83, #14, #81, #117, #108 and #13 had a dignified dining experience during the breakfast meal on 11/07/18. This was a random opportunity for discovery. Resident Identifiers: #60, #86, #83, #14, #81, #117, #108 and #13. Facility Census: 112. Findings include: A) Observations of the breakfast meal on the south unit began at 7:15 a.m. on 11/07/18. When the observation began several residents seated in the dining room all ready had their meals. There were four (4) U - Shaped tables. The residents sitting at these tables needed assistance with their meals and were unable to feed themselves. After all the residents seated at the other tables in the dining room were served the staff began serving the residents who needed assistance with their meals. Resident # 81 was served his breakfast at 8:00 a.m. After Resident #81 was served his meal the surveyor left the dining room and returned at 8:30 a.m. At 8:30 a.m. Resident #81's tablemate's did not have their meals nor did the table beside Resident #81's table. Also, there was no one assisting Resident #81 with his meal. Once the surveyor returned to the dining room the staff again began serving the remaining resident who did not have a meal. Resident #117 was not served her meal until 8:33 a.m., Resident #108 was not served her meal until 8:37 a.m., and Resident #13 was not served her meal until 8:41 a.m. Nurse Aide # 51 did not begin feeding Resident #81, #117, #108 and #13 until 8:45 a.m. one (1) and one/half (1/2) hour after the other residents in the dining room were all ready served their meals. While NA #51 was serving these residents NA # 29 was serving the residents seated at the next table Resident #83 was not served her meal until 8:38 a.m., Resident #14 was not served her meal until 8:33 a.m., Resident #86 was not served her meal until 8:41 a.m., and Resident #60 was not served her meal until 8:47 a.m. An interview with NA #51 at 8:48 a.m. on 11/07/18 confirmed it usually does not take this long to serve the residents. She stated that she and NA #51 had to assist another resident to the restroom and that is why it took so long. An interview with NA #51 at 9:22 a.m. on 11/07/18 indicated that on a typical day they are completely threw with the dining process by 9:00 a.m. An interview with the Director of Nursing (DON) at approximately 10:00 a.m. on 11/07/18 revealed that it should take no more than an hour to serve all residents their meals. She indicated other staff should have assisted the resident to the restroom and the dining process should not have been interrupted.",2020-09-01
3349,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-11-12,580,D,0,1,2C7711,"Based on medical record review and staff interview, the facility failed to immediately inform Resident #72's representative and physician after the resident had two falls with injuries. This was true for one (1) of two (2) residents reviewed for the care area of falls. Resident identifier: #72. Facility census: 115. Findings included: a) Resident #72 Review of Resident #72's medical records revealed the resident experienced a fall on 08/31/18 at 8:40 PM. The Resident Incident Report at 08/31/18 stated, Heard alarm coming from a residents (sic) room and the sound of someone falling. This nurse ran in to room and discovered resident on floor laying on the floor mat in another residents (sic) room on right hip. The injury was described as, 1.5 by 1.5 bruise to right elbow, 3 cm by (second measurement not given) linear shaped bruise to right forarm (sic), reddened palm. The Resident Incident Report stated the resident's representative was notified about the fall on 09/04/18 at 7:03 PM. The area of the report to indicate when the physician was notified was blank. An Interdisciplinary Team (IDT) Meeting was held on 09/04/18 at 2:53 PM to discuss Resident #72's fall on 08/31/31. The IDT note stated, MD made aware. A nurse's note written on 09/04/18 at 7:03 PM stated, MPOA notified of incident from 08/31/18. During an interview on 11/12/18 at 1:35 PM, the Director of Nursing (DoN) stated there was no indication Resident #72's physician was notified of the fall on 08/31/18 before the IDT meeting on 09/04/18. The DoN also stated Resident #72's representative was not notified about the resident's fall on 08/31/18 until 09/04/18. The DoN stated the facility realized during the IDT meeting on 09/04/18 that the representative had not been notified about the fall. Review of Resident #72's medical records also revealed the resident experienced a fall on 11/09/18 at 5:16 AM. The Resident Incident Report stated, Resident lying in bed, told staff member, I fell . Assessment revealed 4 cm hematoma to right side of forehead with abrasion. The Resident Incident Report stated Resident #72's representative was notified about the fall on 11/10/18 at 7:17 PM. The area of the report to indicate when the physician was notified was blank. A Nursing Note written on 11/10/18 at 7:05 PM stated (typed as written), Staff assisted resident to bed CNA (Certified Nursing Assistant) alerted this nurse that resident was jerking. This nurse went to room and resident's head and arms were jerking, only lasted about 30 seconds. Afterward resident was alert and answering questions yes and no. Call to (resident's attending physician), awaiting return call. A Nursing Note written on 11/10/18 at 8:20 PM stated, Left message for (Registered Nurse #8) and (resident's attending physician) to return phone call regarding resident. At 7:40 PM, notified (Registered Nurse #19) of resident fall on 11/09/18 and two episodes of body jerking that was observed. RN instructed this nurse to send resident to ER (emergency room ) for evaluation. Notified resident POA (power of attorney) (POA's name) of resident fall and sending to ER for evaluation. During an interview on 11/12/18 at 1:35 PM, the Director of Nursing (DoN) stated there was no indication of an attempt to notify Resident #72's physician of the fall on 11/09/18 until 11/10/18 at 7:05 PM. The DoN also stated there was no indication Resident's #72's representative was notified of the fall on 11/09/18 until 11/10/18 at 7:17 PM.",2020-09-01
3350,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-11-12,582,D,0,1,2C7711,"Based on record review and staff interview the facility failed to ensure each resident received the appropriate and/or complete notice of Medicare non coverage when the Medicare coverage ended. This was true for three (3) of three (3) residents reviewed for the care area of beneficiary protection notification. Resident Identifiers: #26, #105, #43. Facility Census: 115. Findings Include: a) Resident #26 A record review completed at 8:00 a.m. on 11/12/18 found Resident #26's discharge date from Medicare services was 07/16/18. Her notice of Medicare Non Coverage (NOMNC) was requested from the facility staff. An interview with the Social Worker #2 at 11:38 a.m. on 11/12/18 revealed she did not have a copy of the letter she sent to Resident #26's responsible party. She indicated that she keeps a log, but does not keep a copy of the letter unless the responsible party signs it and sends it back. She presented the log she maintains, but Resident #26's name was not listed on the log. Social Worker #2 explained she was only receiving Medicare services for nursing and not therapy and that is why she was not on the Log. b) Resident #105 A record review completed at 8:00 a.m. on 11/12/18 found Resident #105's discharge date from Medicare services was 08/08/18. Her NOMNC was requested from the facility staff. Her notice was provided by Social Worker #2. The appropriate notices were sent, but Form CMS -NOMNC was not completed to include the Quality Improvement Organization therefore the responsible party would have had no way of knowing who to contact to request an appeal. An interview with the Nursing Home Administrator at approximately 12:00 p.m. on 11/12/18 confirmed the Quality Improvement Organization name and contact information was not inserted as required. c) Resident #43 A record review completed at 8:00 a.m. on 11/12/18 found Resident #43's discharge date from Medicare services was 08/27/18. Her notice of NOMNC was requested from the facility staff. At approximately 12:00 p.m. on 11/12/18 Social Worker #2 provided form CMS- which was provided to Resident #43's responsible party. This form was not dated as to when it was provided and indicated the reason for Resident #43's discharge from Medicare services was because she had met her maximum potential in Occupational, Physical and Speech therapy. Social Worker #2 indicated this was the only notice provided. The facility should have also provided CMS NOMNC to Resident #43's responsible party.",2020-09-01
3351,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-11-12,585,D,0,1,2C7711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, observation, and staff interview, the facility failed to address and take prompt efforts to resolve a grievance. This was a random opportunity for discovery. Resident identifier: #78. Facility census: 115. Findings include: a) Resident #78 On 11/05/18 at 12:15 PM, the resident was asked if she had any problems with other residents. She replied, I am constantly telling others to please leave my room. They come in all the time. The resident said she had told people but they say they can't do anything because those people are confused. During the interview, Resident #85 wandered into the residents room. The resident said see here she comes, always nosing around. Resident #78 told Resident #85 to, Go on, get out of here, this isn't your room. Resident #78 repeated this several times and pointed to the door. Resident #85 finally left the room. Record review found the resident was admitted to the facility on [DATE]. She was placed in the dementia unit upon admission and continues to resident in this unit. According to the Dementia Care Unit/Special Care Unit policy revised on 02/03/16, the unit exists, .to better meet dementia residents' needs and to protect residents with dementia in nursing facilities. The purpose of the dementia locked unit is to provide dementia residents with a positive quality of life and maximum individualized care that promotes rights, dignity, comfort and independence in the least restrictive environment Review of the residents most recent minimum data set (MDS) a quarterly, with an assessment reference date of 10/03/18 found Resident #78 had no problems with making herself understood and understanding others. The resident had no issues with inattention, disorganized thinking or altered level of consciousness. There were no issues with rejection of care or wandering behavior. Her brief interview for mental status (BIMS) found she achieved a score of 12. A score of 12 indicates mild confusion. Review of the nursing notes found the following documentation: 10/16/18 4:28 AM, Resident came to nurses' station stating that a man keeps coming into her room. She states that she is scared and wants out of this place. Resident said she didn't trust the man and didn't know if he was going to rape her or not. When nurse tried redirecting her she continued to say that she didn't feel safe and that she wanted to speak with the social worker. Resident said that every time she requests to speak with the social worker, she never comes to see her. There was a note placed at nurses station for day shift nurse to pass on to Social Worker. 09/30/18 at 11:19 PM, Resident (name of resident) came to this nurse and stated, you know that great big guy that lives here. He came into my room and laid in my bed onto my papers even though I told him not to. I punched him in his gut. Then he grabbed me by my wrist and not they hurt. Staff said this resident came out into the hallway and asked them to get the other resident out of her bed. Instructed resident if the gentleman came back into her room to call out for staff and they would get him out of her room. Resident stated, It is not going to matter anyway because I am leaving this place in the morning. No discoloration or breaks on the skin observed to both lower arms. Review of the resident's current care plan found the following problem: Potential alteration in mood related to history of (Name of Resident) acknowledging feeling down, having little interest in doing things, trouble sleeping and concentrating at times. She continues to adjust to facility and environment. The goal associated with the problem: Will maintain positive mood as evidenced by participating in activities/outings of interest, voicing feeling to staff, having positive interactions with other residents in lounge or dining room once a day throughout next review. Interventions included: Visit with resident and allow her time to voice feelings, concerns she may be having. At 3:30 PM on 11/06/18, the activity director, #105 was asked if she was aware Resident #78 was upset because residents were coming into her room. [NAME] #105 said this was a dementia unit and residents did wonder about freely. She wasn't aware of Resident #105's concerns. [NAME] #105 accompanied the surveyor to Resident #78's room. The resident voiced concerns about other residents coming into her room to the surveyor and [NAME] #105. E #105 completed a grievance/concern form at this time. Review of the form dated 11/06/18, found the following: (Name of Resident) voiced concerns to me and the surveyor that residents were coming in her room. She stated that she tried to get a male resident out of her room and he proceeded to get in her roommates' bed. AD and surveyor talked to (Name of Resident) about the stop sign strip placed at her door and asked her if it was helping to keep residents out. She said it was helping. However a female resident had been in her room. I asked her if she would like a stop sign added to her door. She said yes. I talked to (name of the registered nurse case manager) about her concerns and she gave me a stop sign to place on her door. (Name of Resident) said she thought it would help . At 8:12 AM on 11/08/18 both facility social workers: SW #2 and SW #135 were asked if either of them had talked to the resident after she said she wanted to see the social worker on 10/16/18. At the close of the survey on 11/12/18, at 4:30 PM no information had been provided to substantiate the social workers have visited with this resident to specifically address her concerns voiced on 10/16/18. A grievance/concern form was completed on 11/06/18, after surveyor intervention.",2020-09-01
3352,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-11-12,600,K,0,1,2C7711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the Centers for Medicare and Medicaid Services Appendix PP State Operations Manual and staff interview the facility failed to ensure all residents were free from verbal and physical abuse from other residents. Resident #110, Resident #93, and Resident #105 have been identified as residents who have on several occasions demonstrated verbally and physically abusive behaviors towards other residents residing on the south wing of the facility. These incidents have been ongoing at least since at least 08/2018. The facility has not demonstrated that they provided enough protection to prevent resident to resident abuse and to protect the other residents currently residing on the south wing of the facility. Residents residing on the south unit have voiced fear of resident #110 and Resident #93 one resident has voiced that he is to fearful to sit in the hallway. Resident #24 was fearful of resident #110 and was afraid he was going to sexually assault her the facility failed to address this fear and failed to make this resident feel safe while residing in the facility. The facility has put into place interventions of redirection and medication changes, but the residents behaviors of physical and verbal abuse continue indicating the interventions have not been successful in changing the residents behavior and/or protecting the other residents residing on the South Wing. These failures have placed all residents currently residing on the South Wing of the facility at an immediate risk for serious harm. The facility was notified of the Immediate Jeopardy on 11/07/18 at 2:56 p.m. The facility submitted a plan of correction to the state agency at 4:52 p.m. on 11/07/18. The plan of correction was accepted by the state agency at 5:18 p.m. on 11/07/18. The state agency observed for implementation of the accepted plan of correction and the Immediate Jeopardy was abated at 6:58 p.m. on 11/07/18. Once the immediate jeopardy was abated a deficient practice remained and the scope and severity was decreased from a K to an E. A deficient practice remained for Resident #78 because the facility failed to address an allegation of possible alleged abuse from another resident. For Resident #85 the facility failed to ensure this wandering resident was supervised to prevent resident to resident abuse from other residents directed toward this resident. These failures have the potential to effect more than an isolated number of residents. Resident Identifiers: #110, #105, #93, #24, #78 and #85. Facility Census: 115. Findings include: a) Resident #110 Observations of Resident #110 at 11:00 a.m. on 11/05/18 found him entering the Room of Resident #60. The resident was in bed and she had visitor. Resident #110 began cursing Resident #60's visitor and waving his arms in the air. The surveyor alerted staff that this visitor needed some help. The staff intervened and removed Resident #110 from Resident #60's room. At 11:05 a.m. on 11/05/18 this surveyor entered the room of Resident #60 to speak with her visitor. During the interview with Resident #60's visitor Resident #110 returned to the room and again began cursing at this surveyor and Resident #60's visitor. He stated, You all are a bunch of God Damn idiots . I am going to [***] ing die . This is stupid God Damn[***]and you need to [***] ing die. Resident #110 was waving his arms in the air as he screamed the above statements. After about three (3) minutes staff came and again removed Resident #110 from Resident #60's room. Resident #60's visitor indicated this was the first time she had ever seen this gentleman, but he was obviously not happy. A review of Resident #110's incident reports regarding his behavior toward other residents at 12:00 p.m. on 11/06/18 found the following occasions where Resident #110 was in a resident to resident altercation: -- 07/07/18 - Resident #110 and Resident #80 (roommates at the time) got into a fight and Resident #80 received a bruise to top of his right hand and a laceration to his lip. No injuries were noted to Resident #110 and the staff indicated they would continue to monitor for other behavioral episodes. -- 08/28/18 - Resident #110 and nurse were walking down the hallway when Resident #98 who was standing at the nurses' station began yelling and pointing at Resident #110 stating that he had pushed him down. Resident #110 shouted back, You are damn right I did and I will do it again you stupid nigger. Resident #98 was assessed to have an 8 by 5 centimeter abrasion to his left side. Review of the progress notes beginning on 09/01/18 through present at 10:30 a.m. on 11/07/18 found the following notes concerning resident to resident incidents: -- 09/21/18 at 4:32 a.m. - Resident extremely agitated at beginning of shift. Every attempt to redirect was unsuccessful and resident became combative. Resident was given a sandwich for snack with a drink. Played music that resident likes but would not calm down. Resident is confused to the point of no talking down or redirecting. Resident began arguing and getting in the face of other residents. Both nurses attempted to just let resident walk freely and calm down but was unsuccessful. Unable to pass medication due to resident up on cart so close yelling in our faces. When asked to please back up resident would curse and throw things. Called (name of attending physician) at 9:45 p.m. to ask for orders. (Name of attending) physician ordered [MEDICATION NAME] 1 mg (by mouth) PO as a one time order. After resident was administered the [MEDICATION NAME] 1 mg the resident calmed down over the next 30 minutes and this nurse was able to get him to lay down and resident was cooperative. Resident rested throughout the remaining of the night with eyes closed. -- 09/23/18 10:39 p.m. - Resident came down 300 hall during my med pass and was going into other residents room yelling and cursing at them. When trying to redirect resident her cursed at me and smacked my arm. He continued to bother two (2) female residents that were standing in the hallway. I told the two female residents to return to their rooms and shut the door. (First name of Resident #110) could not be redirected. -- 09/23/18 11:02 p.m. Resident had medication at 8:00 p.m. Attempted to help resident to bed at 9:00 p.m. Resident got up shortly after and wandered down 300 hall. Went in several rooms and they would scream for him to get out and he would then get in their faces and when we got to the room he was cursing and drawing his fist back to hit a female resident. Resident was redirected but was only able to get him out of the side of the room where the woman was. Resident then grabbed this nurse and (First and Last Name of NA #102) and pushed us down and was punching us. NA (First and Last Name of NA # 118) came in room and resident also punched her and grabbed her arms while cursing and being out of control. Once Resident wandered down the hall this nurse told 1 CNA to stay on hall and 1 cna to close the fire doors and stay there until able to call (name of attending physician) for orders. (Name of attending physician) order to send resident out to the emergency room -- 10/10/18 10:33 p.m. - During HS med pass resident came up to this nurse and was very agitated resident yelling no you stupid [***] go [***] yourself, I offered resident a snack and that calmed him down for a while but resident began pacing up and down the hallway. I asked resident what was wrong and he said you don't know anything you [***] . Resident going by other residents doorways and hollering stupid [***] . Attempted to redirect resident without success. Will continue to monitor for behaviors. -- 10/21/18 at 8:40 a.m. Resident was visited in the South Lounge for P[NAME] (plan of care) assessment. He was reading (name of newspaper) and was able to identify orientation questions from this paper. Resident was friendly throughout assessment, but stated that he was mad at a peer. He pointed several times at different residents and said that he could blow them up with a airplane. Resident was redirected and completed the assessment. Resident scored an 11/15 (11 of 15) on his BIMS (Brief Interview for Mental Status)., and endorsed trouble sleeping and feeling tired at times. -- 10/30/18 12:39 a.m. - Resident entered into a verbal argument after wandering into another residents room. This nurse intervened and redirected both residents. Resident easily redirected. Will continue to monitor. Review of Resident #110's care plan found the following Problem statement: (First Name of Resident #110) has delusions of combat related to heavy drinking while watching war movies per family. He is aggressive with staff and other residents with delusions of people trying to kill him. The goal statement associated with this problem was: (First name of Resident #110) will not obtain any major injury. Target date of 01/23/19. Interventions related to this problem and goal statement included: -- Provide diversion activities for (First name of Resident #110). Added on 07/05/18. -- Approach (First name of Resident #110) positively and in calm, accepting manner. Added on 07/05/18. -- Assign staff to account for (First name of Resident #110) whereabouts throughout the day. Added on 07/05/18. -- Monitor and document (First name of Resident #110) behavior. Added on 07/05/18. -- Redirected (First name of Resident #110) to room or lounge when laying in inappropriate areas. Added on 07/05/18. -- Do not play war movies on lounge TV with (First name of Resident #110) in attendance. Added on 07/05/18 -- Send to emergency room . Added on 08/28/18 -- Redirect (First name of Resident #110) to a calm and quiet environment. Added on 08/28/18. -- Send to ER [DATE] for evaluations due to combative behaviors. Added on 09/21/18. -- Will see in house psychiatrist next visit. Added on 09/24/18. A review of Resident #110's Minimum Data Set (MDS) assessments with assessment reference dates of 07/19/18 and 10/18/18 found resident had Physical behavioral symptoms towards others 1 to 3 days during the seven day look back period. The MDS also indicated Resident #110 had verbal behavioral symptoms directed toward others 4 to 6 days during the look back period. These findings were discussed during an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) beginning at 1:14 p.m. and concluding at 1:41 p.m. The NHA stated that she would put together a time line to show what interventions they had put into place for Resident #110. Later that afternoon the NHA provided the following time line regarding Resident #110's behaviors and the facility's interventions. The NHA provided a time line to show what they had done for this resident to keep other residents safe: --08/13/18 redirection with music behind nurses station with staff --08/18/18 redirected and relaxed with music --08/18/18 redirected and resident to bed resting --08/21/18 successfully redirected by staff. --08/28/18 out to ER they gave him [MEDICATION NAME] and then he returned to us --08/29/18 [MEDICATION NAME] was increased by Dr. --09/20/18 Ordered one-time [MEDICATION NAME] --09/21/81 redirected successfully with food and music later [MEDICATION NAME] order changed, and [MEDICATION NAME] ordered. --09/23/18 TO (name of local hospital) ER and returned --10/02/18 redirected to his room and then rested quietly (nursing note for this date says redirection was not successful.) --10/03/18 redirected through change in environment. --10/10/18 Gave snacks and he calmed down --10/30/18 redirected Upon reviewing the in house psychiatrist schedule, Resident #110 had been placed on his list to be seen when he rounds here at the facility. Care plan interventions include: diversional activities, naps rest periods, snacks, meds as ordered, approach calmly, psych consult scheduled. Review of the in-house psychiatrist's visits to facility found visits occurred on 08/25/18, 09/15/18, and 10/27/18, but there was no evidence Resident #110 was seen. The list also indicated the resident was to be seen because he had [MEDICAL CONDITION] (post-traumatic stress disorder) and unable to redirect combative with staff and residents. A care plan intervention was added on 09/24/18 indicating the resident would be seen by the in-house psychiatrist on the next visit which would have been 10/27/18 but Resident #110 was not seen and he continued to have verbally and physically abusive behaviors. During an interview with Resident #24 on 11/05/18 at 1:33 P.M., she said a male resident (she was referring to Resident #110) came into her room and told her he was going to rape her. That really scared her. Further investigation found a nurse's note, dated 09/22/18 at 11:43 PM confirmed Resident #24's statement. The note included, Resident stated that (Resident #110's name) came into her room and stated that he was going to kill her and he wanted to have sex with her. She stated that she came to the facility to be safe and is now scared. Resident was assured that she is safe. No further investigation could be found as to the circumstances before, during or after the alleged incident occurred. The author of the nursing note was unavailable for contact. During an interview on 11/05/18 at 11:46 AM, Resident #80 stated, (Resident #110) wants to fight me .he makes fun of me and makes faces at me .he tries to get a rise out of me. When asked if he participated in facility activities, Resident #80 stated, I have to stay in my room . otherwise I would have a chair in the hallway. Resident #80 stated Resident #110 had never touched him. When asked if he was afraid of Resident #110, Resident #80 stated, You never know what is going to happen. During the Resident Council meeting on 11/06/18 at 11:05 AM, Resident #80 said Resident #110 and Resident #93 .are bad and makes it where they can't come out of room. Resident #80 stated they had reported it to nurses and they did nothing. Resident #80 stated Resident #83 beat him in the head. Resident #80 stated. when the two of them are together they are really bad. He said, They terrorize us. Resident #24 stated Residents #110 and #93 came in her in her room and would not leave. Resident #110 had told Resident #93 to hold the door closed, she said that she had to fight him, while Resident #93 was holding the door closed. She was pulling on the door and yelling for help, finally the workers came. They told her they had to pull Resident #93's hand off the door to help her. Another time Resident #110 also brought a blanket in her room and said he wanted to have sex with her and she said no and yelled for him to leave her room. He also was in her bed sleeping one day and when she told the staff, they told her to let him sleep he will get up when he wakes up. Resident #24 also stated that Resident #110 was beating Resident #62 and she and another male resident had to get him away from her. They took Resident #62 up to the offices by the lounge and when they reported it to staff, staff just said, Well he doesn't know what he is doing and told him to apologize. Resident #24 commented, (Name of Resident #110) is a big guy and he scares me. During an interview with Resident #78 on 11/06/18 at 11:14 a.m., she said Resident #110 was in her bed two times, she too was told that when he wakes up he will leave. She also stated that other residents just wander in and out of her home all the time. South wing Activities Director #105 was asked whether residents had come to her office and reported to her about Resident #110 hitting Resident #62. She said, These residents have dementia, so they are very forgetful and are not always reliable. She asked if this surveyor was familiar with caring for those with Dementia. On 11/08/18 after the notification of the Immediate Jeopardy on 11/07/18 Resident #110 was sent to see the in-house psychiatrist at his office in the community. The psychiatrist admitted Resident #110 to a psychiatric unit for medication stabilization on 11/08/18. At the time of exit on 11/12/18 at 5:00 p.m. no further information was provided regarding the management of Resident #110's behaviors. b) Resident #105 A review of Resident #105's incident reports at 12:00 p.m. on 11/07/18 found the following incidents which involved a resident to resident altercation (Resident identifier numbers have been substituted for residents' names and room numbers designated as XXX for confidentiality): -- 08/03/18 - Resident #105 gently slapped other resident with open hand. Resident #105 was very difficult to redirect. Combative with staff and cursing other residents. Resident redirected to her room. (Please note other resident not identified by facility) -- 08/19/18 4:40 p.m. - called to hallway in front of room XXX. Resident #105 smacked Resident #102 on the right hand. No injuries. Residents separated and redirected. -- 09/03/18 9:20 p.m. - Heard yelling from room XXX. Upon entering the room staff witnessed Resident #105 slap Resident #93 across the right cheek and was cursing at him. Resident #93 then in turn slapped Resident #105 across both her cheeks. -- 10/22/18 6:30 p.m. - Resident #105 and Resident #112 were overheard yelling at each other. Resident #105 was slapping Resident #112 in the face. Other resident attempted to kick Resident #105 but missed. -- 10/23/18 1:15 p.m. - Therapy staff observed Resident #105 go into Resident #112's room. Resident #112 asked Resident #105 to leave and Resident #105 became angry and slapped Resident #112 with an open hand across the face and grabbed the resident's left arm. Review of Resident #105's nursing notes found the following additional occasions when Resident #105 was involved in a verbal or physical altercation with other residents: -- 09/01/18 at 6:19 p.m. - according to Resident #98, Resident #105 entered his room and hit him in the stomach and scratched his left upper cheek and behind his left ear, and his left upper lip. Following that Resident #98 punched Resident #105 in the lower left jaw. Resident #105 then began to curse Resident #98. The housekeeper overheard and entered the room to separate the residents. -- 09/11/18 at 12:59 a.m. - Heard yelling coming from room XXX. Upon entering witnessed staff attempting to redirect 2 residents who were yelling at one another. The nurse redirected the other resident in one direction while staff redirected Resident #105 in the opposite direction. After talking to staff it was told to this nurse that Resident #105 had slapped the resident on the right cheek and was cursing him. Following her slap the other resident then slapped her on both cheeks. No injuries noted. -- 09/29/18 12:30 a.m. - Earlier this shift resident was loud. Yelling at other residents to get out of her room and she was in theirs. Resident easily redirected by staff. At time Resident was observed striking out at staff and other residents. No physical contact was made. -- 10/04/18 3:43 p.m. - Resident has been in an up and down mood today. One minute she will be happy and then the next moment the resident is heard down the hall saying you're a whore, growling at people, and hitting people. Resident has been easily redirected each time by different staff members. -- 10/03/18 6:20 a.m. - Resident has been wandering in and out of rooms this AM (morning). Resident repeatedly lying people are in her bed. Resident pointed to another residents room and said she was going to knock the hell out of them and show them what she was made of. Resident was redirected to her room and explained to her that other residents were not in her room. Resident was laying in bed with eyes closed at this time. -- 10/17/18 at 4:27 p.m. - Resident has been resting in bed most of shift. This am (morning) at breakfast this resident began yelling at the resident across the table at her. When staff went intervene resident stood up and started yelling at staff and hitting them and continued to yell at the other resident . -- 10/26/18 12:12 a.m. - Resident #105 wandered into another residents room and got in verbal altercation with that resident. Easily redirected. No complaints voiced -- 10/30/18 6:10 p.m. - Resident #105 out in the hallway and got into a verbal altercation with another resident when this resident attempted to go into that residents room. The resident began yelling that she was going to kill that [***] . When attempting to redirect Resident #105 began hitting and pulling this nurse's hair. A review of Resident #105's care plan found statement of: (First Name of Resident #105) displays physically aggressive behavior. The goal associated with this care plan was: (First name of Resident #105) displays physically aggressive behavior. This goal had a target date of 01/23/19. The interventions related to this problem and goal included: -- Social Services to evaluate and visit with (First name of Resident #105). Added on 08/08/18. -- Activities staff to visit with (First name of Resident #105) and provide diversional activities. Added on 08/08/18. -- Monitor and document (First name of Resident #105)'s behavior. Added on 08/08/18. -- Do not argue with (First name of Resident #105). Added on 08/08/18. -- Identify causes for behavior and reduce factors that may provoke (First name of Resident #105). Added on 08/08/18 -- Praise (First name of Resident #105) for demonstrating desired behavior. Added on 08/08/18. -- Talk with (First name of Resident #105) in calm voice when behavior is disruptive. Added on 08/08/18. -- Remove (First name of Resident #105) from public area when behavior is disruptive and unacceptable. Added on 08/08/18. -- Encourage responsible party/family to visit with (First name of Resident #105). Added on 08/18/18. -- Redirect (First name of Resident #105) when she is intrusive to other residents space. Added on 08/20/18. -- Encourage staff to spend time with (First name of Resident #105) to feel comfortable. Added on 09/14/18. -- Apply stop sign to door. Added on 09/12/18. -- When resistant to care provide (First name of Resident #105) with positive distractions. Added on 10/16/18. -- Try to identify triggers that cause behaviors. Added on 10/23/18. A review of Resident #105's Minimum Data Set (MDS) assessment with assessment reference dates (ARD) of 07/10/18 and 10/15/18 found Resident #105 had verbal and physical behaviors directed toward others one (1) to three (3) days during each look back period. During an interview with the Administrator (NHA) and the Director of Nursing (DON) beginning at 1:14 p.m. and concluding at 1:41 p.m. on 11/06/18, these findings were discussed. The NHA stated that she would put together a time line to show what interventions they had put into place for Resident #105. The following morning, on 11/07/18, the NHA provided a time line to show what they had done for this resident to keep other residents safe. The following is the timeline provided typed as written: -- 08/03/18 redirected. -- 08/05/18 redirected. -- 08/10/18 redirected. -- 08/17/18 redirected and snacks provided. -- 08/19/18 redirected. -- 08/22/18 permission to see psychiatrist obtained. -- 08/25/18 seen by (Name of in-house psychiatrist). No new medication changes. -- 08/30/18 redirected encouraged rest period. -- 09/01/18 redirected. -- 09/04/18 redirected, monitored, praise family was called and asked them to come and visit. -- 09/06/18 redirected to room, staff member sat with resident until she fell asleep. -- 09/09/18 seen by MD. No new orders offered snacks and provided rest period. -- 09/11/18 redirected. -- 09/12/18 spoke with RP (responsible party) about hearing aide declined. -- 09/12/18 applied stop sign to door. -- 09/29/18 redirected. -- 10/03/18 redirection and encouraged rest period. -- 10/15/18 used music for redirection and rest period. -- 10/16/18 environmental change. -- 10/23/18 snack/redirection. -- 10/27/18 saw (Name of in house psychiatrist) again and increase [MEDICATION NAME]. -- Care planned interventions include: activities, attempts to identify cause of agitation, calm approach, praise, change environment when needed, encourage family visits, psych consult, stop sign on door and med's as ordered. -- Med's include: [MEDICATION NAME], and [MEDICATION NAME]. Review of Resident #105's medications found she was started on [MEDICATION NAME] 125 mg by mouth twice a day on 10/27/18. Resident was started on [MEDICATION NAME] 25 mg twice a day and [MEDICATION NAME] 40 mg once daily beginning on 07/10/18, the date of her admission. Resident #105 received the [MEDICATION NAME] for a [DIAGNOSES REDACTED]. There was no evidence in the medical record that these medications were ever reviewed for effectiveness in controlling the residents behaviors. At the time of exit on 11/12/18 at 5:00 p.m. no further information was provided. c) Resident #93 Abuse During record review of nurses notes in the electronic chart the following notes were as listed below. On 4/19/18 at 6:19 AM Nursing notes, Resident # 93 agitated after Nursing Assistance NA dressed him this am. Afterwards he would run up to her and telling her he was going to beat the[***]out of her with his fist drawn back. Resident did this three times. On 4/19/18 at 1:38 PM, states Resident # 93 will ambulate to his desired location. He does need direction to his room at time. He is usually pleasant. Neither staff nor Resident have voiced any problems in room or roommate. by Social Services (SS) Emily Cozort On 5/07/18 at 8:34 PM, Resident # 93 grabbed a black marker from the nurse and went to a resident being fed, raised the marker above her head. As the nurse went to take the marker away for him he took his right elbow and rammed it into the nurses left breast then immediately hit the nurse in the right jaw with his fist with great force. On 5/ 8/18 at 3:43 PM, Resident # 93 was combative pouring his water on the floor chewing up his meds and spiting them on the floor. On 5/12/18 at 6:57 PM, Resident # 93 had struck another resident in the dining room. Unable to redirect Resident was immediately removed from the dining room, he was cursing and saying I will kill them Let me at em right now Registered Nurse (RN) in charge was notified and decision was made to send to the ER for evaluation. On 5/17/18 at 4:33 Pm Resident # 93 agitated wondering up and down hall keeps talking about people getting blown up On 5/18/18 at 10:23 PM, Resident # 93 pushed another resident to the floor. Resident # 93 observed with hands around the other resident's neck. Resident # 93 was assisted to his room. This was report and witnessed by the housekeeper. (This happened in the lounge). On 5/19/18 at 6:17 AM, Resident # 93 combative and uncooperative with others. Resident # 93 striking out at others. On 5/29/18 at 10:41 PM, Resident # 93 stated to fight with staff. Resident # 93 scratched, slapped and attempted to kick staff. On 5/31/18 at 11:59 PM Resident # 93 combative with staff striking out. Resident # 93 hit the nurse in the face he attempted to hit her several more times. Resident # 93 stated that he was in Cambodia we have to get them before they get us. On 6/9/18 at 10:37 PM, Resident # 93 told the nurse, I'm going to f*ck up your head. He then made a fist with his right hand and chased the nurse around the table. He was also going up to another resident's family and couldn't be redirected. On 6/11/18 at 3:41 PM, Resident # 93 has been agitated this shift. Resident # 93 has grabbed staff members wrist and neck. Is hard to redirect On 6/20/18 at 1:44 PM, Inter Department Team (IDT) met and discussed combative behaviors with other residents on 5/19 On 7/14/18 at 3:48 PM, Resident # 93 hit staff in the chest while trying to ambulate to the bathroom, On 7/26/18 at 6:38 PM Resident # 93 asked nurse if she would suck him off. On 8/24/18 at 10:31 PM, Resident # 93 was observed to try and go into another resident's room. the other resident was trying to get him out of his room, both residents hit each other. On 8/27/18 IDT Met about physical contact with another resident. On 8/28/18 at 7:05 PM, Resident # 93 became agitated after witnessing another residents agitation . required 2 NA to walk with him he was trying to strike out cursing and tried to kick the nurse. It took 45 minutes to calm down. On 9/3/18 at 3:45 AM, Resident # 93's roommate accused Resident # 93 of beating him up. When nurse entered the room both men sitting on the side of the bed facing each other. Resident # 93 had no brief on it was next to the other resident's bed. On 9/03/18 at 11:13 PM, NA trying to remove resident from another resident's room. On 9/9/18 at 6:56 PM, another resident yelled at Resident # 93 who was in the hallway. the two started yelling and pushing each other. Resident # 93 hit the other resident in the jaw. On 9/10/18 at 12:00 AM Resident # 93 was agitated On 9/11/18 at 12:43 PM, NA heard Resident # 93 cursing and yelling in another resident's room [ROOM NUMBER]. She saw the other resident slap this resident in the face then Resident # 93 slapped her on both sides of her face before he could be re-directed. On 9/18/18 at 4:58 PM, Resident # 93 was found on the floor of another resident's room, He was assisted off the floor. On 11/4/18 at 6:24 AM, Resident # 93 agitated and difficult to redirect moving chairs and flipping tables in the lounge. On 11/5/18 at 12:29 PM, told nurse she was going to get a give her a butt whoppin On 11/07/18 at 12:30 PM, Administrator and DoN was asked what they had done to protect the other Residents from Resident #93. The administrator said that, they have had IDT meeting about the problem. They were asked what steps they have put in place to keep him from hurting the vulnerable residents. They had no answers. On 11/07/18 at 3:19 PM, came out of his room walked across the hall was briefly in room [ROOM NUMBER] Staff member called him back to his room, He is receiving one on one supervision at this time. d) Resident #24 On 11/05/18 at 1:33 PM, the resident said she didn't like being at the facility because another resident came to her room and tried to have sex with her. She said she did not think she belonged in this place, locked up. This resident resided on the locked unit of the Dementia care unit. Record review found the resident was admitted to the dementia unit on 08/06/18, after a stay in a local hospital where she was diagnosed as having a Neurocognitive disorder, most likely secondary to Alzheimer's Dementia with behavioral changes. The physician determined the resident lacked capacity to make medical decisions. Review of the licensed nurses notes found the following entry dated 09/22/18 at 11:43 PM: Resident stated that (Name of resident #110) came into her room and stated that he was going to kill her and he wanted to have sex with her. She stated that she came to the facility to be safe and is now scared. Resident was assured that she is safe. There was no further information regarding this incident was provided in the nurses notes. On 11/06/18 at 10:56 AM, Registered Nurse (RN) #19, identified herself as the dementia units case manager. When asked if she or anyone conducted any interviews or investigation related to the alleged incident or identified the circumstances of what occurred prior to during or after the alleged allegation voiced by (TRUNCATED)",2020-09-01
3353,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-11-12,607,E,0,1,2C7711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the Centers for Medicare and Medicaid Services Appendix PP State Operations Manual and staff interview the facility failed to ensure it implemented is abuse policy in regards to the prevention of abuse and the protection of all residents. Resident #110, Resident #93, and Resident #105 have been identified as residents who have on several occasions demonstrated verbally and physically abusive behaviors towards other residents residing on the south wing of the facility. These incidents have been ongoing at least since 08/2018. The facility has not demonstrated that they provided enough protection to prevent resident to resident abuse and to protect the other residents currently residing on the south wing of the facility. Residents residing on the south unit have voiced fear of resident #110 and Resident #93 one resident has voiced that he is to fearful to sit in the hallway. Resident #24 was fearful of resident #110 and was afraid he was going to sexually assault her the facility failed to address this fear and failed to make this resident feel safe while residing in the facility. The facility has put into place interventions of redirection and medication changes, but the residents behaviors of physical and verbal abuse continue indicating the interventions have not been successful in changing the residents behavior and/or protecting the other residents residing on the South Wing. Also for Resident #78 the facility failed to address an allegation of possible alleged abuse from another resident. For Resident #85 the facility failed to ensure this wandering resident was supervised to prevent resident to resident abuse from other residents directed toward this resident. These failures have the potential to effect more than an isolated number of residents. Resident Identifiers: #110, #105, #93, #24, #78 and #85. Facility Census: 115. Findings include: a) Resident #110 Observations of Resident #110 at 11:00 a.m. on 11/05/18 found him entering the Room of Resident #60. The resident was in bed and she had visitor. Resident #110 began cursing Resident #60's visitor and waving his arms in the air. The surveyor alerted staff that this visitor needed some help. The staff intervened and removed Resident #110 from Resident #60's room. At 11:05 a.m. on 11/05/18 this surveyor entered the room of Resident #60 to speak with her visitor. During the interview with Resident #60's visitor Resident #110 returned to the room and again began cursing at this surveyor and Resident #60's visitor. He stated, You all are a bunch of God Damn idiots . I am going to [***] ing die . This is stupid God Damn[***]and you need to [***] ing die. Resident #110 was waving his arms in the air as he screamed the above statements. After about three (3) minutes staff came and again removed Resident #110 from Resident #60's room. Resident #60's visitor indicated this was the first time she had ever seen this gentleman, but he was obviously not happy. A review of Resident #110's incident reports regarding his behavior toward other residents at 12:00 p.m. on 11/06/18 found the following occasions where Resident #110 was in a resident to resident altercation: -- 07/07/18 - Resident #110 and Resident #80 (roommates at the time) got into a fight and Resident #80 received a bruise to top of his right hand and a laceration to his lip. No injuries were noted to Resident #110 and the staff indicated they would continue to monitor for other behavioral episodes. -- 08/28/18 - Resident #110 and nurse were walking down the hallway when Resident #98 who was standing at the nurses' station began yelling and pointing at Resident #110 stating that he had pushed him down. Resident #110 shouted back, You are damn right I did and I will do it again you stupid nigger. Resident #98 was assessed to have an 8 by 5 centimeter abrasion to his left side. Review of the progress notes beginning on 09/01/18 through present at 10:30 a.m. on 11/07/18 found the following notes concerning resident to resident incidents: -- 09/21/18 at 4:32 a.m. - Resident extremely agitated at beginning of shift. Every attempt to redirect was unsuccessful and resident became combative. Resident was given a sandwich for snack with a drink. Played music that resident likes but would not calm down. Resident is confused to the point of no talking down or redirecting. Resident began arguing and getting in the face of other residents. Both nurses attempted to just let resident walk freely and calm down but was unsuccessful. Unable to pass medication due to resident up on cart so close yelling in our faces. When asked to please back up resident would curse and throw things. Called (name of attending physician) at 9:45 p.m. to ask for orders. (Name of attending) physician ordered [MEDICATION NAME] 1 mg (by mouth) PO as a one time order. After resident was administered the [MEDICATION NAME] 1 mg the resident calmed down over the next 30 minutes and this nurse was able to get him to lay down and resident was cooperative. Resident rested throughout the remaining of the night with eyes closed. -- 09/23/18 10:39 p.m. - Resident came down 300 hall during my med pass and was going into other residents room yelling and cursing at them. When trying to redirect resident her cursed at me and smacked my arm. He continued to bother two (2) female residents that were standing in the hallway. I told the two female residents to return to their rooms and shut the door. (First name of Resident #110) could not be redirected. -- 09/23/18 11:02 p.m. Resident had medication at 8:00 p.m. Attempted to help resident to bed at 9:00 p.m. Resident got up shortly after and wandered down 300 hall. Went in several rooms and they would scream for him to get out and he would then get in their faces and when we got to the room he was cursing and drawing his fist back to hit a female resident. Resident was redirected but was only able to get him out of the side of the room where the woman was. Resident then grabbed this nurse and (First and Last Name of NA #102) and pushed us down and was punching us. NA (First and Last Name of NA # 118) came in room and resident also punched her and grabbed her arms while cursing and being out of control. Once Resident wandered down the hall this nurse told 1 CNA to stay on hall and 1 cna to close the fire doors and stay there until able to call (name of attending physician) for orders. (Name of attending physician) order to send resident out to the emergency room -- 10/10/18 10:33 p.m. - During HS med pass resident came up to this nurse and was very agitated resident yelling no you stupid [***] go [***] yourself, I offered resident a snack and that calmed him down for a while but resident began pacing up and down the hallway. I asked resident what was wrong and he said you don't know anything you [***] . Resident going by other residents doorways and hollering stupid [***] . Attempted to redirect resident without success. Will continue to monitor for behaviors. -- 10/21/18 at 8:40 a.m. Resident was visited in the South Lounge for P[NAME] (plan of care) assessment. He was reading (name of newspaper) and was able to identify orientation questions from this paper. Resident was friendly throughout assessment, but stated that he was mad at a peer. He pointed several times at different residents and said that he could blow them up with a airplane. Resident was redirected and completed the assessment. Resident scored an 11/15 (11 of 15) on his BIMS (Brief Interview for Mental Status)., and endorsed trouble sleeping and feeling tired at times. -- 10/30/18 12:39 a.m. - Resident entered into a verbal argument after wandering into another residents room. This nurse intervened and redirected both residents. Resident easily redirected. Will continue to monitor. Review of Resident #110's care plan found the following Problem statement: (First Name of Resident #110) has delusions of combat related to heavy drinking while watching war movies per family. He is aggressive with staff and other residents with delusions of people trying to kill him. The goal statement associated with this problem was: (First name of Resident #110) will not obtain any major injury. Target date of 01/23/19. Interventions related to this problem and goal statement included: -- Provide diversion activities for (First name of Resident #110). Added on 07/05/18. -- Approach (First name of Resident #110) positively and in calm, accepting manner. Added on 07/05/18. -- Assign staff to account for (First name of Resident #110) whereabouts throughout the day. Added on 07/05/18. -- Monitor and document (First name of Resident #110) behavior. Added on 07/05/18. -- Redirected (First name of Resident #110) to room or lounge when laying in inappropriate areas. Added on 07/05/18. -- Do not play war movies on lounge TV with (First name of Resident #110) in attendance. Added on 07/05/18 -- Send to emergency room . Added on 08/28/18 -- Redirect (First name of Resident #110) to a calm and quiet environment. Added on 08/28/18. -- Send to ER [DATE] for evaluations due to combative behaviors. Added on 09/21/18. -- Will see in house psychiatrist next visit. Added on 09/24/18. A review of Resident #110's Minimum Data Set (MDS) assessments with assessment reference dates of 07/19/18 and 10/18/18 found resident had Physical behavioral symptoms towards others 1 to 3 days during the seven day look back period. The MDS also indicated Resident #110 had verbal behavioral symptoms directed toward others 4 to 6 days during the look back period. These findings were discussed during an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) beginning at 1:14 p.m. and concluding at 1:41 p.m. The NHA stated that she would put together a time line to show what interventions they had put into place for Resident #110. Later that afternoon the NHA provided the following time line regarding Resident #110's behaviors and the facility's interventions. The NHA provided a time line to show what they had done for this resident to keep other residents safe: --08/13/18 redirection with music behind nurses station with staff --08/18/18 redirected and relaxed with music --08/18/18 redirected and resident to bed resting --08/21/18 successfully redirected by staff. --08/28/18 out to ER they gave him [MEDICATION NAME] and then he returned to us --08/29/18 [MEDICATION NAME] was increased by Dr. --09/20/18 Ordered one-time [MEDICATION NAME] --09/21/81 redirected successfully with food and music later [MEDICATION NAME] order changed, and [MEDICATION NAME] ordered. --09/23/18 TO (name of local hospital) ER and returned --10/02/18 redirected to his room and then rested quietly (nursing note for this date says redirection was not successful.) --10/03/18 redirected through change in environment. --10/10/18 Gave snacks and he calmed down --10/30/18 redirected Upon reviewing the in house psychiatrist schedule, Resident #110 had been placed on his list to be seen when he rounds here at the facility. Care plan interventions include: diversional activities, naps rest periods, snacks, meds as ordered, approach calmly, psych consult scheduled. Review of the in-house psychiatrist's visits to facility found visits occurred on 08/25/18, 09/15/18, and 10/27/18, but there was no evidence Resident #110 was seen. The list also indicated the resident was to be seen because he had [MEDICAL CONDITION] (post-traumatic stress disorder) and unable to redirect combative with staff and residents. A care plan intervention was added on 09/24/18 indicating the resident would be seen by the in-house psychiatrist on the next visit which would have been 10/27/18 but Resident #110 was not seen and he continued to have verbally and physically abusive behaviors. During an interview with Resident #24 on 11/05/18 at 1:33 P.M., she said a male resident (she was referring to Resident #110) came into her room and told her he was going to rape her. That really scared her. Further investigation found a nurse's note, dated 09/22/18 at 11:43 PM confirmed Resident #24's statement. The note included, Resident stated that (Resident #110's name) came into her room and stated that he was going to kill her and he wanted to have sex with her. She stated that she came to the facility to be safe and is now scared. Resident was assured that she is safe. No further investigation could be found as to the circumstances before, during or after the alleged incident occurred. The author of the nursing note was unavailable for contact. During an interview on 11/05/18 at 11:46 AM, Resident #80 stated, (Resident #110) wants to fight me .he makes fun of me and makes faces at me .he tries to get a rise out of me. When asked if he participated in facility activities, Resident #80 stated, I have to stay in my room . otherwise I would have a chair in the hallway. Resident #80 stated Resident #110 had never touched him. When asked if he was afraid of Resident #110, Resident #80 stated, You never know what is going to happen. During the Resident Council meeting on 11/06/18 at 11:05 AM, Resident #80 said Resident #110 and Resident #93 .are bad and makes it where they can't come out of room. Resident #80 stated they had reported it to nurses and they did nothing. Resident #80 stated Resident #83 beat him in the head. Resident #80 stated. when the two of them are together they are really bad. He said, They terrorize us. Resident #24 stated Residents #110 and #93 came in her in her room and would not leave. Resident #110 had told Resident #93 to hold the door closed, she said that she had to fight him, while Resident #93 was holding the door closed. She was pulling on the door and yelling for help, finally the workers came. They told her they had to pull Resident #93's hand off the door to help her. Another time Resident #110 also brought a blanket in her room and said he wanted to have sex with her and she said no and yelled for him to leave her room. He also was in her bed sleeping one day and when she told the staff, they told her to let him sleep he will get up when he wakes up. Resident #24 also stated that Resident #110 was beating Resident #62 and she and another male resident had to get him away from her. They took Resident #62 up to the offices by the lounge and when they reported it to staff, staff just said, Well he doesn't know what he is doing and told him to apologize. Resident #24 commented, (Name of Resident #110) is a big guy and he scares me. During an interview with Resident #78 on 11/06/18 at 11:14 a.m., she said Resident #110 was in her bed two times, she too was told that when he wakes up he will leave. She also stated that other residents just wander in and out of her home all the time. South wing Activities Director #105 was asked whether residents had come to her office and reported to her about Resident #110 hitting Resident #62. She said, These residents have dementia, so they are very forgetful and are not always reliable. She asked if this surveyor was familiar with caring for those with Dementia. On 11/08/18 after the notification of the Immediate Jeopardy on 11/07/18 Resident #110 was sent to see the in-house psychiatrist at his office in the community. The psychiatrist admitted Resident #110 to a psychiatric unit for medication stabilization on 11/08/18. At the time of exit on 11/12/18 at 5:00 p.m. no further information was provided regarding the management of Resident #110's behaviors. b) Resident #105 A review of Resident #105's incident reports at 12:00 p.m. on 11/07/18 found the following incidents which involved a resident to resident altercation (Resident identifier numbers have been substituted for residents' names and room numbers designated as XXX for confidentiality): -- 08/03/18 - Resident #105 gently slapped other resident with open hand. Resident #105 was very difficult to redirect. Combative with staff and cursing other residents. Resident redirected to her room. (Please note other resident not identified by facility) -- 08/19/18 4:40 p.m. - called to hallway in front of room XXX. Resident #105 smacked Resident #102 on the right hand. No injuries. Residents separated and redirected. -- 09/03/18 9:20 p.m. - Heard yelling from room XXX. Upon entering the room staff witnessed Resident #105 slap Resident #93 across the right cheek and was cursing at him. Resident #93 then in turn slapped Resident #105 across both her cheeks. -- 10/22/18 6:30 p.m. - Resident #105 and Resident #112 were overheard yelling at each other. Resident #105 was slapping Resident #112 in the face. Other resident attempted to kick Resident #105 but missed. -- 10/23/18 1:15 p.m. - Therapy staff observed Resident #105 go into Resident #112's room. Resident #112 asked Resident #105 to leave and Resident #105 became angry and slapped Resident #112 with an open hand across the face and grabbed the resident's left arm. Review of Resident #105's nursing notes found the following additional occasions when Resident #105 was involved in a verbal or physical altercation with other residents: -- 09/01/18 at 6:19 p.m. - according to Resident #98, Resident #105 entered his room and hit him in the stomach and scratched his left upper cheek and behind his left ear, and his left upper lip. Following that Resident #98 punched Resident #105 in the lower left jaw. Resident #105 then began to curse Resident #98. The housekeeper overheard and entered the room to separate the residents. -- 09/11/18 at 12:59 a.m. - Heard yelling coming from room XXX. Upon entering witnessed staff attempting to redirect 2 residents who were yelling at one another. The nurse redirected the other resident in one direction while staff redirected Resident #105 in the opposite direction. After talking to staff it was told to this nurse that Resident #105 had slapped the resident on the right cheek and was cursing him. Following her slap the other resident then slapped her on both cheeks. No injuries noted. -- 09/29/18 12:30 a.m. - Earlier this shift resident was loud. Yelling at other residents to get out of her room and she was in theirs. Resident easily redirected by staff. At time Resident was observed striking out at staff and other residents. No physical contact was made. -- 10/04/18 3:43 p.m. - Resident has been in an up and down mood today. One minute she will be happy and then the next moment the resident is heard down the hall saying you're a whore, growling at people, and hitting people. Resident has been easily redirected each time by different staff members. -- 10/03/18 6:20 a.m. - Resident has been wandering in and out of rooms this AM (morning). Resident repeatedly lying people are in her bed. Resident pointed to another residents room and said she was going to knock the hell out of them and show them what she was made of. Resident was redirected to her room and explained to her that other residents were not in her room. Resident was laying in bed with eyes closed at this time. -- 10/17/18 at 4:27 p.m. - Resident has been resting in bed most of shift. This am (morning) at breakfast this resident began yelling at the resident across the table at her. When staff went intervene resident stood up and started yelling at staff and hitting them and continued to yell at the other resident . -- 10/26/18 12:12 a.m. - Resident #105 wandered into another residents room and got in verbal altercation with that resident. Easily redirected. No complaints voiced -- 10/30/18 6:10 p.m. - Resident #105 out in the hallway and got into a verbal altercation with another resident when this resident attempted to go into that residents room. The resident began yelling that she was going to kill that [***] . When attempting to redirect Resident #105 began hitting and pulling this nurse's hair. A review of Resident #105's care plan found statement of: (First Name of Resident #105) displays physically aggressive behavior. The goal associated with this care plan was: (First name of Resident #105) displays physically aggressive behavior. This goal had a target date of 01/23/19. The interventions related to this problem and goal included: -- Social Services to evaluate and visit with (First name of Resident #105). Added on 08/08/18. -- Activities staff to visit with (First name of Resident #105) and provide diversional activities. Added on 08/08/18. -- Monitor and document (First name of Resident #105)'s behavior. Added on 08/08/18. -- Do not argue with (First name of Resident #105). Added on 08/08/18. -- Identify causes for behavior and reduce factors that may provoke (First name of Resident #105). Added on 08/08/18 -- Praise (First name of Resident #105) for demonstrating desired behavior. Added on 08/08/18. -- Talk with (First name of Resident #105) in calm voice when behavior is disruptive. Added on 08/08/18. -- Remove (First name of Resident #105) from public area when behavior is disruptive and unacceptable. Added on 08/08/18. -- Encourage responsible party/family to visit with (First name of Resident #105). Added on 08/18/18. -- Redirect (First name of Resident #105) when she is intrusive to other residents space. Added on 08/20/18. -- Encourage staff to spend time with (First name of Resident #105) to feel comfortable. Added on 09/14/18. -- Apply stop sign to door. Added on 09/12/18. -- When resistant to care provide (First name of Resident #105) with positive distractions. Added on 10/16/18. -- Try to identify triggers that cause behaviors. Added on 10/23/18. A review of Resident #105's Minimum Data Set (MDS) assessment with assessment reference dates (ARD) of 07/10/18 and 10/15/18 found Resident #105 had verbal and physical behaviors directed toward others one (1) to three (3) days during each look back period. During an interview with the Administrator (NHA) and the Director of Nursing (DON) beginning at 1:14 p.m. and concluding at 1:41 p.m. on 11/06/18, these findings were discussed. The NHA stated that she would put together a time line to show what interventions they had put into place for Resident #105. The following morning, on 11/07/18, the NHA provided a time line to show what they had done for this resident to keep other residents safe. The following is the timeline provided typed as written: -- 08/03/18 redirected. -- 08/05/18 redirected. -- 08/10/18 redirected. -- 08/17/18 redirected and snacks provided. -- 08/19/18 redirected. -- 08/22/18 permission to see psychiatrist obtained. -- 08/25/18 seen by (Name of in-house psychiatrist). No new medication changes. -- 08/30/18 redirected encouraged rest period. -- 09/01/18 redirected. -- 09/04/18 redirected, monitored, praise family was called and asked them to come and visit. -- 09/06/18 redirected to room, staff member sat with resident until she fell asleep. -- 09/09/18 seen by MD. No new orders offered snacks and provided rest period. -- 09/11/18 redirected. -- 09/12/18 spoke with RP (responsible party) about hearing aide declined. -- 09/12/18 applied stop sign to door. -- 09/29/18 redirected. -- 10/03/18 redirection and encouraged rest period. -- 10/15/18 used music for redirection and rest period. -- 10/16/18 environmental change. -- 10/23/18 snack/redirection. -- 10/27/18 saw (Name of in house psychiatrist) again and increase [MEDICATION NAME]. -- Care planned interventions include: activities, attempts to identify cause of agitation, calm approach, praise, change environment when needed, encourage family visits, psych consult, stop sign on door and med's as ordered. -- Med's include: [MEDICATION NAME], and [MEDICATION NAME]. Review of Resident #105's medications found she was started on [MEDICATION NAME] 125 mg by mouth twice a day on 10/27/18. Resident was started on [MEDICATION NAME] 25 mg twice a day and [MEDICATION NAME] 40 mg once daily beginning on 07/10/18, the date of her admission. Resident #105 received the [MEDICATION NAME] for a [DIAGNOSES REDACTED]. There was no evidence in the medical record that these medications were ever reviewed for effectiveness in controlling the residents behaviors. c) Resident #93 Abuse During record review of nurses notes in the electronic chart the following notes were as listed below. On 4/19/18 at 6:19 AM Nursing notes, Resident # 93 agitated after Nursing Assistance NA dressed him this am. Afterwards he would run up to her and telling her he was going to beat the[***]out of her with his fist drawn back. Resident did this three times. On 4/19/18 at 1:38 PM, states Resident # 93 will ambulate to his desired location. He does need direction to his room at time. He is usually pleasant. Neither staff nor Resident have voiced any problems in room or roommate. by Social Services (SS) On 5/07/18 at 8:34 PM, Resident # 93 grabbed a black marker from the nurse and went to a resident being fed, raised the marker above her head. As the nurse went to take the marker away for him he took his right elbow and rammed it into the nurses left breast then immediately hit the nurse in the right jaw with his fist with great force. On 5/ 8/18 at 3:43 PM, Resident # 93 was combative pouring his water on the floor chewing up his meds and spiting them on the floor. On 5/12/18 at 6:57 PM, Resident # 93 had struck another resident in the dining room. Unable to redirect Resident was immediately removed from the dining room, he was cursing and saying I will kill them Let me at em right now Registered Nurse (RN) in charge was notified and decision was made to send to the ER for evaluation. On 5/17/18 at 4:33 Pm Resident # 93 agitated wondering up and down hall keeps talking about people getting blown up On 5/18/18 at 10:23 PM, Resident # 93 pushed another resident to the floor. Resident # 93 observed with hands around the other resident's neck. Resident # 93 was assisted to his room. This was report and witnessed by the housekeeper. (This happened in the lounge). On 5/19/18 at 6:17 AM, Resident # 93 combative and uncooperative with others. Resident # 93 striking out at others. On 5/29/18 at 10:41 PM, Resident # 93 stated to fight with staff. Resident # 93 scratched, slapped and attempted to kick staff. On 5/31/18 at 11:59 PM Resident # 93 combative with staff striking out. Resident # 93 hit the nurse in the face he attempted to hit her several more times. Resident # 93 stated that he was in Cambodia we have to get them before they get us. On 6/9/18 at 10:37 PM, Resident # 93 told the nurse, I'm going to f*ck up your head. He then made a fist with his right hand and chased the nurse around the table. He was also going up to another resident's family and couldn't be redirected. On 6/11/18 at 3:41 PM, Resident # 93 has been agitated this shift. Resident # 93 has grabbed staff members wrist and neck. Is hard to redirect On 6/20/18 at 1:44 PM, Inter Department Team (IDT) met and discussed combative behaviors with other residents on 5/19 On 7/14/18 at 3:48 PM, Resident # 93 hit staff in the chest while trying to ambulate to the bathroom, On 7/26/18 at 6:38 PM Resident # 93 asked nurse if she would suck him off. On 8/24/18 at 10:31 PM, Resident # 93 was observed to try and go into another resident's room. the other resident was trying to get him out of his room, both residents hit each other. On 8/27/18 IDT Met about physical contact with another resident. On 8/28/18 at 7:05 PM, Resident # 93 became agitated after witnessing another residents agitation . required 2 NA to walk with him he was trying to strike out cursing and tried to kick the nurse. It took 45 minutes to calm down. On 9/3/18 at 3:45 AM, Resident # 93's roommate accused Resident # 93 of beating him up. When nurse entered the room both men sitting on the side of the bed facing each other. Resident # 93 had no brief on it was next to the other resident's bed. On 9/03/18 at 11:13 PM, NA trying to remove resident from another resident's room. On 9/9/18 at 6:56 PM, another resident yelled at Resident # 93 who was in the hallway. the two started yelling and pushing each other. Resident # 93 hit the other resident in the jaw. On 9/10/18 at 12:00 AM Resident # 93 was agitated On 9/11/18 at 12:43 PM, NA heard Resident # 93 cursing and yelling in another resident's room [ROOM NUMBER]. She saw the other resident slap this resident in the face then Resident # 93 slapped her on both sides of her face before he could be re-directed. On 9/18/18 at 4:58 PM, Resident # 93 was found on the floor of another resident's room, He was assisted off the floor. On 11/4/18 at 6:24 AM, Resident # 93 agitated and difficult to redirect moving chairs and flipping tables in the lounge. On 11/5/18 at 12:29 PM, told nurse she was going to get a give her a butt whoppin On 11/07/18 at 12:30 PM, Administrator and DoN was asked what they had done to protect the other Residents from Resident #93. The administrator said that, they have had IDT meeting about the problem. They were asked what steps they have put in place to keep him from hurting the vulnerable residents. They had no answers. On 11/07/18 at 3:19 PM, came out of his room walked across the hall was briefly in room [ROOM NUMBER] Staff member called him back to his room, He is receiving one on one supervision at this time. d) Resident #24 On 11/05/18 at 1:33 PM, the resident said she didn't like being at the facility because another resident came to her room and tried to have sex with her. She said she did not think she belonged in this place, locked up. This resident resided on the locked unit of the Dementia care unit. Record review found the resident was admitted to the dementia unit on 08/06/18, after a stay in a local hospital where she was diagnosed as having a Neurocognitive disorder, most likely secondary to Alzheimer's Dementia with behavioral changes. The physician determined the resident lacked capacity to make medical decisions. Review of the licensed nurses notes found the following entry dated 09/22/18 at 11:43 PM: Resident stated that (Name of resident #110) came into her room and stated that he was going to kill her and he wanted to have sex with her. She stated that she came to the facility to be safe and is now scared. Resident was assured that she is safe. There was no further information regarding this incident was provided in the nurses notes. On 11/06/18 at 10:56 AM, Registered Nurse (RN) #19, identified herself as the dementia units case manager. When asked if she or anyone conducted any interviews or investigation related to the alleged incident or identified the circumstances of what occurred prior to during or after the alleged allegation voiced by Resident #24 on 09/22/18, she replied she was unaware of the allegation. She was unable to provide any further information related to Resident #24's statement. There was no information as to how the facility addressed Resident #110's behaviors. During the resident council meeting held on 11/06/18 at 11:05 AM, Resident #24 said Residents #110 and #93 come in her in her room wouldn't leave her room. She said that on one occasion, Resident #110 told Resident #93 to hold the door closed. She said she had to fight Resident #110 while Resident #93 was holding the door closed. She was pulling on the door and yelling for help, finally the workers came. They told her they had to pull Resident #93's hand off the door to help her. Another time, Resident #110 brought a blanket",2020-09-01
3354,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-11-12,656,E,0,1,2C7711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, and observation, the facility failed to ensure four (4) of 23 sampled residents had person centered care plans developed and or implemented to address the resident's medical, physical, mental and psychosocial needs. Resident #79's care plan was not developed to include all the interventions developed to prevent falls. Resident #78's care plan was not implemented to address emotional status. Resident #85's care plan did not include the residents wandering behaviors. Resident #23's care plan did not include Hospice services. Facility census: 115. Findings include: a) Resident #79 Observation of the resident on 11/07/18 at 9:30 AM found she was seated in the dining room wearing a soft helmet. Review of the residents' current care plan, found the resident was care planned for having a history of falls. The approaches to prevent falls did not include the wearing of a soft helmet. On 11/07/18 at 10:54 AM, Registered Nurse (RN) #74 provided a copy of the physician's orders [REDACTED]. The physicians' order was dated 04/24/18. RN #74 reviewed the care plan and confirmed the intervention was not included on Resident #79's care plan. RN #74 said, I will put that on the care plan right now. b) Resident #78 On 11/05/18 at 12:15 PM, the resident was asked if she had any problems with other residents. She replied, I am constantly telling others to please leave my room. They come in all the time. The resident said she had told people but they say they can't do anything because those people are confused. During the interview, Resident #85 wandered into this residents room. The resident said see here she comes, always nosing around. Resident #78 told Resident #85 to, Go on, get out of here, this isn't your room. Resident #78 repeated this several times and pointed to the door. Resident #85 finally left the room. This resident resides on the Dementia care unit. Review of the nursing notes found the following documentation: 10/16/18 4:28 AM, Resident came to nurses' station stating that a man keeps coming into her room. She states that she is scared and wants out of this place. Resident said she didn't trust the man and didn't know if he was going to rape her or not. When nurse tried redirecting her she continued to say that she didn't feel safe and that she wanted to speak with the social worker. Resident said that every time she requests to speak with the social worker, she never comes to see her. There was a note placed at nurses station for day shift nurse to pass on to Social Worker. 09/30/18 at 11:19 PM, Resident (name of resident) came to this nurse and stated, you know that great big guy that lives here. He came into my room and laid in my bed onto my papers even though I told him not to. I punched him in his gut. Then he grabbed me by my wrist and not they hurt (typed as written). Staff said this resident came out into the hallway and asked them to get the other resident out of her bed. Instructed resident if the gentleman came back into her room to call out for staff and they would get him out of her room. Resident stated, it is not going to matter anyway because I am leaving this place in the morning. No discoloration or breaks on the skin observed to both lower arms. Review of the resident's current care plan found the following problem: Potential alteration in mood related to history of (Name of Resident) acknowledging feeling down, having little interest in doing things, trouble sleeping and concentrating at times. She continues to adjust to facility and environment. The goal associated with the problem: Will maintain positive mood as evidenced by participating in activities/outings of interest, voicing feelings to staff, having positive interactions with other residents in lounge or dining room once a day throughout next review. Interventions included: Visit with resident and allow her time to voice feelings, concerns she may be having. This intervention directed SS would visit with the resident. Review of the residents most recent minimum data set (MDS) a quarterly, with an assessment reference date of 10/03/18 found Resident #78 had no problems with making herself understood and understanding others. The resident had no issues with inattention, disorganized thinking or altered level of consciousness. Her brief interview for mental status (BIMS) found she achieved a score of 12. A score of 12 indicates mild confusion. At 3:30 PM on 11/06/18, the activity director, #105 was asked if she was aware Resident #78 was upset because residents were coming into her room. [NAME] #105 said this was a dementia unit and residents did wonder about freely. She wasn't aware of Resident #105's concerns. [NAME] #105 accompanied the surveyor to Resident #78's room. The resident voiced concerns about other residents coming into her room to the surveyor and [NAME] #105. E #105 completed a grievance/concern form at this time. Review of the form dated 11/06/18, found the following: (Name of Resident) voiced concerns to me and the surveyor that residents were coming in her room. She stated that she tried to get a male resident out of her room and he proceeded to get in her roommates bed. AD and surveyor talked to (Name of Resident) about the stop sign strip placed at her door and asked her if it was helping to keep residents out. She said it was helping. However a female resident had been in her room. I asked her if she would like a stop sign added to her door. She said yes. I talked to (name of the registered nurse case manager) about her concerns and she gave me a stop sign to place on her door. (Name of Resident) said she thought it would help . At 8:12 AM on 11/08/18 both facility social workers: SW #2 and SW #135 were asked if either of them had talked to the resident after she said she wanted to see the social worker on 10/16/18. On 11/12/18 at 9:44 AM, SW #2 provided copies of 2 notes written by herself: The first note dated 11/06/18 at 7:45 PM, (after surveyor intervention) addressed the residents concerns about residents wandering in and out of her room. The second note was dated 10/10/18 at 11:06 AM. This note discussed the resident's care plan meeting. This note made no mention the residents' concern regarding wandering residents. The care plan was also reviewed with SW #2 and SW #135. The intervention to visit with the resident to allow her to voice her concerns as written in the care plan was also discussed with the social worker. At the close of the survey on 11/12/18, at 4:30 PM no information had been provided to substantiate the social workers had visited with this resident to specifically address her concerns voiced on 10/16/18 as directed by the care plan. c) Resident #85 On 11/05/18, the day of entrance to the facility, observation found the resident was wondering aimlessly in and out of other residents rooms around 2:30 PM. The resident was observed on the 300 and 400 hallways of the facility. The resident resides in room [ROOM NUMBER]-B. During an interview with Resident #78 who resident on the 300 hallway, on 11/05/18 at 12:15 PM, Resident #85 wandered into the Resident #78's room. Resident #78 said, See here she comes, always nosing around. Resident #78 told Resident #85 to, Go on, get out of here, this isn't your room. Resident #78 repeated this several times and pointed to the door. Resident #85 finally left the room. While talking to the activity director (AD #105) on the 300 hallway, on 11/06/18 at 3:33 PM, regarding Resident #78 complaints about Resident #85 coming into her bedroom, Resident #85 entered room [ROOM NUMBER]. Resident #85 removed a book and a box of tissues from the nightstand of the Resident in bed-[NAME] Resident #85 then took the items to room [ROOM NUMBER] (occupied by male residents) and proceed to lay down in Bed [NAME] The activity director stated this is a dementia unit and residents wander. The AD director did get Resident #85 to leave the room. The following observations were made by 3 surveyors on the 300 Hallway of the dementia unit on the afternoon of 11/07/18: --At 3:20 PM the Resident #85 entered room [ROOM NUMBER]. The resident looked around the room and then exited the room. --At 3:26 the resident entered room [ROOM NUMBER] and stripped the covers off the bed. The resident then traveled to room [ROOM NUMBER] and placed the covers from room [ROOM NUMBER] onto the A bed in room [ROOM NUMBER]. Resident #85 then traveled to bed-B in room [ROOM NUMBER] and attempted to take the covers from the resident in bed B. The resident in Bed B made a groaning noise and Resident #78 left the room. --At 3:29 PM Resident #85 entered room [ROOM NUMBER]. A nursing assistant (NA #29) was walking down the hallway. NA #29 told Resident #85, That's not your room, come on, get on out of there. Resident #85 left room [ROOM NUMBER] and walked into room [ROOM NUMBER]. Resident #85 took the bed covers from Bed-A on room [ROOM NUMBER] and traveled to room [ROOM NUMBER] with the bedcovers in her hand. The door to room [ROOM NUMBER] was closed. Resident #85 opened the door and entered the room. Resident #85 closed the door behind her. Within a few minutes after Resident #85 entered room [ROOM NUMBER], the surveyors heard a loud male voice coming from inside room [ROOM NUMBER]. (The surveyors did not know room [ROOM NUMBER] was occupied). One surveyor went to the nurses desk to get help, while this surveyor knocked on the door and entered room [ROOM NUMBER]. Upon entrance to room [ROOM NUMBER], the male resident residing in room [ROOM NUMBER] punched Resident #85 in the chest area. The male Resident #98 and was yelling, get out of my room and I mean it. Resident #85 exited the room and entered the 300 hallway. Resident #98 continued to stand in the doorway of his room, red faced and agitated. A third surveyor attempted to calm Resident #98 by talking with him. At 3:43 PM on 11/07/18, Licensed Practical Nurse (LPN #124) came to get Resident #85 after being alerted by the surveyor. LPN #78 said Resident #85 used to be a housekeeper so that's why she tries to make beds and takes covers. LPN #124 examined Resident #85 and said she didn't see any injuries. LPN #124 was asked if the facility had tried giving Resident #85 a basket of sheets, towels or washcloths to fold. LPN #124 said she did not know. Review of the resident #85's most recent quarterly, minimum data set (MDS) with an assessment reference date (ARD) of 10/09/18, found the resident was coded as having wandering behavior every 1 to 3 days during the 7 day look back period. Review of the current care plan found it did not have a specific problem noting the resident is wandering. At 10:05 AM on 11/12/18, the director of nursing confirmed the care plan did not address the residents behavior of wandering into other residents' rooms. d) Resident #23 During a record review on11/05/18 at 12:00 PM, It was revealed Resident #23 was receiving hospice care. The Hospice services started on 05/19/18. The Care Plan reads: Resident #23 will experience a peaceful, dignified death 11/27/18. There was not any mention of when the Hospice will be scheduled to give care, as to when the Registered Nurse will make visits, when the Nurse Aides will visit and what care they will provide. This lack of information on the care plan, results in a lack of communication to the staff providing care for this resident. On 11/06/18 at 12:34 PM, Registered Nurse #74 was asked about the care plan not being personalized. She said that, they discuss that in the inter departmental meetings and so she stated, that she feels like it does not need to be in the Care Plan. She was asked how was it communicated to the rest of the staff if it was not care planned? She shook her head but had no answer. On 11/06/18 at 12:57 PM, Administrator and DoN was informed and shown the care plan they had no comments.",2020-09-01
3355,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-11-12,684,D,0,1,2C7711,"Based on medical record review and staff interview, the facility failed to ensure Resident #72 received treatment and care in accordance with professional standards of practice. The facility failed to ensure prompt transfer of the resident for evaluation when she experienced a change in condition after a fall. This was true for one (1) of 23 residents reviewed during the survey process. Resident identifier: #72. Facility census: 115. Findings included: a) Resident #72 Review of Resident #72's medical records revealed the resident experienced a fall on 11/09/18 at 5:16 AM. The Resident Incident Report stated, Resident lying in bed, told staff member, I fell . Assessment revealed 4 cm hematoma to right side of forehead with abrasion. The area of the report to indicate when the physician was notified was blank. A nursing note written on 11/09/18 at 7:09 AM stated, Resident lying in bed, roommate in bed with resident. Resident stated, I fell . Assessment revealed 4 cm hematoma + abrasion to right side of forehead. Area cleansed and triple antibiotic applied. Hand grasp equal. Pupils reacting to light .No other injuries apparent. Full weight bearing upon standing. Ambulating without difficulty. A Head Injury Check List was initiated on 11/09/18 at 5:15 AM Resident #72's vital signs and neurological status were monitored for 24 hours. The head injury check list indicated Resident #72 remained stable through 11/10/18 at 5:00 AM, when the Head Injury Check List was completed. A nursing note written on 11/09/18 at 10:40 PM stated, Resident is still attempting to get up unassisted. Redirected resident and reeducated resident to not get up without assistance. No signs or symptoms of pain or discomfort observed. No acute distress observed. Hematoma remains to right side of head. BP (blood pressure) 165/80 P (pulse) 82 R (respirations) 21 T (temperature) 97.6. Tolerated HS (nighttime) medications and fluids well. Will continue to monitor. No further nursing notes were written until 11/10/18 at 6:42 PM. This nurse's note stated, Resident has been up to dining room for meals and to lounge in between. Resident has attempted to get up several times unassisted. Alarms in place and in working order. Knot and bruise cont (continues) to right forehead and bruising is now around right eye. No c/o (complaints of) pain or discomfort voiced. Resident took pm meds without difficulty. No s/s (signs and symptoms) of distress observed. Will cont to observe. The next Nursing Note, written on 11/10/18 at 7:05 PM, stated (typed as written), Staff assisted resident to bed CNA (Certified Nursing Assistant) alerted this nurse that resident was jerking. This nurse went to room and resident's head and arms were jerking, only lasted about 30 seconds. Afterward resident was alert and answering questions yes and no. Call to (resident's attending physician), awaiting return call. The next Nursing Note, written on 11/10/18 at 8:20 PM, stated, Left message for (Registered Nurse #8) and (resident's attending physician) to return phone call regarding resident. At 7:40 PM, notified (Registered Nurse #19) of resident fall on 11/09/18 and two episodes of body jerking that was observed. RN instructed this nurse to send resident to ER (emergency room ) for evaluation. Notified resident POA (power of attorney) (POA's name) of resident fall and sending to ER for evaluation. POA said to notify her anytime during the night if we find any information concerning residents (sic) condition of her Notify (name of ambulance service) and (name of hospital) ER of impending transport. Resident out of facility at 8:19 pm en-route to (name of hospital) two attendants assisted. Transfer papers given to attendant. The next Nursing Note, written on 11/10/18 at 11:06 stated, Spoke with (health worker name) at (hospital name) and she said she would be sending resident to a hospital in (city name). (Health worker name) said resident had a subdural hematoma. During an interview on 11/12/18 at 1:35 PM, the Director of Nursing (DoN) stated there was no indication of an attempt to notify Resident #72's physician of the fall on 11/09/18 until 11/10/18 at 7:05 PM. The DoN had no explanation of why the attending physician or why RN #8 did not respond to calls made to them at 7:05 PM. However, the DoN stated the attending physician does travel to other areas in West Virginia, and might not always be able to receive or return calls. The DoN stated the procedure is for the attending physician or a Registered Nurse to determine the need for a transfer to a hospital for an evaluation.",2020-09-01
3356,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-11-12,687,D,0,1,2C7711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure Resident #37 was provided with foot care in accordance with professional standards and practice. diabetes, [MEDICAL CONDITION]. Proper foot care includes to prevent complications from conditions such as This was true for one of one residents reviewed for the care area of foot care. Facility census 118. Findings included: During an interview on 11/05/18 at 11:38 AM, Resident #37 said that, his toe nail is coming off, and they are so long they are cutting his legs. During a record review it was discovered that Resident #37 is a diabetic which requires attention to foot care for his health benefits. On 11/07/18 at 07:30 AM, DoN was asked if she could arrange for a nurse to observe his toes with this surveyor and she agreed. On 11/07/18 at 9:30 AM, Resident # 37 said, this morning just a little bit ago they did come in and cut my toe nails, that nurse said that she never seen anything like it, you know being so long. On 11/07/18 at 9:43 AM, Registered Nurse (RN) #119 said that, she did cut his toe nails this morning. She said that she misunderstood what the DoN said. RN #119 was asked about his toe nails and she said that they were long. Upon viewing this resident's toes, it was noted that there was a rash and scratch marks on his inner right calf. She was asked if he had any Podiatry notes or consults for this resident. She said that she did not know if he had had any but would look. On 11/07/18 at 10 :59 AM, RN #119 provided an order for [REDACTED]. On 11/07/18 at 11:40 AM, DoN was asked about the nurse doing foot care without this surveyor, she said that the nurse misunderstood, and she did foot care.",2020-09-01
3357,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-11-12,690,D,0,1,2C7711,"Based on observation and staff interview the facility failed to prevent excessive urethral tension, accidental removal, and obstruction of urine outflow for Resident #37 with an indwelling Foley catheter. This was true for one (1) of two (2) residents reviewed for urinary catheter. Facility census was 118. Findings included: Resident #37 On 11/05/18 at 11:36 AM, during an interview with Resident # 37, he stated that his catheter leaks and he must keep his gown pulled up to keep it dry. During an observation of Foley catheter care on 11/07/18 at 9:32 AM, with Nursing Assistant (NA) #134, it was noted that the secure devise was improperly being used and the Foley Catheter was being pulled very tight to the right. Resident #37 said they just changed his Foley Catheter yesterday. On 11/07/18 at 9:43 AM, Registered Nurse #119 was asked to look at Resident # 37's Foley catheter and the way it is attached to his leg. She agreed that it was not applied properly and was placed too far away causing tension on the Foley. She stated that she would change it and fix it properly.",2020-09-01
3358,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-11-12,692,D,0,1,2C7711,"The facility failed to ensure Resident #60 was offered sufficient fluid intake to maintain proper hydration and health. Resident #60 consistently consumed less fluids than recommended by the dietician, and the facility failed to identify this and put interventions in place to prevent dehydration. This was true for one (1) of three (3) residents reviewed for the care area of hydration during the Long Term Care Survey Process. Resident Identifier: #60. Facility Census:115. Findings Include: a) Resident #60 An interview with Resident #60's caregiver at 11:00 a.m. on 11/05/18 when asked if she felt Resident #60 got plenty to drink she stated, She seems like she is always thirsty when I come to visit. She stated, I just gave her a glass of ice water and juice and she drank them all. She indicated, I don't know if she gets enough to drink or not. Observations of this residents room found there was no water pitcher available for the resident. Resident #60's caregiver indicated she is not able to give herself water anyway. She indicated, The staff will have to help her drink anything she gets. A review of Resident #60's medical record at 2:56 p.m. on 11/06/18 found a Nutritional Assessment completed by the licensed dietician on 09/04/18 which was the date Resident #60 was admitted to the facility. This nutritional assessment indicated Resident #60 needed 1730 milliliters of fluid each day to maintain her hydration status. A review of the fluid intake roster for Resident #60 from 09/04/18 through current found Resident #60 only met her fluid intake goal of 1730 MLs on the following occasions 09/07/18, 10/01/18, 10/02/18, 10/06/18, 10/16/18, 10/20/18, 10/21/18, 10/22/18, 10/24/18, 10/25/18 and 11/02/18. All other dates in the review period Resident #60 did not meet her recommended fluid intake. An interview with the Director of Nursing (DON) at 10:14 a.m. on 11/08/18 found the Certified Dietary Manager (CDM) usually reviews the fluid intake records and will put interventions in place if they are needed. She was not sure how often the CDM reviewed fluid intakes. An interview with the CDM at 10:28 a.m. on 11/08/18, found she only reviews fluid intakes on a quarterly basis unless the resident would be on weekly weights for some reason. She agreed that she would need to start reviewing these more often and stated she would review Resident #60 and would put some interventions in place for her to help increase her fluid intake.",2020-09-01
3359,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-11-12,725,E,0,1,2C7711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. Evident there was not sufficient staffing on the south wing to care for residents with behavior issues. This had the potential to affect all residents on the south unit of the facility. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. Facility census 115. Findings included: a) Resident #110 Observations of Resident #110 at 11:00 a.m. on 11/05/18 found him entering the Room of Resident #60. The resident was in bed and she had visitor. Resident #110 began cursing Resident #60's visitor and waving his arms in the air. The surveyor alerted staff that this visitor needed some help. The staff intervened and removed Resident #110 from Resident #60's room. At 11:05 a.m. on 11/05/18 this surveyor entered the room of Resident #60 to speak with her visitor. During the interview with Resident #60's visitor Resident #110 returned to the room and again began cursing at this surveyor and Resident #60's visitor. He stated, You all are a bunch of God Damn idiots. I am going to [***] ing die. This is stupid God Damn[***]and you need to [***] ing die. Resident #110 was waving his arms in the air as he screamed the above statements. After about three (3) minutes staff came and again removed Resident #110 from Resident #60's room. Resident #60's care giver indicated this was the first time she had ever seen this gentleman, but he was obviously not happy. A review of Resident #110's incident reports regarding his behavior toward other residents at 12:00 p.m. on 11/06/18 found the following occasions where Resident #110 was in a resident to resident altercation: --07/07/18 Resident #110 and Resident #80 (roommates at the time) got into a fight and Resident #80 received a bruise to top of his right hand and a laceration to his lip. No injuries were noted to Resident #110 and the staff indicated they would continue to monitor for other behavioral episodes. -- 08/28/18 Resident #110 and nurse were walking down the hallway when Resident #98 who was standing at the nurse's station began yelling and pointing at Resident #110 stating that he had pushed him down. Resident #110 shouted back, You are damn right I did and I will do it again you stupid nigger. Resident #98 was assessed to have a 8X5centimeter abrasion to his left side. Review of the progress notes beginning on 09/01/18 through present at 10:30 a.m. on 11/07/18 found the following notes concerning resident to resident incidents: -- 09/21/18 at 4:32 a.m. Resident extremely agitated at beginning of shift. Every attempt to redirect was unsuccessful and resident became combative. Resident was given a sandwich for snack with a drink. Played music that resident likes but would not calm down. Resident is confused to the point of no talking down or redirecting. Resident began arguing and getting in the face of other residents. Both nurses attempted to just let resident walk freely and calm down but was unsuccessful. Unable to pass medication due to resident up on cart so close yelling in our faces. When asked to please back up resident would curse and throw things. Called (name of attending physician) at 9:45 p.m. to ask for orders. (Name of attending) physician ordered [MEDICATION NAME] 1 mg (by mouth) PO as a onetime order. After resident was administered the [MEDICATION NAME] 1 mg the resident calmed down over the next 30 minutes and this nurse was able to get him to lay down and resident was cooperative. Resident rested throughout the remaining of the night with eyes closed. -- 09/23/18 10:39 p.m. Resident came down 300 hall during my med pass and was going into other residents room yelling and cursing at them. When trying to redirect resident her cursed at me and smacked my arm. He continued to bother two (2) female residents that were standing in the hallway. I told the two female residents to return to their rooms and shut the door. (First name of Resident #110) could not be redirected. -- 09/23/18 11:02 p.m. Resident had medication at 8:00 p.m. Attempted to help resident to bed at 9:00 p.m. Resident got up shortly after and wandered down 300 hall. Went in several rooms and they would scream for him to get out and he would then get in their faces and when we got to the room he was cursing and drawing his fist back to hit a female resident. Resident was redirected but was only able to get him out of the side of the room where the woman was. Resident then grabbed this nurse and (First and Last Name of NA #102) and pushed us down and was punching us. NA (First and Last Name of NA # 118) came in room and resident also punched her and grabbed her arms while cursing and being out of control. Once Resident wandered down the hall this nurse told 1 CNA to stay on hall and 1 cna to close the fire doors and stay there until able to call (name of attending physician) for orders. (Name of attending physician) order to send resident out to the emergency room -- 10/10/18 10:33 p.m. During HS med pass resident came up to this nurse and was very agitated resident yelling no your stupid [***] go [***] yourself, I offered resident a snack and that calmed him down for a while, but resident began pacing up and down the hallway. I asked resident what was wrong, and he said you don't know anything you [***] . Resident going by other resident's doorways and hollering stupid [***] . Attempted to redirect resident without success. Will continue to monitor for behaviors. -- 10/21/18 at 8:40 a.m. Resident was visited in the South Lounge for P[NAME] assessment. He was reading (name of newspaper) and was able to identify orientation questions from this paper. Resident was friendly throughout assessment but stated that he was mad at a peer. He pointed several times at different residents and said that he could blow them up with a airplane. Resident was redirected and completed the assessment. Resident scored an 11/15 on his BIMS., and endorsed trouble sleeping and feeling tired at times. -- 10/30/18 12:39 a.m. Resident entered into a verbal argument after wandering into another resident's room. This nurse intervened and redirected both residents. Resident easily redirected. Will continue to monitor. Review of Resident #110's care plan found the following Problem statement: (First Name of Resident #110) has delusions of combat related to heavy drinking while watching war movies per family. He is aggressive with staff and other residents with delusions of people trying to kill him. The goal statement associated with this problem reads as follows: (First name of Resident #110) will not obtain any major injury. Target date of 01/23/19. Interventions related to this problem and goal statement include: -- Provide diversion activities for (First name of Resident #110). Added on 07/05/18. -- Approach (First name of Resident #110) positively and in calm, accepting manner. Added on 07/05/18. -- Assign staff to account for (First name of Resident #110) whereabouts throughout the day. Added on 07/05/18. -- Monitor and document (First name of Resident #110) behavior. Added on 07/05/18. -- Redirected (First name of Resident #110) to room or lounge when laying in inappropriate areas. Added on 07/05/18. -- Do not play war movies on lounge TV with (First name of Resident #110) in attendance. Added on 07/05/18 -- Send to emergency room . Added on 08/28/18. -- Redirect (First name of Resident #110) to a calm and quiet environment. Added on 08/28/18. -- Send to ER [DATE] for evaluations due to combative behaviors. Added on 09/21/18. -- Will see in house psychiatrist next visit. Added on 09/24/18. A review of Resident #110's Minimum Data Set (MDS) with an assessment reference dates of 07/19/18 and 10/18/18 found resident had Physical behavioral symptoms towards others 1 to 3 days during the seven days look back period. The MDS also indicated Resident #110 had verbal behavioral symptoms directed toward others 4 to 6 days during the look back period. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON)beginning at 1:14 p.m. and concluding at 1:41 p.m. on 11/06/18, the above findings were discussed. The NHA stated that she would put together a time line to show what interventions they had put into place for Resident #110. Later that afternoon the NHA provided the following time line in regard to Resident #110's behaviors and the facility interventions. The NHA provided a time line to show what they had done for this resident to keep other residents safe: 8/13/18 redirection with music behind nurse's station with staff 8/18/18 redirected and relaxed with music 8/18/18 redirected and resident to bed resting 08/21/18 successfully redirected by staff. 08/28/18 out to ER they gave him [MEDICATION NAME] and then he returned to us 08/29/18 [MEDICATION NAME] was increased by Dr. 09/20/18 Ordered one-time [MEDICATION NAME] 09/21/81 redirected successfully with food and music later [MEDICATION NAME] order changed, and [MEDICATION NAME] ordered. 09/23/18 TO (name of local hospital) ER and returned 10/2/18 redirected to his room and then rested quietly (nursing note for this date says redirection was not successful.) 10/3/18 redirected through change in environment. 10/10/18 Gave snacks and he calmed down 10/30/18 redirected Upon reviewing the in house psychiatrist schedule, Resident #110 had been placed on his list to be seen when he rounds here at the facility. Care plan interventions include: diversional activities, naps rest periods, snacks, meds as ordered, approach calmly, psych consult scheduled. Please Note; The in-house psychiatrist was at the facility on 10/27/18, 09/15/18 and 08/25/18 and had not seen the resident. The list also indicated the resident was to be seen because he has [MEDICAL CONDITION] and unable to redirect combative with staff and residents. Also, Resident #110 had a care plan intervention added on 09/24/18 indicating he would be seen by the in-house psychiatrist on the next visit which would have been 10/27/18 but Resident #110 was not seen, and he continued to have verbally and physically abusive behaviors. On 11/5/18 at 1:33 P.M. Resident #24 said a male resident (she was referring to Resident #110) came into her room and told her he was going to rape her. That really scared her. Further investigation found a nurse note, dated 09/22/18 at 11:43 PM confirmed the residents statement: Resident stated that [NAME] Resident #110 came into her room and stated that he was going to kill her and he wanted to have sex with her. She stated that she came to the facility to be safe and is now scared. Resident was assured that she is safe. No further investigation could be found as to the circumstances before, during or after the alleged incident occurred. The author of the nursing note is unavailable for contact. During an interview on 11/05/18 at 11:46 AM, Resident #80 stated, (Resident #110) wants to fight me .he makes fun of me and makes faces at me .he tries to get a rise out of me. When asked if he participated in facility activities, Resident #80 stated, I have to stay in my room .otherwise I would have a chair in the hallway. Resident #80 stated Resident #110 has never touched him. When asked if he was afraid of Resident #110, Resident #80 stated, You never know what is going to happen. However, Review of Resident Incident Reports revealed the following: Review of Resident #80's behavior notes also revealed the following recent incident: 10/31/18 at 3:41 PM, Resident #80 was in room with door closed. Resident #110 tried to open door and Resident #80 charged at Resident #110. No physical contact occurred between residents. Resident #80 has a Brief Interview for Mental Status (BIMS) score of 14. He has [DIAGNOSES REDACTED]. He does not have capacity. Of note, Resident #80 has had behaviors of aggression toward other residents and staff. However, the behaviors appear to have been lessened with medication adjustments. During the Resident Council meeting on 11/06/18 at 11:05 AM Resident # 80 indicated Resident #110 and Resident #93 are bad and makes it where they can't come out of room. Resident #80 stated they have reported it to nurses and they do nothing. Resident #80 stated Resident #83 beat him in the head. Resident #80 stated. when the two of them are together they are really bad. He said, they terrorize us. Resident # 24 stated Resident #110 and #93 came in her in her room and wouldn't leave, Resident #110 told Resident #93 to hold the door closed, she said that she had to fight him, while Resident #93 was holding the door closed. She was pulling on the door and yelling for help, finally the workers came. They told her they had to pull Resident #93's hand off the door to help her. Another time Resident #110 also brought a blanket in her room and said he wanted to have sex with her and she said no and yelled for him to leave her room. He also was in her bed sleeping one day and when she told the staff, they told her to let him sleep he will get up when he wakes up. Resident #24 also stated that Resident #110 was beating Resident #62 she and another male resident had to get him away from her. They took Resident #62 up to the offices there by lounge and it was reported to staff and they just said well he don't know what he is doing and told him to apologize. Resident #110 is a big guy and he scares me. During an interview with Resident #78 on 11/06/18 at 11:14 a.m. she said Resident #110 was in her bed two times, she was told the same when he wakes up he will leave. She also stated that other residents just wonder in and out of her home all the time. South Activities Director #105 was asked if residents had come to her office and reported to her about Resident #110 hitting Resident #62. She said, these residents have dementia, so they are very forgetful and are not always reliable. She asked if this surveyor was familiar with caring for those with Dementia. On 11/08/18 after the notification of the Immediate Jeopardy on 11/07/18 Resident #110 was sent to see the in-house psychiatrist at his office in the community. The psychiatrist admitted resident #110 to a physiatrist unit for medication stabilization on 11/08/18. At the time of exit on 11/12/18 at 5:00 p.m. no further information was provided in regard to the management of Resident #110's behaviors. b) Resident #105 A review of Resident #105's incident reports at 12:00 p.m. on 11/07/18 found the following incidents which involved a resident to resident altercation: -- 08/03/18 Resident #105 gently slapped other resident with open hand. Resident #105 was very difficult to redirect. Combative with staff and cursing other residents. Resident redirected to her room. (Please note other resident not identified by facility) -- 08/19/18 4:40 p.m. called to hallway in front of room [ROOM NUMBER]. Resident #105 smacked Resident #102 on the right hand. No injuries. Residents separated and redirected. -- 09/03/18 9:20 p.m. Heard yelling from room [ROOM NUMBER]. Upon entering the room staff witnessed Resident #105 slap Resident #93 across the right cheek and was cursing at him. Resident #93 then in turn slapped Resident #105 across both her cheeks. -- 10/22/18 6:30 p.m. Resident #105 and Resident #112 was overheard yelling at each other. Resident #105 was slapping Resident #112 in the face. Another resident attempted to kick Resident #105 but missed. -- 10/23/18 1:15 p.m. Therapy staff observed Resident #105 got into Resident #112's room. Resident #112 asked Resident #105 to leave and Resident #105 became angry and slapped Resident #112 with an open hand across the face and grabbed the residents left arm. Review of Resident #105's nursing notes found the following additional occasions when resident #105 was involved in a verbal or physical altercation with other residents: -- 09/01/18 at 6:19 p.m. according to Resident #98 resident #105 entered his room and hit him in the stomach and scratched his left upper cheek and behind his left ear, and his left upper lip. Following that Resident #98 punched Resident #105 in the lower left jaw. Resident #105 then began to curse Resident #98. The housekeeper overheard and entered the room to separate the residents. -- 09/11/18 at 12:59 a.m. Heard yelling coming from room [ROOM NUMBER]. Upon entering witnessed staff attempting to redirect 2 residents who were yelling at one another. The nurse redirected the other resident in one direction while staff redirected Resident #105 in the opposite direction. After talking to staff, it was told to this nurse that Resident #105 had slapped the resident on the right cheek and was cursing him. Following her slap, the other resident then slapped her on both cheeks. No injuries noted. --09/29/18 12:30 a.m. Earlier this shift resident was loud. Yelling at other residents to get out of her room and she was in theirs. Resident easily redirected by staff. At time Resident was observed striking out at staff and other residents. No physical contact was made. -- 10/04/18 3:43 p.m. Resident has been in an up and down mood today. One minute she will be happy and then the next moment the resident is heard down the hall saying you're a whore, growling at people, and hitting people. Resident has been easily redirected each time by different staff members. -- 10/03/18 6:20 a.m. Resident has been wandering in and out of rooms this AM. Resident repeatedly lying people are in her bed. Resident pointed to another resident's room and said she was going to knock the hell out of them and show them what she was made of. Resident was redirected to her room and explained to her that other residents were not in her room. Resident was lying in bed with eyes closed at this time. -- 10/17/18 at 4:27 p.m. Resident has been resting in bed most of shift. This am at breakfast this resident began yelling at the resident across the table at her. When staff went intervene resident stood up and started yelling at staff and hitting them and continued to yell at the other resident . -- 10/26/18 12:12 a.m. Resident #105 wandered into another resident's room and got in verbal altercation with that resident. Easily redirected. No complaints voiced. -- 10/30/18 6:10 p.m. Resident #105 out in the hallway and got into a verbal altercation with another resident when this resident attempted to go into that resident's room. The resident began yelling that she was going to kill that [***] . When attempting to redirect Resident #105 began hitting and pulling this nurse's hair. A review of Resident #105's care plan found the following problem statement: (First Name of Resident #105) displays physically aggressive behavior. The goal associated with this care plan read as follows: (First name of Resident #105) displays physically aggressive behavior. This goal had a target date of 01/23/19. The interventions related to this problem and goal include: -- Social Services to evaluate and visit with (First name of Resident #105). Added on 08/08/18. -- Activities staff to visit with (First name of Resident #105) and provide diversional activities. Added on 08/08/18. -- Monitor and document (First name of Resident #105)'s behavior. Added on 08/08/18. -- Do not argue with (First name of Resident #105). Added on 08/08/18. -- Identify causes for behavior and reduce factors that may provoke (First name of Resident #105). Added on 08/08/18 -- Praise (First name of Resident #105) for demonstrating desired behavior. Add on 08/08/18. -- Talk with (First name of Resident #105) in calm voice when behavior is disruptive. Added on 08/08/18. -- Remove (First name of Resident #105) from public area when behavior is disruptive and unacceptable. Added on 08/08/18. --Encourage responsible party/family to visit with (First name of Resident #105). Added on 08/18/18. -- Redirect (First name of Resident #105) when she is intrusive to other resident's space. Added on 08/20/18. -- Encourage staff to spend time with (First name of Resident #105) to feel comfortable. Added on 09/14/18. -- Apply stop sign to door. Added on 09/12/18. -- When resistant to care provide (First name of Resident #105) with positive distractions. Added on 10/16/18. -- Try to identify triggers that cause behaviors. Added on 10/23/18. A review of Resident #105's MDS with an ARDs of 07/10/18 and 10/15/18 found Resident #105 had verbal and physical behaviors directed toward others one (1) to three (3) days during each look back period. During an interview with the NHA and the DON beginning at 1:14 p.m. and concluding at 1:41 p.m. on 11/06/18, the above findings were discussed. The NHA stated that she would put together a time line to show what interventions they had put into place for Resident #105. The following morning on 11/07/18 the NHA provided a time line to show what they had done for this resident to keep other residents safe. The following is the timeline provided typed as written: -- 08/03/18 redirected. -- 08/05/18 redirected. -- 08/10/18 redirected. -- 08/17/18 redirected and snacks provided. -- 08/19/18 redirected. -- 08/22/18 permission to see psychiatrist obtained. -- 08/25/18 seen by (Name of in house psychiatrist). No new medication changes. -- 08/30/18 redirected encouraged rest period. -- 09/01/18 redirected. -- 09/04/18 redirected, monitored, praise family was called and asked them to come and visit. -- 09/06/18 redirected to room, staff member sat with resident until she fell asleep. -- 09/09/18 seen by MD. No new orders offered snacks and provided rest period. -- 09/11/18 redirected. -- 09/12/18 spoke with RP (responsible party) about hearing aid declined. -- 09/12/18 applied stop signs to door. -- 09/29/18 redirected. -- 10/03/18 redirection and encouraged rest period. -- 10/15/18 used music for redirection and rest period. -- 10/16/18 environmental change. -- 10/23/18 snack/redirection. -- 10/27/18 saw (Name of in house psychiatrist) again and increase Departed. -- Care planned interventions include: activities, attempts to identify cause of agitation, calm approach, praise, change environment when needed, encourage family visits, psych consult, stop sign on door and meds as ordered. -- Med's include: [MEDICATION NAME], and [MEDICATION NAME]. Review of Resident #105's medications found she was started on [MEDICATION NAME] 125 mg by mouth twice a day on 10/27/18. Resident was started on [MEDICATION NAME] 25 mg twice a day and [MEDICATION NAME] 40 mg once daily beginning on 07/10/18 the date of her admission. At the time of exit on 11/12/18 at 5:00 p.m. no further information was provided. c) Resident #93 During record review of nurses notes in the electronic chart the following notes were as listed below. On 4/19/18 at 6:19 AM Nursing notes, Resident # 93 agitated after Nursing Assistance NA dressed him this am. Afterwards he would run up to her and telling her he was going to beat the[***]out of her with his fist drawn back. Resident did this three times. On 4/19/18 at 1:38 PM, states Resident # 93 will ambulate to his desired location. He does need direction to his room at time. He is usually pleasant. Neither staff nor Resident have voiced any problems in room or roommate. by Social Services (SS) On 5/07/18 at 8:34 PM, Resident # 93 grabbed a black marker from the nurse and went to a resident being fed, raised the marker above her head. As the nurse went to take the marker away for him he took his right elbow and rammed it into the nurses left breast then immediately hit the nurse in the right jaw with his fist with great force. On 5/ 8/18 at 3:43 PM, Resident # 93 was combative pouring his water on the floor chewing up his meds and spiting them on the floor. On 5/12/18 at 6:57 PM, Resident # 93 had struck another resident in the dining room. Unable to redirect Resident was immediately removed from the dining room, he was cursing and saying I will kill them Let me at em right now Registered Nurse (RN) in charge was notified and decision was made to send to the ER for evaluation. On 5/17/18 at 4:33 PM, Resident # 93 agitated wondering up and down hall keeps talking about people getting blown up On 5/18/18 at 10:23 PM, Resident # 93 pushed another resident to the floor. Resident # 93 observed with hands around the other resident's neck. Resident # 93 was assisted to his room. This was report and witnessed by the housekeeper. (This happened in the lounge). On 5/19/18 at 6:17 AM, Resident # 93 combative and uncooperative with others. Resident # 93 striking out at others. On 5/29/18 at 10:41 PM, Resident # 93 stated to fight with staff. Resident # 93 scratched, slapped and attempted to kick staff. On 5/31/18 at 11:59 PM Resident # 93 combative with staff striking out. Resident # 93 hit the nurse in the face he attempted to hit her several more times. Resident # 93 stated that he was in Cambodia we have to get them before they get us. On 6/9/18 at 10:37 PM, Resident # 93 told the nurse, I'm going to f*ck up your head. He then made a fist with his right hand and chased the nurse around the table. He was also going up to another resident's family and couldn't be redirected. On 6/11/18 at 3:41 PM, Resident # 93 has been agitated this shift. Resident # 93 has grabbed staff members wrist and neck. Is hard to redirect On 6/20/18 at 1:44 PM, Inter Department Team (IDT) met and discussed combative behaviors with other residents on 5/19 On 7/14/18 at 3:48 PM, Resident # 93 hit staff in the chest while trying to ambulate to the bathroom, On 7/26/18 at 6:38 PM Resident # 93 asked nurse if she would suck him off. On 8/24/18 at 10:31 PM, Resident # 93 was observed to try and go into another resident's room. the other resident was trying to get him out of his room, both residents hit each other. On 8/27/18 IDT Met about physical contact with another resident. On 8/28/18 at 7:05 PM, Resident # 93 became agitated after witnessing another residents agitation . required 2 NA to walk with him he was trying to strike out cursing and tried to kick the nurse. It took 45 minutes to calm down. On 9/3/18 at 3:45 AM, Resident # 93's roommate accused Resident # 93 of beating him up. When nurse entered the room both men sitting on the side of the bed facing each other. Resident # 93 had no brief on it was next to the other resident's bed. On 9/03/18 at 11:13 PM, NA trying to remove resident from another resident's room. On 9/9/18 at 6:56 PM, another resident yelled at Resident # 93 who was in the hallway. the two started yelling and pushing each other. Resident # 93 hit the other resident in the jaw. On 9/10/18 at 12:00 AM Resident # 93 was agitated On 9/11/18 at 12:43 PM, NA heard Resident # 93 cursing and yelling in another resident's room [ROOM NUMBER]. She saw the other resident slap this resident in the face then Resident # 93 slapped her on both sides of her face before he could be re-directed. On 9/18/18 at 4:58 PM, Resident # 93 was found on the floor of another resident's room, He was assisted off the floor. On 11/4/18 at 6:24 AM, Resident # 93 agitated and difficult to redirect moving chairs and flipping tables in the lounge. On 11/5/18 at 12:29 PM, told nurse she was going to get a give her a butt whoppin A time line for Resident # 93 provided by the NHA is as follows: -1/31/18 Redirected -2/1/18 Redirected -2/11/18 Encouraged to rest -2/18/18 Redirected -2/28/18 Observation -4/19/18 Redirected to different environment -5/4/18 Seen by (Facility Psychiatrist) -5/7/18 Redirected to different environment -5/12/18 Removed from environment sent to emergency room (ER) for evaluation -5/13/18 Returned from ER with no new orders -5/17/18 Observation -5/18/18 Redirected and observation -5/19/18 Observation -5/29/18 Redirected -5/31/18 Encouraged to rest -6/9/18 Redirected -6/11/18 Redirected -6/20/28 IDT review care plan -8/24/18 Redirected -8/28/18 Staff ambulated with Resident -9/3/18 Redirected rest encouraged -9/9/18 Redirected and removed from environment -9/11/18 Redirection -9/15/18 seen by Psychiatrist continue current medications -11/4/18 Assisted to bed, redirection, snack offered Care Plan Interventions included: Redirection, encourage rest breaks, encourage positive visits from family, follow up with psychiatrist as ordered, be patient and re-assuring, draw privacy curtain during evening hours. On 11/07/18 at 12:30 PM, Administrator and DoN was asked what they had done to protect the other Residents from Resident #93. The administrator said that, they have had IDT meeting about the problem. They were asked what steps they have put in place to keep him from hurting the vulnerable residents. They had no answers. On 11/07/18 at 3:19 PM, came out of his room walked across the hall was briefly in room [ROOM NUMBER] Staff member called him back to his room, He is receiving one on one supervision at this time. d) Resident #24 On 11/05/18 at 1:33 PM, the resident said she didn't like being at the facility because another resident came to her room and tried to have sex with her. She said she did not think she belonged in this place, locked up. This resident resided on the locked unit of the Dementia care unit. Record review found the resident was admitted to the dementia unit on 08/06/18, after a stay in a local hospital where she was diagnosed as having a Neurocognitive disorder, most likely secondary to Alzheimer's Dementia with behavioral changes. The physician determined the resident lacked capacity to make medical decisions. Review of the licensed nurse's notes found the following entry dated 09/22/18 at 11:43 PM: Resident stated that (Name of resident #110) came into her room and stated that he was going to kill her, and he wanted to have sex with her. She stated that she came to the facility to be safe and is now scared. Resident was assured that she is safe. There was no further information regarding this incident was provided in the nurse's notes. On 11/06/18 at 10:56 AM, Registered Nurse (RN) #19, identified herself as the dementia units case manager. When asked if she or anyone conducted any interviews or investigation related to the alleged incident or identified the circumstances of what occurred prior to during or after the alleged allegation voiced by Resident #24 on 09/22/18, she replied she was unaware of the allegation. She was unable to provide any further information related to Resident #24's statement. There was no information as to how the facility addressed Resident #110's behaviors. During the resident council meeting held on 11/06/18 at 11:05 AM, Resident #24 said Residents #110 and #93 come in her in her room wouldn't leave her room. She said that on one occasion, Resident #110 told Resident #93 to hold the door closed. She said she had to fight Resident #110 while Resident #93 was holding the door closed. She was pulling on the door and yelling for help, finally the workers came. They told her they had to pull Resident #93's hand off the door to help her. Another time, Resident (TRUNCATED)",2020-09-01
3360,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-11-12,756,D,0,1,2C7711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the pharmacist's review addressed a gradual dose reduction for Resident #80's antianxiety medication. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident Identifier: #80. Facility census: 115. Findings include: a) Resident #80 Resident #80 was admitted to the facility 10/23/17. Upon admission, [MEDICATION NAME] 0.5 mg orally twice a day was ordered for unspecified anxiety disorder. This dosage had remained the same from admission to the present. The medical records contained no rationale as to why a gradual dose reduction was contraindicated. Resident #80 had been seen by a psychiatrist on 07/21/18, 08/25/18, and 10/27/18. On 07/21/18, the psychiatrist stated, Continue his present treatment. On 08/25/18, the psychiatrist stated, Mood little anxious and Pt (patient) will continue his treatment. On 10/27/18, the psychiatrist stated, Pt's mood is a little anxious at this time. However, contraindication for a gradual dose reduction of Resident #80's [MEDICATION NAME] was not specifically documented. Additionally, Resident #80's attending physician notes did not specifically document a contraindication for a gradual dose reduction of Resident #80's [MEDICATION NAME]. Monthly medication reviews were completed by the consultant pharmacist (MONTH) through (MONTH) (YEAR). In these reviews, the pharmacist did not address that a gradual dose reduction had not been addressed for Resident #80's [MEDICATION NAME]. During an interview on 11/12/18 01:34 PM, the Director of Nursing (DoN) stated she will make sure a gradual dose reduction of Resident #80's [MEDICATION NAME] was addressed.",2020-09-01
3361,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-11-12,761,E,0,1,2C7711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview, the facility failed to ensure medications were labeled in accordance with currently accepted professional principles. A multi-dose [MEDICATION NAME] vial located in the medication room for the 300 and 400 hallway was not dated when opened. This had the potential to affect any resident who was prescribed a [MEDICATION NAME] injection. Facility census: 115. Findings included: a) Facility task - medication storage and labeling On 11/06/18 at 9:03 AM, observation was made of the medication storage room located in the 300 and 400 hallway of the facility. In the refrigerator, a [MEDICATION NAME] vial was noted to be opened as evidenced by the cap being missing on the vial. However, neither the vial nor the box had been dated when the vial was opened. [MEDICATION NAME] is used to diagnose [MEDICAL CONDITION]. Licensed Practical Nurse #109 was present during the medication storage room observation and confirmed the [MEDICATION NAME] vial was not dated when opened. On 11/06/18 at 9:10 AM, the Director of Nursing verified the [MEDICATION NAME] vial had not been dated when opened. The facility's policy Medication Errors stated, Vials are to be dated when opened.",2020-09-01
3362,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-11-12,838,E,0,1,2C7711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility assessment review, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations on the South Wing. The Facility Assessment did not address the problems on the south wing related to resident to resident abuse issues, which has been an on going problem for months. This issue had the potential to affect more than an isolated number of residents. Facility census 115. Findings included: a) Resident #110 Observations of Resident #110 at 11:00 a.m. on 11/05/18 found him entering the Room of Resident #60. The resident was in bed and she had visitor. Resident #110 began cursing Resident #60's visitor and waving his arms in the air. The surveyor alerted staff that this visitor needed some help. The staff intervened and removed Resident #110 from Resident #60's room. At 11:05 a.m. on 11/05/18 this surveyor entered the room of Resident #60 to speak with her visitor. During the interview with Resident #60's visitor Resident #110 returned to the room and again began cursing at this surveyor and Resident #60's visitor. He stated, You all are a bunch of God Damn idiots. I am going to [***] ing die. This is stupid God Damn[***]and you need to [***] ing die. Resident #110 was waving his arms in the air as he screamed the above statements. After about three (3) minutes staff came and again removed Resident #110 from Resident #60's room. Resident #60's care giver indicated this was the first time she had ever seen this gentleman, but he was obviously not happy. A review of Resident #110's incident reports regarding his behavior toward other residents at 12:00 p.m. on 11/06/18 found the following occasions where Resident #110 was in a resident to resident altercation: --07/07/18 Resident #110 and Resident #80 (roommates at the time) got into a fight and Resident #80 received a bruise to top of his right hand and a laceration to his lip. No injuries were noted to Resident #110 and the staff indicated they would continue to monitor for other behavioral episodes. -- 08/28/18 Resident #110 and nurse were walking down the hallway when Resident #98 who was standing at the nurse's station began yelling and pointing at Resident #110 stating that he had pushed him down. Resident #110 shouted back, You are damn right I did and I will do it again you stupid nigger. Resident #98 was assessed to have a 8X5centimeter abrasion to his left side. Review of the progress notes beginning on 09/01/18 through present at 10:30 a.m. on 11/07/18 found the following notes concerning resident to resident incidents: -- 09/21/18 at 4:32 a.m. Resident extremely agitated at beginning of shift. Every attempt to redirect was unsuccessful and resident became combative. Resident was given a sandwich for snack with a drink. Played music that resident likes but would not calm down. Resident is confused to the point of no talking down or redirecting. Resident began arguing and getting in the face of other residents. Both nurses attempted to just let resident walk freely and calm down but was unsuccessful. Unable to pass medication due to resident up on cart so close yelling in our faces. When asked to please back up resident would curse and throw things. Called (name of attending physician) at 9:45 p.m. to ask for orders. (Name of attending) physician ordered [MEDICATION NAME] 1 mg (by mouth) PO as a onetime order. After resident was administered the [MEDICATION NAME] 1 mg the resident calmed down over the next 30 minutes and this nurse was able to get him to lay down and resident was cooperative. Resident rested throughout the remaining of the night with eyes closed. -- 09/23/18 10:39 p.m. Resident came down 300 hall during my med pass and was going into other residents room yelling and cursing at them. When trying to redirect resident her cursed at me and smacked my arm. He continued to bother two (2) female residents that were standing in the hallway. I told the two female residents to return to their rooms and shut the door. (First name of Resident #110) could not be redirected. -- 09/23/18 11:02 p.m. Resident had medication at 8:00 p.m. Attempted to help resident to bed at 9:00 p.m. Resident got up shortly after and wandered down 300 hall. Went in several rooms and they would scream for him to get out and he would then get in their faces and when we got to the room he was cursing and drawing his fist back to hit a female resident. Resident was redirected but was only able to get him out of the side of the room where the woman was. Resident then grabbed this nurse and (First and Last Name of NA #102) and pushed us down and was punching us. NA (First and Last Name of NA # 118) came in room and resident also punched her and grabbed her arms while cursing and being out of control. Once Resident wandered down the hall this nurse told 1 CNA to stay on hall and 1 cna to close the fire doors and stay there until able to call (name of attending physician) for orders. (Name of attending physician) order to send resident out to the emergency room -- 10/10/18 10:33 p.m. During HS med pass resident came up to this nurse and was very agitated resident yelling no your stupid [***] go [***] yourself, I offered resident a snack and that calmed him down for a while, but resident began pacing up and down the hallway. I asked resident what was wrong, and he said you don't know anything you [***] . Resident going by other resident's doorways and hollering stupid [***] . Attempted to redirect resident without success. Will continue to monitor for behaviors. -- 10/21/18 at 8:40 a.m. Resident was visited in the South Lounge for P[NAME] assessment. He was reading (name of newspaper) and was able to identify orientation questions from this paper. Resident was friendly throughout assessment but stated that he was mad at a peer. He pointed several times at different residents and said that he could blow them up with a airplane. Resident was redirected and completed the assessment. Resident scored an 11/15 on his BIMS., and endorsed trouble sleeping and feeling tired at times. -- 10/30/18 12:39 a.m. Resident entered into a verbal argument after wandering into another resident's room. This nurse intervened and redirected both residents. Resident easily redirected. Will continue to monitor. Review of Resident #110's care plan found the following Problem statement: (First Name of Resident #110) has delusions of combat related to heavy drinking while watching war movies per family. He is aggressive with staff and other residents with delusions of people trying to kill him. The goal statement associated with this problem reads as follows: (First name of Resident #110) will not obtain any major injury. Target date of 01/23/19. Interventions related to this problem and goal statement include: -- Provide diversion activities for (First name of Resident #110). Added on 07/05/18. -- Approach (First name of Resident #110) positively and in calm, accepting manner. Added on 07/05/18. -- Assign staff to account for (First name of Resident #110) whereabouts throughout the day. Added on 07/05/18. -- Monitor and document (First name of Resident #110) behavior. Added on 07/05/18. -- Redirected (First name of Resident #110) to room or lounge when laying in inappropriate areas. Added on 07/05/18. -- Do not play war movies on lounge TV with (First name of Resident #110) in attendance. Added on 07/05/18 -- Send to emergency room . Added on 08/28/18. -- Redirect (First name of Resident #110) to a calm and quiet environment. Added on 08/28/18. -- Send to ER [DATE] for evaluations due to combative behaviors. Added on 09/21/18. -- Will see in house psychiatrist next visit. Added on 09/24/18. A review of Resident #110's Minimum Data Set (MDS) with an assessment reference dates of 07/19/18 and 10/18/18 found resident had Physical behavioral symptoms towards others 1 to 3 days during the seven days look back period. The MDS also indicated Resident #110 had verbal behavioral symptoms directed toward others 4 to 6 days during the look back period. During an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON)beginning at 1:14 p.m. and concluding at 1:41 p.m. on 11/06/18, the above findings were discussed. The NHA stated that she would put together a time line to show what interventions they had put into place for Resident #110. Later that afternoon the NHA provided the following time line in regard to Resident #110's behaviors and the facility interventions. The NHA provided a time line to show what they had done for this resident to keep other residents safe: 8/13/18 redirection with music behind nurse's station with staff 8/18/18 redirected and relaxed with music 8/18/18 redirected and resident to bed resting 08/21/18 successfully redirected by staff. 08/28/18 out to ER they gave him [MEDICATION NAME] and then he returned to us 08/29/18 [MEDICATION NAME] was increased by Dr. 09/20/18 Ordered one-time [MEDICATION NAME] 09/21/81 redirected successfully with food and music later [MEDICATION NAME] order changed, and [MEDICATION NAME] ordered. 09/23/18 TO (name of local hospital) ER and returned 10/2/18 redirected to his room and then rested quietly (nursing note for this date says redirection was not successful.) 10/3/18 redirected through change in environment. 10/10/18 Gave snacks and he calmed down 10/30/18 redirected Upon reviewing the in house psychiatrist schedule, Resident #110 had been placed on his list to be seen when he rounds here at the facility. Care plan interventions include: diversional activities, naps rest periods, snacks, meds as ordered, approach calmly, psych consult scheduled. Please Note; The in-house psychiatrist was at the facility on 10/27/18, 09/15/18 and 08/25/18 and had not seen the resident. The list also indicated the resident was to be seen because he has [MEDICAL CONDITION] and unable to redirect combative with staff and residents. Also, Resident #110 had a care plan intervention added on 09/24/18 indicating he would be seen by the in-house psychiatrist on the next visit which would have been 10/27/18 but Resident #110 was not seen, and he continued to have verbally and physically abusive behaviors. On 11/5/18 at 1:33 P.M. Resident #24 said a male resident (she was referring to Resident #110) came into her room and told her he was going to rape her. That really scared her. Further investigation found a nurse note, dated 09/22/18 at 11:43 PM confirmed the residents statement: Resident stated that [NAME] Resident #110 came into her room and stated that he was going to kill her and he wanted to have sex with her. She stated that she came to the facility to be safe and is now scared. Resident was assured that she is safe. No further investigation could be found as to the circumstances before, during or after the alleged incident occurred. The author of the nursing note is unavailable for contact. During an interview on 11/05/18 at 11:46 AM, Resident #80 stated, (Resident #110) wants to fight me .he makes fun of me and makes faces at me .he tries to get a rise out of me. When asked if he participated in facility activities, Resident #80 stated, I have to stay in my room .otherwise I would have a chair in the hallway. Resident #80 stated Resident #110 has never touched him. When asked if he was afraid of Resident #110, Resident #80 stated, You never know what is going to happen. However, Review of Resident Incident Reports revealed the following: Review of Resident #80's behavior notes also revealed the following recent incident: 10/31/18 at 3:41 PM, Resident #80 was in room with door closed. Resident #110 tried to open door and Resident #80 charged at Resident #110. No physical contact occurred between residents. Resident #80 has a Brief Interview for Mental Status (BIMS) score of 14. He has [DIAGNOSES REDACTED]. He does not have capacity. Of note, Resident #80 has had behaviors of aggression toward other residents and staff. However, the behaviors appear to have been lessened with medication adjustments. During the Resident Council meeting on 11/06/18 at 11:05 AM Resident # 80 indicated Resident #110 and Resident #93 are bad and makes it where they can't come out of room. Resident #80 stated they have reported it to nurses and they do nothing. Resident #80 stated Resident #83 beat him in the head. Resident #80 stated. when the two of them are together they are really bad. He said, they terrorize us. Resident # 24 stated Resident #110 and #93 came in her in her room and wouldn't leave, Resident #110 told Resident #93 to hold the door closed, she said that she had to fight him, while Resident #93 was holding the door closed. She was pulling on the door and yelling for help, finally the workers came. They told her they had to pull Resident #93's hand off the door to help her. Another time Resident #110 also brought a blanket in her room and said he wanted to have sex with her and she said no and yelled for him to leave her room. He also was in her bed sleeping one day and when she told the staff, they told her to let him sleep he will get up when he wakes up. Resident #24 also stated that Resident #110 was beating Resident #62 she and another male resident had to get him away from her. They took Resident #62 up to the offices there by lounge and it was reported to staff and they just said well he don't know what he is doing and told him to apologize. Resident #110 is a big guy and he scares me. During an interview with Resident #78 on 11/06/18 at 11:14 a.m. she said Resident #110 was in her bed two times, she was told the same when he wakes up he will leave. She also stated that other residents just wonder in and out of her home all the time. South Activities Director #105 was asked if residents had come to her office and reported to her about Resident #110 hitting Resident #62. She said, these residents have dementia, so they are very forgetful and are not always reliable. She asked if this surveyor was familiar with caring for those with Dementia. On 11/08/18 after the notification of the Immediate Jeopardy on 11/07/18 Resident #110 was sent to see the in-house psychiatrist at his office in the community. The psychiatrist admitted resident #110 to a physiatrist unit for medication stabilization on 11/08/18. At the time of exit on 11/12/18 at 5:00 p.m. no further information was provided in regard to the management of Resident #110's behaviors. b) Resident #105 A review of Resident #105's incident reports at 12:00 p.m. on 11/07/18 found the following incidents which involved a resident to resident altercation: -- 08/03/18 Resident #105 gently slapped other resident with open hand. Resident #105 was very difficult to redirect. Combative with staff and cursing other residents. Resident redirected to her room. (Please note other resident not identified by facility) -- 08/19/18 4:40 p.m. called to hallway in front of room [ROOM NUMBER]. Resident #105 smacked Resident #102 on the right hand. No injuries. Residents separated and redirected. -- 09/03/18 9:20 p.m. Heard yelling from room [ROOM NUMBER]. Upon entering the room staff witnessed Resident #105 slap Resident #93 across the right cheek and was cursing at him. Resident #93 then in turn slapped Resident #105 across both her cheeks. -- 10/22/18 6:30 p.m. Resident #105 and Resident #112 was overheard yelling at each other. Resident #105 was slapping Resident #112 in the face. Another resident attempted to kick Resident #105 but missed. -- 10/23/18 1:15 p.m. Therapy staff observed Resident #105 got into Resident #112's room. Resident #112 asked Resident #105 to leave and Resident #105 became angry and slapped Resident #112 with an open hand across the face and grabbed the residents left arm. Review of Resident #105's nursing notes found the following additional occasions when resident #105 was involved in a verbal or physical altercation with other residents: -- 09/01/18 at 6:19 p.m. according to Resident #98 resident #105 entered his room and hit him in the stomach and scratched his left upper cheek and behind his left ear, and his left upper lip. Following that Resident #98 punched Resident #105 in the lower left jaw. Resident #105 then began to curse Resident #98. The housekeeper overheard and entered the room to separate the residents. -- 09/11/18 at 12:59 a.m. Heard yelling coming from room [ROOM NUMBER]. Upon entering witnessed staff attempting to redirect 2 residents who were yelling at one another. The nurse redirected the other resident in one direction while staff redirected Resident #105 in the opposite direction. After talking to staff, it was told to this nurse that Resident #105 had slapped the resident on the right cheek and was cursing him. Following her slap, the other resident then slapped her on both cheeks. No injuries noted. --09/29/18 12:30 a.m. Earlier this shift resident was loud. Yelling at other residents to get out of her room and she was in theirs. Resident easily redirected by staff. At time Resident was observed striking out at staff and other residents. No physical contact was made. -- 10/04/18 3:43 p.m. Resident has been in an up and down mood today. One minute she will be happy and then the next moment the resident is heard down the hall saying you're a whore, growling at people, and hitting people. Resident has been easily redirected each time by different staff members. -- 10/03/18 6:20 a.m. Resident has been wandering in and out of rooms this AM. Resident repeatedly lying people are in her bed. Resident pointed to another resident's room and said she was going to knock the hell out of them and show them what she was made of. Resident was redirected to her room and explained to her that other residents were not in her room. Resident was lying in bed with eyes closed at this time. -- 10/17/18 at 4:27 p.m. Resident has been resting in bed most of shift. This am at breakfast this resident began yelling at the resident across the table at her. When staff went intervene resident stood up and started yelling at staff and hitting them and continued to yell at the other resident . -- 10/26/18 12:12 a.m. Resident #105 wandered into another resident's room and got in verbal altercation with that resident. Easily redirected. No complaints voiced. -- 10/30/18 6:10 p.m. Resident #105 out in the hallway and got into a verbal altercation with another resident when this resident attempted to go into that resident's room. The resident began yelling that she was going to kill that [***] . When attempting to redirect Resident #105 began hitting and pulling this nurse's hair. A review of Resident #105's care plan found the following problem statement: (First Name of Resident #105) displays physically aggressive behavior. The goal associated with this care plan read as follows: (First name of Resident #105) displays physically aggressive behavior. This goal had a target date of 01/23/19. The interventions related to this problem and goal include: -- Social Services to evaluate and visit with (First name of Resident #105). Added on 08/08/18. -- Activities staff to visit with (First name of Resident #105) and provide diversional activities. Added on 08/08/18. -- Monitor and document (First name of Resident #105)'s behavior. Added on 08/08/18. -- Do not argue with (First name of Resident #105). Added on 08/08/18. -- Identify causes for behavior and reduce factors that may provoke (First name of Resident #105). Added on 08/08/18 -- Praise (First name of Resident #105) for demonstrating desired behavior. Add on 08/08/18. -- Talk with (First name of Resident #105) in calm voice when behavior is disruptive. Added on 08/08/18. -- Remove (First name of Resident #105) from public area when behavior is disruptive and unacceptable. Added on 08/08/18. --Encourage responsible party/family to visit with (First name of Resident #105). Added on 08/18/18. -- Redirect (First name of Resident #105) when she is intrusive to other resident's space. Added on 08/20/18. -- Encourage staff to spend time with (First name of Resident #105) to feel comfortable. Added on 09/14/18. -- Apply stop sign to door. Added on 09/12/18. -- When resistant to care provide (First name of Resident #105) with positive distractions. Added on 10/16/18. -- Try to identify triggers that cause behaviors. Added on 10/23/18. A review of Resident #105's MDS with an ARDs of 07/10/18 and 10/15/18 found Resident #105 had verbal and physical behaviors directed toward others one (1) to three (3) days during each look back period. During an interview with the NHA and the DON beginning at 1:14 p.m. and concluding at 1:41 p.m. on 11/06/18, the above findings were discussed. The NHA stated that she would put together a time line to show what interventions they had put into place for Resident #105. The following morning on 11/07/18 the NHA provided a time line to show what they had done for this resident to keep other residents safe. The following is the timeline provided typed as written: -- 08/03/18 redirected. -- 08/05/18 redirected. -- 08/10/18 redirected. -- 08/17/18 redirected and snacks provided. -- 08/19/18 redirected. -- 08/22/18 permission to see psychiatrist obtained. -- 08/25/18 seen by (Name of in house psychiatrist). No new medication changes. -- 08/30/18 redirected encouraged rest period. -- 09/01/18 redirected. -- 09/04/18 redirected, monitored, praise family was called and asked them to come and visit. -- 09/06/18 redirected to room, staff member sat with resident until she fell asleep. -- 09/09/18 seen by MD. No new orders offered snacks and provided rest period. -- 09/11/18 redirected. -- 09/12/18 spoke with RP (responsible party) about hearing aid declined. -- 09/12/18 applied stop signs to door. -- 09/29/18 redirected. -- 10/03/18 redirection and encouraged rest period. -- 10/15/18 used music for redirection and rest period. -- 10/16/18 environmental change. -- 10/23/18 snack/redirection. -- 10/27/18 saw (Name of in house psychiatrist) again and increase Departed. -- Care planned interventions include: activities, attempts to identify cause of agitation, calm approach, praise, change environment when needed, encourage family visits, psych consult, stop sign on door and meds as ordered. -- Med's include: [MEDICATION NAME], and [MEDICATION NAME]. Review of Resident #105's medications found she was started on [MEDICATION NAME] 125 mg by mouth twice a day on 10/27/18. Resident was started on [MEDICATION NAME] 25 mg twice a day and [MEDICATION NAME] 40 mg once daily beginning on 07/10/18 the date of her admission. At the time of exit on 11/12/18 at 5:00 p.m. no further information was provided. c) Resident #93 During record review of nurses notes in the electronic chart the following notes were as listed below. On 4/19/18 at 6:19 AM Nursing notes, Resident # 93 agitated after Nursing Assistance NA dressed him this am. Afterwards he would run up to her and telling her he was going to beat the[***]out of her with his fist drawn back. Resident did this three times. On 4/19/18 at 1:38 PM, states Resident # 93 will ambulate to his desired location. He does need direction to his room at time. He is usually pleasant. Neither staff nor Resident have voiced any problems in room or roommate. by Social Services (SS) On 5/07/18 at 8:34 PM, Resident # 93 grabbed a black marker from the nurse and went to a resident being fed, raised the marker above her head. As the nurse went to take the marker away for him he took his right elbow and rammed it into the nurses left breast then immediately hit the nurse in the right jaw with his fist with great force. On 5/ 8/18 at 3:43 PM, Resident # 93 was combative pouring his water on the floor chewing up his meds and spiting them on the floor. On 5/12/18 at 6:57 PM, Resident # 93 had struck another resident in the dining room. Unable to redirect Resident was immediately removed from the dining room, he was cursing and saying I will kill them Let me at em right now Registered Nurse (RN) in charge was notified and decision was made to send to the ER for evaluation. On 5/17/18 at 4:33 PM, Resident # 93 agitated wondering up and down hall keeps talking about people getting blown up On 5/18/18 at 10:23 PM, Resident # 93 pushed another resident to the floor. Resident # 93 observed with hands around the other resident's neck. Resident # 93 was assisted to his room. This was report and witnessed by the housekeeper. (This happened in the lounge). On 5/19/18 at 6:17 AM, Resident # 93 combative and uncooperative with others. Resident # 93 striking out at others. On 5/29/18 at 10:41 PM, Resident # 93 stated to fight with staff. Resident # 93 scratched, slapped and attempted to kick staff. On 5/31/18 at 11:59 PM Resident # 93 combative with staff striking out. Resident # 93 hit the nurse in the face he attempted to hit her several more times. Resident # 93 stated that he was in Cambodia we have to get them before they get us. On 6/9/18 at 10:37 PM, Resident # 93 told the nurse, I'm going to f*ck up your head. He then made a fist with his right hand and chased the nurse around the table. He was also going up to another resident's family and couldn't be redirected. On 6/11/18 at 3:41 PM, Resident # 93 has been agitated this shift. Resident # 93 has grabbed staff members wrist and neck. Is hard to redirect On 6/20/18 at 1:44 PM, Inter Department Team (IDT) met and discussed combative behaviors with other residents on 5/19 On 7/14/18 at 3:48 PM, Resident # 93 hit staff in the chest while trying to ambulate to the bathroom, On 7/26/18 at 6:38 PM Resident # 93 asked nurse if she would suck him off. On 8/24/18 at 10:31 PM, Resident # 93 was observed to try and go into another resident's room. the other resident was trying to get him out of his room, both residents hit each other. On 8/27/18 IDT Met about physical contact with another resident. On 8/28/18 at 7:05 PM, Resident # 93 became agitated after witnessing another residents agitation . required 2 NA to walk with him he was trying to strike out cursing and tried to kick the nurse. It took 45 minutes to calm down. On 9/3/18 at 3:45 AM, Resident # 93's roommate accused Resident # 93 of beating him up. When nurse entered the room both men sitting on the side of the bed facing each other. Resident # 93 had no brief on it was next to the other resident's bed. On 9/03/18 at 11:13 PM, NA trying to remove resident from another resident's room. On 9/9/18 at 6:56 PM, another resident yelled at Resident # 93 who was in the hallway. the two started yelling and pushing each other. Resident # 93 hit the other resident in the jaw. On 9/10/18 at 12:00 AM Resident # 93 was agitated On 9/11/18 at 12:43 PM, NA heard Resident # 93 cursing and yelling in another resident's room [ROOM NUMBER]. She saw the other resident slap this resident in the face then Resident # 93 slapped her on both sides of her face before he could be re-directed. On 9/18/18 at 4:58 PM, Resident # 93 was found on the floor of another resident's room, He was assisted off the floor. On 11/4/18 at 6:24 AM, Resident # 93 agitated and difficult to redirect moving chairs and flipping tables in the lounge. On 11/5/18 at 12:29 PM, told nurse she was going to get a give her a butt whoppin A time line for Resident # 93 provided by the NHA is as follows: -1/31/18 Redirected -2/1/18 Redirected -2/11/18 Encouraged to rest -2/18/18 Redirected -2/28/18 Observation -4/19/18 Redirected to different environment -5/4/18 Seen by (Facility Psychiatrist) -5/7/18 Redirected to different environment -5/12/18 Removed from environment sent to emergency room (ER) for evaluation -5/13/18 Returned from ER with no new orders -5/17/18 Observation -5/18/18 Redirected and observation -5/19/18 Observation -5/29/18 Redirected -5/31/18 Encouraged to rest -6/9/18 Redirected -6/11/18 Redirected -6/20/28 IDT review care plan -8/24/18 Redirected -8/28/18 Staff ambulated with Resident -9/3/18 Redirected rest encouraged -9/9/18 Redirected and removed from environment -9/11/18 Redirection -9/15/18 seen by Psychiatrist continue current medications -11/4/18 Assisted to bed, redirection, snack offered Care Plan Interventions included: Redirection, encourage rest breaks, encourage positive visits from family, follow up with psychiatrist as ordered, be patient and re-assuring, draw privacy curtain during evening hours. On 11/07/18 at 12:30 PM, Administrator and DoN was asked what they had done to protect the other Residents from Resident #93. The administrator said that, they have had IDT meeting about the problem. They were asked what steps they have put in place to keep him from hurting the vulnerable residents. They had no answers. On 11/07/18 at 3:19 PM, came out of his room walked across the hall was briefly in room [ROOM NUMBER] Staff member called him back to his room, He is receiving one on one supervision at this time. d) Resident #24 On 11/05/18 at 1:33 PM, the resident said she didn't like being at the facility because another resident came to her room and tried to have sex with her. She said she did not think she belonged in this place, locked up. This resident resided on the locked unit of the Dementia care unit. Record review found the resident was admitted to the dementia unit on 08/06/18, after a stay in a local hospital where she was diagnosed as having a Neurocognitive disorder, most likely secondary to Alzheimer's Dementia with behavioral changes. The physician determined the resident lacked capacity to make medical decisions. Review of the licensed nurse's notes found the following entry dated 09/22/18 at 11:43 PM: Resident stated that (Name of resident #110) came into her room and stated that he was going to kill her, and he wanted to have sex with her. She stated that she came to the facility to be safe and is now scared. Resident was assured that she is safe. There was no further information regarding this incident was provided in the nurse's notes. On 11/06/18 at 10:56 AM, Registered Nurse (RN) #19, identified herself as the dementia units case manager. When asked if she or anyone conducted any interviews or investigation related to the alleged incident or identified the circumstances of what occurred prior to during or after the alleged allegation voiced by Resident #24 on 09/22/18, she replied she was unaware of the allegation. She was unable to provide any further information related to Resident #24's statement. There was no information as to how the facility addressed Resident #110's behaviors. During the resident council meeting held on 11/06/18 at 11:05 AM, Resident #24 said Residents #110 and #93 come in her in her room wouldn't leave her room. She said that on one occasion, Resident #110 told Resident #93 to hold the door closed. She said she had to fight Resident #110 while Resident #93 was holding the door closed. She was pulling on the door and yelling for help, finally the workers came. They told her they had to pull Resident #93's hand off the door to help her. Another time, Resident #110 brought a blanket in her room and said he wanted to have sex with her. She said no and yelled for him to leave her room. He also was in her bed sleeping one day. When she told the staff, they told her to let him sleep, he will get up when he wakes up. Resident #110 is a big guy and he scares me. At 12:44 PM on 11/06/18, social worker, SW #2 said she was unaware of the allegation. SW #2 said the pr (TRUNCATED)",2020-09-01
3363,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-11-12,842,D,0,1,2C7711,"Based on resident interview, medical record review, and staff interview, the facility failed to ensure a complete and accurate medical record for one (1) of 23 residents reviewed during the survey process. Resident #80's Oral Health Assessment Tool for Dental Screening was inaccurately completed. Resident identifier: #80. Facility census: 115. Findings included: a) Resident #80 During an interview on 11/05/18 at 12:01 PM, Resident #80 stated his teeth were in poor condition, although they weren't causing him any pain or discomfort. An Oral Health Assessment Tool for Dental Screening dated 10/03/18, checked No decayed or broken teeth/roots. A Minimum Data Set (MDS) with Assessment Reference Date (ARD) 10/04/18 documented Obvious or likely cavity or broken natural teeth. A Nutritional Assessment completed 10/10/18 documented Dental: cavity or broken natural teeth. During an interview on 11/08/18 at 9:58 AM Registered Nurse (RN) Case Manager #19 stated Resident #80's Oral Health Assessment Tool for Dental Screening dated 10/03/18 was erroneous. She stated Resident #80 had decayed or broken teeth, and this should have been indicated on the form.",2020-09-01
3364,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-11-12,865,E,0,1,2C7711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the Centers for Medicare and Medicaid Services Appendix PP State Operations Manual and staff interview the facility failed to ensure the Quality Assurance and Assessment Committee (QAA) made good faith attempts to correct quality deficiencies which it had knowledge of or should have had knowledge of. The QAA committee reviews incident reports as part of their identification process to determine if there is changes that need to be made to better serve the residents. There was a distinct trend in the incident reports of Resident to Resident abuse on the south wing of the facility. The QAA committee failed to identify and attempt to correct this quality deficiencies which was discovered during the Long Term Care Survey Process and was determined to be an Immediate Jeopardy. This practice had the potential to effect more than an isolated number of residents residing on the South unit of the facility. Resident Identifiers: #110, #105, #93, #24, #78, #85. Facility Census: 115. Findings include: a) Resident #110 Observations of Resident #110 at 11:00 a.m. on 11/05/18 found him entering the Room of Resident #60. The resident was in bed and she had visitor. Resident #110 began cursing Resident #60's visitor and waving his arms in the air. The surveyor alerted staff that this visitor needed some help. The staff intervened and removed Resident #110 from Resident #60's room. At 11:05 a.m. on 11/05/18 this surveyor entered the room of Resident #60 to speak with her visitor. During the interview with Resident #60's visitor Resident #110 returned to the room and again began cursing at this surveyor and Resident #60's visitor. He stated, You all are a bunch of God Damn idiots . I am going to [***] ing die . This is stupid God Damn[***]and you need to [***] ing die. Resident #110 was waving his arms in the air as he screamed the above statements. After about three (3) minutes staff came and again removed Resident #110 from Resident #60's room. Resident #60's visitor indicated this was the first time she had ever seen this gentleman, but he was obviously not happy. A review of Resident #110's incident reports regarding his behavior toward other residents at 12:00 p.m. on 11/06/18 found the following occasions where Resident #110 was in a resident to resident altercation: -- 07/07/18 - Resident #110 and Resident #80 (roommates at the time) got into a fight and Resident #80 received a bruise to top of his right hand and a laceration to his lip. No injuries were noted to Resident #110 and the staff indicated they would continue to monitor for other behavioral episodes. -- 08/28/18 - Resident #110 and nurse were walking down the hallway when Resident #98 who was standing at the nurses' station began yelling and pointing at Resident #110 stating that he had pushed him down. Resident #110 shouted back, You are damn right I did and I will do it again you stupid nigger. Resident #98 was assessed to have an 8 by 5 centimeter abrasion to his left side. Review of the progress notes beginning on 09/01/18 through present at 10:30 a.m. on 11/07/18 found the following notes concerning resident to resident incidents: -- 09/21/18 at 4:32 a.m. - Resident extremely agitated at beginning of shift. Every attempt to redirect was unsuccessful and resident became combative. Resident was given a sandwich for snack with a drink. Played music that resident likes but would not calm down. Resident is confused to the point of no talking down or redirecting. Resident began arguing and getting in the face of other residents. Both nurses attempted to just let resident walk freely and calm down but was unsuccessful. Unable to pass medication due to resident up on cart so close yelling in our faces. When asked to please back up resident would curse and throw things. Called (name of attending physician) at 9:45 p.m. to ask for orders. (Name of attending) physician ordered [MEDICATION NAME] 1 mg (by mouth) PO as a one time order. After resident was administered the [MEDICATION NAME] 1 mg the resident calmed down over the next 30 minutes and this nurse was able to get him to lay down and resident was cooperative. Resident rested throughout the remaining of the night with eyes closed. -- 09/23/18 10:39 p.m. - Resident came down 300 hall during my med pass and was going into other residents room yelling and cursing at them. When trying to redirect resident her cursed at me and smacked my arm. He continued to bother two (2) female residents that were standing in the hallway. I told the two female residents to return to their rooms and shut the door. (First name of Resident #110) could not be redirected. -- 09/23/18 11:02 p.m. Resident had medication at 8:00 p.m. Attempted to help resident to bed at 9:00 p.m. Resident got up shortly after and wandered down 300 hall. Went in several rooms and they would scream for him to get out and he would then get in their faces and when we got to the room he was cursing and drawing his fist back to hit a female resident. Resident was redirected but was only able to get him out of the side of the room where the woman was. Resident then grabbed this nurse and (First and Last Name of NA #102) and pushed us down and was punching us. NA (First and Last Name of NA # 118) came in room and resident also punched her and grabbed her arms while cursing and being out of control. Once Resident wandered down the hall this nurse told 1 CNA to stay on hall and 1 cna to close the fire doors and stay there until able to call (name of attending physician) for orders. (Name of attending physician) order to send resident out to the emergency room -- 10/10/18 10:33 p.m. - During HS med pass resident came up to this nurse and was very agitated resident yelling no you stupid [***] go [***] yourself, I offered resident a snack and that calmed him down for a while but resident began pacing up and down the hallway. I asked resident what was wrong and he said you don't know anything you [***] . Resident going by other residents doorways and hollering stupid [***] . Attempted to redirect resident without success. Will continue to monitor for behaviors. -- 10/21/18 at 8:40 a.m. Resident was visited in the South Lounge for P[NAME] (plan of care) assessment. He was reading (name of newspaper) and was able to identify orientation questions from this paper. Resident was friendly throughout assessment, but stated that he was mad at a peer. He pointed several times at different residents and said that he could blow them up with a airplane. Resident was redirected and completed the assessment. Resident scored an 11/15 (11 of 15) on his BIMS (Brief Interview for Mental Status)., and endorsed trouble sleeping and feeling tired at times. -- 10/30/18 12:39 a.m. - Resident entered into a verbal argument after wandering into another residents room. This nurse intervened and redirected both residents. Resident easily redirected. Will continue to monitor. Review of Resident #110's care plan found the following Problem statement: (First Name of Resident #110) has delusions of combat related to heavy drinking while watching war movies per family. He is aggressive with staff and other residents with delusions of people trying to kill him. The goal statement associated with this problem was: (First name of Resident #110) will not obtain any major injury. Target date of 01/23/19. Interventions related to this problem and goal statement included: -- Provide diversion activities for (First name of Resident #110). Added on 07/05/18. -- Approach (First name of Resident #110) positively and in calm, accepting manner. Added on 07/05/18. -- Assign staff to account for (First name of Resident #110) whereabouts throughout the day. Added on 07/05/18. -- Monitor and document (First name of Resident #110) behavior. Added on 07/05/18. -- Redirected (First name of Resident #110) to room or lounge when laying in inappropriate areas. Added on 07/05/18. -- Do not play war movies on lounge TV with (First name of Resident #110) in attendance. Added on 07/05/18 -- Send to emergency room . Added on 08/28/18 -- Redirect (First name of Resident #110) to a calm and quiet environment. Added on 08/28/18. -- Send to ER [DATE] for evaluations due to combative behaviors. Added on 09/21/18. -- Will see in house psychiatrist next visit. Added on 09/24/18. A review of Resident #110's Minimum Data Set (MDS) assessments with assessment reference dates of 07/19/18 and 10/18/18 found resident had Physical behavioral symptoms towards others 1 to 3 days during the seven day look back period. The MDS also indicated Resident #110 had verbal behavioral symptoms directed toward others 4 to 6 days during the look back period. These findings were discussed during an interview with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) beginning at 1:14 p.m. and concluding at 1:41 p.m. The NHA stated that she would put together a time line to show what interventions they had put into place for Resident #110. Later that afternoon the NHA provided the following time line regarding Resident #110's behaviors and the facility's interventions. The NHA provided a time line to show what they had done for this resident to keep other residents safe: 8/13/18 redirection with music behind nurses station with staff 8/18/18 redirected and relaxed with music 8/18/18 redirected and resident to bed resting 08/21/18 successfully redirected by staff. 08/28/18 out to ER they gave him [MEDICATION NAME] and then he returned to us 08/29/18 [MEDICATION NAME] was increased by Dr. 09/20/18 Ordered one-time [MEDICATION NAME] 09/21/81 redirected successfully with food and music later [MEDICATION NAME] order changed, and [MEDICATION NAME] ordered. 09/23/18 TO (name of local hospital) ER and returned 10/2/18 redirected to his room and then rested quietly (nursing note for this date says redirection was not successful.) 10/3/18 redirected through change in environment. 10/10/18 Gave snacks and he calmed down 10/30/18 redirected Upon reviewing the in house psychiatrist schedule, Resident #110 had been placed on his list to be seen when he rounds here at the facility. Care plan interventions include: diversional activities, naps rest periods, snacks, meds as ordered, approach calmly, psych consult scheduled. Review of the in-house psychiatrist's visits to facility found visits occurred on 08/25/18, 09/15/18, and 10/27/18, but there was no evidence Resident #110 was seen. The list also indicated the resident was to be seen because he had [MEDICAL CONDITION] (post-traumatic stress disorder) and unable to redirect combative with staff and residents. A care plan intervention was added on 09/24/18 indicating the resident would be seen by the in-house psychiatrist on the next visit which would have been 10/27/18 but Resident #110 was not seen and he continued to have verbally and physically abusive behaviors. During an interview with Resident #24 on 11/05/18 at 1:33 P.M., she said a male resident (she was referring to Resident #110) came into her room and told her he was going to rape her. That really scared her. Further investigation found a nurse's note, dated 09/22/18 at 11:43 PM confirmed Resident #24's statement. The note included, Resident stated that (Resident #110's name) came into her room and stated that he was going to kill her and he wanted to have sex with her. She stated that she came to the facility to be safe and is now scared. Resident was assured that she is safe. No further investigation could be found as to the circumstances before, during or after the alleged incident occurred. The author of the nursing note was unavailable for contact. During an interview on 11/05/18 at 11:46 AM, Resident #80 stated, (Resident #110) wants to fight me .he makes fun of me and makes faces at me .he tries to get a rise out of me. When asked if he participated in facility activities, Resident #80 stated, I have to stay in my room . otherwise I would have a chair in the hallway. Resident #80 stated Resident #110 had never touched him. When asked if he was afraid of Resident #110, Resident #80 stated, You never know what is going to happen. During the Resident Council meeting on 11/06/18 at 11:05 AM, Resident #80 said Resident #110 and Resident #93 .are bad and makes it where they can't come out of room. Resident #80 stated they had reported it to nurses and they did nothing. Resident #80 stated Resident #83 beat him in the head. Resident #80 stated. when the two of them are together they are really bad. He said, They terrorize us. Resident #24 stated Residents #110 and #93 came in her in her room and would not leave. Resident #110 had told Resident #93 to hold the door closed, she said that she had to fight him, while Resident #93 was holding the door closed. She was pulling on the door and yelling for help, finally the workers came. They told her they had to pull Resident #93's hand off the door to help her. Another time Resident #110 also brought a blanket in her room and said he wanted to have sex with her and she said no and yelled for him to leave her room. He also was in her bed sleeping one day and when she told the staff, they told her to let him sleep he will get up when he wakes up. Resident #24 also stated that Resident #110 was beating Resident #62 and she and another male resident had to get him away from her. They took Resident #62 up to the offices by the lounge and when they reported it to staff, staff just said, Well he doesn't know what he is doing and told him to apologize. Resident #24 commented, (Name of Resident #110) is a big guy and he scares me. During an interview with Resident #78 on 11/06/18 at 11:14 a.m., she said Resident #110 was in her bed two times, she too was told that when he wakes up he will leave. She also stated that other residents just wander in and out of her home all the time. South wing Activities Director #105 was asked whether residents had come to her office and reported to her about Resident #110 hitting Resident #62. She said, These residents have dementia, so they are very forgetful and are not always reliable. She asked if this surveyor was familiar with caring for those with Dementia. On 11/08/18 after the notification of the Immediate Jeopardy on 11/07/18 Resident #110 was sent to see the in-house psychiatrist at his office in the community. The psychiatrist admitted Resident #110 to a psychiatric unit for medication stabilization on 11/08/18. At the time of exit on 11/12/18 at 5:00 p.m. no further information was provided regarding the management of Resident #110's behaviors. b) Resident #105 A review of Resident #105's incident reports at 12:00 p.m. on 11/07/18 found the following incidents which involved a resident to resident altercation (Resident identifier numbers have been substituted for residents' names and room numbers designated as XXX for confidentiality): -- 08/03/18 - Resident #105 gently slapped other resident with open hand. Resident #105 was very difficult to redirect. Combative with staff and cursing other residents. Resident redirected to her room. (Please note other resident not identified by facility) -- 08/19/18 4:40 p.m. - called to hallway in front of room XXX. Resident #105 smacked Resident #102 on the right hand. No injuries. Residents separated and redirected. -- 09/03/18 9:20 p.m. - Heard yelling from room XXX. Upon entering the room staff witnessed Resident #105 slap Resident #93 across the right cheek and was cursing at him. Resident #93 then in turn slapped Resident #105 across both her cheeks. -- 10/22/18 6:30 p.m. - Resident #105 and Resident #112 were overheard yelling at each other. Resident #105 was slapping Resident #112 in the face. Other resident attempted to kick Resident #105 but missed. -- 10/23/18 1:15 p.m. - Therapy staff observed Resident #105 go into Resident #112's room. Resident #112 asked Resident #105 to leave and Resident #105 became angry and slapped Resident #112 with an open hand across the face and grabbed the resident's left arm. Review of Resident #105's nursing notes found the following additional occasions when Resident #105 was involved in a verbal or physical altercation with other residents: -- 09/01/18 at 6:19 p.m. - according to Resident #98, Resident #105 entered his room and hit him in the stomach and scratched his left upper cheek and behind his left ear, and his left upper lip. Following that Resident #98 punched Resident #105 in the lower left jaw. Resident #105 then began to curse Resident #98. The housekeeper overheard and entered the room to separate the residents. -- 09/11/18 at 12:59 a.m. - Heard yelling coming from room XXX. Upon entering witnessed staff attempting to redirect 2 residents who were yelling at one another. The nurse redirected the other resident in one direction while staff redirected Resident #105 in the opposite direction. After talking to staff it was told to this nurse that Resident #105 had slapped the resident on the right cheek and was cursing him. Following her slap the other resident then slapped her on both cheeks. No injuries noted. -- 09/29/18 12:30 a.m. - Earlier this shift resident was loud. Yelling at other residents to get out of her room and she was in theirs. Resident easily redirected by staff. At time Resident was observed striking out at staff and other residents. No physical contact was made. -- 10/04/18 3:43 p.m. - Resident has been in an up and down mood today. One minute she will be happy and then the next moment the resident is heard down the hall saying you're a whore, growling at people, and hitting people. Resident has been easily redirected each time by different staff members. -- 10/03/18 6:20 a.m. - Resident has been wandering in and out of rooms this AM (morning). Resident repeatedly lying people are in her bed. Resident pointed to another residents room and said she was going to knock the hell out of them and show them what she was made of. Resident was redirected to her room and explained to her that other residents were not in her room. Resident was laying in bed with eyes closed at this time. -- 10/17/18 at 4:27 p.m. - Resident has been resting in bed most of shift. This am (morning) at breakfast this resident began yelling at the resident across the table at her. When staff went intervene resident stood up and started yelling at staff and hitting them and continued to yell at the other resident . -- 10/26/18 12:12 a.m. - Resident #105 wandered into another residents room and got in verbal altercation with that resident. Easily redirected. No complaints voiced -- 10/30/18 6:10 p.m. - Resident #105 out in the hallway and got into a verbal altercation with another resident when this resident attempted to go into that residents room. The resident began yelling that she was going to kill that [***] . When attempting to redirect Resident #105 began hitting and pulling this nurse's hair. A review of Resident #105's care plan found statement of: (First Name of Resident #105) displays physically aggressive behavior. The goal associated with this care plan was: (First name of Resident #105) displays physically aggressive behavior. This goal had a target date of 01/23/19. The interventions related to this problem and goal included: -- Social Services to evaluate and visit with (First name of Resident #105). Added on 08/08/18. -- Activities staff to visit with (First name of Resident #105) and provide diversional activities. Added on 08/08/18. -- Monitor and document (First name of Resident #105)'s behavior. Added on 08/08/18. -- Do not argue with (First name of Resident #105). Added on 08/08/18. -- Identify causes for behavior and reduce factors that may provoke (First name of Resident #105). Added on 08/08/18 -- Praise (First name of Resident #105) for demonstrating desired behavior. Added on 08/08/18. -- Talk with (First name of Resident #105) in calm voice when behavior is disruptive. Added on 08/08/18. -- Remove (First name of Resident #105) from public area when behavior is disruptive and unacceptable. Added on 08/08/18. -- Encourage responsible party/family to visit with (First name of Resident #105). Added on 08/18/18. -- Redirect (First name of Resident #105) when she is intrusive to other residents space. Added on 08/20/18. -- Encourage staff to spend time with (First name of Resident #105) to feel comfortable. Added on 09/14/18. -- Apply stop sign to door. Added on 09/12/18. -- When resistant to care provide (First name of Resident #105) with positive distractions. Added on 10/16/18. -- Try to identify triggers that cause behaviors. Added on 10/23/18. A review of Resident #105's Minimum Data Set (MDS) assessment with assessment reference dates (ARD) of 07/10/18 and 10/15/18 found Resident #105 had verbal and physical behaviors directed toward others one (1) to three (3) days during each look back period. During an interview with the Administrator (NHA) and the Director of Nursing (DON) beginning at 1:14 p.m. and concluding at 1:41 p.m. on 11/06/18, these findings were discussed. The NHA stated that she would put together a time line to show what interventions they had put into place for Resident #105. The following morning, on 11/07/18, the NHA provided a time line to show what they had done for this resident to keep other residents safe. The following is the timeline provided typed as written: -- 08/03/18 redirected. -- 08/05/18 redirected. -- 08/10/18 redirected. -- 08/17/18 redirected and snacks provided. -- 08/19/18 redirected. -- 08/22/18 permission to see psychiatrist obtained. -- 08/25/18 seen by (Name of in-house psychiatrist). No new medication changes. -- 08/30/18 redirected encouraged rest period. -- 09/01/18 redirected. -- 09/04/18 redirected, monitored, praise family was called and asked them to come and visit. -- 09/06/18 redirected to room, staff member sat with resident until she fell asleep. -- 09/09/18 seen by MD. No new orders offered snacks and provided rest period. -- 09/11/18 redirected. -- 09/12/18 spoke with RP (responsible party) about hearing aide declined. -- 09/12/18 applied stop sign to door. -- 09/29/18 redirected. -- 10/03/18 redirection and encouraged rest period. -- 10/15/18 used music for redirection and rest period. -- 10/16/18 environmental change. -- 10/23/18 snack/redirection. -- 10/27/18 saw (Name of in house psychiatrist) again and increase [MEDICATION NAME]. -- Care planned interventions include: activities, attempts to identify cause of agitation, calm approach, praise, change environment when needed, encourage family visits, psych consult, stop sign on door and med's as ordered. -- Med's include: [MEDICATION NAME], and [MEDICATION NAME]. Review of Resident #105's medications found she was started on [MEDICATION NAME] 125 mg by mouth twice a day on 10/27/18. Resident was started on [MEDICATION NAME] 25 mg twice a day and [MEDICATION NAME] 40 mg once daily beginning on 07/10/18, the date of her admission. Resident #105 received the [MEDICATION NAME] for a [DIAGNOSES REDACTED]. There was no evidence in the medical record that these medications were ever reviewed for effectiveness in controlling the residents behaviors. At the time of exit on 11/12/18 at 5:00 p.m. no further information was provided. c) Resident #93 During record review of nurses notes in the electronic chart the following notes were as listed below. On 4/19/18 at 6:19 AM Nursing notes, Resident # 93 agitated after Nursing Assistance NA dressed him this am. Afterwards he would run up to her and telling her he was going to beat the[***]out of her with his fist drawn back. Resident did this three times. On 4/19/18 at 1:38 PM, states Resident # 93 will ambulate to his desired location. He does need direction to his room at time. He is usually pleasant. Neither staff nor Resident have voiced any problems in room or roommate. by Social Services (SS) On 5/07/18 at 8:34 PM, Resident # 93 grabbed a black marker from the nurse and went to a resident being fed, raised the marker above her head. As the nurse went to take the marker away for him he took his right elbow and rammed it into the nurses left breast then immediately hit the nurse in the right jaw with his fist with great force. On 5/ 8/18 at 3:43 PM, Resident # 93 was combative pouring his water on the floor chewing up his meds and spiting them on the floor. On 5/12/18 at 6:57 PM, Resident # 93 had struck another resident in the dining room. Unable to redirect Resident was immediately removed from the dining room, he was cursing and saying I will kill them Let me at em right now Registered Nurse (RN) in charge was notified and decision was made to send to the ER for evaluation. On 5/17/18 at 4:33 PM, Resident # 93 agitated wondering up and down hall keeps talking about people getting blown up On 5/18/18 at 10:23 PM, Resident # 93 pushed another resident to the floor. Resident # 93 observed with hands around the other resident's neck. Resident # 93 was assisted to his room. This was report and witnessed by the housekeeper. (This happened in the lounge). On 5/19/18 at 6:17 AM, Resident # 93 combative and uncooperative with others. Resident # 93 striking out at others. On 5/29/18 at 10:41 PM, Resident # 93 stated to fight with staff. Resident # 93 scratched, slapped and attempted to kick staff. On 5/31/18 at 11:59 PM Resident # 93 combative with staff striking out. Resident # 93 hit the nurse in the face he attempted to hit her several more times. Resident # 93 stated that he was in Cambodia we have to get them before they get us. On 6/9/18 at 10:37 PM, Resident # 93 told the nurse, I'm going to f*ck up your head. He then made a fist with his right hand and chased the nurse around the table. He was also going up to another resident's family and couldn't be redirected. On 6/11/18 at 3:41 PM, Resident # 93 has been agitated this shift. Resident # 93 has grabbed staff members wrist and neck. Is hard to redirect On 6/20/18 at 1:44 PM, Inter Department Team (IDT) met and discussed combative behaviors with other residents on 5/19 On 7/14/18 at 3:48 PM, Resident # 93 hit staff in the chest while trying to ambulate to the bathroom, On 7/26/18 at 6:38 PM Resident # 93 asked nurse if she would suck him off. On 8/24/18 at 10:31 PM, Resident # 93 was observed to try and go into another resident's room. the other resident was trying to get him out of his room, both residents hit each other. On 8/27/18 IDT Met about physical contact with another resident. On 8/28/18 at 7:05 PM, Resident # 93 became agitated after witnessing another residents agitation . required 2 NA to walk with him he was trying to strike out cursing and tried to kick the nurse. It took 45 minutes to calm down. On 9/3/18 at 3:45 AM, Resident # 93's roommate accused Resident # 93 of beating him up. When nurse entered the room both men sitting on the side of the bed facing each other. Resident # 93 had no brief on it was next to the other resident's bed. On 9/03/18 at 11:13 PM, NA trying to remove resident from another resident's room. On 9/9/18 at 6:56 PM, another resident yelled at Resident # 93 who was in the hallway. the two started yelling and pushing each other. Resident # 93 hit the other resident in the jaw. On 9/10/18 at 12:00 AM Resident # 93 was agitated On 9/11/18 at 12:43 PM, NA heard Resident # 93 cursing and yelling in another resident's room [ROOM NUMBER]. She saw the other resident slap this resident in the face then Resident # 93 slapped her on both sides of her face before he could be re-directed. On 9/18/18 at 4:58 PM, Resident # 93 was found on the floor of another resident's room, He was assisted off the floor. On 11/4/18 at 6:24 AM, Resident # 93 agitated and difficult to redirect moving chairs and flipping tables in the lounge. On 11/5/18 at 12:29 PM, told nurse she was going to get a give her a butt whoppin A time line for Resident # 93 provided by the NHA is as follows: -1/31/18 Redirected -2/1/18 Redirected -2/11/18 Encouraged to rest -2/18/18 Redirected -2/28/18 Observation -4/19/18 Redirected to different environment -5/4/18 Seen by (Facility Psychiatrist) -5/7/18 Redirected to different environment -5/12/18 Removed from environment sent to emergency room (ER) for evaluation -5/13/18 Returned from ER with no new orders -5/17/18 Observation -5/18/18 Redirected and observation -5/19/18 Observation -5/29/18 Redirected -5/31/18 Encouraged to rest -6/9/18 Redirected -6/11/18 Redirected -6/20/28 IDT review care plan -8/24/18 Redirected -8/28/18 Staff ambulated with Resident -9/3/18 Redirected rest encouraged -9/9/18 Redirected and removed from environment -9/11/18 Redirection -9/15/18 seen by Psychiatrist continue current medications -11/4/18 Assisted to bed, redirection, snack offered Care Plan Interventions included: Redirection, encourage rest breaks, encourage positive visits from family, follow up with psychiatrist as ordered, be patient and re-assuring, draw privacy curtain during evening hours. On 11/07/18 at 12:30 PM, Administrator and DoN was asked what they had done to protect the other Residents from Resident #93. The administrator said that, they have had IDT meeting about the problem. They were asked what steps they have put in place to keep him from hurting the vulnerable residents. They had no answers. On 11/07/18 at 3:19 PM, came out of his room walked across the hall was briefly in room [ROOM NUMBER] Staff member called him back to his room, He is receiving one on one supervision at this time. d) Resident #24 On 11/05/18 at 1:33 PM, the resident said she didn't like being at the facility because another resident came to her room and tried to have sex with her. She said she did not think she belonged in this place, locked up. This resident resided on the locked unit of the Dementia care unit. Record review found the resident was admitted to the dementia unit on 08/06/18, after a stay in a local hospital where she was diagnosed as having a Neurocognitive disorder, most likely secondary to Alzheimer's Dementia with behavioral changes. The physician determined the resident lacked capacity to make medical decisions. Review of the licensed nurses notes found the following entry dated 09/22/18 at 11:43 PM: Resident stated that (Name of resident #110) came into her room and stated that he was going to kill her and he wanted to have sex with her. She stated that she came to the facility to be safe and is now scared. Resident was assured that she is safe. There was no further information regarding this incident was provided in the nurses notes. On 11/06/18 at 10:56 AM, Registered Nurse (RN) #19, identified herself as the dementia units case manager. When asked if she or anyone conducted any interviews or investigation related to the alleged incident or identified the circumstances of what occurred prior to during or after the alleged allegation voiced by Resident #24 on 09/22/18, she replied she was unaware of the allegation. She was unable to provide any further information related to Resident #24's statement. There was no information as to how the facility addressed Resident #110's behaviors. During the resident council meeting held on 11/06/18 at 11:05 AM, Resident #24 said Residents #110 and #93 come in her in her room wouldn't leave her room. She said that on one occasion, Resident #110 told Resident #93 to hold (TRUNCATED)",2020-09-01
3365,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2018-11-12,880,F,0,1,2C7711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review, the facility failed to maintain the clean laundry area to prevent cross contamination of linens to help prevent the development and transmission of communicable diseases and infections. The clean laundry area contained an appliance that promoted the spread of infection. This practice had the potential to affect all residents. Facility census: 115. Findings included: a) At 9:07 AM on 11/06/18 observation of laundry area revealed a small white commercial sized Hot Point washing machine placed in the corner of the clean laundry area next to the folding table. This washing machine was used to wash resident's personal clothing items, or residents clothing that required special laundering attention. Per Laundry Supervisor (LS) #76 the washing machine was used to wash the clothes of residents with allergies [REDACTED]. The washer was being utilized by the facility. b) On 11/06/18 at 9:55 AM review of the facility's Environmental Services/Housekeeping/Laundry policy for handling linens to prevent and control infection stated all potentially contaminated linens were to be handled with appropriate measures to prevent cross-contamination. LS# 76 agreed that having the commercial washing machine located on the clean side of the laundry area with the dryers and folding table was unsanitary and posed a risk for cross contamination to clean linens when being used. c) Administrator #88 and Director of Nursing (DoN) #83 were notified of this finding and agreed the washing machine should not be on the clean side of the laundry area with the dryers due to the possibility of cross contamination of the clean linens.",2020-09-01
3366,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2019-12-18,578,D,0,1,KDKE11,"**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 twenty-one (21) Residents reviewed during the long-term care survey process had advance directives completed as recognized by State Law. Resident identifier: #22. Facility census: 110. Findings included: a) Resident #22 Record review found a West Virginia Physician orders [REDACTED]. The POST form directed the Resident was a do not resuscitate (DNR). The section entitled, Medically Administered Fluids and Nutrition, directed the resident to have IV (intravenous) fluids for a trial period of no longer than ________. The specified time period was not completed on the POST form. In 2002 the POST form was incorporated into the West Virginia Health Care Decisions Act ( 16-30-2.) The directions for completing the POST form, compiled by the West Virginia Center for End of Life, require documentation of the length of the trial period for IV fluids. On 12/17/19 at 10:00 AM, the Social Service Director (SSD) #37 confirmed the POST form was not completed in its' entirety. SSD #37 said she would contact the POA and update the form as well as having the facility physician review the POST form. On 12/17/19 at 10:10 AM, the administrator said the SSD was already working on getting Resident #22's POST form completed.",2020-09-01
3367,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2019-12-18,641,E,0,1,KDKE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the minimum data set (MDS) assessments for the facility's residents were coded accurately in the areas of nutritional status, hospice services, and medications. This deficient practice was found for five (5) of 22 residents sampled during the long term care survey process (LTCSP). Resident identifiers: #354, #49, #92, #102, #67. Facility census: 110. Findings included: a) Resident #354 During the survey section K (nutritional status) of Resident #354's minimum data set (MDS) assessments was reviewed as part of the nutrition care area. On the quarterly MDS with an assessment reference date (ARD) of 06/26/19 significant weight loss was coded. However, a review of Resident #354's weight change history revealed no significant weight loss. On the discharge MDS with an ARD of 09/09/19 significant weight loss was coded, but a review of Resident #354's weight change history found no significant weight loss. On the 14-day MDS with an ARD of 09/30/19 significant weight loss and significant weight gain were coded, but a review of Resident #354's weight change history found neither significant weight loss nor significant weight gain. The above information was discussed with the facility's Certified Dietary Manager (CDM) on 12/17/19 at 1:36 PM. The CDM said Resident #354 had not had any significant weight changes during the time periods corresponding with the above MDS assessments and agreed the assessments had been coded incorrectly. On 12/17/19 at 1:39 PM the above information was discussed with the facility's Director of Nursing (DON) and Administrator, and no further information was provided. b) Resident #49 During the survey section K (nutritional status) of Resident #49's minimum data set (MDS) assessments was reviewed as part of the nutrition care area. On the 14-day MDS with an assessment reference date (ARD) of 07/04/19 Resident #49's weight was coded as 153 pounds and significant weight loss was coded. A review of Resident #49's weight change history found Resident #49 weighed 150.8 pounds at the time of the assessment and had no significant weight loss. On the 5-day MDS with an ARD of 07/24/19 significant weight loss was coded, but a review of Resident #49's weight change history found no significant weight loss. On the significant change in status MDS with an ARD of 08/14/19 significant weight loss was coded, but a review of Resident #49's weight change history found no significant weight loss. On the discharge MDS with an ARD of 10/10/19 significant weight loss was coded, but a review of Resident #49's weight change history found no significant weight loss. On the significant change in status MDS with an ARD of 10/28/19 Resident #49's weight was coded as 143 pounds and significant weight loss was coded. However, a review of Resident #49's weight change history found that Resident #49 weighed 144.2 pounds at the time of the assessment and had no significant weight loss. The above information was discussed with the facility's Certified Dietary Manager (CDM) on 12/17/19 at 1:36 PM. The CDM said Resident #49 had not had any significant weight changes during the time periods corresponding with the above MDS assessments. The CDM also agreed that the weight had been coded incorrectly on the 14-day MDS with an ARD of 07/04/19 as well as the significant change in status MDS with an ARD of 10/28/19. On 12/17/19 at 1:39 PM this information was discussed with the facility's Director of Nursing (DON) and Administrator, and no further information was provided. c) Resident #92 Medical record review found the Resident had a physician's orders [REDACTED]. Review of the most recent MDS, a quarterly, with an ARD of 10/02/19, found the MDS did not reflect the resident was receiving Hospice care. At 8:42 AM on 12/17/19, Registered Nurse Case Manager, RN #33 confirmed the MDS was coded incorrectly. She said, I will do a correction right now. On 12/17/19 at 9:00 AM, the Director Of Nursing (DON) confirmed the MDS was coded incorrectly. d) Resident #102 Review of Resident #102's medical records found Resident #102's medication regimen contained [MEDICATION NAME] ( an antipsychotic). Review of Resident #102's MDSs found a quarterly MDS with an ARD of 11/19/19, under Section N0450 section [NAME] was marked 08/01/19 (indicating the date the physician documented a gradual dose reduction(GDR) was clinically contraindicated). Further review of Resident #102's physician documented found on 08/02/19, the physician documented a GDR of [MEDICATION NAME] was clinically contraindicated. On 12/17/19 at 1:00 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON), confirmed Resident #102's MDS were incorrectly coded. e) Resident #67 Review of Resident #67's medical records found Resident #67's medication regimen contained [MEDICATION NAME] (a diuretic) and [MEDICATION NAME] (an antipsychotic). Review of Resident #67's significant change MDSs with an ARD of 07/08/19 and a quarterly MDS with an ARD of 09/27/19, found Section N0400 [NAME] was coded with a 0 (indicating the number of days the resident received a diuretic). Additionally, N0450 section D was coded with a 0 (indicating no physician documentation that a gradual dose reduction(GDR) was clinically contraindicated). Further review of Resident #67's physician documentation, found on 07/01/19, the physician documented a GDR of [MEDICATION NAME] was clinically contraindicated. Additionally, a review of Resident #67's Medication Administration Records (MAR) for (MONTH) and (MONTH) found the resident received diuretic ([MEDICATION NAME]) seven (7) days during each look-back periods. An interview with the Nursing Home Administrator and Director of Nursing on 12/17/19 at 1:00 p.m., confirmed the two (2) MDSs with the ARD dates of 07/08/19 and 09/27/19 were coded incorrectly in regards to Resident #67's use of [MEDICATION NAME] and GDR documentation.",2020-09-01
3368,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2019-12-18,761,E,0,1,KDKE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to date three (3) out of four (4) multi-use vials when opened during an observation of medication storage. This practice had the potential to affect more than an isolated number of residents. Resident identifier: #99. Facility census: 110. Findings included: a) Resident # 99 During an observation of the medication cart on the 400 hall on 12/17/19 at 8:43 AM, Licensed Practical Nurse (LPN) #136, verified there was no date on the vials to indicate when the vials of [MEDICATION NAME] R and [MEDICATION NAME] ( these medications are used to treat and control the level of the glucose in the blood for people who have diabetes), were initially opened. Record review found Resident #99 had a [DIAGNOSES REDACTED]. Resident #99 had physician's orders [REDACTED]. LPN #136 stated, she would let the Director of Nurses (DON) know about the vials not being dated. b) [MEDICATION NAME] vial During a tour of the medication storage room on the 300 and 400 hall on the morning of 12/17/19, with LPN #134, it was found the multi-use vial of [MEDICATION NAME] (T), (used to check if a resident has or does not have tuberculoses) was not dated when opened. LPN #134 verified there was no date on the vial to indicate when it was initially opened. On 12/17/19 at 8:54 AM, the DON and Administrator said they were aware of medications not being labeled with an open date. c) Facility Policy Facility Policy, titled, Medication Storage, dated: 12/2018, stated, All opened vials, liquids, eye drops, ointments, creams, and inhaled medications are to be dated when opened.",2020-09-01
3369,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2019-12-18,880,F,0,1,KDKE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. This failed practice had the potential to affect all residents residing in the facility. Resident identifiers: #22, and #15. Facility census: 110. Findings included: a) Facility task - infection control On 12/17/19 at 2:14 PM, a tour of the laundry room was conducted with the Administrator and the Housekeeping and Laundry Supervisor. The dirty laundry room contained a large plastic bin. The Housekeeping and Laundry Supervisor explained this bin was for dirty cleaning rags. These rags are sent out for laundering rather than being laundered in the facility. The rags are placed in plastic bags and then placed in the plastic bin. The laundering service picks up the rags and also exchanges the bin every week. Upon inspection, the bin did not have a liner. The bottom of the bin contained black debris in the back left corner. A piece of cardboard was lying on the bottom of the bin, covering approximately one-sixth of the bottom of the bin. Also lying on the bottom of the bin were what appeared to be medical waste consisting of a gauze pad with a dark substance on it and a gauze pad with plastic tape. The Administrator stated she would have the bin removed to be cleaned and sanitized. No further information was provided through the completion of the survey. b) Resident #22 Observation of the Resident at 11:09 AM on 12/16/19, found the resident sleeping in her bed. The Resident had a portable oxygen concentrator at her bedside. The concentrator was in use. The middle part of the tubing, coming out of the concentrator, was resting in the trash can, situated between the oxygen concentrator and the resident's bed. The prongs of the nasal cannula tubing were inserted in the Resident's nostrils. Record review found a physician's orders [REDACTED]. On 12/17/19 at 8:25 AM, observation with Licensed Practical Nurse (LPN) #145 found the tubing from the oxygen concentrator was laying in the floor beside the resident's bed. The concentrator was in use and the nasal cannula prongs were inserted in the Resident's nostrils. LPN #145 confirmed the tubing should not be in the floor. LPN #145 wrapped the excess tubing around the concentrator and positioned the concentrator directly beside the Resident's bed. In addition, LPN #145 confirmed the Resident does not get out of bed, is unable to turn and reposition on her own; therefore, the Resident would be unable to move the oxygen tubing on her own. At 8:38 AM on 12/17/19, the Director of Nursing (DON) confirmed the oxygen tubing should not be in the floor. c) Resident #15 Observation of the resident on 12/16/19, at approximately 11:30 AM, found the resident resting in her bed. Further observation found the resident was receiving continuous oxygen via a oxygen concentrator. The tubing coming from the oxygen concentrator was laying in the floor between the concentrator and the nasal cannula. Record review found a physician's orders [REDACTED]. On 12/17/19 at 8:35 AM, observation found the oxygen tubing laying in the floor beside the Resident's bed. The concentrator was in use. LPN # 145 confirmed the tubing from the concentrator should not be in the the floor. At 8:38 AM on 12/17/19, the Director of Nursing (DON) confirmed the oxygen tubing should not be in the floor. d) Employee #137 During medication administration observation, on 12/17/19 at 8:50 am, Employee #137 obtained a blood pressure and heart rate for Resident #49 using a wrist cuff machine. Employee #137, placed the wrist cuff machine in the medication cart without cleansing the wrist cuff. Interview with Director of Nursing (DON) on 12/17/19 at 11:15 a.m., found the wrist cuff machine was used by multiple residents and was to be cleaned after usage.",2020-09-01
3854,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,156,D,0,1,DBHB11,"Based on staff interview and record review, the facility failed to ensure Resident #43 received notice of the decision to terminate Medicare covered services two (2) days prior to the proposed end of Medicare services. This was true for one (1) of three (3) residents reviewed for the mandatory care area of liability notices and beneficiary appeal. Resident identifier: #43. Facility census: 62. Findings include: a) Resident #43 At 1:25 p.m. on 01/18/17, Business Office Manager (BOM) #4, provided a copy of the notice of Medicare non-coverage form, Centers for Medicare and Medicaid Services (CMS) form # , issued to Resident #43. The form noted the resident's Medicare services would end on 11/29/16. The first day of non-skilled services would begin on 11/30/16. The resident's responsible party signed the form on 11/29/16. BOM #43 said she was only the keeper of the form, she did not provide the form to the resident's responsible party. She identified the social worker as the employee responsible for issuing the form. At 1:43 p.m. on 01/18/17, Social Worker #84 was unable to provide documentation the responsible party was notified of the determination to end services two (2) days before the proposed cut of services. The responsible party could have been contacted by telephone if unavailable to sign the form; however, no documentation was available to substantiate contact was made with the responsible party within the required time frame. Providing the notice two (2) days prior the end of services allows the resident/responsible party time to contact the Quality Improvement Organization (QIO) if they wish to appeal the decision. Resident #43 remained in the facility with benefit days remaining when the notice of Medicare non-covered services form was given.",2020-04-01
3855,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,160,D,0,1,DBHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to release the balance of two (2) deceased residents ' personal funds to the individual or probate jurisdiction administering the individual's estate as provided by State law. Resident identifiers: #96 and #32. Facility census: 62. Findings include: a) At 10:59 a.m. on [DATE], review of the care area of person funds review with the Accounts Payable (AP) Employee #9 found the following: 1. Resident #32 Resident #96 expired on [DATE]. At the time of death, the resident had $963.45 remaining in her personal funds account. On [DATE], a check for this amount was issued to a funeral home. 2. Resident #96 Resident #96 expired on [DATE]. The balance remaining in the personal funds account at the time of death was $158.10. On [DATE], a check was issued to a funeral home for this amount. b) Upon the death of a resident, the balance of the personal funds can only be released to the individual or probate jurisdiction administering the resident's estate. AP #9 confirmed the funeral home was not the probate jurisdiction administering the estates of Residents #32 and #96. c) At 8:40 a.m. on [DATE], these findings were discussed with the administrator, director of nursing, and Vice President of Operations #112. The administrator said the check issued to the funeral home for Resident #32 was still in the outgoing. She retrieved the check from the mail after surveyor intervention.",2020-04-01
3856,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,241,D,0,1,DBHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a random observation and staff interview, the facility failed to ensure Resident #43 had a dignified dining experience during the noon time meal on 01/16/17. Resident #43 was not served lunch as the same time as her roommate. Resident identifier: #43. Facility Census: 62. Findings include: a) Observation of the noon time meal on 01/16/17 beginning at 11:30 a.m. found two (2) residents in room [ROOM NUMBER] . The staff served Resident #38 (Bed A) her noon time meal at 11:45 p.m. on 01/16/17. Nursing staff brought a meal for Resident #43 (Bed B) at 12:07 p.m. on 01/16/17. This was twenty-two (22) minutes after her roommate was served her food. Nursing had to bring Resident #43's meal from the dining room cart. An interview with the Director of Nursing (DON) at 12:10 p.m. on 01/16/17 confirmed Resident #43 was not served at the same time as her roommate. She further verified both roommates should have received their trays at the same time.",2020-04-01
3857,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,242,D,0,1,DBHB11,"Based on resident interview, family interview, record review, and staff interview, the facility failed to ensure two (2) of three (3) resident's reviewed for the care area of choices during Stage 2 of the Quality Indicator Survey (QIS) received personal care consistent with their past interests. The residents' choice for bathing practices, an aspect of their lives that was significant to them, was not consistent with their past preferences. Resident identifiers: #69 and #35. Facility census: 62. Findings include: a) Resident #69 At 11:47 a.m. on 01/16/17, when asked, Do you choose how many times a week you take a bath or shower? the resident responded No, and said he would shower every day if at home. The resident said when he was admitted to the facility in (MONTH) (YEAR), he was told by staff what his shower days would be. He did not feel he had a choice because, That is the schedule here. At 12:40 p.m. on 01/17/17, when asked how the facility determined a resident's shower schedule, corporate Registered Nurse (RN) #108 identified Licensed Practical Nurse (LPN) #93 as the one who would have spoken to Resident #69 regarding his shower scheduled. At 12:45 p.m. on 01/17/17, LPN #93 said the resident's room number and bed determined shower schedules. She said she told the residents when they would receive their showers and if she received no feedback, she assumed this schedule was okay with the resident. On 01/17/17 at 12:55 p.m., the surveyor and the director of nursing (DON) spoke with the resident regarding the shower schedule. Resident #69 said he would like a shower daily and the evening would be fine with him. The DON told the resident his request would be honored. Review of the care plan found the resident had capacity to make decisions regarding his care. b) Resident #35 The resident's medical power of attorney (MPOA), interviewed during Stage 1 of the QIS at 12:53 p.m. on 01/16/17, said the resident did not receive the same number of showers based on past preference. The MPOA said showers were given three (3) times a week and a bed bath was to be provided on the days when showers were not provided. The MPOA said the resident would have a shower daily if she were at home. Three (3) showers a week would be all right if she would just receive a bed bath in between the shower days, but this isn't happening. At 12:40 p.m. on 01/17/17, Corporate Registered Nurse (RN) #108 was asked how the facility determined a resident's shower schedule. RN #108 identified Employee #93 as the Licensed Practical Nurse (LPN) who discusses the shower schedule with the residents on this resident's hallway. At 12:45 p.m. on 01/17/17, LPN #93 said shower schedules are determined by your room number and bed. She said she tells the resident when they will be receiving their showers and if she receives no feedback, then she assumes this schedule is OK with the resident. On 01/18/17 at 10:00 a.m. review of the computerized shower schedules for the months of (MONTH) (YEAR) and (MONTH) (YEAR) found the resident received only one (1) bed bath, which occurred on 12/13/16. According to the documentation on the shower scheduled, the resident received a shower on 12/01/16, 12/03/16, 12/06/16, 12/08/16, 12/10/16, 12/15/16, 12/17/16, 12/20/16, 12/22/16, 12/24/16, 12/27/16, 12/29/16, 12/31/16, 01/03/17, 01/05/17, 01/07/17, 01/10/17, 01/12/17, 01/14/17, and 01/17/17. At 8:40 a.m. on 01/19/17, these findings were provided to the administrator, director of nursing, RN #108, and Vice President of Operations #112. The facility provided no further information as of the close of the survey on 01/19/17 at 3:45 p.m.",2020-04-01
3858,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,253,E,0,1,DBHB11,"Based on observation and staff interview, the facility failed to ensure the overhead vents in the shower room and in room #14 were free from dust. This had the potential to affect more than an isolated number of residents currently residing in the facility. Facility Census: 62. Findings Include: a) Observations on 01/18/17 at 10:40 p.m. found the overhead vent in the facility's shower room to be covered with a thick layer of dust. The dust was thick it was hard to determine how many slats were in the vent because the dust gathered on each individual slat was so thick that the dust was meeting and the separation of the slats was not visible. This was also true for the overhead vent in the resident bathroom of room #14. A tour with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) between 8:52 a.m. and 8:59 a.m. on 01/19/17 confirmed the vents in the shower room and in room #14 needed cleaned.",2020-04-01
3859,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,272,D,0,1,DBHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Resident Assessment Instrument (RAI) version 3.0 manual, and staff interview, the facility failed to ensure three (3) significant change in status (SCSA) Minimum Data Set (MDS) assessments for Resident #20 accurately reflected medications Resident #20 received during the seven (7) day lookback periods. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #20. Facility Census: 62. Findings include: a) Resident #20 1. A review of Resident #20's medical record at 9:47 a.m. on 01/18/17 found the SCSA MDS with an assessment reference date (ARD) of 05/20/16, identified the resident received an anticoagulant medication seven (7) of the seven (7) days during the lookback period. Review of Resident #20's Medication Administration Record [REDACTED]. 2. Review of the SCSA MDS with an ARD of 06/30/16, found it identified the resident did not receive an antianxiety medication during the 7-day lookback period. The assessment also identified the resident received an anticoagulant during this period. Review of Resident #20's MAR for the look back period of 06/24/16 through 06/30/16 found Resident #20 received [MEDICATION NAME] (an antianxiety medication) seven (7) of the seven (7) days during the look back period and did not receive any anticoagulant medications during the lookback period. 3. The SCSA MDS with an ARD of 12/31/16 indicated the resident received an anticoagulant medication seven (7) of the seven (7) days during the lookback period. Review of Resident #20's MAR for the look back period of through 12/25/16 through 12/31/16 found Resident #20 did not receive any anticoagulant medications during the look back period. b) A review of the RAI manual at 11:30 a.m. on 01/18/17 found the following coding instructions, Antianxiety: Record the number of day an anxiolytic medication was received by the resident at any time during the 7- day look back period (or since admission/entry if less than 7 days). Further review of the RAI manual found it also included Anticoagulant (e.g. [MEDICATION NAME], or low molecular weight [MEDICATION NAME]): Record the number of days an anticoagulant medication was received by the resident at any time during the 7 day look back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medication such as aspirin/extended release, [MEDICATION NAME], or [MEDICATION NAME] here. An interview with Registered Nurse (RN) MDS Coordinator #81 at 11:42 a.m. on 01/18/17 confirmed the SCSA MDSs were inaccurate in the area of medications. She said she counted the resident's [MEDICATION NAME] ([MEDICATION NAME]) as an anticoagulant and she must have just missed seeing the [MEDICATION NAME] on the 06/30/16 assessment. She stated she did not know you were not supposed to count [MEDICATION NAME] as an anticoagulant medication.",2020-04-01
3860,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,278,D,0,1,DBHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Resident Assessment Instrument (RAI) version 3.0 manual, and staff interview, the individual completing the medication section of Resident #20's quarterly Minimum Data Set (MDS) failed to accurately reflect what types of medications Resident #20 received during the seven (7) day look back period. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #20. Facility Census: 62. Findings include: a) Resident #20 A review of Resident #20's medical record at 9:47 a.m. on 01/18/17, found the Quarterly MDS with an ARD of 09/30/16 identified the resident received an anticoagulant medication seven (7) of the seven (7) days during the look back period. The assessment also identified the resident did not receive a diuretic during the seven (7) day look back. Review of Resident #20's Medication Administration Record [REDACTED]. A review of the RAI manual at 11:30 a.m. on 01/18/17 found the following coding instructions pertaining to item N0410 G, Diuretic: Record the number of day a diuretic medication was received by the resident at any time during the 7-day look back period (or since admission/entry if less than 7 days). Further review of the RAI manual found the following coding instructions for item N0410E, Anticoagulant (e.g. [MEDICATION NAME], or low molecular weight [MEDICATION NAME]): Record the number of days an anticoagulant medication was received by the resident at any time during the 7 day look back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medication such as aspirin/extended release, [MEDICATION NAME], or [MEDICATION NAME] here. An interview with Registered Nurse (RN) MDS Coordinator #81 at 11:42 a.m. on 01/18/17 confirmed the quarterly MDS with an ARD of 09/30/16 was inaccurate in the area of medications. She indicated that she counted the resident's [MEDICATION NAME] ([MEDICATION NAME]) as an anticoagulant and she must have just missed seeing the [MEDICATION NAME] (diuretic). She stated she did not know you were not supposed to count [MEDICATION NAME] as an anticoagulant medication.",2020-04-01
3861,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,279,D,0,1,DBHB11,"**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 based on a resident's comprehensive assessment. This practice affected one (1) of six (6) residents whose care plans were reviewed for the care area of unnecessary medications. The care plan for Resident #89 did not address pain. Resident #89. Facility census: 62. Findings include a) Resident #89 A review of the medical record for Resident #89 on 01/18/17 revealed the comprehensive Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/21/16 identified the resident had a [DIAGNOSES REDACTED]. Review of the resident's comprehensive care plan found it did not address pain. An interview on 01/19/17 at 9:15 a.m. with the director of nursing (DON) verified the comprehensive care plan did not address pain for Resident #89.",2020-04-01
3862,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,280,D,0,1,DBHB11,"Based on family interview, observation of the resident, record review, and staff interview, the facility failed to keep the resident/responsible party informed regarding decisions for care and treatment. This was true for one (1) of one (1) resident reviewed for the care area of participation in care planning. Resident identifier: #35. Facility census: 62. Findings include: a) Resident #35 On 01/16/17 at 12:53 p.m., during Stage 1 of the Quality Indicator Survey (QIS), the responsible party of Resident #35 said she did not feel staff included her in decisions regarding medicine, therapy, and other treatments. The resident's medical power of attorney (MPOA) provided the following example: She said she asked for a different wheelchair that would allow some support for her mother's neck. She said her mother had broken her neck during a fall at the facility and since that time, her mother's ability to hold her head upright had been decreasing. She said she asked for a reclining wheelchair like the ones she had seen other residents using at the facility. She said she was told none was available. According to the MPOA, no one had followed up with her regarding a wheelchair for her mother. She said her mother no longer used her current wheelchair for locomotion and she felt her mother would be more comfortable if she could have a wheelchair that reclined instead of her current wheelchair that required her mother to sit upright. Observation of the resident during the interview with the MPOA, noted her sitting upright in a Broda chair with her chin resting on her chest During an interview at 9:31 a.m. on 01/19/17, Certified Occupational Therapy Assistant (COTA) #100 said a screen for positioning was completed in (MONTH) (YEAR). On 12/05/16, Occupational Therapist (OT) #107 had a handwritten note on the screen indicating the family wanted to hold off on the screening. COTA #100 provided a copy of a second screen dated 12/29/16 that noted, Refer patient to OT for further evaluation secondary to patient family request patient be evaluated for a decline in positioning while up to Broda chair. At 9:35 a.m. on 01/19/17, OT #107 said that sometime in the latter part of (MONTH) (YEAR), the family asked him to proceed with getting their mother a new wheelchair. He said he started looking for wheelchairs that would be appropriate for Resident #35. I submitted a request to purchase a chair to the office people. As of last week, when I asked, the chair I requested had not been approved for purchase. OT #107 said COTA #100 had e-mailed a request to the administrator. COTA #100 provided a copy of an e-mail dated 01/05/17. The e-mail sent to the administrator included a price quote and a picture of the new Broda chair requested by OT #107. At 9:59 a.m. on 01/19/17, the administrator said she received the request from therapy and was going to pass the quote along to Vice President of Operations #112, but she had not done so at this time. At 10:06 a.m. on 01/19/17, COTA #100, OT #107, and the administrator were interviewed together. The administrator said the resident was already in a Broda chair and did not need another one. OT #107 said the Broda chair he wanted to order was not what the resident was using now. COTA #100 said the resident needed to be evaluated for the appropriate chair, Before we spend all that money on a new chair. These staff members were informed the MPOA did not request a new chair; she just wanted a chair that would allow support for her mother's neck. The MPOA even suggested a reclining geri-chair like the ones she had seen other residents using, but was told there were no reclining chairs available. The administrator said plenty of reclining chairs were available in a storage unit. The administrator, COTA #100, and OT #107 were not able to provide any information the family had been advised of how the facility planned to proceed regarding the MPOA's request for a chair that would provide some support for her mother's neck.",2020-04-01
3863,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,281,E,0,1,DBHB11,"Based on record review, policy review, and staff interview, the facility failed to provide services according to accepted standards of clinical practice in regards to medication administration for 39 of 62 residents currently residing in the facility. Two (2) Licensed Practical Nurses (LPN) administering evening and bedtime medications did not sign their names on the Medication Administration Record [REDACTED]. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: #67, #78, #29, #75, #55, #1, #14, #23, #74, #36,#38, #50, #77, #52, #65, #57, #17, #3, #2, #35, #8, #56, #28, #22, #70, #95, #79, #7, #97, #89, #24, #58, #47, #72, #21, #20, #46, #61, and #15. Facility Census: 62. Findings include: On 01/18/17 at 9:30 p.m., the facility was entered to observe evening shift's medication pass. LPN #94 and LPN #95 said all of their medications had been given and there were not any medication passes to be observed at that time. LPN #94 was requested to provide medication administration records (MAR) for residents randomly chosen for review. Upon asking for the MAR for Resident #54, LPN #94 stated she had not yet passed the medications to Resident #54. LPN #94 was told when she did give Resident #54's medications, the surveyor would use that opportunity to observe the medication pass for Resident #54. At 10:04 p.m., while preparing to do the medication pass for Resident #54, LPN #94 said she had not yet signed off on any of the medications she had administered that evening. LPN #94 stated she had started giving medications at 7:00 p.m. and had yet to sign off on any of the medications given. When LPN #94 was asked, When should you sign off on medications? she stated, When I give them. I should sign off and document that they are given as soon as I give them. On 01/18/17 at 10:10 p.m., LPN #95 was asked her if she had signed off on the medications she had given that evening. LPN #95 stated she had not signed the EMAR (electronic medication administration records) at the time the medications were given, and that she was signing off on some of them now. A list of resident's names that had been given medications without LPN #95 signing at the time of dispensing was requested. On 01/18/17 at 10:25 p.m., an interview with the recently acting interim director of nurses, Registered Nurse (RN #109), revealed LPN #95 was a recent hire and LPN #94 had done some training of LPN #95. RN #109 confirmed facility policy and standard of practice dictate nurses sign the EMAR at the time medications are given. The RN verified that not documenting in the EMAR at the time the medications were given would cause the record to be inaccurate for the time the residents received their medication. RN #109 stated disciplinary actions would be taken for both LPN #94 and LPN #95. A list of all residents that had evening and bedtime medications given by LPN #94 and LPN #95, and whose MARs had not been signed by LPN #94 and LPN #95 at the time the medications were given to the residents, was requested. The requested list of residents' names provided on 01/18/17 at 11:03 p.m., revealed LPN #94 gave medications to twenty-nine (29) residents without documenting medications had been given in the EMAR (electronic medication administration record) at the time they were given. LPN #95 gave medications to ten (10) residents without documenting medications had been given in the EMAR at the time they were given. On 01/18/17 at 11:11 p.m., a walk through of the facility to interview any residents identified on the list that might still be awake found Residents #20, #21, and #89 were awake. All three (3) residents stated they did receive their evening and bed time medications. On 01/19/17 at 8:04 a.m., review of facility's policy 6.0 'General Dose Preparation and Medication Administration revealed, #6. After medication administration, facility staff should take all measures required by Facility policy and Applicable Law, including but not limited to the following: 6.1 Document necessary medication administration/treatment information (e.g. when medications are opened, when medications are given .) on appropriate forms. According to Lippincott's 2012 Nursing Drug Handbook, Rights of Medication Administration the 8 rights of medication administration are: 1. Right patient . 2. Right medication . 3. Right dose . 4. Right route . 5. Right time - Check the frequency of the ordered medication. - Double-check that you are giving the ordered dose at the correct time. - Confirm when the last dose was given. 6. Right documentation - Document administration AFTER giving the ordered medication. - Chart the time, route, and any other specific information as necessary. 7. Right reason ., 8. Right response .",2020-04-01
3864,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,282,E,0,1,DBHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure care plan interventions were implement for four (4) of eighteen (18) resident's whose care plans were reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #69's insulin was not administered according to physician's orders [REDACTED]. Resident #35's care plan was not implemented for weight loss. Resident #61's interventions for fall prevention were not implemented according to the care plan. The facility did not implement the intervention to provide supplements to Resident #10 as outlined in the care plan. Resident identifiers: #69, #35, #61, and #10. Facility census: 62. Findings include: a) Resident #69 Review of the resident's current care plan found the problem: Hyper/[DIAGNOSES REDACTED] (high/low blood sugar) related to insulin dependent diabetic status. The revision date for this problem was 12/04/16. The goal associated with this problem was: Resident will be free from any signs or symptoms of hypo/[MEDICAL CONDITION] as evidenced by absence of frequent urination, increased thirst, fruity breath, stupor, sweating, tremor, confusion, etc. daily through next review period. Interventions included: Administer insulin per physician's orders [REDACTED].>Record review found the resident was admitted to the facility on [DATE]. Review of the current physician's orders [REDACTED]. The parameters specified to contact the physician if the resident's blood sugar (BS) was less than 60 or greater than 400. Review of the Medication Administration Record [REDACTED]. [MEDICATION NAME] flex pen solution Pen-injector 100 unit/ml (milliliter). Inject 10 units subcutaneously after meals for diabetes mellitus. [MEDICATION NAME] Solution 100 unit/ml (insulin [MEDICATION NAME]) Inject 35 unit subcutaneously at bedtime for diabetes mellitus. In (MONTH) (YEAR), the resident was to receive; [MEDICATION NAME] flex pen solution Pen-injector 100 unit/ML (milliliter). Inject 10 units subcutaneously after meals for diabetes mellitus. [MEDICATION NAME] Solution 100 unit/ml (insulin [MEDICATION NAME]) Inject 35 unit subcutaneously at bedtime for diabetes mellitus. The MAR for (MONTH) (YEAR) noted the resident's [MEDICATION NAME] remained the same, but the [MEDICATION NAME] 100 units/ml was increased to 12 units on 01/12/17. At 9:47 a.m. on 01/18/17, the resident's MARs for 08/03/16 through 01/18/17 were reviewed with the corporate Registered Nurse (RN) #108 and RN #109 (the former acting director of nursing). On 08/19/16, 08/21/16, 08/30/16, and 08/31/16, the resident's 6:00 a.m. dose of [MEDICATION NAME] solution were initialed and circled by the nurse on the MAR. RN #108 verified nurses' initials that were circled meant the medication was not given. On 0/20/16, the resident's 8:15 a.m. dose of [MEDICATION NAME] was again initialed and circled by the nurse. On 01/15/17 at 9:53, a nurse's note was written indicating the resident's [MEDICATION NAME] solution was held due to low blood sugar and at the request of the resident. RN #108 and RN #109 verified the insulin could not be held without physician's orders [REDACTED]. In addition the resident's blood sugar was 53 on 08/19/16 at 6:00 a.m. There was no evidence the physician was contacted per the parameters specified with the accu-cheks. RN #108 and #109 verified the resident's insulin was not administered per physician's orders [REDACTED]. At 9:30 a.m. on 01/19/17, the care plan was discussed with RN #81 and RN #82, both minimum data set (MDS) coordinators. b) Resident #35 Review of the resident's current care plan found the problem: Risk of altered nutrition/hydration status related to diagnosis, history of poor PO (by mouth) intake, etc. revised on 01/04/17 One of the goals associated with this problem was resident would consume 50% or greater at most meals through next review. Interventions included: Provide increased calories and protein with 8 ounces whole milk with meals and fortified foods one item per tray. Observations at 11:55 a.m. on 01/17/17, noted the resident eating her noon meal in the Atrium with her daughter. A carton of fat free milk was on the resident's tray. At 12:05 p.m. on 01/17/17, Assistant Food Services Director #3 verified the resident did not receive 8 ounces of whole milk. At 9:30 a.m. on 01/19/17, the care plan was discussed with RN #81 and RN #82, both minimum data set (MDS) coordinators. c) Resident #61 A review of Resident #61's medical record at 2:17 p.m. on 01/17/17 found a care plan with the following focus statement (typed as written): Potential for falls related to HX (history of) falls with fracture which is complicated by [MEDICAL CONDITION], muscle weakness and other multiple medical problems. Resident is able to ambulate (walk) independently about the facility. This focus statement was initiated on 09/12/14 with a revision date of 01/05/17. The goal associated with this focus statement was, Resident will have no falls with injury such as fracture, dislocation, head trauma or any injury requiring hospitalization through next review. This goal had an initiation date of 09/12/14 with a revision date of 09/08/16 and a target date of 04/06/17. The interventions associated with this focus statement and goal included: -- Ensure resident is wearing non skid socks while in bed and non skid shoes when ambulating or transferring. (This was added as an intervention on 02/27/15 with a revision date of 05/20/16.) -- Nurse to turn on night light at bedside at 9pm to help prevent falls. (This was added as an intervention on 12/31/16.) During an interview with Registered Nurse (RN) #109 at 4:06 p.m. on 01/18/17, when asked what interventions were put into place to help prevent Resident #61 from falling she stated, He has a night light at his bedside that we turn on at night. She also confirmed the care plan indicated that he should be wearing non skid socks while in bed and non skid shoes when ambulating or transferring. At 4:10 p.m. on 01/18/17, observation of the resident accompanied by the Director of Nursing and RN #109 found the resident lying in his bed. He did have a night light which was battery operated sitting in his window seal. Resident #61 was not wearing non skid socks at the time of this observation. After the observation was complete RN #109 confirmed he was not wearing non skid socks. She stated, He had his shoes on before he laid down. During an interview with Licensed Practical Nurse (LPN) #95 at 9:46 p.m. on 01/18/17, she stated that she was Resident #61's nurse and would be until 6:00 a.m. the following morning. When asked what interventions Resident #61 had in place related to his falls she stated, He has a low bed and a fall mat I think. (Please note neither of these things were an intervention for Resident #61.) She was then asked how she would know what new interventions a resident had if they were added when she was not there, and she stated, They pass that along to us verbally during report. She stated, If we really need to we can always look at the physician's orders [REDACTED].#95 did not mention looking at Resident #61's care plan for any fall interventions. Observations of Resident #61's room at 10:00 p.m. on 01/18/17 found the room to be dark. The overhead lights were turned off and the night light which was sitting in the window sill was not turned on as directed in the care plan. At 10:28 p.m. on 01/18/17, RN #109 was asked to observe Resident #61's room. She confirmed the resident's night light was not on and should have been. She promptly entered the room and turned on the light. d) Resident #10 A review of Resident #10's medical record at 10:22 a.m. on 01/17/16 found a physician's orders [REDACTED]. (Nepro is a supplement especially formulated for people on [MEDICAL TREATMENT].) A review of Resident #10's care plan found the following focus statement (typed as written): Risk for altered nutrition/hydration status related to dx (diagnosis) including [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]) w/ (with) HD ([MEDICAL TREATMENT]) and fluid restriction, mech (mechanically) altered diet, weight fluctuations r/t (related to) [MEDICAL TREATMENT] and fluid balance expected to [MEDICAL TREATMENT] and disease process . This focus statement was initiated on 11/01/16, revised on 11/01/16. The goals associated with this focus statement included: Weight expected to fluctuate due to [MEDICAL TREATMENT] and end stage [MEDICAL CONDITION] Will provide proper nutrition to resident daily through next review This goal was initiated on 11/20/15, revised on 02/26/15, and had a target date of 02/04/17. The interventions associated with this focus statement and goal included, (typed as written): Nepro 1 can po (by mouth) tid (three times a day). This intervention was initiated on 04/26/16. Provide supplements nepro TID as ordered. This intervention was initiated on 08/26/16. Review of the electronic system used by the Nurse Aides to document supplement percentages and other care they provided to the resident, found in the last 14 days, from 01/04/17 through 01/17/17, the supplement percentage was only documented twice (2) daily. An interview with Registered Nurse (RN) # 109 at 3:57 p.m. on 01/18/17 confirmed the supplement was only documented in the record as given twice daily instead of three (3) times daily as directed by the care plan. RN #109 then reviewed the resident's Medication Administration Record [REDACTED]. She confirmed that according to the documentation Resident #10 only received her Nepro supplement two (2) times a day instead of the ordered three (3) times a day.",2020-04-01
3865,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,309,E,0,1,DBHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and resident interview, the facility failed to implement Resident #78's physician's orders for finger stick blood sugars and sliding scale insulin coverage for twenty-five (25) days after admission. For Resident #78, the facility also failed to obtain an ordered basic metabolic panel (BMP), failed to ensure the resident kept an appointment with a consulting physician ([MEDICATION NAME]), and failed to administer/hold an antihypertensive ([MEDICATION NAME]) according to the physician ordered parameters. For Resident #9, the facility failed to ensure arrangements were provided for two appointments with consulting physicians (psychiatrist and urologist), failed to administer [MEDICATION NAME] (steroid) as directed for the treatment of [REDACTED]. For Resident #10, the facility failed to administer Nepro (supplement) as directed by the physician orders. The physician ordered the supplement to be given three (3) times a day, but the facility only administered it twice daily. For Resident #27, the facility failed to establish a care plan based on the resident's assessed needs for transfers. For Resident #69, the facility failed to follow the physician's parameters for insulin and the nursing staff held the resident's insulin without physician input. This was true for five (5) of eighteen (18) sampled stage 2 residents reviewed during Quality Indicator Survey (QIS). Resident identifiers: #78, #9, #10, #27, #69. Facility Census: 62 Findings include: a) Resident #78 Review of Resident #78 medical records on 01/18/17 at 10:00 a.m. found this seventy-seven (77) year old female was admitted to the facility on [DATE] from an acute care hospital. Her [DIAGNOSES REDACTED]. Discharge instructions from the acute care facility and approved by the attending physician at the facility included: 1. Finger sticks before meals and night (four times daily) for thirty (30) days and administer sliding scale insulin using [MEDICATION NAME] Regular insulin PRN (as needed) as follows: -- less than 150 - no insulin -- 151-200 - 2 units of insulin -- 201-250 - 4 units of insulin -- 251-300 - 6 units of insulin -- 301-350 - 8 units of insulin -- greater than 350 - give 10 units of insulin and call the physician Review of the resident's Medication Administration Record (MAR) for (MONTH) (YEAR), found the finger sticks and sliding scale were not completed from 08/03/16 through 08/25/16. 2. On 08/25/16, the physician ordered, Finger sticks twice daily and contact the physician blood sugar is less than 60 or greater than 350. Further review of the MAR and nurses' notes for (MONTH) (YEAR) found the resident's blood sugar was 377 at 6:00 a.m. on 08/28/16. There was no evidence the physician was notified. On 08/29/16, the physician ordered, Finger sticks twice daily and contact the physician blood sugar is less than 60 or greater than 400. Review of MAR and nurse's notes for (MONTH) and (MONTH) (YEAR), found: -- on 09/04/16 at 6:00 a.m. blood sugar was 430, -- on 09/11/16 at 6:00 a.m. blood sugar 400, and -- on 09/05/16 at 4:00 p.m. blood sugar 423. The record contained no evidence the physician was notified. 3. The physician ordered a complete blood count (CBC), basic metabolic panel (BMP) and [MEDICATION NAME] time/international ratio (PT/INR) in two days (08/05/16) then as directed by the facility physician. Record review found no evidence the BMP was obtained on 08/05/16 4. Review of the resident's medical record found an appointment with ([MEDICATION NAME]'s Name) on 08/16/16 at 12:15 p.m. was not attended. 5. [MEDICATION NAME] (antihypertension medication) 12.5 milligrams (mg) through feeding tube twice daily. Hold if systolic blood pressure (b/p) is less than 110 or if heart rate/pulse less than 70. Review of the MAR for August, September, October, November, and (MONTH) (YEAR) and (MONTH) (YEAR) found the following the following issues: -- 08/03/16 at 10:00 p.m. - no pulse obtained -- 08/04/16 at 10:00 a.m. and 10:00 p.m. - no pulses obtained -- 08/05/16 at 10:00 p.m. pulse 98- [MEDICATION NAME] not given -- 08/11/16 at 10:00 p.m. pulse 84-[MEDICATION NAME] not given -- 08/16/16 at 10:00 p.m. - no blood pressure obtained -- 08/18/16 at 10:00 p.m. - no blood pressure obtained -- 08/26/16 at 10:00 p.m. - no blood pressure obtained -- 08/30/16 at 10:00 p.m. - no blood pressure or pulse obtained -- 08/31/16 at 10:00 p.m. - no blood pressure or pulse obtained -- 09/01/16 through 09/15/16 at 9:00 a.m. no pulses obtained (total of 15 days) -- 11/18/16 at 9:00 a.m. - Pulse 68- medication given -- 11/23/16 at 9:00 p.m. - Pulse 68- medication given -- 11/24/16 at 9:00 a.m. - Pulse 68- medication given -- 11/24/16 at 9:00 p.m. - Pulse 66- medication given -- 11/25/16 at 9:00 p.m. - Pulse 68- medication given -- 11/28/16 at 9:00 p.m. - Pulse 68- medication given -- 12/02/16 at 9:00 p.m. - Pulse 68- medication given -- 12/06/16 at 9:00 p.m. - No pulse- medication given -- 12/20/16 at 9:00 p.m. - Pulse 68- medication given -- 12/24/16 at 9:00 p.m. - Pulse 68- medication given -- 01/14/17 at 9:00 a.m. - Pulse 68- medication given During an interview with Corporate Registered Nurse (CRN) #108, Registered Nurse (RN) #109 (the former director of nursing (DON), the current DON, and the Nursing Home Administrator (NHA) on 01/19/17 at 11:00 a.m., the following were reviewed/discussed: -- The resident's medical records, since admission on 08/03/16 through 08/25/16, did not contain evidence of finger sticks with sliding scale coverage as ordered. -- It was confirmed on 08/28/16, 09/04/16, 09/05/16, and 09/11/16, the physician was not notified of blood sugars above the physician-established parameters. -- It was verified Resident #78 was not sent to the scheduled appointment with the [MEDICATION NAME] -- A BMP was not obtained on 08/05/16 as ordered -- Review of the blood pressures and pulses for the physician prescribed parameters were not obtained and/or the medication was not held or not given according to the physician-established parameters. b) Resident #9 Review of Resident #9's medical records on 01/18/17 at 2:00 p.m., found this eighty-six (86) year old female, admitted to the facility on [DATE] from an acute care hospital, had [DIAGNOSES REDACTED]. 1. Discharge instructions from the acute care facility and approved by her attending physician at the facility included appointments with a psychiatrist in two (2) to three (3) weeks for follow-up for major [MEDICAL CONDITION] and with a urologist in four (4) weeks for retention of urine and recurrent urinary tract infections. 2. Review of physician's orders found an order written [REDACTED]. This was ordered for an exacerbation of the resident's [MEDICAL CONDITION]. The [MEDICATION NAME] was started on 12/23/16 and the resident was given 40 mg on 12/23/16, 12/24/16, and 12/25/16 at 9:00 a.m. On 12/26/16, Resident #9 should have received [MEDICATION NAME] 30 mg, but did not receive that dose until 12/27/16. 3. Review of the physician's orders found an order dated 11/17/16 for, Finger sticks twice daily. Call the doctor if blood sugar is less than 60 or if blood sugar greater than 350. Review of the (MONTH) and (MONTH) (YEAR) MARs and nurses' notes revealed: -- 12/17/16 at 4:30 p.m. - blood sugar 372 - no notification of doctor -- 12/24/16 at 6:00 a.m. - blood sugar 376 - no notification of doctor -- 12/25/16 at 4:30 p.m. - blood sugar 398 - no notification of doctor During an interview with Corporate Registered Nurse (CRN) #108, Registered Nurse (RN) #109 (the previous director of nursing) (DON), RN #110, the current DON, and the Nursing Home Administrator (NHA) on 01/19/17 at 11:00 a.m., review of Resident #9's medical records verified: -- the facility failed to schedule the appointments as directed, -- Resident #9 missed a dose of [MEDICATION NAME] on 12/26/16, and -- Resident #9's blood sugar was outside of the physician-established parameters and the physician was not notified. c) Resident #10 A review of Resident #10's medical record at 10:22 a.m. on 01/17/16 found a physician's order dated 12/26/16 for, Nepro three (3) times a day for supplement. Review of the electronic system used by the Nurse Aides to document supplement percentages and other care provide to a resident, revealed the percentage of the Nepro Resident #10 consumed in the last 14 days (from 01/04/17 through 01/17/17) was only documented twice (2) daily. An interview with Registered Nurse (RN) #109 at 3:57 p.m. on 01/18/17 confirmed the supplement was documented in the record as given twice daily instead of three times daily as ordered by the physician. RN #109 then reviewed the resident's Medication Administration Record and confirmed it was not documented there either. She confirmed that according to the documentation Resident #10 only received her Nepro supplement two (2) times a day instead of the ordered three (3) times a day. d) Resident #27 A review of Resident #27's medical record at 9:25 a.m. on 01/19/17 found a Lift/Transfer Tool completed by Licensed Practical Nurse (LPN) #68 on 10/19/16. The facility used the Lift/Transfer Tool to assesses how a resident should be transferred from surface to surface i.e. bed to chair and/or chair to bed safely. The tool identified five (5) lift options the assessor could select based on the accurate completion of the assessment of Resident #27's ability's and condition. The 5 options were: -- No lift needed. (Suggest use of gait belt.) -- Sit to stand Lift is required. -- Total Lift required. -- Transfer requires assist of 2 (two) staff with use of gait belt. -- Consult Therapy Services to determine transfer assist level. Review of the Lift/Transfer tool completed by LPN #68 for Resident #27 found the LPN had chosen three (3) options for safe transfer for Resident #27: -- No lift needed (Suggest use of gait belt.) -- Sit to Stand lift is required. -- Transfer requires assist of 2 staff with the use of gait belt. Review of Resident #27's care plan found Resident #27 was to be transferred with the assistance of one (1) staff member. The care plan did not mention the use of a gait belt or the use of a sit to stand lift. An interview with RN #109 and Corporate RN #108 at 11:33 a.m. on 01/19/2017, confirmed the lift transfer tool for Resident #27 was not completed correctly; therefore it did not fulfill its intended purpose of telling staff how Resident #27 should be transferred. They agreed the form was not clear on how the resident should have been transferred during her stay and therefore one could not be certain if the one person assist for transfers identified on the care plan was the correct and safest way to transfer Resident #27. e) Resident #69 During Stage 1 of the Quality Indicator Survey (QIS), the resident said he was worried the facility was, Going to kill me with insulin. He said the nurses came into his room to give his insulin and they had not even taken his blood sugar first. They can't give me insulin if they don't check my blood sugar first, just think what could happen if I didn't ask them. The resident, admitted to the facility on [DATE], had capacity to make medical decisions. Review of the current physician's orders dated 01/03/16 found an order to obtain accuchecks at AC (before meals) and HS (before sleep). The parameters specified to contact the physician if the blood sugar (BS) was less than 60 or greater than 400. Review of the medication administration record (MAR) for (MONTH) (YEAR) found the resident was receiving the following insulins for treatment of [REDACTED].>-- [MEDICATION NAME] flex pen solution Pen-injector 100 unit/ml (milliliter). Inject 6 units subcutaneously after meals for diabetes mellitus. -- [MEDICATION NAME] Solution 100 unit/ml (insulin [MEDICATION NAME]) Inject 25 unit subcutaneously at bedtime for diabetes mellitus. In (MONTH) (YEAR), the resident was to receive: -- [MEDICATION NAME] flex pen solution Pen-injector 100 unit/ml (milliliter). Inject 10 units subcutaneously after meals for diabetes mellitus. -- [MEDICATION NAME] Solution 100 unit/ml (insulin [MEDICATION NAME]) Inject 35 unit subcutaneously at bedtime for diabetes mellitus. The MAR for (MONTH) (YEAR) noted the resident's [MEDICATION NAME] remained the same, but the [MEDICATION NAME] 100 units/ml was increased to 12 units on 01/12/17. At 9:47 a.m. on 01/18/17, the resident's MARs for 08/03/16 through 01/18/17 were reviewed with the Corporate Registered Nurse (RN #108) and RN #109 (the former acting director of nursing). The review identified the following: -- On 08/19/16, 08/21/16, 08/30/16, and 08/31/16, the nurse initialed and circled the resident's 6:00 a.m. dose of [MEDICATION NAME] solution. RN #108 verified the nurses' initials that were circled, indicated the medication was not given. -- On 10/20/16, the nurse again initialed and circled the resident's 8:15 a.m. dose of [MEDICATION NAME]. -- On 01/15/17 at 9:53 a.m., a nurse wrote a progress note indicating the resident's [MEDICATION NAME] solution was held due to a low blood sugar and at the request of the resident. RN #108 and RN #109 verified the insulin could not be held without physician's orders. Both RNs were unable to find verification the physician was contacted and advised the nurse to hold the insulin. -- In addition, the resident's blood sugar was 53 on 08/19/16 at 6:00 a.m. There was no evidence the physician was contacted per the parameters specified with the accuchecks. -- Review of the MARs from 08/03/16 through 01/18/17 found the facility obtained the resident's blood sugars at 6:00 a.m. and 5:00 p.m. The physician's order dated 08/04/16 directed Accu-checks AC (before meals) and HS (hour of sleep) which was two (2) times a day. The resident received three (3) meals a day, meaning the resident's blood sugars should have been completed four (4) times a day, not two (2).",2020-04-01
3866,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,322,E,0,1,DBHB11,"Based on record review and staff interview, the facility failed to ensure complications from Resident #61's feeding tube were minimized by providing the correct type, rate, and volume of the feeding as ordered by the resident's attending physician. Resident #61 was not given the correct bolus feedings from 12/11/16 through 01/10/17. This was true for one (1) of one (1) resident reviewed for the care area of tube feeding during Stage 2 of the quality indicator survey (QIS). Resident #61. Facility Census: 62. Findings Include: a) Resident #61 A review of Resident #61's medical record found the following nutrition/weight progress note written by the facility's registered dietitian (RD): -- RD note dated 12/09/16 (typed as written): RD TF (tube feeding) note. Diet; Reg. (regular) pureed. PO (by mouth) intake past week 51 - 75% X (symbol for times) 3 (three) meals and 76-100% X 3 days. Adequate po intake. TF: Glucerna 1.2 1 (one) can 2 (two) X day w/ (with) 120 cc (cubic centimeter) flush bid (twice a day) = (symbol for equals) 570 kcal (kilocalorie), 28.4 gm (grams) prot. (protein), 384 cc free fluid, 624 cc w/ flushes. Wt. (weight) history: 12/9 (2016) 149# (pounds), 11/2 (2016) 156.8#, 6/3 (2016) 155.8# - wt. loss trend x 1, 3, and 6 months. Rec. (Recommend) TF - Glucerna 1.5 bolus 1 can 2 X a day w/ 120 cc flush bid to provide 712 kcal, 39 gm prot., 360 cc free fluid, 600 cc w/ current flushes. Weekly wts. (weights) x 4. Will fup (follow up) prn (as needed). Further review of the medical record found on 12/11/16 Resident #61 began receiving Glucerna 1.5 one (1) can two (2) times daily as recommended by the RD. However, upon further review of the Medication Administration Record [REDACTED]. According, to the MAR, Resident #61 received one (1) can of Glucerna 1.2 and one (1) can of Glucerna 1.5 twice daily at 9:00 a.m. and 9:00 p.m. beginning on 12/11/16 through 01/07/17, when he should have only received one (1) can of Glucerna 1.5 two (2) times daily at 9:00 a.m. and 9:00 p.m. Further review of the record found the following general progress note dated 01/08/17 (typed as written): Note Text: Dietician emailed about weight loss, but no response yet I called her. (Name of RD) ordered to increase tube feeding to three cans per day. I called and spoke to resident's poa (power of attorney), (name and relationship of POA), and she is in agreement with the change to his P[NAME] (Plan Of Care). (Name of attending physician) asked the dietician to initiate and changes on Friday. Order initiated. Additional review of the MAR found Resident #61 stopped receiving Glucerna 1.2 one (1) can two (2) times daily on 01/08/17 and began receiving Glucerna 1.2 one (1) can three (3) times daily as recommended by the RD on 01/08/17. He began receiving the Glucerna 1.2 three (3) times daily via is feeding tube at 8:00 a.m., 12:00 p.m. and 5:30 p.m. daily. He received this for the first time on 01/08/17 at 5:30 p.m. However; the MAR indicated [REDACTED]. The Glucerna 1.5 should have been discontinued upon the starting of the Glucerna 1.2 three (3) times daily. He received the Glucerna 1.5 at 9:00 p.m. on 01/08/17, at 9:00 a.m. and 9:00 p.m. on 01/09/17, and at 9:00 a.m. on 01/10/17 when he should not have received it. These findings were reviewed with Registered Nurse (RN) #109 and Corporate RN #108 at 9:22 a.m. on 01/18/17. They confirmed from 12/11/16 through 01/10/17, Resident #61 did not receive the correct enteral feeding as recommended by the RD and ordered by the attending physician.",2020-04-01
3867,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,323,E,0,1,DBHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to ensure the environment over which it had control was as free from accident hazards as possible. Staff did not consistently implement planned interventions across all shifts to help prevent Resident #61 from falling. This was true for one (1) of three (3) residents reviewed for the care area of accidents during Stage 2 of the Quality Indicator Survey (QIS). Additionally, the Oak Hall had multiple pieces of equipment sitting in the hall making the hall congested and creating trip hazards and blocking residents' access to the handrails. In addition, the handrails on the Oak Hall were not free of splinters. These randomly discovered issues were found throughout the course of the QIS and had the potential to affect more than an isolated number of residents. Resident Identifier: #61. Facility Census: 62. Findings Include: a) Resident #61 A review of Resident #61's medical record at 2:17 p.m. on 01/17/17 found he had the following falls within the last 30 days: -- 12/23/16 at 4:00 a.m. - Resident #61 was found sitting on the floor beside his bed and reported he was trying to go to the bathroom. -- 01/13/17 at 2:30 a.m. - Resident was laying on floor beside his bed. He stated that he was trying to go to the bathroom. -- 01/14/17 at 5:30 a.m. - Resident was found lying on the floor. The resident's pants were down and there was feces on the floor. The resident was unable to state what he was trying to do when he fell . -- 01/16/17 at 6:45 a.m. - The resident was found sitting on the floor with his back against the bed. The resident was again unable to tell the staff what happened. A review of Resident #61's care plan found a focus statement (typed as written): Potential for falls related to HX (history of) falls with fracture which is complicated by Alzheimer's Disease, muscle weakness and other multiple medical problems. Resident is able to ambulate (walk) independently about the facility. This focus statement was initiated on 09/12/14 with a revision date of 01/05/17. The goal associated with this focus statement was, Resident will have no falls with injury such as fracture, dislocation, head trauma or any injury requiring hospitalization through next review. This goal had an initiation date of 09/12/14 with a revision date of 09/08/16 and a target date of 04/06/17. The interventions associated with this focus statement and goal included: -- Ensure resident is wearing non-skid socks while in bed and non-skid shoes when ambulating or transferring. This was added as an intervention on 02/27/15 with a revision date of 05/20/16. -- Nurse to turn on night light at bedside at 9:00 p.m. to help prevent falls. This was added as an intervention on 12/31/16. During an interview with Registered Nurse (RN) #109 at 4:06 p.m. on 01/18/17, when asked what interventions were put into place to help prevent Resident #61 from falling, she stated, He has a night light at his bedside that we turn on at night. She also confirmed the care plan indicated that he should be wearing non-skid socks while in bed and non-skid shoes when ambulating or transferring. At 4:10 p.m. on 01/18/17, the Director of Nursing and RN #109 were present for observations of Resident #61. The resident was lying on his bed, but was not wearing non-skid socks. A battery operated a night light sat on his window sill. After completion of the observation, RN #109 confirmed he was not wearing non-skid socks. She stated, He had his shoes on before he laid down. During an interview with Licensed Practical Nurse (LPN) #95 at 9:46 p.m. on 01/18/17, she stated she was Resident #61's nurse and would be until 6:00 a.m. the following morning. When asked what interventions Resident #61 had in place related to his falls she stated, He has a low bed and a fall mat I think. (Please note neither of these things were an intervention for Resident #61.) When asked how she would know what new interventions a resident had if they were added when she was not there, she stated, They pass that along to us verbally during report. She stated, If we really need to, we can always look at the physician's orders [REDACTED].#95 did not mention looking at Resident #61's care plan for any fall interventions. Observations of Resident #61's room at 10:00 p.m. on 01/18/17 found the room dark. The overhead lights were turned off and the night light sitting in the window sill was not turned on as directed in the care plan. At 10:28 p.m. on 01/18/17, RN #109 was asked to observe Resident #61's room. She confirmed the resident's night light was not on and should have been. She promptly entered the room and turned on the light. b) Handrails Observation on 01/17/17 at 1:00 p.m. revealed the facility failed to ensure the handrails on the Oak Hallway were free of splinters. The wooden handrails were rough with splinters. Upon inspection and rubbing against the railing, a splinter broke off the railing penetrating the surveyor's clothing and skin. When shown the wooden handrails, the Administrator agreed the handrails presented a splinter hazard and stated she would have them repaired. c) Oak Hall 1. Observations on 01/17/17 at 1:05 p.m. noted Nurse Aide (NA) #5 removing a mechanical lift from room 37 on Oak Hall. The NA left the lift against the wall in the hallway between room 37 and room 39 and walked away. The lower parts of the mechanical lift, where the wheels attached, were approximately six (6) inches into the doorway of room 39. Room 39's door was shut at the time the lift was left in the hall. A few moments later a visitor of the resident residing in room 39, came out of room 39 and almost tripped on the mechanical lift. 2. Also observed on the other side of room 39's doorway, on the same side of the hall, the medication cart was parked. On the opposite side of the hallway, a large metal lunch tray cart sat across from where the mechanical lift was parked. Additionally on the opposite side of the hallway, an isolation cart sat across from the medication cart. This created congestion and blocked the residents' access to the handrails in the area. The Administrator, who was coming down the hall, when shown the congested area of the hallway said things should only be stored on one side of the hall. The Administrator immediately had staff remove items to uncluttered the hallway. .",2020-04-01
3868,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,325,D,0,1,DBHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure a resident received a therapeutic diet for weight loss. In addition, monitoring and evaluation of the effectiveness of the interventions added for weight loss did not occur due to inaccurate documentation of the amount consumed by the resident. This was true for one (1) of three (3) residents reviewed for the care area of nutrition. Resident identifier: #35. Facility census: 62. Findings include: a) Resident #35 During Stage 2 of the Quality Indicator Survey (QIS), the resident was selected for review due to a weight loss. Record review found the resident's weight was 120.9# (pounds) on 11/02/16. On 11/23/16, the resident was discharged to the hospital. She returned to the facility on [DATE] at which time her recorded weight was 113.4# on 11/25/16. The facility acknowledged the resident's weight loss on 11/29/16. The physician was contacted and did not add any interventions as the resident was already receiving house shakes. Review of the physician's orders [REDACTED]. The resident's weight was 110.5# on 01/02/17, 111.4# on 01/06/17, and 111# on 01/10/17. On 01/9/17, the dietary manager recorded the following note: This is a dietary note on (name of resident) for her quarterly review of 1/2/17. (Name of resident) has had a 10.4# weight loss during the review of this quarter which is 8.6%. Her current weight is 110.5 and she is eating 51-75% of all meals. She eats in the Atrium room and is receiving a house shake BID (two times a day). On 12/01/16, the registered dietitian saw the resident. The dietitian noted the weight loss and documented the resident had a weight gain in the past week and weight could fluctuate due to the use of a diuretic. The resident's weight was 117# on 12/01/16. House shakes were to continue. On 01/11/17, the dietitian saw the resident and ordered 1 fortified food item per tray, 8 ounces of whole milk, and ice cream with lunch and dinner. At 11:55 a.m. on 01/17/17, the resident was eating her noon meal in the Atrium with her daughter. A carton of fat free milk was on the resident's tray. At 12:05 p.m. on 01/17/17, Assistant Food Services Director #3 verified the resident did not receive 8 ounces of whole milk as ordered by the dietitian. Observation of the resident at 2:20 p.m. on 01/17/17 found she her sleeping in bed. The resident's house shake was sitting on bedside stand. The carton was open and contained a straw, but was full. At 3:15 p.m. on 01/17/17, the same house shake was still sitting on the resident's bedside table. The carton remained full. According to the information recorded in the computer, the resident consumed 100% of the house shake at 2:52 p.m. on 01/17/17. At 3:20 p.m. on 01/17/17, Register Nurse (RN) Unit Manager #83 observed the house shake sitting on the resident's bedside. She verified the resident had not consumed 100% of the house shake as documented in the computer. RN #83 said she thought the carton appeared to be full. She said the nurse aide (NA) who recorded the resident's intake was going to be in trouble. Observations at 11:30 a.m. on 01/18/17, found the 10:00 a.m. house shake in the resident's garbage can beside her bed. The carton was opened, but again appeared to be full. As of 1:45 p.m. on 01/18/17, the percentage of the 10:00 a.m. house shake the resident had consumed had not been recorded in the computer. At 3:15 p.m. on 01/18/17, observation of the computer documentation found NA #17 had recorded the resident consumed 100% of the house shake. At 3:19 p.m. on 01/18/17, during an interview with NA #17 in the presence of Licensed Practical Nurse (LPN) #93, the LPN on Resident #35's unit, when asked whether she had given the resident her 10:00 a.m. house shake, NA #17 said she did not give the resident her house shake. When asked how she knew the percentage consumed, NA #17 said she recorded the percentage of the house shake consumed by accident. She said she did not know how much of the house shake the resident consumed.",2020-04-01
3869,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,353,E,0,1,DBHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, policy review, and observation, the facility failed to ensure qualified nursing staff provided day to day care to meet the resident's needs and in an environment which promoted each resident's physical, mental, and psychosocial well-being, to enhance their quality of life. The facility failed to implement Resident #78's diabetes management (finger sticks and sliding scale insulin) for twenty-five (25) days after the resident's admission, failed to obtain an ordered basic metabolic panel (BMP), failed to ensure the resident kept an appointment scheduled with a consulting physician ([MEDICATION NAME]), and failed to administer/hold an antihypertensive ([MEDICATION NAME]) according to the physician ordered parameters. For Resident #9, the facility failed to ensure arrangements were provided for two (2) appointments with consulting physicians, failed to administer [MEDICATION NAME] (steroid) as directed for the treatment if exacerbation of [MEDICAL CONDITIONS], and failed to notify the physician when the resident's blood sugars were outside of the physician ordered parameters. For Resident #10, the facility failed to administer Nepro (supplement) as directed by the physician orders. For Resident #27, the facility failed to ensure the assessed lift, transfer and positioning assessment correlated with the resident's care plan to ensure staff knew how to safely transfer the resident. For Resident #69, the facility failed to follow the physician ordered parameters for insulin and the nursing staff held the resident's insulin without orders. For Residents #67, #78, #29, #75, #55, #1, #14, #23, #74, #36,#38, #50, #77, #52, #65, #57, #17, #3, #2, #35, #8, #56, #28, #22, #70, #95, #79, #7, #97, #89, #24, #58, #47, #72, #21, #20, #46, #61, and #15, nurses failed to document medications immediately after administration. These practices had the potential to affect more than a limited number of residents residing at the facility. Resident identifiers: #67, #78, #29, #75, #55, #1, #14, #23, #74, #36,#38, #50, #77, #52, #65, #57, #17, #3, #2, #35, #8, #56, #28, #22, #70, #95, #79, #7, #97, #89, #24, #58, #47, #72, #21, #20, #46, #61, #15, #9, #10, #27, and #69. Facility census: 62. Findings include: a) Record review, policy review, and staff interview, the facility failed to provide services according to accepted standards of clinical practice in regards to medication administration for 39 of 62 residents currently residing in the facility. Two (2) Licensed Practical Nurses (LPN) administering evening and bedtime medications did not sign their names on the medication administration record (MAR), as the medication was being given as per accepted standards of clinical practice and facility policy. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: #67, #78, #29, #75, #55, #1, #14, #23, #74, #36,#38, #50, #77, #52, #65, #57, #17, #3, #2, #35, #8, #56, #28, #22, #70, #95, #79, #7, #97, #89, #24, #58, #47, #72, #21, #20, #46, #61, and #15. On 01/18/17 at 9:30 p.m., the facility was entered to observe evening shift's medication pass. LPN #94 and LPN #95 said all of their medications had been given and there were not any medication passes to be observed at that time. LPN #94 was requested to provide medication administration records (MAR) for residents randomly chosen for review. Upon asking for the MAR for Resident #54, LPN #94 stated she had not yet passed the medications to Resident #54. LPN #94 was told when she did give Resident #54's medications, the surveyor would use that opportunity to observe the medication pass for Resident #54. At 10:04 p.m., while preparing to do the medication pass for Resident #54, LPN #94 said she had not yet signed off on any of the medications she had administered that evening. LPN #94 stated she had started giving medications at 7:00 p.m. and had yet to sign off on any of the medications given. When LPN #94 was asked, When should you sign off on medications? she stated, When I give them, I should sign off and document that they are given as soon as I give them. On 01/18/17 at 10:10 p.m., LPN #95 was asked her if she had signed off on the medications she had given that evening. LPN #95 stated she had not signed the EMAR (electronic medication administration records) at the time the medications were given, and that she was signing off on some of them now. A list of resident's names that had been given medications without LPN #95 signing at the time of dispensing was requested. On 01/18/17 at 10:25 p.m., an interview with the recently acting interim director of nurses, Registered Nurse (RN #109), revealed LPN #95 was a recent hire and LPN #94 had done some training of LPN #95. RN #109 confirmed facility policy and standard of practice dictate nurses sign the EMAR at the time medications are given. The RN verified that not documenting in the EMAR at the time the medications were given would cause the record to be inaccurate for the time the residents received their medication. RN #109 stated disciplinary actions would be taken for both LPN #94 and LPN #95. A list of all residents that had evening and bedtime medications given by LPN #94 and LPN #95, and whose MARs had not been signed by LPN #94 and LPN #95 at the time the medications were given to the residents, was requested. The requested list of residents' names provided on 01/18/17 at 11:03 p.m., revealed LPN #94 gave medications to twenty-nine (29) residents without documenting medications had been given in the EMAR (electronic medication administration record) at the time they were given. LPN #95 gave medications to ten (10) residents without documenting medications had been given in the EMAR at the time they were given. On 01/18/17 at 11:11 p.m., a walk through of the facility to interview any residents identified on the list that might still be awake found Residents #20, #21, and #89 were awake. All three (3) residents stated they did receive their evening and bed time medications. On 01/19/17 at 8:04 a.m., review of facility's policy 6.0 'General Dose Preparation and Medication Administration revealed, #6. After medication administration, facility staff should take all measures required by Facility policy and Applicable Law, including but not limited to the following: 6.1 Document necessary medication administration/treatment information (e.g. when medications are opened, when medications are given .) on appropriate forms. According to Lippincott's 2012 Nursing Drug Handbook, Rights of Medication Administration the 8 rights of medication administration are: 1. Right patient . 2. Right medication . 3. Right dose . 4. Right route . 5. Right time - Check the frequency of the ordered medication. - Double-check that you are giving the ordered dose at the correct time. - Confirm when the last dose was given. 6. Right documentation - Document administration AFTER giving the ordered medication. - Chart the time, route, and any other specific information as necessary. 7. Right reason ., 8. Right response . b) Medical record review, staff interview, and resident interview, revealed the facility failed to implement Resident #78's physician's orders [REDACTED]. For Resident #9, the facility failed to ensure arrangements were provided for two appointments with consulting physicians (psychiatrist and urologist), failed to administer [MEDICATION NAME] (steroid) as directed for the treatment of [REDACTED]. For Resident #10, the facility failed to administer Nepro (supplement) as directed by the physician orders. The physician ordered the supplement to be given three (3) times a day, but the facility only administered it twice daily. For Resident #27, the facility failed to establish a care plan based on the resident's assessed needs for transfers. For Resident #69, the facility failed to follow the physician's parameters for insulin and the nursing staff held the resident's insulin without physician input. 1. Resident #78 a. Review of Resident #78 medical records on 01/18/17 at 10:00 a.m. found this seventy-seven (77) year old female was admitted to the facility on [DATE] from an acute care hospital. Her [DIAGNOSES REDACTED]. Discharge instructions from the acute care facility and approved by the attending physician at the facility included: Finger sticks before meals and night (four times daily) for thirty (30) days and administer sliding scale insulin using [MEDICATION NAME] Regular insulin PRN (as needed) as follows: -- less than 150 - no insulin -- 151-200 - 2 units of insulin -- 201-250 - 4 units of insulin -- 251-300 - 6 units of insulin -- 301-350 - 8 units of insulin -- greater than 350 - give 10 units of insulin and call the physician Review of the resident's Medication Administration Record (MAR) for (MONTH) (YEAR), found the finger sticks and sliding scale were not completed from 08/03/16 through 08/25/16. b. On 08/25/16, the physician ordered, Finger sticks twice daily and contact the physician blood sugar is less than 60 or greater than 350. Further review of the MAR and nurses' notes for (MONTH) (YEAR) found the resident's blood sugar was 377 at 6:00 a.m. on 08/28/16. There was no evidence the physician was notified. On 08/29/16, the physician ordered, Finger sticks twice daily and contact the physician blood sugar is less than 60 or greater than 400. Review of MAR and nurse's notes for (MONTH) and (MONTH) (YEAR), found: -- on 09/04/16 at 6:00 a.m. blood sugar was 430, -- on 09/11/16 at 6:00 a.m. blood sugar 400, and -- on 09/05/16 at 4:00 p.m. blood sugar 423. The record contained no evidence the physician was notified. c. The physician ordered a complete blood count (CBC), basic metabolic panel (BMP) and [MEDICATION NAME] time/international ratio (PT/INR) in two days (08/05/16) then as directed by the facility physician. Record review found no evidence the BMP was obtained on 08/05/16 d. Review of the resident's medical record found an appointment with ([MEDICATION NAME]'s Name) on 08/16/16 at 12:15 p.m. was not attended. e. [MEDICATION NAME] (antihypertension medication) 12.5 milligrams (mg) through feeding tube twice daily. Hold if systolic blood pressure (b/p) is less than 110 or if heart rate/pulse less than 70. Review of the MAR for August, September, October, November, and (MONTH) (YEAR) and (MONTH) (YEAR) found the following the following issues: -- 08/03/16 at 10:00 p.m. - no pulse obtained -- 08/04/16 at 10:00 a.m. and 10:00 p.m. - no pulses obtained -- 08/05/16 at 10:00 p.m. pulse 98- [MEDICATION NAME] not given -- 08/11/16 at 10:00 p.m. pulse 84-[MEDICATION NAME] not given -- 08/16/16 at 10:00 p.m. - no blood pressure obtained -- 08/18/16 at 10:00 p.m. - no blood pressure obtained -- 08/26/16 at 10:00 p.m. - no blood pressure obtained -- 08/30/16 at 10:00 p.m. - no blood pressure or pulse obtained -- 08/31/16 at 10:00 p.m. - no blood pressure or pulse obtained -- 09/01/16 through 09/15/16 at 9:00 a.m. no pulses obtained (total of 15 days) -- 11/18/16 at 9:00 a.m. - Pulse 68- medication given -- 11/23/16 at 9:00 p.m. - Pulse 68- medication given -- 11/24/16 at 9:00 a.m. - Pulse 68- medication given -- 11/24/16 at 9:00 p.m. - Pulse 66- medication given -- 11/25/16 at 9:00 p.m. - Pulse 68- medication given -- 11/28/16 at 9:00 p.m. - Pulse 68- medication given -- 12/02/16 at 9:00 p.m. - Pulse 68- medication given -- 12/06/16 at 9:00 p.m. - No pulse- medication given -- 12/20/16 at 9:00 p.m. - Pulse 68- medication given -- 12/24/16 at 9:00 p.m. - Pulse 68- medication given -- 01/14/17 at 9:00 a.m. - Pulse 68- medication given f. During an interview with Corporate Registered Nurse (CRN) #108, Registered Nurse (RN) #109 (the former director of nursing (DON), the current DON, and the Nursing Home Administrator (NHA) on 01/19/17 at 11:00 a.m., the following were reviewed/discussed: -- The resident's medical records, since admission on 08/03/16 through 08/25/16, did not contain evidence of finger sticks with sliding scale coverage as ordered. -- It was confirmed on 08/28/16, 09/04/16, 09/05/16, and 09/11/16, the physician was not notified of blood sugars above the physician-established parameters. -- It was verified Resident #78 was not sent to the scheduled appointment with the [MEDICATION NAME] -- A BMP was not obtained on 08/05/16 as ordered -- Review of the blood pressures and pulses for the physician prescribed parameters were not obtained and/or the medication was not held or not given according to the physician-established parameters. 2. Resident #9 Review of Resident #9's medical records on 01/18/17 at 2:00 p.m., found this eighty-six (86) year old female, admitted to the facility on [DATE] from an acute care hospital, had [DIAGNOSES REDACTED]. a. Discharge instructions from the acute care facility and approved by her attending physician at the facility included appointments with a psychiatrist in two (2) to three (3) weeks for follow-up for major [MEDICAL CONDITION] and with a urologist in four (4) weeks for retention of urine and recurrent urinary tract infections. b. Review of physician's orders [REDACTED]. This was ordered for an exacerbation of the resident's [MEDICAL CONDITION]. The [MEDICATION NAME] was started on 12/23/16 and the resident was given 40 mg on 12/23/16, 12/24/16, and 12/25/16 at 9:00 a.m. On 12/26/16, Resident #9 should have received [MEDICATION NAME] 30 mg, but did not receive that dose until 12/27/16. c. Review of the physician's orders [REDACTED]. Call the doctor if blood sugar is less than 60 or if blood sugar greater than 350. Review of the (MONTH) and (MONTH) (YEAR) MARs and nurses' notes revealed: -- 12/17/16 at 4:30 p.m. - blood sugar 372 - no notification of doctor -- 12/24/16 at 6:00 a.m. - blood sugar 376 - no notification of doctor -- 12/25/16 at 4:30 p.m. - blood sugar 398 - no notification of doctor During an interview with Corporate Registered Nurse (CRN) #108, Registered Nurse (RN) #109 (the previous director of nursing) (DON), RN #110, the current DON, and the Nursing Home Administrator (NHA) on 01/19/17 at 11:00 a.m., review of Resident #9's medical records verified: -- the facility failed to schedule the appointments as directed, -- Resident #9 missed a dose of [MEDICATION NAME] on 12/26/16, and -- Resident #9's blood sugar was outside of the physician-established parameters and the physician was not notified. 3. Resident #10 A review of Resident #10's medical record at 10:22 a.m. on 01/17/16 found a physician's orders [REDACTED]. Review of the electronic system used by the Nurse Aides to document supplement percentages and other care provide to a resident, revealed the percentage of the Nepro Resident #10 consumed in the last 14 days (from 01/04/17 through 01/17/17) was only documented twice (2) daily. An interview with Registered Nurse (RN) #109 at 3:57 p.m. on 01/18/17 confirmed the supplement was documented in the record as given twice daily instead of three times daily as ordered by the physician. RN #109 then reviewed the resident's Medication Administration Record and confirmed it was not documented there either. She confirmed that according to the documentation Resident #10 only received her Nepro supplement two (2) times a day instead of the ordered three (3) times a day. 4. Resident #27 A review of Resident #27's medical record at 9:25 a.m. on 01/19/17 found a Lift/Transfer Tool completed by Licensed Practical Nurse (LPN) #68 on 10/19/16. The facility used the Lift/Transfer Tool to assesses how a resident should be transferred from surface to surface i.e. bed to chair and/or chair to bed safely. The tool identified five (5) lift options the assessor could select based on the accurate completion of the assessment of Resident #27's ability's and condition. The 5 options were: -- No lift needed. (Suggest use of gait belt.) -- Sit to stand Lift is required. -- Total Lift required. -- Transfer requires assist of 2 (two) staff with use of gait belt. -- Consult Therapy Services to determine transfer assist level. Review of the Lift/Transfer tool completed by LPN #68 for Resident #27 found the LPN had chosen three (3) options for safe transfer for Resident #27: -- No lift needed (Suggest use of gait belt.) -- Sit to Stand lift is required. -- Transfer requires assist of 2 staff with the use of gait belt. Review of Resident #27's care plan found Resident #27 was to be transferred with the assistance of one (1) staff member. The care plan did not mention the use of a gait belt or the use of a sit to stand lift. An interview with RN #109 and Corporate RN #108 at 11:33 a.m. on 01/19/2017, confirmed the lift transfer tool for Resident #27 was not completed correctly; therefore it did not fulfill its intended purpose of telling staff how Resident #27 should be transferred. They agreed the form was not clear on how the resident should have been transferred during her stay and therefore one could not be certain if the one person assist for transfers identified on the care plan was the correct and safest way to transfer Resident #27. 5. Resident #69 During Stage 1 of the Quality Indicator Survey (QIS), the resident said he was worried the facility was, Going to kill me with insulin. He said the nurses came into his room to give his insulin and they had not even taken his blood sugar first. They can't give me insulin if they don't check my blood sugar first, just think what could happen if I didn't ask them. The resident, admitted to the facility on [DATE], had capacity to make medical decisions. Review of the current physician's orders [REDACTED]. The parameters specified to contact the physician if the blood sugar (BS) was less than 60 or greater than 400. Review of the medication administration record (MAR) for (MONTH) (YEAR) found the resident was receiving the following insulins for treatment of [REDACTED].>-- [MEDICATION NAME] flex pen solution Pen-injector 100 unit/ml (milliliter). Inject 6 units subcutaneously after meals for diabetes mellitus. -- [MEDICATION NAME] Solution 100 unit/ml (insulin [MEDICATION NAME]) Inject 25 unit subcutaneously at bedtime for diabetes mellitus. In (MONTH) (YEAR), the resident was to receive: -- [MEDICATION NAME] flex pen solution Pen-injector 100 unit/ml (milliliter). Inject 10 units subcutaneously after meals for diabetes mellitus. -- [MEDICATION NAME] Solution 100 unit/ml (insulin [MEDICATION NAME]) Inject 35 unit subcutaneously at bedtime for diabetes mellitus. The MAR for (MONTH) (YEAR) noted the resident's [MEDICATION NAME] remained the same, but the [MEDICATION NAME] 100 units/ml was increased to 12 units on 01/12/17. At 9:47 a.m. on 01/18/17, the resident's MARs for 08/03/16 through 01/18/17 were reviewed with the Corporate Registered Nurse (RN #108) and RN #109 (the former acting director of nursing). The review identified the following: -- On 08/19/16, 08/21/16, 08/30/16, and 08/31/16, the nurse initialed and circled the resident's 6:00 a.m. dose of [MEDICATION NAME] solution. RN #108 verified the nurses' initials that were circled, indicated the medication was not given. -- On 10/20/16, the nurse again initialed and circled the resident's 8:15 a.m. dose of [MEDICATION NAME]. -- On 01/15/17 at 9:53 a.m., a nurse wrote a progress note indicating the resident's [MEDICATION NAME] solution was held due to a low blood sugar and at the request of the resident. RN #108 and RN #109 verified the insulin could not be held without physician's orders [REDACTED]. -- In addition, the resident's blood sugar was 53 on 08/19/16 at 6:00 a.m. There was no evidence the physician was contacted per the parameters specified with the accuchecks. -- Review of the MARs from 08/03/16 through 01/18/17 found the facility obtained the resident's blood sugars at 6:00 a.m. and 5:00 p.m. The physician's orders [REDACTED]. The resident received three (3) meals a day, meaning the resident's blood sugars should have been completed four (4) times a day, not two (2). b) Record review and staff interview revealed the facility failed to ensure complications from Resident #61's feeding tube were minimized by providing the correct type, rate, and volume of the feeding as ordered by the resident's attending physician. Resident #61 was not given the correct bolus feedings from 12/11/16 through 01/10/17. 1. A review of Resident #61's medical record found the following nutrition/weight progress note written by the facility's registered dietitian (RD): -- RD note dated 12/09/16 (typed as written): RD TF (tube feeding) note. Diet; Reg. (regular) pureed. PO (by mouth) intake past week 51 - 75% X (symbol for times) 3 (three) meals and 76-100% X 3 days. Adequate po intake. TF: Glucerna 1.2 1 (one) can 2 (two) X day w/ (with) 120 cc (cubic centimeter) flush bid (twice a day) = (symbol for equals) 570 kcal (kilocalorie), 28.4 gm (grams) prot. (protein), 384 cc free fluid, 624 cc w/ flushes. Wt. (weight) history: 12/9 (2016) 149# (pounds), 11/2 (2016) 156.8#, 6/3 (2016) 155.8# - wt. loss trend x 1, 3, and 6 months. Rec. (Recommend) TF - Glucerna 1.5 bolus 1 can 2 X a day w/ 120 cc flush bid to provide 712 kcal, 39 gm prot., 360 cc free fluid, 600 cc w/ current flushes. Weekly wts. (weights) x 4. Will fup (follow up) prn (as needed). Further review of the medical record found on 12/11/16 Resident #61 began receiving Glucerna 1.5 one (1) can two (2) times daily as recommended by the RD. However, upon further review of the Medication Administration Record (MAR) it was discovered Resident #61 continued to receive Glucerna 1.2 one (1) can two (2) times a daily as previously ordered. According, to the MAR, Resident #61 received one (1) can of Glucerna 1.2 and one (1) can of Glucerna 1.5 twice daily at 9:00 a.m. and 9:00 p.m. beginning on 12/11/16 through 01/07/17, when he should have only received one (1) can of Glucerna 1.5 two (2) times daily at 9:00 a.m. and 9:00 p.m. Further review of the record found the following general progress note dated 01/08/17 (typed as written): Note Text: Dietician emailed about weight loss, but no response yet I called her. (Name of RD) ordered to increase tube feeding to three cans per day. I called and spoke to resident's poa (power of attorney), (name and relationship of POA), and she is in agreement with the change to his P[NAME] (Plan Of Care). (Name of attending physician) asked the dietician to initiate and changes on Friday. Order initiated. Additional review of the MAR found Resident #61 stopped receiving Glucerna 1.2 one (1) can two (2) times daily on 01/08/17 and began receiving Glucerna 1.2 one (1) can three (3) times daily as recommended by the RD on 01/08/17. He began receiving the Glucerna 1.2 three (3) times daily via is feeding tube at 8:00 a.m., 12:00 p.m. and 5:30 p.m. daily. He received this for the first time on 01/08/17 at 5:30 p.m. However; the MAR indicated Resident #61 continued to receive Glucerna 1.5 one (1) can two (2) times daily at 9:00 a.m. and 9:00 p.m. until 01/10/17 after the 9:00 a.m. administration. The Glucerna 1.5 should have been discontinued upon the starting of the Glucerna 1.2 three (3) times daily. He received the Glucerna 1.5 at 9:00 p.m. on 01/08/17, at 9:00 a.m. and 9:00 p.m. on 01/09/17, and at 9:00 a.m. on 01/10/17 when he should not have received it. These findings were reviewed with Registered Nurse (RN) #109 and Corporate RN #108 at 9:22 a.m. on 01/18/17. They confirmed from 12/11/16 through 01/10/17, Resident #61 did not receive the correct enteral feeding as recommended by the RD and ordered by the attending physician. 2. Record review, staff interview, and observation, revealed the facility failed to ensure the environment over which it had control was as free from accident hazards as possible. Staff did not consistently implement planned interventions across all shifts to help prevent Resident #61 from falling. A review of Resident #61's medical record at 2:17 p.m. on 01/17/17 found he had the following falls within the last 30 days: -- 12/23/16 at 4:00 a.m. - Resident #61 was found sitting on the floor beside his bed and reported he was trying to go to the bathroom. -- 01/13/17 at 2:30 a.m. - Resident was laying on floor beside his bed. He stated that he was trying to go to the bathroom. -- 01/14/17 at 5:30 a.m. - Resident was found lying on the floor. The resident's pants were down and there was feces on the floor. The resident was unable to state what he was trying to do when he fell . -- 01/16/17 at 6:45 a.m. - The resident was found sitting on the floor with his back against the bed. The resident was again unable to tell the staff what happened. A review of Resident #61's care plan found a focus statement (typed as written): Potential for falls related to HX (history of) falls with fracture which is complicated by [MEDICAL CONDITION], muscle weakness and other multiple medical problems. Resident is able to ambulate (walk) independently about the facility. This focus statement was initiated on 09/12/14 with a revision date of 01/05/17. The goal associated with this focus statement was, Resident will have no falls with injury such as fracture, dislocation, head trauma or any injury requiring hospitalization through next review. This goal had an initiation date of 09/12/14 with a revision date of 09/08/16 and a target date of 04/06/17. The interventions associated with this focus statement and goal included: -- Ensure resident is wearing non-skid socks while in bed and non-skid shoes when ambulating or transferring. This was added as an intervention on 02/27/15 with a revision date of 05/20/16. -- Nurse to turn on night light at bedside at 9:00 p.m. to help prevent falls. This was added as an intervention on 12/31/16. During an interview with Registered Nurse (RN) #109 at 4:06 p.m. on 01/18/17, when asked what interventions were put into place to help prevent Resident #61 from falling, she stated, He has a night light at his bedside that we turn on at night. She also confirmed the care plan indicated that he should be wearing non-skid socks while in bed and non-skid shoes when ambulating or transferring. At 4:10 p.m. on 01/18/17, the Director of Nursing and RN #109 were present for observations of Resident #61. The resident was lying on his bed, but was not wearing non-skid socks. A battery operated a night light sat on his window sill. After completion of the observation, RN #109 confirmed he was not wearing non-skid socks. She stated, He had his shoes on before he laid down. During an interview with Licensed Practical Nurse (LPN) #95 at 9:46 p.m. on 01/18/17, she stated she was Resident #61's nurse and would be until 6:00 a.m. the following morning. When asked what interventions Resident #61 had in place related to his falls she stated, He has a low bed and a fall mat I think. (Please note neither of these things were an intervention for Resident #61.) When asked how she would know what new interventions a resident had if they were added when she was not there, she stated, They pass that along to us verbally during report. She stated, If we really need to, we can always look at the physician's orders [REDACTED].#95 did not mention looking at Resident #61's care plan for any fall interventions. Observations of Resident #61's room at 10:00 p.m. on 01/18/17 found the room dark. The overhead lights were turned off and the night light sitting in the window sill was not turned on as directed in the care plan. At 10:28 p.m. on 01/18/17, RN #109 was asked to observe Resident #61's room. She confirmed the resident's night light was not on and should have been. She promptly entered the room and turned on the light. c) Observation, record review, and staff interview, the facility failed to ensure a resident received a therapeutic diet for weight loss. In addition, monitoring and evaluation of the effectiveness of the interventions added for weight loss did not occur due to inaccurate documentation of the amount consumed by the resident. 1. Resident #35 During Stage 2 of the Quality Indicator Survey (QIS), the resident was selected for review due to a weight loss. Record review found the resident's weight was 120.9# (pounds) on 11/02/16. On 11/23/16, the resident was discharged to the hospital. She returned to the facility on [DATE] at which time her recorded weight was 113.4# on 11/25/16. The facility acknowledged the resident's weight loss on 11/29/16. The physician was contacted and did not add any interventions as the resident was already receiving house shakes. Review of the physician's orders [REDACTED]. The resident's weight was 110.5# on 01/02/17, 111.4# on 01/06/17, and 111# on 01/10/17. On 01/9/17, the dietary manager recorded the following note: This is a dietary note on (name of resident) for her quarterly review of 1/2/17. (Name of resident) has had a 10.4# weight loss during the review of this quarter which is 8.6%. Her current weight is 110.5 and she is eating 51-75% of all meals. She eats in the Atrium room and is receiving a house shake BID (two times a day). On 12/01/16, the registered dietitian saw the resident. The dietitian noted the weight loss and documented the resident had a weight gain in the past week and weight could fluctuate due to the use of a diuretic. The resident's weight was 117# on 12/01/16. House shakes were to continue. On 01/11/17, the dietitian saw the resident and ordered 1 fortified food item per tray, 8 ounces of whole milk, and ice cream with lunch and dinner. At 11:55 a.m. on 01/17/17, the resident was eating her noon meal in the Atrium with her daughter. A carton of fat free milk was on the resident's tray. At 12:05 p.m. on 01/17/17, Assistant Food Services Director #3 verified the resident did not receive 8 ounces of whole milk as ordered by the dietitian. Observation of the resident at 2:20 p.m. on 01/17/17 found she her sleeping in bed. The resident's house shake was sitting on bedside stand. The carton was open and contained a straw, but was full. At 3:15 p.m. on 01/17/17, the same house shake was still sitting on the resident's bedside table. The carton remained full. According to the information recorded in the computer, the resident consumed 100% of the house shake at 2:52 p.m. on 01/17/17.<b (TRUNCATED)",2020-04-01
3870,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,371,E,0,1,DBHB11,"Based on observation and staff interview, the facility failed to store and prepare food under sanitary conditions. During the tour of the kitchen, food was discovered in the refrigerator opened and not dated, and the convection oven was found dirty. This had the potential to affect all residents who received food from this central location. Facility census: 62 Findings include a) Kitchen tour During the kitchen tour on 01/16/17 at 11:05 a.m., a 12 ounce bag of cranberries was found opened and not dated in the reach in refrigerator and the inside glass of the door of the top convection oven had a heavy accumulation of a grease-like substance. In an interview on 01/16/17 at 11:08 a.m., the dietary manager (DM) verified the 12 ounce bag of cranberries was not dated after opening and he also agreed the top convection oven needed cleaned.",2020-04-01
3871,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,425,D,0,1,DBHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide pharmaceutical services to meet the needs of Resident #54. Melatonin was not available to be given to the residetn as order by the physician. This was true of one (1) of thirty-four (34) opportunities for medication administration. Resident identifier: #54. Facility census: 62. Findings include: a) Resident #54 The pharmacy failed to ensure Resident #54's prescribed Melatonin 5 milligram (mg) was available for the resident. At 10:50 p.m. on 01/18/17, LPN #94 stated the pharmacy had been contacted by day shift requesting Resident #54's prescribed Melatonin 5 mg by mouth at bedtime, but the pharmacy had yet to send it. LPN #94, accompanied by the surveyor, checked the emergency supply of medication to see if melatonin was available in the emergency stock of medication. In the facility's emergency stock of medication, Melatonin 3 mg tablets was the only dosage of Melatonin found. LPN was unable to administer the 5 mg of Melatonin on 01/18/17 as prescribed. Review of physician's orders [REDACTED].",2020-04-01
3872,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,441,D,0,1,DBHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to implement practices designed to prevent infection and/or cross-contamination for one (1) of two (2) residents reviewed in Stage 2 of the Quality Indicator Survey (QIS) for residents administered medication via a Gastrostomy Tube ([DEVICE]). This had the potential to affect any resident receiving feedings and/or medications via a [DEVICE]. Resident identifier: #20. Facility Census: 62 Findings include: a) Resident #20 On 01/16/17 at 3:14 p.m., during observation of medication pass, RN #91 administered medication via Resident #20's [DEVICE]. The syringe used to funnel the medication and water flushes popped off the end of the [DEVICE] while the nurse administered the medications. The syringe dropped onto the resident's exposed stomach, outside of resident's brief, and outside of the [DEVICE] dressing, which were unclean surfaces. The RN picked up the syringe and placed it back on the end of the [DEVICE] and continued administering the water flushes and other medication. An interview with the RN, after she completed Resident #20's medication pass, revealed the RN agreed she should have cleaned the syringe or obtained a new syringe before continuing to give the medication through the [DEVICE].",2020-04-01
3873,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,514,E,0,1,DBHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure complete and accurate documentation for thirty-nine (39) of forty (40) resident's receiving evening and bedtime medications, and one (1) resident monitored for the percentage of nutritional supplements consumed. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #67, #78, #29, #75, #55, #1, #14, #23, #74, #36, #38, #50, #77, #52, #65, #57, #17, #3, #2, #35, #8, #56, #28, #22, #70, #95, #79, #7, #97, #89, #24, #58, #47, #72, #21, #20, #46, #61, #15, and #35. Facility Census: 62 Findings include: a) On 01/18/17 at 10:25 p.m., an interview with the recently acting interim director of nurses, Registered Nurse (RN #109), revealed facility policy and standard of practice dictate nurses sign the EMAR at the time medications were given. The RN verified that by not documenting in the EMAR at the time the medications were given, would cause the record to be inaccurate for the time the residents received their medication. RN #109 stated disciplinary actions would be taken for both LPN#94 and LPN#95. A list of all residents that had evening and bedtime medication given by LPN #94 and LPN #95, and whose MARs had not been signed by LPN #94 and LPN #95 at the time the medications were given to the residents, was requested. The requested list of resident's names provided on 01/18/17 at 11:03 p.m., revealed LPN #94 gave medications to twenty-nine (29) residents without documenting medications had been given in the EMAR (electronic medication administration record) at the time they were given. LPN #95 gave medications to ten (10) residents without documenting medications had been given in the EMAR at the time they were given. b) Resident #35 During Stage 2 of the Quality Indicator Survey (QIS), the resident was selected for review due to a weight loss. Review of the physician's orders [REDACTED]. Observation of the resident at 2:20 p.m. on 01/17/17 found she was sleeping in bed. The resident's house shake was sitting on bedside stand. The carton had been opened and contained a straw, but appeared to be full. At 3:15 p.m. on 01/17/17, the same house shake was still sitting on the resident's bedside table. The carton remained full. The computer recording of the house shake had been recorded as the resident consuming 100% of the house shake at 2:52 p.m. on 01/17/17. At 3:20 p.m. on 01/17/17, Register Nurse (RN) Unit Manager #83 was asked to observe the house shake sitting on the resident's bedside. She verified the resident had not consumed 100% of the house shake as documented in the computer. RN #83 said she thought the carton appeared to be full. At 11:30 a.m. on 01/18/17, the 10:00 a.m. house shake was observed in the resident's garbage can beside her bed. The carton was opened, but again appeared to be full. At 1:45 p.m. on 01/18/17, observation of the percentage of the 10:00 a.m. house shake had not been recorded in the computer. At 3:15 p.m. on 01/18/17, observation of the computer documentation found NA #17 had recorded the resident consumed 100% of the house shake. At 3:19 p.m., NA #17 was interviewed with Licensed Practical Nurse (LPN) #93, the LPN on Resident #35's unit present. When asked if she had given the resident her 10:00 a.m. house shake, the NA replied did not give the resident her house shake. When asked how she knew the percentage consumed, NA #17 said she recorded the percentage of the house shake consumed by accident. She said she did not know how much of the house shake the resident consumed.",2020-04-01
3874,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,520,C,0,1,DBHB11,"Based on record review and staff interview, the facility failed to ensure the medical director or his designee attended quarterly Quality Assurance and Assessment (QA&A) meetings. This practice was discovered during review of the mandatory facility task of QA&[NAME] Facility census: 62. Findings include: a) The QA&A quarterly attendance sign-in sheets were reviewed with the administrator at 9:16 a.m. on 01/19/17. Review of the attendance sign-in sheets from 01/01/16 to 01/19/17 found the medical director only signed two (2) attendance sheets - 04/28/16 and 10/27/16. The administrator was unable to verify the medical director or his designee attended quarterly QA&A meetings as required by the regulations.",2020-04-01
4292,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2016-06-01,242,D,0,1,8JZH11,"Based on resident interview, medical record review, and staff interview, the facility failed to create an environment which respected the right of a resident to exercise bedtime preferences and medication regimen. This practice affected one (1) of one (1) stage 2 sample residents reviewed for choices. Resident identifier: Resident #70. Facility census: 116 Findings include: a) Resident #70 During a stage one interview, on 05/23/16 at 3:51 p.m., Resident #70 said she was not allowed to choose when she goes bed at night. When asked to explain, the resident said she would like to go to sleep around 9:00 p.m. She related her medication administration was from 10:00 p.m. - 10:30 p.m. and it just messes up the whole night. Resident #70 related staff usually assisted her to bed around 7:00 p.m., but left her in her street clothing. The resident related a staff member would start performing evening care around 8:00 p.m., and she would like to have her medication at this time. Upon inquiry, the resident said when she asked the nurse about receiving the medication earlier the nurse said it could not be changed, and refused the request. The quarterly minimum data set, with an assessment reference date of 05/31/16 at 1:02 p.m., indicated Resident #70 had a brief interview for mental status (BIMS) with a score of 15 (cognitively intact). A care plan review, completed on 05/31/16 at 1:37 p.m , revealed a focus which indicated the facility would honor Resident #70's preferences. It also noted she was capable of making medical decisions. A follow-up interview with Resident #70, on 06/01/16 at 8:55 a.m., revealed the facility still administered medication late at night. Licensed Practical Nurse (LPN) #115, interviewed on 06/01/16 immediately following the conversation with Resident #70, related the resident was awakened at night for medications. The nurse said the medication times could be readjusted with physician approval. The Medication Administration Record [REDACTED]. She agreed the medication could be administered an hour earlier, rather than later. During another interview with Resident #70, along with LPN #115, the resident again related she wanted to retire and not be awakened for her bedtime medications. The nurse asked her what she received when awakened, and the resident informed her it was all of the bedtime medications. She again related it interfered with her sleep. An interview with the Director of Nursing (DON) on 06/01/16 at 9:15 a.m., confirmed staff should have administered Resident #70's medications as requested, if not contraindicated.",2020-02-01
4293,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2016-06-01,253,E,0,1,8JZH11,"Based on observation and staff interview the facility failed to provide maintenance services to ensure residents rooms were in good repair. Bathrooms contained large areas of unpainted plaster, and caulking was missing around a sink and a commode base for four (4) of 32 rooms observed during stage one (1) of the Quality Indicator Survey. This practice had the potential to affect more than a limited number of residents. Facility census: 116. Findings include: a) During stage one (1) observations on 05/24/16 between 9:56 a.m. and 11:43 a.m., revealed the following cosmetic imperfections: - Room 107 - The bathroom contained a large area of plaster which had not been painted. - Room 108 - The bathroom contained a large area of plaster which had not been painted. - Room 311 - Caulking was missing around the edges of the bathroom sink. - Room 317 - No caulking was visible around the toilet base. b) The maintenance director, on 06/01/16 at about 9:30 a.m., toured the rooms and confirmed the areas were in disrepair.",2020-02-01
4294,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2016-06-01,323,K,0,1,8JZH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on water temperature measurements, observations, medical record reviews, staff interviews, and review of the Guidance to Surveyors found in the State Operations Manual published by the Centers for Medicare & Medicaid Services (CMS), the facility failed to ensure the resident environment, over which it had control, was as free from accident hazards as possible. Water temperature measurements taken between 6:00 p.m. and 6:30 p.m. on 05/23/16 with the maintenance department using their thermometer found the following water temperatures in the resident hands sinks in resident rooms: -- Room 310 the water temperature was 125.7 degrees Fahrenheit (F) -- Room 303 the water temperature was 126.4 degrees F -- Central Bath 300 hall the water temperature was 127.1 degrees F On 05/24/16 at 10:32 a.m., an additional temperature of 123.1 in room 313 by the maintenance department, was not within acceptable parameters. The maintenance director confirmed, during an interview on 05/23/16 between 5:30 p.m. and 6:30 p.m., the water temperatures had been all over the place, and had been erratic for a long period of time. The maintenance director expressed awareness that the water temperatures were erratic, indicated no intervention had been initiated to identify and correct the problem, and provided no evidence to indicate the facility had properly maintained the mixing valves. This discovery was determined an immediate jeopardy situation, with the potential to affect all residents who were able to independently wash their hands and who had cognitive impairments. At 3:10 p.m. on 05/24/16, the Associate Nursing Home Administrator (ANHA), and the Director of Nursing (DON) were notified of the immediate jeopardy due to the elevated water temperature, and the facility ' s culpability in knowing the problem existed without implementing a plan to correct the problem. The facility provided a plan of correction at 4:23 p.m. on 05/24/16. The State agency required revisions to the P[NAME], and upon review, the immediate jeopardy was abated at 6:55 p.m. on 05/24/16. Sixteen (16) residents were identified as being at risk for immediate jeopardy or harm as a result of the elevated water temperatures. They suffered from cognitive impairments and were identified by facility staff as able to independently wash their hands in resident hand sinks. The 16 residents identified were Resident #104, #101, #112, #118, #98, #22, #90, #76, #71, #114, #29, #126, #125, #121, #120, and #34. Findings Include: a) At 4:13 p.m. on 05/23/16, during Stage 1 of the Quality Indicator Survey (QIS), the water in the hand sink in room 215 was felt by the surveyor by placing her hand under the running water. Within about five (5) seconds the water was too hot to place ones hands under comfortably. With continued hand washing for an additional ten (10) seconds, the surveyors ' hands turned a reddish color. The water in rooms 214 and 205 also felt uncomfortable. Due to this concern, the surveyor requested the maintenance department take the water temperature in rooms 214 and 215 and 205. The temperatures were 113.3 degrees Fahrenheit (F), 117.4 degrees F and 117.4 degrees F respectively. Another observation, on 05/23/16 at about 6:00 p.m., revealed uncomfortable water temperatures in rooms 303 and 310. Upon request, the maintenance director used the facility thermometer and obtained a temperature of 126.4 degrees F in room 303 and 125.7 degrees F in room 310. Resident #104, resided in room 303 and Resident #112 resided in room 310. These residents were able to independently wash their hands at the hand sink in their rooms. At 6:11 p.m. on 05/23/16, the maintenance director also obtained a temperature in the Central Bath 300 sink using the facility's thermometer. The water temperature was 127.1 degrees F. He indicated it was too hot. Due to this elevated temperature, additional water temperatures in other rooms throughout the facility were checked. The maintenance director confirmed room 303 was the room closest to the water heater on the south hall and room 310 was over half way down the hallway, on the opposite side of the corridor. All temperatures were obtained by the maintenance director, using the same thermometer. While obtaining temperatures, the temperature would spike, drop and rise again, within seconds. The director held the thermometer under running water, but did not utilize a cup for consistency. Upon request, he changed the position of the thermometer under the water stream, and the temperature raised. He agreed the temperatures obtained were dependent upon the position of the thermometer. If not positioned correctly, an accurate temperature was not obtained. According to Table 1 in the Guidance to Surveyors related to comfortable/safe water temperatures, found in Appendix PP of the CMS State Operations Manual, a third (3rd) degree burn can occur at 120 degrees F with an exposure time of five (5) minutes, at 124 degrees F with an exposure time of three (3) minutes, at 127 degrees F with an exposure time of one (1) minute, at 133 degrees F with an exposure time of 15 seconds, and at 140 degrees F with an exposure time of 5 seconds, noting that burns can occur even at water temperatures below that level depending on the exposed individual's condition and the length of exposure. Rooms 100 Central Bath, 108, 203 Central Bath, 205, 215, 303, 306, 310, 313, 409, were chosen to demonstrate this was a facility wide problem. Water temperatures were obtained on the north (100 and 200) and south (300 and 400) halls due to uncomfortable water temperatures. Since rooms 100 Central Bath, 203 Central Bath and 303 were closest to the water heaters and Room 217 furthest away from the water heaters, it was likely the water in the rooms between the two (2) were also elevated, placing additional residents at risk, resulting in a determination the problem was facility wide. The Director of Maintenance indicated the water temperatures were checked weekly. He confirmed the water was too hot, and the temperatures had been erratic, but did not know why. The director related the mixing valves were maintained every six (6) weeks and valves were changed out. He also related temperatures were more stable when staff used a lot of water such as when providing showers. During an additional interview with the maintenance director at 7:23 p.m. on 05/23/16, he related a work order was placed each time the mixing valves were cleaned and when water temperatures were obtained. Upon request, the director reviewed work orders from 05/01/15 through 05/23/16. He related he was unable to find any evidence the mixing valves had been maintained for either the north or south halls. He related a hot water heater had been changed due to leakage, but no other maintenance. Upon request, the maintenance director provided his water temperature log beginning on 02/01/6 through 05/23/16. Temperatures were completed weekly, and upon request when staff complained of hot water. The south hall temperatures included: --02/15/16 room 413 was 114.8 --02/22/16 south soiled utility was 114.0 --02/29/16 south soiled utility was 113.8 --03/07/16 south soiled utility was 114 --03/18/16 room 314 was 115.8 and room 410 was 113.5 --03/21/16 south soiled utility was 115.6 --03/28/16 south soiled utility was 112.9, room 314 was 115.8 and room 410 was 113.5 --04/11/16 south soiled utility was 114.5 --04/18/16 south soiled utility was 115.2, room 314 was 113.8 and room 413 was 114.5 --05/09/16 south soiled utility was 115.9, room 314 was 114.8 and room 410 was 116.5 --05/16/16 room 314 temperature was 114.8 and room 410 was 116.5 --05/23/16 south soiled utility was 115.8, room 312 was 115 and room 410 was 113.1 North hall temperatures included: --02/15/16 north soiled utility was 116.5 --02/15/16 north soiled utility was 116.5 --02/22/16 north soiled utility was 110.6 --02/25/16 room 109 was 118.3 and room 217 was 117.5. The director related the temperature was obtained due to complaints of hot water. --02/29/16 north soiled utility was 111.2 --03/07/16 north soiled utility was 116.4 --03/14/16 north soiled utility was 115.6 --03/21/16 north soiled utility was 104.9 --03/28/16 north soiled utility was 116.0 and room 109 was 114.1 --04/04/16 north soiled utility was 114.2 --04/11/16 north soiled utility was 114.1 --04/18/16 north soiled utility was 116.1, and room 112 was 112.1 --04/25/16 north soiled utility was 111.7 --05/02/16 north soiled utility was 115.8, room 112 was 113.9 and room 214 was 112.5 --05/09/16 north soiled utility was 117.4, room 112 was 113.1 and room 214 was 112.1 --05/16/16 north soiled utility was 117.8, room 112 was 113.3 --05/23/16 north soiled utility was 118.2 Upon inquiry, the maintenance director related the facility recorded the temperature obtained after the water stabilized, not at the temperature spike. Upon exiting the interview with the maintenance director, a list of residents who were capable of utilizing the sink in the room and the central bath were obtained from the South hall Registered Nurse Case Manager. During an interview with Maintenance #53, on 05/24/16 at 9:15 a.m., he related the process used for obtaining water temperatures, he stated he held the thermometer under the water and allowed the water to run over it. He confirmed he did not utilize a cup. Further inquiry revealed he had not calibrated the thermometer. Additionally, he did not utilize the same thermometer as the maintenance director. Upon request Maintenance #53 calibrated the thermometer and began to obtain temperatures. The surveyor also calibrated a thermometer to obtain temperatures simultaneously. Maintenance #53 confirmed the temperatures were not accurate, due to the thermometer was not always under the water. He obtained a cup and related the temperatures were more consistent. He related the director had adjusted the hot water temperature on 05/23/16 prior to exiting the facility, but he had turned it back up this morning. Temperatures were as follows: --Room 303 - 118 degrees F --Room 301 - 118.3 degrees F --Room 403 - 118.2 degrees F --Room 412 - 117.2 degrees F --Room 310 - 315.1 degrees F --Room 400 Central Bath - 116.1 degrees F --Room 300 Central Bath - 111.98 degrees F --Room 100 Central Bath - 115.5 degrees F --Room 113 - 115 degrees F --Room 108 - 119 degrees F The facility was asked to provide a list of all residents on the dementia unit who were able to independently wash their hands at the resident hand sinks and/or use the 300 central bath independently. This list contained the names of sixteen (16) residents. Of those 16 residents, only 8 were identified as being at risk for serious harm due to their severe cognitive impairments. The medical records of all 16 residents were reviewed and found the following eight (8) residents had a BIMS score less than seven (7) indicating a severe cognitive impairment. --Resident #101 had a BIMS score of 99. --Resident #118 had a BIMS score of 99. --Resident #98 had a BIMS score of four (04). --Resident #90 had a BIMS score of five (5). --Resident #76 had a BIMS score of four (04). --Resident #121 had a BIMS score of 99. --Resident #120 had a BIMS score of three (03). --Resident #34 had a BIMS score of seven (07). Three residents on the North hall were identified as independent and included: --Resident #86 had a BIMS score of six (06). --Resident #76 had a BIMS score of four (04). --Resident #75 had a BIMS score of four (04). Sixteen (16) residents were identified as being at risk for serious harm as a result of the elevated water temperatures. They suffered from cognitive impairments and were identified by facility staff as able to independently wash their hands in resident hand sinks. The sixteen (16) residents identified were: Resident #104, #101, #112, #118, #98, #22, #90, #76, #71, #114, #29, #126, #125, #121, #120, and #34. This discovery was determined an immediate jeopardy situation, with the potential to affect all residents who were able to independently wash their hands and who had cognitive impairments. At 3:10 p.m. on 05/24/16, the Associate Nursing Home Administrator (ANHA), and the Director of Nursing (DON) were notified of the immediate jeopardy due to the elevated water temperature, and the facility ' s culpability in knowing the problem existed without implementing a plan to correct the problem. The maintenance director expressed awareness that the water temperatures were erratic, indicated no intervention had been initiated to identify and correct the problem, and provided no evidence to indicate the facility had properly maintained the mixing valves. The ANHA related the temperatures were too hot, and a temperature of 127.1 was unacceptable. The facility provided a plan of correction at 4:23 p.m. on 05/24/16. The State agency required revisions to the P[NAME], and upon review, the immediate jeopardy was abated at 6:55 p.m. on 05/24/16. No deficient practice remained after removal of the immediate jeopardy. b) Plan of correction The facility provided a plan of correction at 4:23 p.m. on 05/24/16. The State agency requested the facility to revise its plan of correction (P[NAME]) to include continued monitoring after the mixing valves were installed to ensure the facility could maintain a continuous water temperature of 110 degrees F; to ensure nursing staff had access to thermometers to check for hot water temperatures; when in-servicing staff on checking water temperatures would begin; and resubmit the P[NAME]. The plan of correction was resubmitted and approved. As the facility had already begun to implement the P[NAME], the immediate jeopardy was abated at 6:55 p.m. on 05/24/16. The plan indicated all residents had been checked for potential injury and skin assessments were performed on all residents with no injury noted. All residents had the potential to be affected. Hot water was immediately turned off in every resident room. Signs were placed in rooms not to turn the hot water back on until further notice. The maintenance department turned the water temperatures down to 110 degrees F. Water temperatures will be checked every 30 minutes by the maintenance department until the water temperatures are at steady 100-110 degrees for 24 hours. Maintenance will be here to check water temperatures for the next 24 hours and longer if needed. New mixing valves have been ordered and are supposed to arrive 05/25/16. Valves are to be placed in service upon arrival. Water temperature checks will be performed after installation to ensure proper function. Expected completion date of installation will be 06/01/16. Water temperatures will be checked every eight (8) hours daily after installation one sink down each hallway and in utility rooms to ensure proper temperatures. Findings will be reported to the Administrator and reviewed by the safety committee monthly and reported to Quality Assurance (QA) for review. Logs have been started for water temperatures. All nursing staff will be in-serviced on how to check water temperatures properly and to check temperatures if they feel that the water may be too hot to check temperatures. Staff has been advised that water temperatures should be between 100-110 degrees. Thermometers have been supplied to the nursing department to be used for testing. Nursing staff are being trained at shift change daily until all nursing staff are in-serviced. Expected completion date of training will be 05/27/16. Water temperature logs will be reviewed with the administrator and reviewed by the safety committee monthly and reported to QA for review. A follow-up interview with the administrator, on 05/25/16 at 3:30 p.m., revealed the plan of correction had not been implemented as presented due to the facility received an e-mail indicating the parts had not been shipped as planned. The facility continued with 30 minute checks of water temperatures and ordered new thermostats for each hot water heater. The DON related on 05/25/16 she and the administrator made rounds with the maintenance department, and utilized the cup method to check water temperatures. On 05/26/16 at 9:30 a.m., an interview with the administrator revealed he had hired a plumbing company to analyze and fix the water temperature problem. During an interview with the plumber, he related the pressure tank was not big enough to support the system. He related the pressure caused the hot water to back flow into the cold water line. He was holding the pipe and related, It's (it is) red hot right now. He also indicated it was dangerous to turn down the heater temperature because it could cause the thermostat to stick. He related a check valve would be placed on the cold water line to prevent back flow and to change the expansion tank. The administrator told the plumber to change the mixing valve also. The administrator was informed a revised plan of correction would have to be submitted and accepted by the State agency. The revised plan of correction was submitted to the facility on [DATE] at 10:47 a.m. and was accepted. The facility continued its corrective actions including education and water temperature checks. During the time the staff were making revisions to the plan of correction, the State agency observed for implementation of the plan of correction. The facility's Policies and Procedures of water temperature safety were reviewed and noted to contain all required information including information pertaining to a process staff should follow should they notice the water temperature was too warm. The hand sinks of the facility were observed and noted to have the hot water turned off. The facility had placed signs on the sinks advising staff and residents not to use the hot water until further notice. The facility provided education sign in sheets for all staff currently working. Nurse stations contained several thermometers to check water temperatures. Finally, random staff interviews were conducted and the staff were knowledgeable of the water temperature situation and knowledgeable of the policy and procedure on which they were educated. The facility added the following information to the revised plan of correction, submitted by the facility at 10:47 a.m. on 05/26/16: The facility added the following information to the plan of correction, Per (Plumbing Company) current water temperatures should remain below 110 degrees with thermostats on each water tank set below 110 degrees. The maintenance department will continue to do 30-minute temperature checks on hot water until 06/02/16. Current tempering valves on water tanks are not working correctly. This will be replaced on 05/31/16 also with the installation of new and proper size expansion tanks and new high velocity bronze circulating pumps will be installed with proper plumbing. Expected completion date is 06/02/16. (Plumbing Company) will educate the maintenance department on operation and maintenance of tempering valve at completion of installation. (Plumbing Company) will be on call for any problems that may occur over the weekend and until installation has been completed. Water temperatures will be checked every eight (8) hours daily for two (2) weeks after installation, two (2) sinks down each hallway, one at the far end of the hallway and one down the middle of the hallway, and in utility rooms to ensure proper temperatures. Should testing show that temperatures are in the correct range testing of water temperatures will be added to the daily preventative maintenance log. Findings on these reports will be reported to the administrator weekly and reviewed by the safety committee monthly and reported to QA quarterly for review. No deficient practice remained after removal of the immediate jeopardy.",2020-02-01
4295,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2016-06-01,332,D,0,1,8JZH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure a medication error rate of not more than five (5) percent. Medication administration observation identified two (2) medication errors out of thirty-six (36) opportunities for error. This resulted in a medication error rate of five point five percent (5.5 %). This affected one (1) of five (5) residents observed for medication administration. Resident identifier: #86. Facility census: 116. Findings include: a) Medication Error #1 for Resident #86 On 05/25/16 at 8:23 a.m., licensed nurse Employee #17 administered [MEDICATION NAME] 0.25 milligrams (mg) to Resident #86. [MEDICATION NAME] is a cardiovascular medication that slows the heart rate. The nurse did not assess the pulse rate and rhythm prior to administration of the medication. Review of the medical record on 05/25/16 at 9:15 a.m. found physician's orders [REDACTED]. once daily by mouth. During interview with Employee #17 on 05/26/16 at 9:30 a.m., she said there is no directive on the computer that asks for a pulse assessment, nor is there a physician order [REDACTED]. Review of the electronic medical record at this time, found the pulse rate for the resident was obtained on eight (8) occasions between 05/09/16 and 05/25/16, and found to be between 58 and 68 beats per minute each time. The most recent evidence of pulse assessment occurred on 05/24/16 at 6:47 p.m., and it was within normal limits. The nurse agreed no one checked the resident's pulse this morning. She checked the pulse at this time, and found it was irregular in rhythm, and sixty-two (62) beats per minute. On 05/23/16 at 11:33 a.m., the director of nursing (DON) said it is a standard of practice to obtain the pulse rate prior to administering [MEDICATION NAME], and it should have been done today. Upon inquiry, she said the facility does not have a policy to obtain a pulse reading prior to giving [MEDICATION NAME]. She agreed the physician is typically notified if the pulse rate is less than sixty (60) beats per minute, to obtain his directive as to whether to give the medication or abstain. b) Medication Error #2 for Resident #86 On 05/25/16 at 8:25 a.m. Licensed Practical Nurse (LPN) #17 administered two (2) inhalations of [MEDICATION NAME] 200/ micrograms (mcg), via a hand-held nebulizer, with approximately three (3) minutes between the two (2) inhalations. [MEDICATION NAME] is an inhaled [MEDICATION NAME][MEDICATION NAME] that relaxes muscles in the airway to improve breathing. After the inhalations, the nurse gave the resident a cup of water and directed her to rinse her mouth well. The resident rinsed her mouth with the water, then swallowed the rinse water. Upon inquiry, the nurse said she typically asks the residents to rinse their mouths after the administration of inhalers, but does not direct them to spit out the rinse water. She read aloud the pharmacy directions on the inhaler, which directed to rinse the mouth after use. An interview was conducted with the DON on 05/25/16 at 11:33 a.m. She said pharmacy does not label the medication boxes or inhalers with directives to spit out the rinse water. Rather, it directs only to rinse the mouth after their use. She said every nurse can access information sheets on each medication via the electronic medication administration system. At 11:50 a.m. on 05/25/16, the DON provided a six (6) page manufacturer's information sheet on [MEDICATION NAME]. On page two (2) it states Gargle and rinse your mouth with water after each use of this medication to help prevent dryness, irritation, and yeast infections (thrush) in the mouth and throat. Do not swallow the rinse water.",2020-02-01
4296,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2016-06-01,425,D,0,1,8JZH11,"Based on observation, staff interview, and review of the facility's insulin and injectable diabetes medication chart, the facility failed, in collaboration with the pharmacist, to assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident. An opened and partially used multi-dose vial of Lantus insulin for Resident #53, was opened and used for greater than the number of days directed by the manufacturer. Use of medication from a multi-dose vial opened for a time period greater than that recommended by the manufacturer, had the potential to negatively impact the safety and/or potency of the medication. This had the potential to affect one (1) of five (5) insulin dependent diabetics on the North Hall. Resident identifier: #53. Facility census: 116. Findings include: a) Resident #53 Observation of the North Hall medication cart on 05/24/16 at 4:00 p.m. found an opened and partially used vial of Lantus insulin for Resident #53. The date inscribed on the vial, 04/14/16, indicated the date it was initially opened. The label on the medication box directed to discard the vial after twenty-eight (28) days, but did not contain a written date as to when to discard it. Licensed Practical Nurse (LPN) #87 said the vial should have been dated to discard it on 05/12/16, but was not. She agreed that had the vial contained the actual, written date to discard, nursing staff may not have overlooked it. She immediately disposed of that vial. She ordered a new vial of Lantus insulin from the pharmacy, which she said would arrive this evening. On 05/25/16 at 11:33 a.m. the director of nursing (DON) provided a copy of an insulin and injectable diabetes medication chart, faxed from Pharmacy Audit Assistance Service (PAAS) National. According to this chart the facility referenced, the expiration date for a vial of Lantus insulin was twenty-eight (28) days after initially opened. She agreed Resident #53's Lantus insulin should have been discarded at 28 days after having been initially opened, and was not.",2020-02-01
4297,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2016-06-01,431,E,0,1,8JZH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, manufacturer's guideline review, and Center for Disease Control and Prevention (CDC) recommendations, the facility failed, in collaboration with the pharmacist, to ensure the safe and effective use of medications. A multi-dose vial of Purified Protein Derivative (PPD), a medication which is injected beneath the skin to aid in the detection of exposure to [DIAGNOSES REDACTED], was not dated when initially opened. This had the potential to negatively impact the safety and/or potency of the medication, and had the potential to affect any resident who might receive an injection of medication/serum from this vial. One (1) of two (2) medication storage room refrigerators contained a vial of PPD serum that was not labeled when initially opened. Facility census: 116. Findings include: Observation of the North Hall medication storage refrigerator on 05/24/16 at 3:55 p.m. revealed a ten (10) test vial of purified protein derivative (PPD), with a small amount remaining. The vial contained no date to indicate when it was initially opened, or when to discard it. Licensed Practical Nurse (LPN) #115 estimated there was probably one (1) dose left in the vial. She said nursing staff must discard opened multi-dose vials of PPD after thirty (30) days of initial open date. She discarded the vial immediately, since it could not be determined how long it had been opened. Review of manufacturer's guidelines at this time found that Aplisol purified protein derivative vials in use for more than thirty (30) days should be discarded. Review of Centers for Disease Control and Prevention (CDC) recommendations revealed that the United States Pharmacopoeia (USP) General Chapter 797 recommends the following for multi-dose vials of sterile pharmaceuticals: If a multi-dose vial has been opened or accessed (that is, needle-punctured), the vial should be dated and discarded within twenty-eight (28) days, unless the manufacturer specifies a different (shorter or longer) date for that opened vial.",2020-02-01
4956,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-10-15,323,D,0,1,CC4M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, staff interview, review of incident reports, and review of a manufacturer's operational manual , the facility failed to ensure one (1) of three (3) residents reviewed for the Care Area of Skin Conditions (non-pressure related) was provided care in a manner which was as free from accident hazards as possible. The facility failed to safely transfer the resident via the mechanical lift and failed to ensure two (2) facility staff assisted with transfers using the mechanical lift. Resident identifier: #20. Facility census: 52. Findings include: a) Resident #20 Resident #20 was observed, on 10/13/15 at 8:14 a.m., with greater than a four (4) by four (4) inch wrap on the right shin. Review of the resident's electronic medical record, on 10/15/15 at 8:30 a.m., revealed the skin tear occurred during a transfer with the mechanical lift on 09/09/15. Medical record review, on 10/13/15 at 3:30 p.m., revealed the resident's [DIAGNOSES REDACTED]. The resident's two (2) most recent quarterly Minimum Data Sets (MDS) were reviewed on 10/13/15 at 3:40 p.m. The MDSs, with assessment reference dates (ARDs) of 06/16/15 and 09/14/15, each indicated in Section G, Functional Status, that the support required for transfer was, 2 + persons physical assist. physician's orders [REDACTED]. The resident's care plan, reviewed on 10/15/15 at 9:04 a.m., contained an intervention directing staff to, Use mechanical lift x2 assist for transfers as ordered. That same directive appeared in the Point of Care instruction which was provided to the Nursing Assistants (NAs). Resident #20's progress notes, in the electronic medical record, were reviewed on 10/15/15 at 8:30 a.m. An 09/09/15 note, documented at 21:50, stated, CALLED TO RSD'S (resident's) ROOM BY STAFF. RSD WAS NOTED TO HAVE TWO SKIN TEARS TO THE RIGHT LOWER LEG CONSISTENT WITH BUMPING ON W/C DURING TRANSFER INTO THE BED. RSD STATED I BUMPED IT WHEN I WAS GETTING INTO BED. NEW ORDER FOR BACITRACIN AND BAND AID TO RIGHT LOWER LEG SKIN TEAR QDAY (each day) AND PRN (as needed). DENIED ANY PAIN. LEFT MSG (message)FOR (name of physician) TO CALL FACILITY. WILL CONTINUE TO MONITOR. During interviews, on 10/15/15 at 9:50 a.m., with Resident #20 and Staff Member (SM) #51, each recalled the 09/09/15 incident when the skin tear occurred. Resident #20 acknowledged the mechanical lift was necessary for her transfers, and said it was used during the transfer on 09/09/15, when the skin tear occurred. She recalled the incident and stated SM #51 had operated the mechanical lift alone. She described that SM #51's shoe had come down on her leg. SM #51 confirmed the accuracy of the resident's description of the incident. The facility's incident report and accompanying employee statements for the 09/09/15 incident were reviewed on 10/14/15 at 10:30 a.m. The report was not specific regarding the use of the mechanical lift nor how many staff were assisting the resident at the time of the incident. Additionally, the facility did not have a policy specific to the use of the mechanical lift. The facility provided the manufacturer's operation manual for the device, which directed,the required number of staff members must be present during a transfer.",2019-04-01
4957,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-10-15,441,E,0,1,CC4M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a random opportunity for observation, staff interviews, review of facility policies and procedures, and review of the Centers for Disease Control (CDC) website for blood glucose monitoring, the facility failed to ensure an effective infection control program to prevent, to the extent possible, the transmission of disease and infection. The facility failed to disinfect glucometers between resident use. This had the potential to affect seven (7) of seven (7) current residents, identified by the facility, who received finger stick glucose monitoring using the facility's communal glucometers. Facility census: 52. Findings include: a) On 10/14/15 at 11:07 a.m., a random observation revealed Licensed Practical Nurse (LPN) #112 was standing at the medication cart cleaning a glucometer (Assure Platinum Glucose Meter) with an [MEDICATION NAME] alcohol wipe. An interview with LPN #112 at the time of the observation, regarding if that was what she used to clean the glucometer, verified she cleaned the glucometer between residents with only [MEDICATION NAME] alcohol and used nothing else. LPN #112 inquired if she was correct in doing so. LPN #112 further verified the glucometer used was not for single use but used to assess multiple residents' blood glucose levels. During an interview, on 10/14/15 at 1:10 p.m., the Director of Nursing (DON) verified the facility only cleaned the communal blood glucometers with [MEDICATION NAME] alcohol, and did not disinfect the devices. On 10/14/15 at 3:48 p.m., the DON provided the facility's undated Glucometer Disinfection and the Assure Platinum Blood Glucose Monitoring System Manufacturer Guidelines for Cleaning and Disinfecting. This documentation indicated the Assure Platinum Glucometer should be cleaned with soap and water or [MEDICATION NAME] alcohol and disinfected with an EPA-registered disinfectant detergent or germicide approved for healthcare settings, or a solution of 1:10 concentration of bleach. On 10/14/15, CDC's website was reviewed for Infection Prevention during Blood Glucose Monitoring. The information, last updated on 05/02/12, stated if blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. The CDC website also noted if the manufacturer did not specify how the device should be cleaned and disinfected, then it should not be shared.",2019-04-01
5272,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2015-02-19,282,D,0,1,117C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, record review, and observation, the facility failed to implement the care plans for three (3) residents of twenty-one (21) residents whose care plans were reviewed. The care plan for falls was not implemented for Resident #91. Residents #85 and #31 each had care plans related to nutritional status which were not implemented. Resident identifiers: #91, #85, and #31. Facility census: 112. Findings include: a) Resident #91 Resident #91 was admitted to the facility on [DATE] and had multiple [DIAGNOSES REDACTED]. A review of the most recent full Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was coded as having falls prior to admission, and also as having fallen since admission to the facility. A review of the fall investigation report provided by the facility entitled, Post-Incident Actions, revealed Resident #91 sustained a head injury due to a fall on 01/29/15 at 9:00 p.m. A review of the current care plan, which was undated, indicated Resident #91 was at risk for falls as she gets up unassisted and gets in the floor on the mat at times. The care plan goal indicated Resident #91 will not experience any injuries related to falls. The goal's target date was listed as 05/20/15. The care plan listed the following approaches or interventions to reduce or prevent falls: 1. Prefers wearing non-skid footwear 2. Maintain soft helmet to head at all times when up 3. Maintain hipsters at all times 4. Maintain bed alarm at all times 5. Maintain bed in lowest position 6. Chair mat alarm at all times when up 7. Ambulation times one assist 8. Maintain floor mat alarm at bedside An observation of Resident #91 was conducted on 02/18/15 at 11:00 a.m. The resident was observed wearing regular No-Nonsense brand of white socks while in bed. The socks were labeled with the resident's name on them. They were not the non-skid socks as indicated in the care plan. Another resident observation was conducted on 02/18/15 at 12:58 p.m. The resident was up in the chair eating lunch. The chair was located on the far side of the resident's room near the window. Resident #91 was still not wearing non-skid socks. In addition, she was not wearing shoes or the soft helmet as directed by the care plan. A third observation was conducted on 02/19/15 at approximately 8:35 a.m. The resident was out of bed in the chair being assisted by staff to eat breakfast. Again, the resident had on regular white socks without skid protection. An interview was conducted with Employee #134, MDS Registered Nurse (MDS/RN) on 02/19/15 at approximately 11:00 a.m. MDS/RN #134 identified herself as the facility case manager for Resident #91. MDS/RN #134 stated the resident should be wearing non-skid socks, should wear a soft helmet when out of bed, and should also be wearing hipsters to pad any falls should they occur. On 02/19/15 at approximately 11:10 a.m., the resident was observed with MDS/RN #134. At this time the resident was back in bed, still wearing plain white socks. MDS/RN #134 felt the socks with her hands and confirmed they were plain white socks without any skid protection. MDS/RN #134 looked in the resident's room and closet, and was unable to locate any non-skid socks. MDS/RN #134 stated she would find some non-skid socks for the resident. MDS/RN #134 was asked if Resident #91 was wearing the hipsters that were identified as an intervention in the care plan. MDS/RN #134 felt underneath the resident's clothing to verify if she was wearing the hipsters. She confirmed the resident was not wearing the hipsters. MDS/RN #134 stated the hipsters were to be worn when the resident was out of bed. Further review of the care plan for Resident #91 revealed the hipsters were to be worn at all times. An interview was conducted with Employee #91, Director of Nursing (DON), on 02/19/15 at approximately 11:45 a.m. The deviations from the care plan regarding the non- skid socks, hipsters, and the soft helmet were all shared with the DON. The DON conveyed she had already been made aware of the concerns by MDS/RN #134. b) Resident #85 Resident #85 was re-admitted to the facility on [DATE] after being hospitalization for a [DIAGNOSES REDACTED]. Review of Resident #85's most recent Minimum Data Set (MDS), dated [DATE], revealed the resident had short and long term memory loss and her cognition was severely impaired. Her functional status documentation indicated she required the physical assistance of one (1) staff to eat. The MDS also noted Resident #85 weighed 143 pounds which was a 5% or more weight loss in the last month, and she was not on a physician prescribed weight loss regimen. She was noted to be on a mechanically altered therapeutic diet. Review of Resident #85's current care plan for nutrition, dated 02/02/15, identified the resident had a potential for weight loss due to a decline in her appetite. The care plan also noted she had experienced a recent weight loss while in the hospital for pneumonia. Interventions included staff would provide the resident assistance with her meal, cue her to eat, and monitor her food intake. Review of the nursing notes revealed Resident #85 became ill on 01/13/15, and was sent to the hospital with a [DIAGNOSES REDACTED].#85 weighed 159 pounds. She returned to the facility on [DATE]. Her weight on re-admission was noted as 145 pounds. This was a 14 pound (9.7%) weight loss from her weight prior to going to the hospital. Further review of the clinical record revealed the resident's health continued to decline after returning from the hospital, and she was placed on Hospice services on 01/30/15. A dietary note, dated 02/10/15, indicated Resident #85 had a significant change in her condition. The documentation described the resident's current weight was 145 pounds. It noted this was a 5% or more loss in the past 30 days. Employee #89, Certified Dietary Manager (CDM), documented the resident remained on hospice. The CDM documented the resident's average meal intake was 31%. The CDM indicated she would refer the resident to the dietitian if she experienced any further weight loss. Review of the weight records on 02/18/15 did not reveal any further weight loss. Review of the nutritional intake log for (MONTH) (YEAR) and (MONTH) (YEAR) revealed the resident consumed less than 25% of each of the 86 meals served during this time period. There was no evidence staff provided the resident with assistance during mealtime when she refused to eat, or only ate 25% of her food. Observation of Resident #85, on 02/18/15 at 8:00 a.m., revealed the resident was in bed with her eyes closed. Her meal tray was on her over-the-bed table and nothing had been touched. Observation again on this date at 8:05 a.m., 8:10 a.m., and 8:15 a.m. revealed the resident's eyes were still closed. Staff were observed providing care and feeding other residents. Employees #23 and #15, Nurse Aides (NA), were asked if Resident #85 required assistance eating her meals. They both stated they were not sure what assistance she required. The NAs stated they did not usually work the 100 Hall. They indicated they would find out if the resident required assistance with her meals. NA #15 asked Employee #110, Licensed Practical Nurse Staff (LPN), what type of assistance Resident #85 required with her meals. The LPN stated she was not sure, so she went to ask a full-time NA (NA #21) assigned to the 100 Hall. NA #21 stated the resident required assistance with meals. She stated the resident used to be able to feed herself, but over the past few weeks she had not been able to do so. The NA said staff had been feeding her. NA #21 stated she worked the top half of the 100 Hall, and another full-time NA worded the bottom half of the hall. She stated the other NA had been off due to illness, so the staff working were not usually assigned to this hall. On 02/19/15 at 10:00 a.m., Employee #135 (MDS/RN), Employee #108 (In-Service Director), and Employee #91(Director of Nursing) were informed of that observations and record review revealed Resident #85 was not receiving assistance with her meals as the care plan indicated. c) Resident #31 Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record revealed an admission weight of 171 pounds on 08/12/14. Subsequent weights were as follows: -- On 08/26/14 the resident weighed 145 pounds, a difference of 26 pounds or 15.2% since admission -- On 09/01/14 the resident weighed 140.2 pounds, a difference of 30.8 pounds or 18% since admission -- On 09/09/14 the resident weighed 141.8 pounds, a difference of 29.2 pounds or 17% since admission -- On 09/16/14 the resident weighed 145.4 pounds, a difference of 25.6 pounds or 14.9% since admission -- On 09/23/14 the resident weighed 147.4 pounds, a difference of 23.6 pounds or 13.8% since admission -- On 10/01/14 the resident had two (2) recorded weights of 141.4 and 146.8 pounds, a difference of 29.6 and 24.2 pounds or 17.3% and 14.2%since admission -- On 11/01/14 the resident weighed 134.6 pounds, a difference of 36.4 pounds or 21.3% since admission -- On 11/03/14 the resident weighed 135.2 pounds, a difference of 35.8 pounds or 20.9% since admission -- On 11/18/14 the resident weighed 129.4 pounds, a difference of 41.6 pounds or 24.3% since admission -- On 11/25/14 the resident weighed 130.6 pounds, a difference of 40.4 pounds or 23.6% since admission -- On 12/01/14 the resident weighed 130.1 pounds, a difference of 40.9 pounds or 23.9% since admission -- On 01/01/15 the resident weighed 133.8 pounds, a difference of 37.2 pounds or 21.8% since admission -- On 02/01/15 the resident weighed 120 pounds, a difference of 51 pounds or 29.8% since admission -- On 02/02/15 the resident weighed 120.6 pounds, a difference of 50.4 pounds or 29.5% since admission -- On 02/10/15 the resident weighed 119 pounds, a difference of 52 pounds or 30.4% since admission -- On 02/17/15 the resident weighed 119.4 pounds, a difference of 51.6 pounds or 30.2% since admission Review of the clinical record revealed a dietary progress note written, on 08/13/14 by the Registered Dietician (RD), indicating Juven (a nutritional supplement) twice daily and milk shakes as needed would be ordered. Review of the clinical record revealed a dietary progress note written on 08/26/14 at 7:16 a.m. by Employee #89, Certified Dietary Manager (CDM). It noted the resident's current weight was 171.2 pounds. This note was not amended or corrected to reflect that the resident's weight taken on 08/26/14 at 9:30 a.m. was in fact 145 pounds, not 171.2 pounds. The note indicated the resident's nutritional status would be monitored and referred to the RD as needed. No additional dietary interventions were ordered at this time. Further review of the clinical record revealed the next dietary progress note was not written by the RD until 11/20/14. By this time, the resident weighed 129.4 pounds, reflecting a severe weight loss of 41.6 pounds or 24.3% since admission, three (3) months prior. The clinical record failed to reveal any dietary progress notes or assessments between 08/26/14 and 11/20/14, a period of approximately three (3) months wherein the resident lost 15.6 pounds or 10.8% of her body weight. The RD recommended Ensure Clear (a nutritional supplement) three (3) times daily and Great Shakes with meals. Review of the resident's nutrition care plan revealed the following interventions: -- Ensure clear 200 ml 3 x daily, -- Great Shakes with meals, -- Dietitian to evaluate and follow up as needed, -- Juven 1 packet BID (twice daily), -- Weigh resident every week for 4 weeks or until weight is stable; -- Record results and report any loss to physician and dietitian; and -- Promptly offer resident food alternatives when appropriate for any meal served. An interview with CDM #89 and Director of Nursing (DON) #91 was conducted on 02/18/15 at 3:30 p.m. CDM #89 stated she was notified of weight loss when residents were weighed, and made referrals to the RD. CDM #89 was unable to explain why the dietary progress note written on 08/26/14 was not corrected or amended to include the weight obtained later in the day on 08/26/14 of 145 pounds, reflecting a weight loss of 26 pounds or 15.2% of the resident's body weight since admission 14 days prior. CDM #89 was unable to explain why the resident was not seen by the RD until 11/20/14. CDM #89 was also unable to explain why new dietary interventions were not added until 11/21/14, a period of three (3) months when the resident continued to lose a significant amount of weight, an additional 15.6 pounds or 10.8% of the resident's body weight or 26 pounds or 15.2% weight loss since admission. A subsequent interview was conducted with CDM #89 on 02/18/15 at 4:20 p.m. CDM #89 stated the admission weight of 171 pounds was questionably inaccurate as hospital records prior to admission indicated the resident weighed 168 pounds before she had an above the knee amputation. CDM #89 stated the resident was referred to the RD on 11/04/14, but was not seen by the RD until 11/20/14. CDM #89 stated she did not refer residents to the RD until a resident loses 5% or more in 30 days. CDM #89 said that using the weight of 145 pounds on 08/26/14 as baseline, the 5% weight loss did not occur until 11/01/14. Review of the clinical record revealed no notes questioning the accuracy of the initial weight of 171 pounds. In fact, the RD used the weight of 171 pounds in her note on 11/20/14 which stated, Concern with major weight loss. She is down 42 pounds since her admission 3 months ago. From 171 to 129. In addition, the progress note by the RD documented a recommendation to, Consider appetite stimulant at this time. Review of the clinical record revealed no orders or considerations for an appetite stimulant. Observation of the resident eating breakfast, on 02/19/15, revealed the resident was not served a Great Shake with meals as directed by her care plan. An interview with the resident was conducted at this time. She said that she was not served Great Shakes with meals. Review of the clinical record revealed there was no documented evidence the resident was offered or received Great Shakes with meals.",2019-02-01
5273,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2015-02-19,325,G,0,1,117C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, record review, and observation, the facility failed to ensure two (2) of four (4) residents reviewed for nutrition maintained, to the extent possible, acceptable parameters of nutritional status. Resident #31 ' s weight was not accurately assessed. The resident had severe weight losses which were not identified and addressed in a timely manner. In addition the weight loss interventions suggested by the dietitian and/or those in the resident's care plan were not implemented. For Resident #85, the care plan for assistance at meals and the registered dietitian's recommendations for dietary supplements were not implemented. The failure to provide necessary care and services resulted in actual harm to these residents. Resident identifiers: #31 and #85. Facility census: 112. Findings include: a) Resident #31 Resident #31 was admitted to the facility on [DATE]. Review of the clinical record revealed documentation of an admission weight of 171 pounds on 08/12/14. The resident ' s weight was retaken, on 08/26/14 at 9:30 a.m. Her weight was 145 pounds, not 171 pounds as originally recorded. The resident ' s weight remained in the range of 145 pounds between 08/26/14 and 09/23/14. During this time period, the resident ' s weight went down to 140.2 pounds, then gradually up to 147.4 pounds on 09/23/14. There were no significant weight losses since the verified weight of 145 pounds. The resident ' s weight records for 10/01/14 showed two (2) different weights, 141.4 pounds and 146.8 pounds. There was no further weight assessment and nothing was found which clarified how much the resident actually weighed on 10/01/14. When the resident was weighed on 11/01/14, she weighed 134.6 pounds. There was no evidence the facility immediately recognized this weight loss was either a significant weight loss or a severe weight loss, depending on how much the resident actually weighed on 10/01/14. If the resident weighed 141.4 pounds on 10/01/14, and weighed 134.6 pounds on 11/01/14, she experienced a significant weight loss of 5% in one (1) month. On the other hand, if the resident weighed 146.8 pounds on 10/01/14, and weighed 134.6 pounds on 11/01/14, she experienced a severe weight loss of 8.3% in one (1) month. There was no evidence interventions were implemented to addresses the resident ' s new weight loss. On 11/03/14, the resident ' s recorded weight was 135.2 pounds. On 11/18/14, the resident weighed 129.4 pounds. This was an additional loss of 4.29% in 15 days (severe). If the resident weighed 141.4 pounds on 10/01/14, by 11/18/14 she had lost 9.27% between 10/01/14 and 11/18/14, which represented a severe weight loss. If the resident weighed 146.8 pounds on 10/01/14, the weight loss was 13.4% between 10/01/14 and 11/18/14. Between 11/18/14 and 01/01/15, the resident ' s weight remained stable. On 11/25/14, she weighed 130.6 pounds, on 12/01/14, she weighed 130.1 and on 01/01/15, she weighed 133.8 pounds. When the resident was weighed on 02/01/15, she weighed 120 pounds. This represented yet another severe weight loss of 10.31% between 01/01/15 and 02/01/15. There was no evidence this additional weight loss was identified and/or addressed. In four (4) months, between 10/01/14 and 02/01/15, the resident lost 15.13% of her total body weight if she weighed 141.4 on 10/01/14. She lost a total of 18.26% of her total body weight if she weighed 146.8 pounds on 10/01/14. The facility did not verify if the resident weighed 141.4 pounds or 146.8 pounds on 10/01/14. Either way, severe weight losses were not identified and promptly addressed. Review of the clinical record revealed a dietary progress note written, on 08/13/14, by the Registered Dietitian (RD), indicating Juven (a nutritional supplement) twice daily and milk shakes as needed would be ordered. Review of the clinical record revealed a dietary progress note, written on 08/26/14 at 7:16 a.m., by Employee #89, Certified Dietary Manager (CDM). It noted the resident's current weight was 171.2 pounds. This note was not amended or corrected to reflect that the resident's weight, taken on 08/26/14 at 9:30 a.m., was 145 pounds, not 171.2 pounds. The note indicated the resident's nutritional status would be monitored and referred to the RD as needed. The medical record contained no dietary progress notes or RD assessments between 08/26/14 and 11/20/14, a period of nearly three (3) months. During that period, the resident ' s weight records for 10/01/14 showed two (2) different weights, 141.4 pounds and 146.8 pounds which were not clarified. On 11/01/14, the resident weighed 134.6 pounds, and had lost either 5% (significant loss) or 8.3% (severe loss) in one (1) month, depending on which weight was used for calculation. On 11/03/14, the resident ' s recorded weight was 135.2 pounds; however, the resident weighed 129.4 pounds on 11/18/14, an additional loss of 4.29% in 15 days (severe). There was no evidence the DM or the RD promptly identified, assessed, and/or addressed the first significant (or severe) weight loss, which should have been identified after the resident was weighed on 11/01/14. The next dietary progress note, written by the RD, was not written until 11/20/14. By that time, the resident was losing weight at a faster pace. In fifteen (15) days she had lost an additional 4.29%, from 135.2 pounds on 11/03/14 to 129.4 pounds on 11/1814. The RD ' s 11/20/14 note included a recommendation for Ensure Clear (a nutritional supplement) three (3) times daily and Great Shakes with meals. The notes did not question the accuracy of the initial weight of 171 pounds. In fact, the RD used the weight of 171 pounds in her note on 11/20/14 which stated, Concern with major weight loss. She is down 42 pounds since her admission 3 months ago. From 171 to 129. In addition, the progress note by the RD included a recommendation to, Consider appetite stimulant at this time. There was no evidence the facility implemented these recommendations. As well, the clinical record revealed no orders or considerations for an appetite stimulant. Review of the resident's nutrition care plan revealed the following interventions: -- Ensure clear 200 ml 3 x daily, -- Great Shakes with meals, -- Dietitian to evaluate and follow up as needed, -- Juven 1 packet BID (twice daily), -- Weigh resident every week for 4 weeks or until weight is stable; -- Record results and report any loss to physician and dietitian; and -- Promptly offer resident food alternatives when appropriate for any meal served. There was no evidence the dietitian evaluated and followed up on the resident ' s nutritional status and needs as care planned. An interview with CDM #89 and Director of Nursing (DON) #91 was conducted on 02/18/15 at 3:30 p.m. Upon inquiry, CDM #89 stated she was notified of weight losses when residents were weighed, and made referrals to the RD. CDM #89 was unable to explain why the dietary progress note written on 08/26/14 was not corrected or amended to include the weight obtained later, on 08/26/14, of 145 pounds. CDM #89 was also unable to explain why the resident was not seen by the RD until 11/20/14. In addition, CDM #89 was unable to explain why new dietary interventions were not added until 11/21/14, a period of three (3) months. A subsequent interview was conducted with CDM #89 on 02/18/15 at 4:20 p.m. CDM #89 confirmed the resident was not referred to the RD until 11/04/14, and was not seen by the RD until 11/20/14. CDM #89 stated she did not refer residents to the RD until a resident lost 5% or more in 30 days. CDM #89 said that using the weight of 145 pounds on 08/26/14 as baseline, the 5% weight loss did not occur until 11/01/14. Observation of the resident eating breakfast, on 02/19/15, revealed the resident was not served a Great Shake with meals as directed by her care plan. An interview with the resident was conducted at this time. She said that she was not served Great Shakes with meals. Review of the clinical record revealed there was no evidence the resident was offered or received Great Shakes with meals. b) Resident #85 Resident #85 was re-admitted to the facility on [DATE] after being hospitalization for a [DIAGNOSES REDACTED]. Review of Resident #85's most recent Minimum Data Set (MDS), dated [DATE], revealed the resident had short and long term memory loss and her cognition was severely impaired. Her functional status documentation indicated she required the physical assistance of one (1) staff to eat. The MDS also noted Resident #85 weighed 143 pounds which was a 5% or more weight loss in the last month, and she was not on a physician prescribed weight loss regimen. She was noted to be on a mechanically altered therapeutic diet. Review of Resident #85's current care plan for nutrition dated 02/02/15 identified the resident had a potential for weight loss due to a decline in her appetite and she had experienced a recent weight loss while in the hospital for pneumonia. Interventions included the staff would provide the resident assistance with her meal, cue her to eat, monitor her food intake. Interventions included: -- determine resident's food preferences; -- allow ample time to consume food; -- provide the resident assistance with meals; -- cue the resident to eat; -- monitor the resident's food intake; -- record and report any decline to the physician and dietitian; -- promptly offer the resident food alternatives when appropriate; and -- the dietitian to evaluate and follow up as needed. Review of the nursing notes revealed Resident #85 became ill on 01/13/15 and was sent to the hospital with a [DIAGNOSES REDACTED].#85 weighed 159 pounds. She returned to the facility on [DATE]. Her weight on re-admission was noted as 145 pounds. This was a 14 pound (9.7%) weight loss from her weight prior to going to the hospital. Further review of the clinical record revealed the resident's health continued to decline after returning from the hospital, and she was placed on Hospice services on 01/30/15. Dietary notes, dated 02/03/15, revealed a referral for weight loss. Documentation on the note indicated Resident #85 was receiving hospice services and had not been eating or drinking well. The note indicated her weight was down to 145 pounds, from her pre-hospital weight of 159 pounds. The registered dietitian (RD) wrote a recommendation to stop all dietary restrictions, such as the current order for a no concentrated sweets diet, and placed the resident on a regular mechanical soft diet. The RD also documented the resident drank some Ensure for the nursing staff, and recommended that staff provide the resident a supplement as needed. There was no evidence this information regarding the supplement was relayed to nursing staff, to ensure staff were aware to offer the resident a dietary supplement as needed. A dietary note, dated 02/10/15, indicated Resident #85 had a significant change in her condition. The documentation described the resident's current weight was 145 pounds. It noted this was a 5% or more loss in the past 30 days. Employee #89, Certified Dietary Manager (CDM), documented the resident remained on hospice. The CDM documented the resident's average meal intake was 31%. The CDM indicated she would refer the resident to the dietitian if the resident experienced any further weight loss. Review of the weight records on 02/18/15 did not reveal any further weight loss. Review of the nutritional intake log for (MONTH) (YEAR) and (MONTH) (YEAR) revealed the resident consumed less than 25% of each of the 86 meals served during this time period. Review of the meal intake log indicated the following: If Resident #85: -- consumed 25% of the meal, there was a notation alternative offered. -- consumed 0% of the meal, there was a notation nurse was notified. Interview with Employee #127, Licensed Practical Nurse (LPN) and Employee #135, MDS Registered Nurse (MDS/RN) Nurse #135, on 02/18/15 at 2:20 p.m., revealed the documentation of alternative offered and nurse notified on the meal intake log was generated by the computer. It was not something the nurse aide actually documented. Further interview with LPN #127 revealed if she was told by the Nurse Aide, that a resident refused to eat, she would look to see if the resident had an order for [REDACTED]. On 02/18/15 at 2:30 p.m., interview with LPN #110, who was providing care to Resident #85, revealed she was not aware if Resident # 85 had an order for [REDACTED]. LPN #110 stated she did not work on the 100 Hall very often, so she was not sure if the resident had been receiving supplements and/or how the resident had been eating. At that time, LPN #127 and MDS/RN #135 both stated if there was not an order for [REDACTED].#135 confirmed Resident #85 did not currently have an order for [REDACTED]. Observation of Resident #85, on 02/18/15 at 8:00 a.m., revealed the resident was in bed with her eyes closed. Her meal tray was on her over-the-bed table and nothing had been touched. Observation again on this date at 8:05 a.m., 8:10 a.m., and 8:15 a.m. revealed the resident's eyes were still closed. Staff were observed providing care and feeding other residents. Employees #23 and #15, Nurse Aides (NA), were asked if Resident #85 required assistance eating her meals. They both stated they were not sure what assistance she required. The NAs stated they did not usually work the 100 Hall. They indicated they would find out if the resident required assistance with her meals. NA #15 asked Employee #110, Licensed Practical Nurse Staff (LPN), what type of assistance Resident #85 required with her meals. The LPN stated she was not sure, so she went to ask a full-time NA (NA #21) assigned to the 100 Hall. NA #21 stated the resident required assistance with meals. She stated the resident used to be able to feed herself, but over the past few weeks she had not been able to do so. The NA said staff had been feeding her. NA #21 stated she worked the top half of the 100 Hall, and another full-time NA worded the bottom half of the hall. She stated the other NA had been off due to illness, so the staff working were not usually assigned to this hall. Observation at lunch, on 02/18/15 at 12:20 p.m., revealed NA #21 attempted to feed Resident #85. During this observation the resident refused to eat, but NA #21 was able to get her to drink a small amount of water. The NA stated she did not offer the resident any type of dietary supplement. She said she was not aware she should be giving the resident any type of supplement. The NA documented Resident #85 consumed 0% of her meal. Interview with NA #21, on 02/18/15 at 2:35 p.m., revealed she worked the top half of the 100 Hall, and another full-time NA worded the bottom half of the hall. She stated that NA had been off due to illness, so the staff working were not usually assigned to the hall. NA #21 stated she had never provided Resident #85 with any type of nutritional supplement. She said if a resident refused to eat, she documented it in the meal intake area in the computer and then she told the nurse. She stated the nurse would be the one to give a resident the additional supplement or to provide the nurse aide the supplement to give to the resident. On 02/18/15 at 3:15 p.m., an interview was conducted with MDS/RN #135 and In-Service Director #108 on 02/18/15 at 3:15 p.m. When asked if Resident #85 received any dietary supplements due to her decline in meal intake, MDS/RN #135 stated the resident received Hospice and indicated it was expected the resident would lose weight. She said they would never force a resident to eat or drink anything. When explained that the question being asked was if any resident refused meals or only ate 25% of their meal, would staff offer any type of dietary supplement. MDS/RN #135 said Resident #85 did not have a current order for a supplement, nor had there been any recommendations for the resident to receive any type of dietary supplement. The MDS/RN #135 was informed that there was a dietary note, dated 02/03/15, by the dietitian which contained documentation that it was okay to provide a supplement to Resident #85 as needed. She stated she was not aware the dietitian had written that recommendation. A discussion was held with MDS/RN #135, In-Service Director #108 and the Director of Nursing #91 on 02/19/15 at 10:00 a.m. At that time, they were informed that observations and record review revealed Resident #85 was not receiving assistance with her meals as the care plan indicated. They were also informed that although Resident #85 was consistently consuming less than 25% of her meal, there was no evidence she was receiving any type of dietary supplement. The nurses verified the system currently in place did not provide an area for documenting a supplement if the resident did not eat. They were not able to provide evidence, for the days on which Resident #85 consumed less than 25% of her meal, that she received a nutritional supplement of any kind.",2019-02-01
5274,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2015-02-19,441,D,0,1,117C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review and observations, the facility failed to maintain infection control practices to prevent potential cross contamination for one (1) out of one (1) residents reviewed for infection control. Tubes of stock medications, used for more than one resident, were taken into Resident #85 ' s room and used for treatment. Resident identifier: #85. Facility census: 112. Findings include: a) Resident #85 Review of documentation on DATE at TIME revealed Resident #85 had excoriation to her buttocks area. A medicated cream was ordered to be applied to the affected area. On 02/18/15 at 10:50 a.m. the treatment to Resident #85's buttocks was observed. Employee #23, Nurse Aide (NA) stated the resident currently gets cream to her buttocks. She left the room and returned with a used tube of Zinc Oxide. She laid the tube of cream onto the resident ' s bed side table. She NA #23 assisted the resident to turn onto her side and placed the tube of cream onto the resident ' s bed without benefit of a barrier. Once the resident was rolled onto her side, NA #23 stated the resident had a dressing on her buttocks area and a nurse would need to complete the treatment. When asked if the tube of Zinc Oxide belonged to Resident #85, the NA #23 said there was no name on the tube. She stated she was not sure if it was the resident ' s tube of cream or not. NA #23 left the room and took the tube of Zinc Oxide with her. NA #23 gave the tube of Zinc Oxide to Employee #110, Licensed Practical Nurse (LPN). LPN #110 and Employee #145, Infection Control Nurse, came into Resident #85's room to conduct the dressing change. LPN #110 had the tube of Zinc Oxide and a tube of [MEDICATION NAME] cream. LPN #110 placed the tubes of [MEDICATION NAME] and Zinc Oxide onto a pad on the resident ' s bed. After LPN #110 performed the treatment she took both tubes of medications and placed them onto the medication cart. LPN #110 and Infection Control Nurse #145, were asked if the two tubes of medication were stock medications also used for other residents. The Infection Control Nurse #145 stated these were stock medications and staff should not be taking the actual tubes into the resident ' s rooms. Infection Control Nurse #145 stated the correct procedure was for staff to place a small amount of ordered medication into a cup to take into the resident ' s room to prevent the potential spread of infection. Both tubes of medication were disposed of by the Infection Control Nurse #145. She verified the staff did not follow procedures to prevent potential cross contamination between residents.",2019-02-01
5571,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2015-10-07,167,C,1,0,52YO11,"Based on observation and staff interview, the facility failed to ensure the results of the most recent survey were posted. In addition, the facility also did not post a notice of the availability of the survey results. This had the potential to affect all residents in the facility. Facility census: 118. Findings include: a) On 10/06/15 at 1:00 p.m., observation of the survey results book revealed the book contained survey results from 2009, 2010, and 2011. The most recent survey results were not in the survey book. The facility's most recent survey was conducted on 02/19/15. At 1:30 p.m. on 10/06/15, Registered Nurse (RN) #6 and Social Worker (SW) #152 agreed the results of the most recent survey were not posted in the survey results book. On 10/07/15 at 1:12 p.m., an observation of the survey results book revealed a blue three (3) ring binder was used as the survey results book. The book was located in a wooden rack mounted on the wall. A notice of the location of the survey results book was not posted anywhere in the facility, to let the residents or visitors know where they could locate the results. SW #152 agreed the facility did not have a notice posted identifying the location of the survey results.",2018-10-01
5572,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2015-10-07,502,D,1,0,52YO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a laboratory test was obtained in a timely manner for one (1) of two (2) residents reviewed. A hemoglobin A1C (HGA1C) test, to test measure the average plasma glucose concentration over prolonged periods of time, was ordered and scheduled, but was not obtained. Resident identifier: #20. Facility census: 118. Findings include: a) Resident #20 On 10/07/15 at 12:00 p.m., a review of Resident #20's medical record found a physician's orders [REDACTED]. The medical record revealed the resident had an HGA1C completed on 01/26/15. That was the last HGA1C that was completed in (YEAR). (The HGA1C (glycated hemoglobin) test measures the average plasma glucose concentration over prolonged periods of time.) During an interview with Registered Nurse (RN) #6 on 10/07/15 at 12:15 p.m., the RN confirmed the facility should have obtained the HGA1C in (MONTH) (YEAR) and did not.",2018-10-01
5950,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,241,E,0,1,GK2611,"Based on observation and staff interview, the facility failed to ensure four (4) randomly observed residents were cared for in a manner and in an environment that maintained or enhanced each resident's dignity and respect. During meal service in the Atrium, Residents #91, #73, and #76 were not served meals at the same time as all other residents seated at their table. Resident #40 who was eating in her room, was not served at the same time as her roommate. Resident identifiers: #91, #73, #76, and #40. Facility census: 64. Findings Include: a) Residents #91, #73, and #76 Observations at 11:50 a.m. on 07/28/14, in the Atrium dining room, revealed Residents #78, #91, #73, and #76 were seated at Table #1 waiting for the lunch meal. At 11:55 a.m., Resident #78 was served his meal. Residents #91, #73, and #76 were sitting at the same table as Resident #78, and did not receive their meals at the same time. Residents #91, #73, and #76 were not served their meal until five (5) other residents sitting at three (3) different tables were served their meals. At 12:08 p.m., Resident #73 was served his meal. An interview with the Assisted Living Coordinator (ALC) Registered Nurse (RN) #133, on 07/28/14 at 12:00 p.m., confirmed Residents #91, #73 and #76 were not served their meal at the same time as others seated at their table. He indicated that all residents sitting at the same table should have been served their meals at the same time. . b) Residents #84 and #40 Observation of meal delivery on Goodall Hall, on 07/28/14, found Residents #84 and #40 were waiting for their lunch. At 11:45 a.m., Resident #84 received her meal. Nursing staff served residents in Rooms #18, #22, and #21 before returning to serve Resident #40 her meal at 12:02 p.m. Nurse aide (NA) #67 was interviewed at 12:15 p.m. on 07/28/14. She stated she did not serve Resident #84, and did not know why both residents did not receive their meals at the same time. NA #67 said, This should not have happened because both trays were on the same cart. At 11:21 a.m. on 08/04/14, the observations made during the noon meal on 07/28/14 were discussed with Employee #90, the Vice President of Health Service. Employee #90 said residents occupying the same room should be served meals at the same time.",2018-05-01
5951,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,246,D,0,1,GK2611,"Based on observation and staff interview, the facility failed to ensure one (1) of five (5) residents observed during the lunch meal on 07/28/14 received services in the facility with reasonable accommodations of their individual needs. The table at which Resident #21 was seated was too high. Resident identifier: #21. Facility census: 64. Findings include: a) Resident #21 An observation at 12:05 p.m. on 07/28/14 revealed Resident #21 sitting in the Atrium at a table that was too high for her. The tabletop was eye level with Resident #21 and was not conducive to a pleasurable dining experience. An interview with the director of quality improvement/registered nurse (RN) #96, at 12:10 p.m. on 07/28/14, confirmed the table top was eye level with Resident #21. When asked if Resident #21 would be able to see her food sitting on the table, she replied, She is blind so she could not see it anyway. She further stated she thought those tables were adjustable and she was not sure why it was so high. According to the resident's quarterly minimum data set assessment, with an assessment reference date of 07/08/14, reviewed on 08/04/14 at 6:53 p.m., the resident required limited assistance with eating. The assessment also identified the resident had severely impaired vision. Therefore, the height of the table was an important factor in allowing this resident to maintain her highest practicable level of independence in her ability to feed herself.",2018-05-01
5952,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,253,D,0,1,GK2611,"Based on observation and staff interview, the facility failed to ensure effective housekeeping services for one (1) of thirty-five (35) census sample residents. The resident had a stand up fan in her room. The plastic outer casing of the fan was covered in black dust and debris. Resident identifier: #11. Facility census: 64. Findings include: a) Resident #11 On 07/29/14 at 2:11 p.m., an observation in Resident #11's room revealed the resident had a stand up fan. The white plastic casing of the fan was covered in black dust and debris. At 2:15 p.m. on 07/29/14, Employee #38 (housekeeping) went into the resident's room, looked at the fan, and agreed it needed cleaned.",2018-05-01
5953,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,272,D,0,1,GK2611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to accurately complete comprehensive minimum data set (MDS) assessments for two (2) of seventeen (17) residents whose MDSs were reviewed. The MDS in the areas of pressure ulcers was not accurate for Resident #89. The MDS for dental status was not accurate for Resident #91. Resident identifiers: #89 and #91. Facility census: 64. Findings include: a) Resident #89 The review of the wound assessment, on 07/31/14 at 9:00 a.m., revealed Resident #89 had a Stage II pressure ulcer on the top of his left foot. It also revealed the resident had a Stage II pressure ulcer on the left lateral leg that developed on 07/15/14. A review of the physician's orders [REDACTED]. The order also stated to apply triple antibiotic ointment to the top of the left foot and cover with border foam dressing daily until healed. The treatment for [REDACTED]. Observation of Resident #89's wounds, with licensed practical nurse (LPN) #12, on 07/31/14 at 9:50 a.m., revealed the resident had a Stage II pressure ulcer on top of the left foot, and a Stage II pressure ulcer on the left lateral leg. In an interview with LPN #12, on 07/31/14 at 9:55 a.m., she confirmed Resident #89 had a Stage II pressure ulcer on top of the left foot, and a Stage II on the left lower lateral leg. On 07/31/14 at 9:53 a.m., a review of Resident #89's MDS assessments revealed a significant change in status assessment with an assessment reference date (ARD) of 07/17/14. Item M0300 (current number of unhealed pressure ulcers at each stage) reflected the resident did not have any unhealed pressure ulcers. An interview with the registered nurse/charge nurse (RN-CN) #101, on 07/31/14 at 11:15 a.m., revealed the area started out as a skin tear. The staff applied a round donut to protect the integrity of the skin. Employee #101 indicated the donut had rubbed the left outer leg and the top of the resident's foot. Employee #101 said these areas had developed into Stage II pressure ulcers on 07/15/14. In an interview with the MDS coordinator (MDSC) #103, on 07/31/14 at 11:20 a.m., she stated she was unaware the skin tear to the left lateral leg and the skin tear on top of the left food had turned into a Stage II pressure ulcer. She indicated she was unaware the donut was rubbing the resident's leg until the RN-CN #101 told her on 07/31/14. Employee #101 confirmed when she did the MDS assessment she did not code the areas as Stage II pressure ulcers. She stated she would notify the physician and get clarification because she felt these ulcers were related to peripheral artery disease (PAD). A review of Resident #89's physician progress notes [REDACTED]. b) Resident #91 Observation of the resident's oral cavity, on 07/29/14 at 9:34 a.m., during Stage 1 of the Quality Indicator Survey found the resident's upper and lower natural teeth were discolored and broken. Review of the resident's admission MDS, with an ARD of 04/16/14, on 07/30/14 at 9:07 a.m., found Section L0200, entitled Dental, did not reflect the resident had any dental issues. At 9:39 a.m. on 07/30/14, observation of the resident's oral cavity with Employee #101, a registered nurse, found the resident's teeth were broken and decayed. Employee #101 said, She definitely has some dental issues. Further review of the resident's 04/09/14 admission nursing assessment, dated 04/09/14, found the section entitled, Oral / Dental noted the resident had obvious or likely cavity or broken natural teeth and mouth or facial pain, discomfort or difficulty with chewing. Employee #103 the registered nurse MDS coordinator was interviewed on 07/30/14 at 10:01 a.m. Employee #103 said the dental section on the MDS was incorrect, and commented, That was marked by mistake.",2018-05-01
5954,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,279,D,0,1,GK2611,"**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 to describe the provision of services needed to meet the needs of three (3) of seventeen (17) residents whose care plans were reviewed. Resident #19 did not have a care plan addressing an eighteen (18) pound weight loss occurring within eleven (11) days after admission to the facility. Resident #89 did not have a care plan addressing hospice services. Resident #46 did not have a care plan addressing behaviors which required the use of an antipsychotic medication. Resident identifiers: #19, #89, and #46. Facility census: 64. Findings include: a) Resident #19 Review of the medical record found the resident was admitted to the facility on [DATE]. A nursing admission assessment, completed on 05/21/14, recorded the resident's admission weight as 151.03 pounds and height as 58 inches. Further review of the resident's weights noted the first weight recorded in the computer was 133 pounds on 06/01/14. The resident did not trigger the facility to address the weight loss because the facility failed to accurately record the admission weight of 151.03 pounds in the computer. Review of the current care plan on 07/29/14 found the facility did not address the resident's weight loss. The registered dietitian, Employee #32, was interviewed at 2:30 p.m. on 07/29/14. She stated she did not address the resident's weight loss when the facility knew, or should have known, the resident experienced an 18 pound weight loss in just 11 days. She said she did not know the resident had lost weight until 06/10/14. The registered dietitian said, The nursing staff has to tell me and they didn't. When I noticed a weight loss on 06/10/14 I had her re-weighed and her weight was 133 pounds. She agreed the care plan failed to address an actual weight loss. b) Resident #89 A review of Resident #89's medical record on 07/31/14 at 9:02 a.m., revealed a physician order [REDACTED].>Review of the resident's comprehensive care plan found no care plan for hospice services. On 07/31/14 at 11:05 a.m., the comprehensive care plan was reviewed with the registered nurse-charge nurse (RN-CN) (Employee #101) and minimum data set coordinator (MDSC) Employee #103. Both of the nurses confirmed there was no care plan for hospice services. c) Resident #46 A review of Resident #46's medical record, on 07/30/14 at 2:00 p.m., revealed a [DIAGNOSES REDACTED]. He had an order for [REDACTED].>Review of the comprehensive care plan for Resident #46 found it did not address the resident's hallucinations and/or behaviors which necessitated the use of an antipsychotic medication. The care plan contained no non-pharmacological interventions, no identification of behaviors to monitor, and no identification of potential side effects of the medication which should be monitored. An interview with the charge nurse RN #101, on 07/31/14 at 1:10 p.m., verified Resident #46 was readmitted to the facility on [DATE] with a new order for an antipsychotic medication. She reviewed the care plan and confirmed there was no care plan related to the problem(s) which required the use of [MEDICATION NAME], or the potential problems in the use of this antipsychotic medication.",2018-05-01
5955,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,280,D,0,1,GK2611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise the care plans for two (2) of seventeen (17) residents whose care plans were reviewed during Stage 2 of the Quality Indicator Survey. The care plans did not reflect current problems, and interventions were not applicable to the residents. Resident #19's care plan was not revised when therapy services were discontinued. Resident #5's care plan was not revised after antipsychotic and hypnotic medications were no longer used. Resident identifiers: #19 and #5. Facility census: 64. Findings include: a) Resident #19 On 07/29/14, review of the resident's current care plan found a problem, Resident has alteration in ADL (activities of daily living) status related to recent hospitalization for pneumonia which is complicated by depression, [MEDICAL CONDITION], muscle weakness, difficulty walking and other multiple medical problems. The goal associated with the problem was, Attempt to improve ADL status AEB (as evidenced by) Resident will work with therapy as ordered toward reaching goals and minimum potential based on her specific abilities daily. The approaches included physical and occupational therapy as ordered. On 07/30/14 at 2:07 p.m., an interview with the physical therapy assistant, Employee #130, found the resident was discharged from occupational therapy on 07/17/14 and from physical therapy on 07/25/14. Review of the current care plan again, on 08/04/14, found the care plan had not been revised to reflect the discontinuation of physical and occupational therapy services. Employee #90, the vice president of health services confirmed, at 5:25 p.m. on 08/04/14, the care plan had not been updated. An interview with Employee #103, the registered nurse minimum data set (MDS) coordinator, at 6:17 p.m. on 08/04/14, found she failed to update the care plan after the therapy services were discontinued. b) Resident #5 A review of Resident #5's medical record at 9:52 a.m. on 08/04/14, revealed the following care plan problem (typed as written): Resident is at risk for drug related complications/side effects associated with use of [MEDICATION NAME] for [MEDICAL CONDITION], [MEDICATION NAME] for sleep disturbances and hallucinations and Oxazapam for anxiety. The goal (typed as written) was: Resident will remain free of drug related complications/side effects and will be maintained on the lowest effective dose possible AEB (as evidenced by) no drug related complications/side effects and staff will attempt to maintain this resident on the lowest effective dosage [MEDICAL CONDITION] medication possible through next review. The interventions put in place to help Resident #5 achieve this goal included, but were not limited to, the following: Observe, document, and report s/s (signs and symptoms) of complications/side effects of use of [MEDICATION NAME]., and Observe, document, and report s/s of complications/side effects of use of Ambien. Review of Resident #5's current physician orders [REDACTED]. Resident #5's care plan also contained the following problem (typed as written): Resident is at risk for injury related to falls due to hx (history) of fall with traumatic injury resulting in a neck fracture which has not properly healed and is complicated by [MEDICAL CONDITION], resident is legally blind, [MEDICAL CONDITIONS], hx of compression fractures, use of narcotics, use of medications antianxiety ([MEDICATION NAME]), antidepressant ([MEDICATION NAME]), [MEDICATION NAME] for hallucinations. Review of Resident #5's physician orders [REDACTED]. The MDS coordinator, Registered Nurse (RN) #103, was interviewed at 12:44 p.m. on 08/04/14. The RN confirmed Resident #5 did not currently receive [MEDICATION NAME], or Ambien. When asked if the care plan was revised to accurately reflect the resident's plan of care she replied, No it was not. She indicated she would have to revise the care plan to reflect the medications Resident #5 currently received.",2018-05-01
5956,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,309,D,0,1,GK2611,"Based on observation, resident interviews, staff interviews, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (1) of two (2) residents reviewed for positioning. The facility failed to provide services to maintain good body alignment and comfortable positioning for a resident while the resident was sitting up in her chair. Resident Identifier: #40. Facility census: 64. Findings include: a) Resident #40 Observation of Resident #40, on 07/29/14 at 2:55 p.m., revealed she was sitting in her recliner chair, leaning to her left at approximately a 40 degree angle. The chair was in an upright position. The resident's feet were resting on the floor. An interview was conducted,on 07/29/14 at 3:00 p.m., with Employee #280, a nursing assistant (NA), in the hall outside the resident's room. During the interview, the resident continued to lean over to her left side at approximately 40 degrees. The NA looked inside the resident's room and stated, She always sits like that. We prop her up when we see she is leaned over. She sits in her chair all the time and she leans to one side, sometimes worse than that. Employee # 280 then demonstrated how the resident leaned over on her left side at approximately 80 degrees, implying the resident sometimes leaned over that far in her chair. The NA straightened back up and said, We always prop her up with a pillow. On 07/29/14 at 3:25 p.m., Employee # 280 walked by and said, She already has a pillow propping her up. The NA then walked on down the hall. On 07/29/14 at 3:35 p.m., observation revealed Resident #40 was slumped over on her left side at approximately 50 degrees. A small pink pillow was noted behind her back. The pillow was not effectively supporting the resident. Observation of Resident #40, on 07/30/14 at 10:05 a.m., revealed the resident was sleeping in her chair. She was lying across the left arm of her recliner chair at 90 degrees, with her feet resting on the floor. Observation revealed there were no pillows for positioning in the chair. A nursing staff member walked past the resident's room and looked in. The staff member made no attempt to reposition the resident. On 07/30/14 at 10:50 a.m., Resident #40 was observed sleeping. She was still in the same position, lying across the left arm of the chair without any kind of supporting apparatus for positioning. At 11:35 a.m. on 07/30/14, an interview was conducted with Resident #40. She was asked, How are you doing? Resident #40 replied, I feel a little discomforted. When asked, Why is that? she replied, It's from my leaning, I was leaned over earlier. I have a tendency to lean to my left. I don't like it. I wish I could stop it. I try to stop it, but I keep on leaning. I have a very difficult time even in the beauty shop. I am leaning even sitting under the hair dryer. It's very difficult . She was leaning to the left at approximately 20 degrees during the interview. Resident #40 was asked, When you lean, can you straighten back up by yourself? Resident #40 replied, No. On 07/30/14 at 3:10 p.m., Employee #991, NA, was observed straightening Resident #40 and repositioning her with pillows. The NA was asked how he knew to reposition Resident #40. Employee #991 replied, The resident looked uncomfortable, so I straightened her. A review of the NA Kiosk (the care plan information for NAs) for Resident #40 was conducted with Employee #991 and Employee #1060 (NA). The Kiosk did not address positioning of the resident. On 07/30/14 at 3:20 p.m., Employee #1060, NA, was asked, How do you know what to do for the residents? She replied, We look at the kiosk, it gives us our instructions, and from time to time they call a staff meeting. There is no set time when meetings are called. Employee #1060 reported positioning of residents had been discussed at the last staff meeting. On 07/30/14 at 3:25 p.m., an interview with Employee #1079, Registered Nurse (RN), revealed NAs know what they are to do for their assigned residents by following the NA care plan in Kiosk system. Employee #1079 also said NAs got a report at the start of their shift and residents have a daily routine. .",2018-05-01
5957,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,311,D,0,1,GK2611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide a restorative program, to maintain or improve the current level of functioning, for one (1) of three (3) residents reviewed for the care area of rehabilitation. A restorative program, after completion of therapy services and as outlined in the physical therapy discharge summary and in the physician's orders [REDACTED].#19. Facility census: 64. Findings include: a) Resident #19 An interview with the physical therapy (PT) assistant, Employee #130, at 2:07 p.m. on 07/30/14, found the resident was discharged from all therapy services on 07/25/14. Occupational therapy (OT) was discontinued on 07/17/14, and PT was discontinued on 07/25/14. On 08/04/14 at 3:02 p.m., OT assistant, Employee #132, stated the resident did not go to a restorative program. She said she did not know why she was not placed in a restorative program. A registered nurse, Employee #101, was interviewed at 3:09 p.m. on 08/04/14. She stated the resident should be on a restorative program. She said she did not know why this had not happened. Employee #101 provided a physician's orders [REDACTED]. Review of the PT discharge summary, dated 07/28/14 at 7:02 p.m., confirmed the discharge disposition was for restorative nursing. There was a goal for training tor take the brace on and off as well as daily gait training. At 3:16 p.m. on 08/04/14, the vice president of health services stated he did not know why the resident was not in a restorative program, but he would find some answers. On 08/04/14 at 4:28 p.m. the physical therapist, Employee #136, stated the discharge summary, which he completed, was incorrect. He stated he should have completed a new summary as the resident was not appropriate for restorative therapy. Employee #136 was unable to provide evidence he had conveyed this information to nursing staff before surveyor intervention. He stated the plans changed when the resident would not wear her brace and he felt it was unsafe for nursing assistants to provide ambulation. He did not provide any explanation as to why the resident could not receive range of motion services, that did not involve ambulation, as directed by the physician's orders [REDACTED].",2018-05-01
5958,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,314,G,0,1,GK2611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, review of information from the National Pressure Ulcer Advisory Panel, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure two (2) of four (4) residents reviewed for pressure ulcers did not develop avoidable pressure ulcers and/or received services to promote healing of existing pressure ulcers. Resident #23 was assessed at high risk for the development of pressure ulcers. The resident had two (2) Stage II pressure ulcers which had not been identified, assessed, or addressed by the facility, resulting in a determination of actual harm to the resident. Resident #19 had bilateral Stage I pressure ulcers to her heels upon admission which were not treated or monitored until after identification during the survey. In addition, the resident expressed pain, associated with the pressure ulcers on her heels, which was not addressed by the facility. Resident Identifiers: #23 and #19. Facility Census: 64. Findings Include: a) Resident #23 In an interview with Registered Nurse (RN) #101, on 07/29/14 at 11:30 a.m., the nurse reported Resident #23 did not have any pressure ulcers. A review of Resident #23's medical record, at 11:00 a.m. on 07/30/14, revealed Resident #23 was readmitted to the facility on [DATE] after a hospitalization due to a fractured femur. The admission nursing assessment indicated Resident #23 had no skin breakdown and/or pressure ulcers upon readmission to the facility. The resident had a Braden Scale for Pressure Sore Risk assessment, completed on 07/08/14, which indicated the resident was at high risk for development of pressure ulcers. A nurse surveyor observed incontinence care for the resident, provided by Nurse Aide (NA) #113, on 07/30/14 at 2:20 p.m. Resident #23 was observed with a pressure ulcer on the left buttock and another on the right buttock. NA #113 stated when she worked with the resident a week ago the resident had only a skin tear to his right buttock, which was caused by shearing. Registered Nurse (RN) #101 was requested to assess Resident #23's buttocks at 2:30 p.m. on 07/30/14. The assessment by RN #101 was observed by the nurse surveyor. The resident had a wound to the right buttock measuring five (5) centimeters (cm) in length and four (4) cm in width. The outer edges of the wound on the right buttock were bright red, and the inner part of the wound was pink/red with one (1) cm of yellow tissue in the center of the wound. Additionally, the resident had a wound to the left buttock that was five (5) cm in length and two (2) cm in width. The outer wound edges were bright red, and the inner part of the wound was white. RN #101 indicated both wounds would be considered Stage II pressure ulcers. (Note: According to the National Pressure Ulcer Advisory Panel (NPUAP) and the Long-Term Care Facility Resident Assessment Instrument User's Manual - Version 3.0, a Stage II pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed without slough. Slough is non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. The presence of the yellow tissue in the right buttock wound suggested the area was a Stage III ulcer rather than a Stage II.) At 2:48 p.m. on 07/30/14, RN #101 stated she was not aware Resident #23 had the pressure areas to his buttocks. She stated she assessed the right buttock on 07/22/14 and found shearing, which was not considered a pressure ulcer. She stated the physician ordered, on 07/22/14, Hydrogel and border foam to shearing on right buttocks daily until healed. She indicated she had not reassessed the area because it was not a pressure ulcer. She said RNs only did weekly assessments on pressure ulcers. When asked if the wound to the right buttock looked worse today than it did on 07/22/14 she replied, Yes it is a lot worse. When asked if the nurses providing the daily treatments had reported to her the wound had become worse, she stated, The LPNs (Licensed Practical Nurses) have not reported the worsening of the wound to me. RN #101 said the LPNs were responsible for notifying the RN in charge of any worsening of an existing wound as well as the identification of any new areas of breakdown. This was supposed to occur on the day the areas were identified. She stated she was not made aware of the wound worsening or the development of the additional wound to the left buttock. RN #101 indicated if it had been reported to the RN as required, the wounds would have been assessed and treatment would have begun prior to this date. She stated it was likely the wound to left buttock started out as a reddened area and/or shearing like the wound to the right buttock, and then progressed to a Stage II pressure ulcer. RN #101 said it should have been identified prior to becoming a Stage II pressure ulcer. During this interview, RN #101 confirmed Resident #23 did not have any pressure ulcers to his buttocks upon readmission to the facility. She said he had a bruise to his right buttock; however, the pressure ulcer now noted was in a completely different part of the resident's buttock than the previously identified bruise. When asked what interventions were in place to prevent Resident #23 from developing pressure ulcers, she stated, He has a Maxi float mattress, he is to be turned and repositioned every two (2) hours, and he is to have zinc applied to his buttocks every eight hours. When asked if the Stage II pressure ulcers should have been identified prior to the observation of incontinence care, during the survey on 07/30/14, RN #101 stated the pressure ulcers should have been identified during the daily treatment (a bandage to the right buttock) provided by the LPNs and NAs should have noticed them during the application of zinc cream to the resident's buttocks three (3) times a day. Interview with the Coordinator of Quality Improvement RN #96, at 9:04 a.m. on 07/31/14, revealed the the NAs were to immediately report, to a LPN or the RN in charge, if skin break down was noticed or a wound was worsening. If noticed or reported to the LPN, the LPN was to immediately report the information to the RN so the area could be assessed, measured, and staged if necessary. She stated if the LPN was providing the treatment daily (bandage) and the NAs were applying the zinc cream three (3) times a day, as well as providing incontinence care, the pressure ulcers to Resident #23's buttocks should have been identified and reported to the RN prior to the identification of the wounds while observing incontinence care during the survey. An additional interview with RN #101, at 10:14 a.m. on 07/31/14, revealed Resident #23's physician had evaluated the resident's wounds. As the result of the evaluation, the physician ordered a treatment of [REDACTED]. RN #101 stated the physician was in agreement with the staging and the measurements of the wounds on the right and left buttock. b) Resident #19 During a Stage 1 Quality Indicator Survey (QIS) interview with RN #101, at 4:33 p.m. on 07/28/14, she stated the resident was admitted with an unstageable DTI (deep tissue injury) to the right toe. Medical record review, during Stage 2 of the QIS, revealed the resident was admitted to the facility on [DATE]. The admission minimum data set (MDS) with an assessment reference date (ARD) of 05/28/14, indicated the resident was admitted with an unstageable pressure area and two (2) Stage I pressure areas. According to the MDS, the resident did not have any unstageable deep tissue injuries (DTI). Review of the admission nursing assessment, completed by the facility on 05/21/14 by a LPN, found the resident, .has multi bruised areas and discoloration on b/l (bilateral) legs . a black in color scabbed area on the left big toe . and a small bruise in the right side of her lower back right above her hip area. There was no mention of any other skin issues. Documentation was added to the admission nursing assessment by a RN, on 05/22/14, indicating the resident had a left great toe nail which was raised, black, and thick. It also noted the tip of the right great toe had an unstageable necrotic area measuring 0.4 cm by 0.5 cm, with no drainage noted. In addition, the note indicated the left and right heels were soft and boggy. The RN coordinator of quality improvement, Employee #96, was interviewed on 07/30/14 at 8:16 a.m. regarding the admission nursing assessment. She agreed the LPN who admitted the resident did not mention any area to the right great toe or any problems with the resident's heels. She was asked how the facility determined the pressure area was present on admission, when the admission assessment, completed on 05/21/14, did not mention the areas. RN #96 said the admitting nurse should have captured those areas during her assessment. An interview with RN #101, at 3:32 p.m. on 07/29/14, found the facility had an order for [REDACTED]. Employee #101 stated she was not aware of any issues with the resident's heels. She said she could find no documentation regarding the heels on the weekly wound sheets completed on 06/05/14, 06/19/14, 07/04/19, 07/11/19, and 07/24/19. During an observation of the resident's bilateral feet with Employee #101, at 4:05 p.m. on 07/29/14, the resident stated her left heel was hurting. She said, I have been telling you all that since I got here. Employee #101 examined the left heel and stated her heel appeared to be covered with dry callus skin and was soft and boggy. An examination of the right heel by Employee #101 yielded the same conclusion. The RN stated she would contact the medical director today. According to the resident assessment instrument (RAI) manual, the definition of a Stage I pressure ulcer is, An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. At 5:00 p.m. on 07/29/14, Employee #101 reviewed the physician's progress notes dated 06/22/14, 06/24/14, 07/07/14 and 07/21/14. She was unable to find any documentation by the physician regarding the pressure areas on the resident's heels. An interview with Employee #101, at 11:00 a.m. on 07/30/14, found the physician examined the resident on 07/30/14 and ordered heel protectors while in bed and [MEDICATION NAME] external cream to be applied twice daily to the legs and feet for dryness. Employee #103, the MDS coordinator was interviewed, at 1:23 p.m. on 07/30/14, regarding the admission MDS. She was asked where the facility obtained the information for completion of the pressure ulcer information on the MDS. She said she did not complete the MDS and the employee who did was not at the facility. She said the employee who completed the MDS must have examined the resident and found the areas. She verified the weekly wound assessments did not mention the resident's heels. RN #103 provided a copy of the care area assessment (CAA) for pressure ulcers indicating the nurse who completed the admission MDS noted the resident was admitted with Stage I areas to the bilateral heels and an unstageable ulcer to the right great toe. She was unable to find any other documentation of the Stage I pressure areas to the bilateral heels. RN #103 concluded the facility had not addressed the Stage I pressure areas to the heels, and these areas were never described on any of the weekly wound sheets. She was unable to find any documentation to support the pressure areas to the heels were being monitored by the facility. An interview with the vice president of health services (VPHS), on 08/04/14 at 10:10 a.m., was conducted to discuss Resident #19's pressure areas and to determine how the facility addressed the resident's complaints of pain, which the resident expressed during observations of her feet on 07/29/14. The VPHS provided copies of pain assessments completed on 05/22/14, 06/03/14, 06/05/14, 06/22/14, and 07/24/14. These pain assessments indicated the resident did not have any pain and no interventions were necessary. The VPHS was again asked what the facility did regarding the resident's complaints of pain during the observation on 07/29/14. On the evening of 08/04/14, at approximately 4:00 p.m., the VPHS was once again asked what interventions the facility implemented regarding the resident's complaints of pain on 07/29/14. At 10:00 a.m. on 08/05/14, the VPHS was again asked about the provision of interventions for pain, related to the resident's complaints on 07/29/14. At the close of the survey, on 08/05/14 at 2:00 p.m., no information had been provided regarding interventions to address Resident #19's complaints of pain to the left heel, which she expressed on 07/29/14.",2018-05-01
5959,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,323,K,0,1,GK2611,"Based on observation, water temperature measurements, staff interviews, review of facility procedures, and resident interview, the facility failed to ensure the resident's environment, over which the facility had control, was as free from accident hazards as possible for 34 of 64 facility residents. On 07/28/14, water temperatures obtained in resident areas on all hallways exceeded 110 degrees Fahrenheit (F). Three (3) resident rooms had water temperatures at sinks which exceeded 120 degrees F. The maintenance department became aware the facility's water temperatures exceeded 120 degrees F at 9:00 a.m. on 07/28/14. Maintenance did not promptly alert staff and enact a plan to ensure resident safety while they were adjusting the water temperatures. Interviews revealed nursing staff and administrative staff were not notified of any concerns regarding excessive hot water temperatures until 4:00 p.m. on 07/28/14. Staff interviews also confirmed that from 9:00 a.m., when the problem was identified, until 4:00 p.m., residents were provided showers as scheduled on the day shift, and showers continued to be provided into the evening shift until 4:00 p.m. At 4:00 p.m. on 07/28/14, a resident, who was receiving a shower, complained to staff the water temperatures were too hot. At that time all staff were advised to discontinue the showering of residents. Residents #20, #39, #36, #85, #52, #18, #31, #5, #13, #81, #50, #95, #15, #97, #49, #70, and #3 were all provided showers on 07/28/14 between 9:00 a.m. and 4:00 p.m. Between the hours of 9:00 a.m. and 4:00 p.m., all hand sinks were accessible to each resident who was able to independently wash his/her hands. Residents #53, #47, #19, #69, #46, #12, #37 , #32, #67, #78, #61, #58, #81, #90, #95, #7, #6, #11, #76, #49, #70, and #3 were all identified by facility staff as residents who were independently able to wash his/her own hands. A determination was made that an immediate jeopardy existed. The immediate jeopardy began at 9:00 a.m. on 07/28/14, when the maintenance department began using the hot water tank servicing the laundry department to service the resident care areas. On 07/28/14 at 6:00 p.m., the Chief Operating Officer, the nursing home administrator of the long term care unit, was notified of the existence of an immediate jeopardy. A plan of correction (P(NAME)) was provided by the facility at 6:15 p.m. on 07/28/14. The P(NAME) indicated the facility would do the following, 1. Water temperatures in the facility are being monitored by the maintenance department on an hourly basis until such time that the water temperatures are stabilized at or below 110 degrees. 2. All residents that received showers throughout the day of 07/28/14 are being assessed by the RN (Registered Nurse) nursing staff to determine that there was no harm such as redness, burning, or excoriation as a result of the water temperatures exceeding 110 degrees. 3. All of the residents have been informed by social services regarding the water temperatures and have been informed not to use the sinks to wash their hands until given clearance from social services. In the meantime, washcloths and hand sanitizer will be provided for cleansing of resident's hands. 4. Signs will be hung above the sinks to remind residents not to use the water. Also the hot water will be turned off to every sink. 5. All showers have been discontinued until such time that the water temperature can be maintained at or below 110 degrees. Bed baths will be used in place of showers. The items outlined in the P(NAME) were observed in place at the time the P(NAME) was provided on 07/28/14 at 6:15 p.m. The P(NAME) was accepted at 6:20 p.m. on 07/28/14; therefore, the immediacy of this deficient practice was abated at 6:20 p.m. on 07/28/14. A deficient practice in the area of accident hazards still remained, so the scope and severity was decreased from a K to an E. In addition to the hot water, observation revealed used disposable shaving razors were not secured in a biohazard container, and were accessible to residents. Also, a bottle of sanitizer was stored in an unlocked shower room to which residents had access. Resident identifiers: #20, #39, #36, #85, #52, #18, #31, #5, #13, #50, #15, #97, #53, #47, #19, #69, #46, #12, #37, #32, #67, #78, #61, #58, #81, #90, #95, #7, #6, #11, #76, #49, #70, and #3. Facility Census: 64 Findings Include: a) Water Temperatures The following temperatures were obtained in resident hand sinks, by facility staff using the facility's thermometer: -- Room #3 at 2:57 p.m. on 07/28/14 120.2 degrees Fahrenheit (F) -- Room #4 at 3:00 p.m. on 07/28/14 113.5 degrees F. -- Room #0 at 3:03 p.m. on 07/28/14 113.4 degrees F. -- Room #18 at 3:05 p.m. on 07/28/14 112.6 degrees F. -- Room #23 at 3:25 p.m. on 07/28/14 120.6 degrees F. -- Room #22 at 3:27 p.m. on 07/28/14 118.6 degrees F. -- Room #0 at 3:30 p.m. on 07/28/14 118.6 degrees F. -- Room #36 at 4:45 p.m. on 07/28/14 122.0 degrees F. -- Room #3 at 5:01 p.m. on 07/28/14 121.8 degrees F. -- Room #36 at 5:05 p.m. on 07/28/14 109.6 degrees F. Interview with the Vice President (VP) of Environmental Services at 3:26 p.m. on 07/28/14, revealed the water tank that serviced the resident care area had . went down . and he had to switch to another tank which serviced the laundry department. He further indicated this hot water tank gets a lot hotter than the one previously servicing the resident areas. He stated the water from the tank which serviced laundry was at 160 degrees F and they had to adjust it down using the mixing valve so it would not be too hot going to resident areas. He stated, We are working to get the water temperature down. We got it down to 140 degrees (F) this morning. He was then asked if the nursing department was notified of the situation and what was put into place to protect the residents while adjustments to the water temperatures were being made. He replied, I don't know about that, we switched over the tanks and we have been taking temperatures trying to get the temperature down. He stated they switched to the tank servicing laundry at about 9:00 a.m. on 07/28/14 and he had no idea if nursing or any other department knew about the situation. He stated, We were focused on getting the residents some hot water. An interview with the director of quality improvement Registered Nurse (RN) #96 and RN #133, at 3:57 p.m. on 07/28/14, revealed the residents received their showers as scheduled that day. RN #96 reported all female residents in the A bed would have received a shower on the day shift. She indicated they usually began giving showers at 9:00 a.m. She further stated evening shift would shower all the male residents in the A beds that night. Neither RN #96, nor RN #133 knew anything about the elevated water temperatures. RN #96 stated, I think they are giving a resident a shower now. She went into the shower room and reported Resident #31 was getting a shower. RN stated the resident told her the water temperature was too hot. She then stated, I am going to instruct the nurse aides (NA) to not give any more showers until this is fixed. No one told us anything about this. We did not know there was a problem. An interview with Licensed Practical Nurse (LPN) #116, at 4:11 p.m. on 07/28/14, revealed residents had been receiving their showers as scheduled. She stated she had not been informed about any issues with the water, and as far as she knew, the water was at a safe temperature for resident use. She stated no one had said anything to her about being careful with the water or about making sure residents did not use the water independently to wash their hands. RN #101, who was working as the charge nurse on 07/28/14, was interviewed at 4:30 p.m. on 07/28/14. She was asked if she had been made aware of any concerns about the hot water. She stated she was not aware of any concerns with the hot water. She said as far as she knew, the residents could use the water as needed and showers should be given as scheduled. Interview with the Chief Operating Officer (COO), at 11:10 a.m. on 08/05/14, revealed he was unaware of the unsafe water temperatures until after 4:00 p.m. on 07/28/14. He was asked if he could provide the water temperatures obtained by the maintenance department while they were attempting to regulate the hot water temperature between 9:00 a.m. and 4:15 p.m. on 07/28/14. He stated, If they took any temperatures while they were regulating the water, I don't have a record of them. The COO was unable to provide any water temperatures for 07/28/14 prior to 4:15 p.m., seven (7) hours after the facility began using the hot water tank servicing laundry to service the resident care area. Those temperatures, when obtained by facility staff using their own thermometer at 4:15 p.m. were: -- Room #7 117 degrees F -- Room #25 119 degrees F -- Room #24 114 degrees F -- Room #31 118 degrees F -- Room #30 114 degrees F -- Room #33 113 degrees F .b) Razors During the initial tour of the facility, on 07/28/14 at 11:53 a.m., an unlocked shower room was observed with a sharps disposal container (a container used to dispose of sharp objects) which was full. Two (2) personal disposable razors were sticking up out of the sharps disposal container. Another disposable razor was observed in a cabinet, with the door open, in the shower room. An interview with the director of quality improvement, Registered Nurse #96 on 07/28/14 at 11:55 a.m., confirmed the sharps disposal container was full. She stated the staff knew better than to leave razors sticking out of the container. She also agreed that the razor in the cabinet should not be there. She stated staff were to get razors out of the Omnicell (storage for healthcare items). Each razor removed from the Omnicell was to be used one (1) time, and then disposed of properly. A review of the facility policy and procedure, on 07/31/14 at 9:40 a.m., revealed each time a razor was needed, it should be obtained from the Omnicell. It noted razors were not to be stored in the shower room at any time, or for any reason. According to the policy, nursing staff was to notify the charge nurse when the sharps container was three-fourths (3/4) full to prevent overfilling and a possible injury to residents and staff. The charge nurse was then responsible for proper disposal and replacement with an empty container for disposal of razors. c) Chemical Observation, on 08/04/14 at 1:20 p.m., revealed the door was open to the shower room. A bottle of Santi-tyze (food contact surfaces sanitizer cleaner and sanitizer for institutional and industrial use) was found on the hand sink in the shower room. In an interview, on 08/04/14 at 1:30 p.m., with registered nurse/charge nurse (RN-CN) #101, the RN confirmed the Santi-tyze cleanser should not be on the hand sink in the shower room. She said nursing assistants (NAs) obtained the Santi-tyze from the housekeepers to clean the shower room. The NAs were supposed to return the Santi-tyze to the housekeepers so the cleanser could be locked up. The RN stated the nursing assistant must have forgotten to return the cleaner to the housekeeper.",2018-05-01
5960,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,325,D,0,1,GK2611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, observation, and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for the care area of nutrition was provided care and services to maintain acceptable parameters of nutritional status. The facility failed to address the resident's expressed dissatisfaction with her meals. In addition, the facility failed to immediately recognize, evaluate, and address an eighteen (18) pound (13.5%) weight loss which, according to medical records, occurred in eleven (11) days. Resident identifier: #19. Facility census: 64. Findings include: a) Resident #19 During an interview with Resident #19 in Stage 1 of the Quality Indicator Survey (QIS), at 8:34 a.m. on 07/29/14, the resident said she had lost weight because she could not eat the food at the facility. She said the food was not good and it was usually cold. She added, The lady in the kitchen had came and talked with me about the food, but it did not do any good. Review of the medical record found the resident was admitted to the facility on [DATE]. A nursing admission assessment, completed on 05/21/14, recorded the resident's admission weight as 151.03 pounds and height as 58 inches. The resident's weights, which were recorded in the computer under vital signs, noted the resident weighed 133 pounds on 06/01/14. The resident's 05/21/14 admission weight, which was 151 pounds, was not noted in the vital signs section in the computer. There was no evidence the resident's eighteen (18) pound (13.5%) weight loss in eleven (11) days was identified or addressed by the facility. The registered dietitian, Employee #32, was interviewed at 2:30 p.m. on 07/29/14. When asked if she addressed the resident's weight loss, she stated she did not address the resident's weight loss because she did not know the resident had lost weight until 06/10/14. She stated, The nursing staff has to tell me and they didn't. When I noticed a weight loss on 06/10/14, I had her re-weighted and her weight was 133 pounds. She further explained the facility has a policy to weigh all new admissions every week for the first four (4) weeks. She provided a copy of the resident's physician's orders [REDACTED]. Employee #32 said this did not happen, and the resident was not weighted again until 07/01/14. She said, When the weight loss was discovered on 06/01/14, the resident should have been re-weighted, that is the policy to re-weigh with a five (5) pound or greater weight change. She said she was now tracking the resident's weight. The registered dietitian acknowledged the care plan only addressed a potential for nutritional issues and not an actual weight loss. Observation of the resident's noon meal on 07/30/14, at approximately 12:30 p.m., found she was served a BBQ brisket, a potato wedge, a slice of bread, milk and coffee. The resident said the meat was terrible and she was unable to eat it. She said, I can eat the potato and the slice of light bread. When advised the other residents had zucchini and baked beans she said, I don't like zucchini, but I would like to have some baked beans. When nursing staff was alerted the resident would like to have baked beans, the dietary manager delivered a bowl of baked beans, which the resident ate and said were very good. The resident was never offered a substitute for the brisket that she left uneaten. Review of the resident's dislikes, with the dietary manager (DM), at 4:30 p.m. on 07/29/14, found zucchini was listed as a dislike, but baked beans were not. The dietary manager was asked what vegetable the resident should have received in place of the zucchini. The DM said she forgot to put on an alternate vegetable. The physician's progress notes, dated 07/05/14, found the statement, . Resident then begins to complain about the food and indicates she is concerned that her current issues tie to this. The progress report noted this visit was an acute visit for the problem of, Malaise. There was no evidence the facility addressed the resident's food concerns as noted by the physician on 07/05/14.",2018-05-01
5961,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,329,D,0,1,GK2611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure three (3) of five (5) residents reviewed for the care area of unnecessary medications, during Stage 2 of the Quality Indicator Survey (QIS), were free of unnecessary medications. Resident #23 had not been considered for a gradual dose reduction of an antipsychotic medication. The facility failed to adequately monitor Resident #5's use of a medication which required a pulse be taken prior to administration. Behavioral symptoms and side effects regarding the use of an antipsychotic medication were not monitored for Resident #46. Resident Identifiers: #23, #5, and #46. Facility Census: 64. Findings include: a) Resident #23 A medical record review, at 4:32 p.m. on 07/29/14, revealed the resident had a physician's orders [REDACTED]. This dose of [MEDICATION NAME] was originally ordered on [DATE], and Resident #23 continued to receive this daily dosage of [MEDICATION NAME]. Further review revealed the resident had been receiving [MEDICATION NAME] oral capsule 40 mg from 05/15/10 until 08/08/11, at which time the [MEDICATION NAME] was reduced to 20 mg a day. Review of the drug regimen reviews, completed by the pharmacist on a monthly basis, revealed the last gradual dose reduction (GDR) of Resident #23's [MEDICATION NAME] was recommended by the pharmacist on 10/09/12. The physician responded to this recommendation by saying, The resident has had a good response to treatment and requires this dose for condition stability. Dose reduction at this time would be contraindicated because benefits outweigh the risks for this patient and reduction is likely to impair the resident function and or cause psychiatric instability. As of 07/29/14, there was no evidence a GDR of [MEDICATION NAME] was recommended, attempted, and/or addressed as clinically contraindicated since 10/09/12. An interview with Registered Nurse (RN) #101, at 9:30 a.m. on 07/30/14, confirmed Resident #23 had not had a GDR recommended, attempted, and/or addressed as clinically contraindicated since 10/09/12. The Vice President of Health Services (VPHS) also stated, at 11:36 a.m. on 08/04/14, he did not see a recommendation, attempt, or that a GDR was addressed by the physician as clinically contraindicated since 10/09/12. In an interview with the consultant pharmacist, at 3:20 p.m. on 08/04/14, he stated a GDR of an antipsychotic medication should be made annually if the resident had been on the medication for longer than one (1) year. He stated even if the physician previously indicated a GDR would be clinically contraindicated, it should still be recommended and either attempted and/or addressed as clinically contraindicated by the physician. He stated if Resident #23 had not had these recommendations since 10/09/12, then it was something he must have missed. b) Resident #5 Review of Resident #5's medical record, at 9:52 a.m. on 08/04/14, revealed a physician's orders [REDACTED]. Resident #5 received this medication due to a [DIAGNOSES REDACTED]. Resident #5's medication administration records and vital sign records were reviewed for the months of May 2014, June 2014 and July 2014. There was no evidence the resident's pulse was obtained prior to the administration of [MEDICATION NAME] on 05/01/14, 05/04/14, 05/10/14, 05/13/14, 05/17/14, 05/19/14, 05/22/14, 05/28/14, 05/29/14, 05/30/14, 06/04/14, 06/15/14, 06/20/14, 06/24/14, 06/29/14, 06/30/14, 07/08/14, 07/12/14, 07/13/14, 07/17/14, 07/18/14, 07/28/14, 07/29/14, and 07/31/14. Interview with the VPHS, at 8:34 a.m. on 08/05/14, confirmed there was no evidence Resident #5's pulse was obtained prior to the administration of [MEDICATION NAME] on the previously mentioned dates. He stated, It looks as if they are giving the medication without obtaining a pulse prior to administering the medication and there is no way to tell if (Resident's name) has received this medication unnecessarily. c) Resident #46Medical record review found the resident was receiving the antipsychotic medication [MEDICATION NAME] 25 mg at night for a [DIAGNOSES REDACTED].Review of the facility's psychopharmacological drug monthly flow records revealed the resident did not have a sheet to describe the targeted behaviors to monitor and also no identified side effects for which the resident needed to be monitored.During an interview, on 08/03/14 at 3:00 p.m., the VPHS said the psychopharmacological drug monthly flow records were where staff were supposed to indicate monitoring for targeted behaviors and side effects. At that time, the VPHS acknowledged Resident #46 did not have a psychopharmacological drug flow sheet for [MEDICATION NAME]. The resident was not being monitored for the use of the [MEDICATION NAME].",2018-05-01
5962,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,356,C,0,1,GK2611,"Based on observation and staff interview, the facility failed to ensure the daily staff posting was posted in a place that was visible to residents and visitors. This had the potential to affect all residents and/or their responsible parties. Facility census: 64. Findings include: a) On 08/04/14 at 3:00 p.m., an observation of the nurse staffing posting revealed it was not located in place that was visible and accessible to residents/visitors. The nurse staffing posting was in a clear plastic holder on the wall. The paper the posting was typed on was sitting sideways in the plastic holder. You could not read the posting without taking it out of the plastic holder. The plastic holder was not within reach of a resident who was in a wheelchair. b) At 3:15 p.m. on 08/04/14, the administrator said he would change the location of the daily staff posting.",2018-05-01
5963,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,364,E,0,1,GK2611,"Based on resident interview, review of grievance concern forms, observation, and food temperature measurements, the facility failed to ensure food was palatable, attractive, and served at temperatures which were acceptable to the residents. Hot foods were not served according to current professional standards and customary practice, which requires hot foods to be no less than 120 degrees Fahrenheit (F) at the time of receipt by the resident. This practice had the potential to affect more than a limited number of residents. Facility census: 64. Findings include: a) Resident interviews During Stage 1 of the Quality Indicator Survey (QIS), nine (9) of fifteen (15) interviewable residents complained of food temperatures and/or food taste. 1) Resident #68 said the food was not always served at proper temperatures, hot foods were not hot and cold foods were not always cold. 2) Resident #19 said the food was cold 3) Resident #91 said the food was barely warm 4) Resident #12 said only once in a while do they get a good meal 5) Resident #31 said the casseroles were horrible 6) Resident #96 said the food was not palatable 7) Resident #5 said cold foods were too warm 8) Resident #3 said the food did not look good 9) Resident #9 said she orders out from town because the food tastes bad. b) Resident complaints Review of grievance / concern forms found eight (8) documented concerns regarding the food since 03/13/14. Complaints included concerns about the menus, uncooked meats, the appearance of the meals, undercooked vegetables, portion sizes, and timely meal delivery. c) Food temperatures on Goodall Hall Observation of the noon meal delivery, on 07/30/14, found the meal cart arrived at 11:55 a.m. At 12:30 p.m., the registered dietitian and the dietary manager were asked to take the temperatures of the foods (with their thermometer) on the last tray on the food cart. The temperatures were: fried zucchini - 110 degrees F baked beans - 115 degrees F beef brisket - 112 degrees F d) Atrium Food Temperature Measurements At 12:16 p.m. on 07/30/14, a test tray containing a regular diet and a test tray containing a pureed diet were placed on the last meal cart to leave the kitchen for service. The meal cart contained resident meal trays for residents who had their noon meal in the Atrium of the facility. The cart containing the test trays left the kitchen at 12:17 p.m. on 07/30/14. The last resident tray on the meal cart was served at 12:35 p.m., at which time the temperatures of the foods on the test trays were taken. The temperatures were taken by the Vice President (VP) of dining services, using a facility thermometer. The following temperatures were obtained and confirmed with the VP of dining services: Pureed Foods -- Fried Zucchini - 98 degrees F -- Baked Beans - 108 degrees F Regular Consistency Foods -- Baked Beans - 106 degrees F -- Fried Zucchini - 115 degrees F -- Beef Brisket - 110 degrees F",2018-05-01
5964,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,366,E,0,1,GK2611,"Based on observation and staff interview, the facility failed to ensure seven (7) of seven (7) residents who disliked zucchini were offered a substitute of similar nutritive value. Each of the residents had a previously identified dislike of zucchini. During the lunch meal on 07/30/14, these residents were not provided or offered another vegetable in place of the zucchini. Resident identifiers: #19, #64, #68, #3, #60, #23, and #42. Facility census: 64. Findings Include: a) Resident #19 Observation of the lunch meal, on 07/30/14 at 12:30 p.m., found the resident was served a BBQ brisket, a potato wedge, a slice of bread, milk and coffee. The resident said the meat was terrible and she was unable to eat it. She said, I can eat the potato and the slice of light bread. When advised the other residents had zucchini and baked beans she said, I don't like zucchini but I would like to have some baked beans. When nursing staff were alerted the resident would like to have baked beans, the dietary manager delivered a bowl of baked beans. The resident ate the baked beans and said were very good. The resident was never offered a substitute for the brisket that she left uneaten. Review of Resident #19's dislikes with the vice president (VP) of dining services, at 4:30 p.m. on 07/29/14, found zucchini was listed as a dislike, but the baked beans were not. The dietary manager was asked what vegetable the resident should have received in place of the zucchini. She said she had forgotten to put on an alternate vegetable. Upon inquiry, she confirmed any resident who had a dislike of zucchini would not have received an alternate vegetable for the noon meal on 07/30/14. b) Residents #64, #68, #3, #60, #23, and #42 The VP of dining services was asked how many residents did not receive a substitution for the zucchini at noon on 07/30/14. In addition to Resident #19, she provided the names of Residents #64, #68, #3, #60, #23, and #42. She indicated all seven (7) residents had voiced a dislike of zucchini and should have been offered an alternate vegetable.",2018-05-01
5965,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,371,F,0,1,GK2611,"Based on observations, record review, and staff interview, the facility failed to store foods under sanitary conditions. During the initial tour of the kitchen, multiple food items were observed opened with no date to indicate when they were opened or when they should be discarded. As well, the dry food storage area contained opened food items which required refrigeration after opening. Additionally, during the initial tour of the nutrition pantry on the nursing unit, multiple food items were found unlabeled and undated. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility Census: 64. Findings Include: a) During the initial tour of the kitchen, at 11:30 a.m. on 07/28/14, the following food items were observed stored in the walk-in cooler, the reach-in cooler and/or the dry goods storage area. Each of the food items was opened and partially used; however, they were not dated as to when they were opened or when they should be discarded. -- In the walk-in cooler was: egg salad, ham salad, chicken salad, mozzarella cheese, parmesan cheese, Swiss cheese, bologna, ham, cheddar cheese cubes, light mayonnaise, balsamic vinaigrette, shredded lettuce, and shredded carrots. -- In the reach-in cooler was: a bottle of apple juice and grape juice. -- In the dry goods storage area was: a bag of coco mix and a bag of muffin mix. b) While touring the dry goods storage area, two (2) opened, partially used bottles of mustard were observed. The dates they were opened were 05/20/14 and 05/23/14. c) The Vice President of Dining Services was interviewed at 11:45 a.m. on 07/28/14. She stated all opened items were to have an open date so staff would be able to determine when the items should be discarded and no longer used. She stated the shelf life of the items, once opened, depended on what type of item it was. She indicated the meat, cheese, fresh vegetables, and juice should be discarded in seven (7) days. The mayonnaise and Balsamic vinaigrette would be discarded in 30 days. She confirmed the items were not labeled with an open date; therefore, a safe-to-use-by (discard date) could not be determined. She stated the mustard which was opened and stored in the dry storage area should have been stored in the coolers in the kitchen once they were opened, and should have been discarded in 30 days. She also confirmed each of the food items should not have been available for use. .d) An observation of the nursing unit nutrition pantry refrigerator was conducted during the initial tour of the facility on 07/28/14 11:30 a.m. The following sanitation issues were identified: 1. A plastic container containing a hamburger, with Resident #72's name on the outside of the container, had no date. 2. A restaurant bag containing hamburgers and a Cinnabon was unlabeled and undated. 3. An opened, undated, unlabeled bottle of natural spring water. 4. One (1) liter of diet Pepsi and two (2) liters of Schweppes ginger ale were found opened, unlabeled and undated. 5. One (1) liter of opened prune juice was unlabeled, and was dated 06/13/14. 6. A plastic container of chicken casserole, labeled for Resident #19, was undated. 7. A plastic bag containing chunks of cheddar cheese was unlabeled and undated. The director of quality improvement, Employee #96, was present during the observation of the nutrition pantry refrigerator. She confirmed the identified items were not appropriately labeled, dated or discarded in a timely manner. e) The facility's practice standards concerning labeling/ dating and discarding foods in the refrigerator was reviewed on 07/31/14 at 10:07 a.m. It indicated the refrigerator was for short-term storage, a maximum of seven (7) days. It also noted all foods were to be labeled and dated. According to the facility's practice standards, food that was not labeled was supposed to be discarded.",2018-05-01
5966,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,425,E,0,1,GK2611,"Based on a random opportunity for observation and staff interview, the facility failed to ensure the safe storage of medications for residents temporarily residing in the long term care section, who would be returning to the assisted living section of the facility. This practice had the potential to affect any resident who was temporarily admitted to long term care from the assisted living section. Facility Census: 64. Findings include: a) Observation of the medication room, on 07/30/14 at 11:30 a.m., found a clear plastic trash bag which contained multiple medications. The bag contained Cephalexin capsules, Meclizine tablets, Doxycline capsules, Ventolin inhaler, CeraVe lotion, Aquaphor ointment, Cetaphil cream, Levothyroxine tablets, Humlin N insulin, Biotene mouthwash, Aspirin 81 milligram (mg) tablets, and Citracel Calcium Citrate tablets. The medications in the bag belonged to multiple residents. Each medication had been opened and used. Two (2) registered nurses (RNs), Employee #96 and Employee #133, were present during the observation. They stated the medications belonged to residents from the assisted living section of the facility who were currently residents in the long term care section of the facility. The nurses explained the medications were going to be used when the residents returned to the assisted living floor. Upon inquiry, the RNs confirmed some of the medications from the trash bag were currently being used for those residents. They agreed the medications for the multiple residents should not be commingled, should be stored separately for each resident, and should not be stored in a trash bag. The nurses immediately destroyed the medications.",2018-05-01
5967,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,428,D,0,1,GK2611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the licensed pharmacist failed to identify and report irregularities for two (2) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). The pharmacist did not identify and report Resident #23 had not had a gradual dose reduction (GDR) of an antipsychotic medication annually. In addition, the pharmacist did not identify and report Resident #5 was administered medication on multiple occasions without first obtaining a pulse as ordered. Resident Identifiers: #23 and #5. Facility Census: 64. Findings include: a) Resident #23 A medical record review, at 4:32 p.m. on 07/29/14, revealed the resident had a physician's orders [REDACTED]. This dose of Geodon was originally ordered on [DATE], and Resident #23 continued to receive this daily dosage of Geodon. Further review revealed the resident had been receiving Geodon oral capsule 40 mg from 05/15/10 until 08/08/11, at which time the Geodon was reduced to 20 mg a day. Review of the drug regimen reviews, completed by the pharmacist on a monthly basis, revealed the last gradual dose reduction (GDR) of Resident #23's Geodon was recommended by the pharmacist on 10/09/12. The physician responded to this recommendation by saying, The resident has had a good response to treatment and requires this dose for condition stability. Dose reduction at this time would be contraindicated because benefits outweigh the risks for this patient and reduction is likely to impair the resident function and or cause psychiatric instability. As of 07/29/14, there was no evidence the pharmacist recommended a GDR of Geodon since 10/09/12. In an interview with the consultant pharmacist, at 3:20 p.m. on 08/04/14, he stated a GDR of an antipsychotic medication should be made annually if the resident had been on the medication for longer than one (1) year. He stated even if the physician previously indicated a GDR would be clinically contraindicated, it should still be recommended and either attempted and/or addressed as clinically contraindicated by the physician. He stated if Resident #23 had not had these recommendations since 10/09/12, then it was something he must have missed. b) Resident #5 Review of Resident #5's medical record, at 9:52 a.m. on 08/04/14, revealed a physician's orders [REDACTED]. Resident #5 received this medication due to a [DIAGNOSES REDACTED]. Resident #5's medication administration records and vital sign records were reviewed for the months of May 2014, June 2014 and July 2014. There was no evidence the resident's pulse was obtained prior to the administration of Metoprolol Succinate on 05/01/14, 05/04/14, 05/10/14, 05/13/14, 05/17/14, 05/19/14, 05/22/14, 05/28/14, 05/29/14, 05/30/14, 06/04/14, 06/15/14, 06/20/14, 06/24/14, 06/29/14, 06/30/14, 07/08/14, 07/12/14, 07/13/14, 07/17/14, 07/18/14, 07/28/14, 07/29/14, and 07/31/14. Interview with the VPHS, at 8:34 a.m. on 08/05/14, confirmed there was no evidence Resident #5's pulse was obtained prior to the administration of Metoprolol Succinate on the previously mentioned dates. The pharmacist's drug regimen reviews were reviewed for the months of May 2014, June 2014, and July 2014. The pharmacist indicated there were no irregularities found during each of these drug regimen reviews. The pharmacist failed to identify and report the irregularity that the resident's pulse not always being obtained prior to the administration of Metoprolol Succinate.",2018-05-01
5968,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,431,E,0,1,GK2611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility, in coordination with the licensed pharmacist, failed to establish a system of medication records that enabled periodic accurate reconciliation, accounting for, and disposition of all controlled medications. The facility had no formal mechanisms in place to safely handle controlled medications, and to maintain accurate and timely medication records. The facility, in coordination with the pharmacist, failed to establish a means to ensure security and safeguarding of controlled medications. There was no system to account for the receipt, usage, disposition, and reconciliation of all controlled medications. The facility was not conducting periodic reconciliations of records of receipt, disposition, and inventory for controlled medications to prevent or identify loss or diversion of these medications. There was no evidence the pharmacist evaluated the facility's systems regarding controlled medications to ensure the facility maintained an accurate accounting of all controlled medications and completed periodic reconciliations. This practice had the potential to affect more than an isolated number of residents. Facility census: 64. Findings include: a) Observation of the medication room, on [DATE] at 11:30 a.m., found a large amount of controlled medications (those which are known to be frequently misused/abused) in a double locked cabinet. Two (2) registered nurses (RNs), Employee #96 and Employee #133, were present during the observation. They stated they were not aware the controlled medications were being stored in the cabinet. Upon inquiry, the RNs said all nurses had access to the cabinet. No logs, indicating who had received these medications and in what dose, were observed in the cabinet. RNs #96 and #133 confirmed the absence of logs related to the medications in the cabinet. The facility had no method of accounting for any of the medications and no method to monitor for and/or recognize potential loss or diversion. All nurses had access to the controlled medications in the cabinet, without accountability of the medication Further observation revealed the controlled medications in the cabinet were those ordered for current residents, discontinued medications for current residents, and controlled medications for discharged and deceased residents. There were names and dosages on the labels for the current residents; however, no records were available to indicate when they were placed in the cabinet or when they were taken out for use. The controlled medications for discharged and deceased residents were intermingled with those for current residents. Some of these were labeled for individual residents; however, some had nothing on the bottle other than the manufacturer's label. The medications found in this cabinet were: Phenobarbital 97.2 milligram (mg) tablets - 60 tablets Tylenol with codeine #2 tablets - 174 tablets Lyrica 200 mg capsules - 30 capsules Restoril 30 mg capsules - 120 capsules Lortab 7XXX,[DATE] mg tablets - 2 tablets Ativan 1 mg tablets - 520 tablets Oxycodone ER( extended release) 10 mg tablets - 30 tablets Xanax 2 mg tablets - 38 tablets Ativan injectable 1 mg per milliliters (ml) - 63 ml Tramadol 50 mg tablets - 512 tablets Morphine elixir 100 mg per 5 ml - 87.75 ml Xanax 0.25 mg tablets - 150 tablets Oxazepam 10 mg capsules - 60 capsules Ativan 2 mg tablets - 76 tablets Ambien 5 mg tablets - 48 tablets Xanax 1 mg tablets - 288 tablets Ativan 0.5 mg tablets - 90 tablets Lortab ,[DATE] mg tablets - 212 tablets Valium 2.5 mg tablets - 30 tablets Oxandrin 2.5 mg tablets - 49 tablets Oxycodone 5 mg tablets - 7 tablets Restoril 15 mg capsules - 30 capsules Klonopin 2 mg tablets - 30 tablets Lortab ,[DATE] mg tablets - 30 tablet b) Interview with the Chief Operating Officer (COO), on [DATE] at 1:00 p.m., revealed in April of 2014 there was a drug diversion involving Xanax. According to the COO, an investigation was conducted. The information was taken to the Quality Assurance Committee and a new process was initiated for the destruction of controlled medication. Under this new process, when a controlled medication was discontinued and/or a resident was discharged , the remaining amount of the medication, along with the Controlled Substance Record indicating the amount to be destroyed, would be placed in a locked box located on the wall in the medication room. Two (2) nurses would sign the Controlled Substance Record and place the medication and the record in the locked box. Only the pharmacist and the director of nursing would have the key to the box. The COO stated he thought this was happening and the issue with controlled medications was resolved. c) During an interview with the pharmacist, Employee #135, on [DATE] at 2:20 p.m., he stated he was not aware there was a large amount of controlled medications which were not being reconciled to prevent loss and/or diversion. d) Interview with the Vice President of Health Services (VPHS), Employee #90, on [DATE] at 11:30 a.m., revealed he was unaware of the controlled medication in the medication room, to which all nurses had access. He confirmed there was no process to do an accurate reconciliation and accounting for controlled medications. The VPHS agreed the facility had no means to determine if there had been a loss and/or a diversion of controlled medications. e) An interview was conducted with the attending physician, Employee #134 on [DATE] at 9:30 a.m When asked if he was aware of the large amount of controlled medications in the cabinet in the medication room, he stated, I knew the nurses had been calling for refills and I questioned as to why they were needing so much medication. I also told the nurses we need to check and see why so many refills were being required, although no one ever informed me as to why so many refills were needed. f) During a review of an Individual Resident's Controlled Substance Record, on [DATE] at 10:15 a.m., it was discovered Resident #50 had a vial of Ativan 2 mg per milliliter (ml) with 29 ml remaining in the vial. A handwritten note was on the bottom of the controlled substance sheet (typed as written): Wasted not refrigerated, (signatures of Employee #136, LPN and Employee #101, RN, charge nurse). Interview with Employee #101, on [DATE] at 10:20 a.m., confirmed she and the LPN destroyed the Ativan because it was not refrigerated as required. Upon inquiry as to whether nurses were to destroy controlled medication, the RN said, No, but the pharmacist, Employee #135, threw it at me and told us to destroy it. In an interview with the pharmacist, Employee #135, on [DATE] at 11:00 a.m., he stated, I don't remember me telling the nurses to destroy Ativan. I have to destroy all controlled medication with the DON present. Nurses are not allowed to destroy controlled medication.",2018-05-01
5969,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,490,F,0,1,GK2611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, resident interview, observation, review of the Resident Assessment Instrument (RAI), staff interview, water temperature measurement, and food temperature measurement, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of its residents. The facility was not administered in accordance with Federal Regulations. Systems to provide optimum quality of care, dietary services, and pharmacy services were not established and / or implemented. - The facility failed to identify, assess and/or provide treatments for Residents #23 and #19, who had pressure ulcers. - The facility failed to ensure the environment was as free as possible from accident hazards over which it had control. - The facility failed to ensure food was palatable, served at temperatures acceptable to the residents, and failed to offered food substitutions. - The facility, in coordination with the licensed pharmacist, failed to ensure safe and secure storage of controlled medications. There was no formal system for periodic reconciliation and accounting of controlled medications to identify loss or diversion of these medications. These practices had the potential to affect all residents. Facility census: 64. Findings include: a) Quality of Care/Pressures ulcers The facility failed to ensure two (2) of four (4) residents reviewed for pressure ulcers did not develop avoidable pressure ulcers and/or received services to promote healing of existing pressure ulcers. Resident #23 was assessed at high risk for the development of pressure ulcers. The resident had two (2) Stage II pressure ulcers which had not been identified, assessed, or addressed by the facility, resulting in a determination of actual harm to the resident. Resident #19 had bilateral Stage I pressure ulcers to her heels upon admission which were not treated or monitored until after identification during the survey. In addition, the resident expressed pain, associated with the pressure ulcers on her heels, which was not addressed by the facility. 1. Resident #23 In an interview with Registered Nurse (RN) #101, on [DATE] at 11:30 a.m., the nurse reported Resident #23 did not have any pressure ulcers. A review of Resident #23's medical record, at 11:00 a.m. on [DATE], revealed Resident #23 was readmitted to the facility on [DATE] after a hospitalization due to a fractured femur. The admission nursing assessment indicated Resident #23 had no skin breakdown and/or pressure ulcers upon readmission to the facility. The resident had a Braden Scale for Pressure Sore Risk assessment, completed on [DATE], which indicated the resident was at high risk for development of pressure ulcers. A nurse surveyor observed incontinence care for the resident, provided by Nurse Aide (NA) #113, on [DATE] at 2:20 p.m. Resident #23 was observed with a pressure ulcer on the left buttock and on the right buttock. NA #113 stated when she worked with the resident a week ago the resident had only a skin tear to his right buttock, which was caused by shearing. Registered Nurse (RN) #101 was requested to assess Resident #23's buttocks at 2:30 p.m. on [DATE]. The assessment by RN #101 was observed by the nurse surveyor. The resident had a wound to the right buttock measuring five (5) centimeters (cm) in length and four (4) cm in width. The outer edges of the wound on the right buttock were bright red, and the inner part of the wound was pink/red with one (1) cm of yellow tissue in the center of the wound. Additionally, the resident had a wound to the left buttock that was five (5) cm in length and two (2) cm in width. The outer wound edges were bright red, and the inner part of the wound was white. RN #101 indicated both wounds would be considered Stage II pressure ulcers. At 2:48 p.m. on [DATE], RN #101 stated she was not aware Resident #23 had the pressure areas to his buttocks. She stated she assessed the right buttock on [DATE] and found shearing, which was not considered a pressure ulcer. She stated the physician ordered, on [DATE], Hydrogel and border foam to shearing on right buttocks daily until healed. She indicated she had not reassessed the area because it was not a pressure ulcer. She said RNs only did weekly assessments on pressure ulcers. When asked if the wound to the right buttock looked worse today than it did on [DATE] she replied, Yes it is a lot worse. When asked if the nurses providing the daily treatments had reported to her the wound had become worse, she stated, The LPNs (Licensed Practical Nurses) have not reported the worsening of the wound to me. RN #101 said the LPNs were responsible for notifying the RN in charge of any worsening of an existing wound as well as the identification of any new areas of breakdown. This was supposed to occur on the day the areas were identified. She stated she was not made aware of the wound worsening or the development of the additional wound to the left buttock. RN #101 indicated if it had been reported to the RN as required, the wounds would have been assessed and treatment would have begun prior to this date. She stated it was likely the wound to left buttock started out as a reddened area and/or shearing like the wound to the right buttock, and then progressed to a Stage II pressure ulcer. RN #101 said it should have been identified prior to becoming a Stage II pressure ulcer. During this interview, RN #101 confirmed Resident #23 did not have any pressure ulcers to his buttocks upon readmission to the facility. She said he had a bruise to his right buttock; however, the pressure ulcer now noted was in a completely different part of the resident's buttock than the previously identified bruise. When asked what interventions were in place to prevent Resident #23 from developing pressure ulcers, she stated, He has a Maxi float mattress, he is to be turned and repositioned every two (2) hours, and he is to have zinc applied to his buttocks every eight hours. When asked if the Stage II pressure ulcers should have been identified prior to the observation of incontinence care, during the survey on [DATE], RN #101 stated the pressure ulcers should have been identified during the daily treatment (a bandage to the right buttock) provided by the LPNs and NAs should have noticed them during the application of zinc cream to the resident's buttocks three (3) times a day. Interview with the Coordinator of Quality Improvement RN #96, at 9:04 a.m. on [DATE], revealed the the NAs were to immediately report, to a LPN or the RN in charge, if skin break down was noticed or a wound was worsening. If noticed or reported to the LPN, the LPN was to immediately report the information to the RN so the area could be assessed, measured, and staged if necessary. She stated if the LPN was providing the treatment daily (bandage) and the NAs were applying the zinc cream three (3) times a day, as well as providing incontinence care, the pressure ulcers to Resident #23's buttocks should have been identified and reported to the RN prior to the identification of the wounds while observing incontinence care during the survey. An additional interview with RN #101, at 10:14 a.m. on [DATE], revealed Resident #23's physician had evaluated the resident's wounds. As the result of the evaluation, the physician ordered a treatment of [REDACTED]. RN #101 stated the physician was in agreement with the staging and the measurements of the wounds on the right and left buttock. 2. Resident #19 During a Stage 1 QIS interview with RN #101, at 4:33 p.m. on [DATE], she stated the resident was admitted with an unstageable DTI (deep tissue injury) to the right toe. Medical record review, during Stage 2 of the QIS, revealed the resident was admitted to the facility on [DATE]. The admission minimum data set (MDS) with an assessment reference date (ARD) of [DATE], indicated the resident was admitted with an unstageable pressure area and two (2) Stage I pressure areas. According to the MDS, the resident did not have any unstageable deep tissue injuries (DTI). Review of the admission nursing assessment, completed by the facility on [DATE] by a LPN, found the resident, .has multi bruised areas and discoloration on b/l (bilateral) legs . a black in color scabbed area on the left big toe . and a small bruise in the right side of her lower back right above her hip area . There was no mention of any other skin issues. Documentation was added to the admission nursing assessment by a RN, on [DATE], indicating the resident had a left great toe nail which was raised, black, and thick. It also noted the tip of the right great toe had an unstageable necrotic area measuring 0.4 cm by 0.5 cm, with no drainage noted. In addition, the note indicated the left and right heels were soft and boggy. The RN coordinator of quality improvement, Employee #96, was interviewed on [DATE] at 8:16 a.m. regarding the admission nursing assessment. She agreed the LPN who admitted the resident did not mention any area to the right great toe or any problems with the resident's heels. She was asked how the facility determined the pressure area was present on admission, when the admission assessment, completed on [DATE], did not mention the areas. RN #96 said the admitting nurse should have captured those areas during her assessment. An interview with RN #101, at 3:32 p.m. on [DATE], found the facility had an order for [REDACTED]. Employee #101 stated she was not aware of any issues with the resident's heels. She said she could find no documentation regarding the heels on the weekly wound sheets completed on [DATE], [DATE], [DATE], [DATE], and [DATE]. During an observation of the resident's bilateral feet with Employee #101, at 4:05 p.m. on [DATE], the resident stated her left heel was hurting. She said, I have been telling you all that since I got here. Employee #101 examined the left heel and stated her heel appeared to be covered with dry callus skin and was soft and boggy. An examination of the right heel by Employee #101 yielded the same conclusion. The RN stated she would contact the medical director today. According to the resident assessment instrument (RAI) manual, the definition of a stage I pressure ulcer is, An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. At 5:00 p.m. on [DATE], Employee #101 reviewed the physician's progress notes dated [DATE], [DATE], [DATE] and [DATE]. She was unable to find any documentation by the physician regarding the pressure areas on the resident's heels. An interview with Employee #101, at 11:00 a.m. on [DATE], found the physician examined the resident on [DATE] and ordered heel protectors while in bed and [MEDICATION NAME] external cream to be applied twice daily to the legs and feet for dryness. Employee #103, the MDS coordinator was interviewed, at 1:23 p.m. on [DATE], regarding the admission MDS. She was asked where the facility obtained the information for completion of the pressure ulcer information on the MDS. She said she did not complete the MDS and the employee who did was not at the facility. She said the employee who completed the MDS must have examined the resident and found the areas. She verified the weekly wound assessments did not mention the resident's heels. RN #103 provided a copy of the care area assessment (CAA) for pressure ulcers indicating the nurse who completed the admission MDS noted the resident was admitted with Stage I areas to the bilateral heels and an unstageable ulcer to the right great toe. She was unable to find any other documentation of the Stage I pressure areas to the bilateral heels. RN #103 concluded the facility had not addressed the Stage I pressure areas to the heels, and these areas were never described on any of the weekly wound sheets. She was unable to find any documentation to support the pressure areas to the heels were being monitored by the facility. An interview with the vice president of health services (VPHS), on [DATE] at 10:10 a.m., was conducted to discuss Resident #19's pressure areas and to determine how the facility addressed the resident's complaints of pain, which the resident expressed during observations of her feet on [DATE]. The VPHS provided copies of pain assessments completed on [DATE], [DATE], [DATE], [DATE], and [DATE]. These pain assessments indicated the resident did not have any pain and no interventions were necessary. The VPHS was again asked what the facility did regarding the resident's complaints of pain during the observation on [DATE]. On the evening of [DATE], at approximately 4:00 p.m., the VPHS was once again asked what interventions the facility implemented regarding the resident's complaints of pain on [DATE]. At 10:00 a.m. on [DATE], the VPHS was again asked about the provision of interventions for pain, related to the resident's complaints on [DATE]. At the close of the survey, on [DATE] at 2:00 p.m., no information had been provided regarding interventions to address Resident #19's complaints of pain to the left heel, which she expressed on [DATE]. 3. At 8:30 a.m. on [DATE], the chief operating officer stated the facility reviewed pressure areas weekly and at the bi-monthly quality assurance (QA) meetings. During the review the administrative staff look at the number of pressure ulcers, the treatments being provided and the progress of healing. When asked how the facility monitored to ensure new areas were reported, he stated the nursing assistants know to report any changes in skin issues to the charge nurse. He was unsure why the facility had not recognized the pressure areas on Resident #23 and #19 before surveyor intervention. He could not provide evidence the facility monitored residents to ensure new pressure areas were recognized and treated. b) Accident Hazards 1. The facility failed to ensure the resident's environment, over which the facility had control, was as free from accident hazards as possible for 34 of 64 facility residents. On [DATE], water temperatures obtained in resident areas on all hallways exceeded 110 degrees Fahrenheit (F). Three (3) Resident rooms had water temperatures at sinks which exceeded 120 degrees F. The maintenance department became aware the facility's water temperatures exceeded 120 degrees F at 9:00 a.m. on [DATE], when the maintenance department began using the hot water tank servicing the laundry department to service the resident care areas. Maintenance did not promptly alert staff and enact a plan to ensure resident safety while they were adjusting the water temperatures. Interviews revealed nursing staff and administrative staff were not notified of any concerns regarding excessive hot water temperatures until 4:00 p.m. on [DATE]. Staff interviews also confirmed that from 9:00 a.m., when the problem was identified, until 4:00 p.m., residents were provided showers as scheduled on the day shift, and showers continued to be provided into the evening shift until 4:00 p.m. At 4:00 p.m. on [DATE], a resident, who was receiving a shower, complained to staff the water temperatures were too hot. Residents #20, #39, #36, #85, #52, #18, #31, #5, #13, #81, #50, #95, #15, #97, #49, #70, and #3 were all provided showers on [DATE] between 9:00 a.m. and 4:00 p.m. Between the hours of 9:00 a.m. and 4:00 p.m., all hand sinks were accessible to each resident who was able to independently wash his/her hands. Residents #53, #47, #19, #69, #46, #12, #37 , #32, #67, #78, #61, #58, #81, #90, #95, #7, #6, #11, #76, #49, #70, and #3 were all identified by facility staff as residents who were independently able to wash his/her own hands. In addition to the hot water, observation revealed used disposable shaving razors were not secured in a biohazard container, and were accessible to residents. Also, a bottle of sanitizer was stored in an unlocked shower room to which residents had access. 2. Razors. During the initial tour of the facility, on [DATE] at 11:53 a.m., an unlocked shower room was observed with a sharps disposal container (a container used to dispose of sharp objects) which was full. Two (2) personal disposable razors were sticking up out of the sharps disposal container. Another disposable razor was observed in a cabinet, with the door open, in the shower room. An interview with the director of quality improvement, Registered Nurse #96 on [DATE] at 11:55 a.m., confirmed the sharps disposal container was full. She stated the staff knew better than to leave razors sticking out of the container. She also agreed that the razor in the cabinet should not be there. A review of the facility policy and procedure, on [DATE] at 9:40 a.m., revealed nursing staff was to notify the charge nurse when the sharps container was three-fourth's (,[DATE]) full to prevent overfilling and a possible injury to resident and staff. The charge nurse was then responsible for proper disposal and replacement with an empty container for disposal of razors. 3. Chemical Observation, on [DATE] at 1:20 p.m., revealed the door was open to the shower room. A bottle of Santi-tyze (food contact surfaces sanitizer cleaner and sanitizer for institutional and industrial use) was found on the hand sink in the shower room. In an interview, on [DATE] at 1:30 p.m., with registered nurse/charge nurse (RN-CN) #101, the RN confirmed the Santi-tyze cleanser should not be on the hand sink in the shower room. She said nursing assistants (NAs) obtained the Santi-tyze from the housekeepers to clean the shower room. The NAs were supposed to return the Santi-tyze to the housekeepers so the cleanser could be locked up. The RN stated the nursing assistant must have forgotten to return the cleaner to the housekeeper. c) Dietary Services The facility failed to ensure food was palatable, attractive, and served at temperatures which were acceptable to the residents. Hot foods were not served according to current professional standards and customary practice, which requires hot foods to be no less than 120 degrees Fahrenheit (F) at the time of receipt by the resident. 1. Resident interviews During stage 1 of the Quality Indicator Survey (QIS), nine (9) of fifteen (15) interviewable residents complained of food temperatures and/or food taste. 2. Resident complaints Review of grievance / concern forms found eight (8) documented concerns regarding the food since [DATE]. Complaints included concerns about the menus, uncooked meats, the appearance of the meals, undercooked vegetables, portion sizes, and timely meal delivery. 3. Food temperatures on Goodall Hall Observation of the noon meal delivery, on [DATE], found the meal cart arrived at 11:55 a.m. At 12:30 p.m., the registered dietitian and the dietary manager were asked to take the temperatures of the foods (with their thermometer) on the last tray on the food cart. The temperatures were: fried zucchini - 110 degrees F baked beans - 115 degrees F beef brisket - 112 degrees F 4. Atrium Food Temperature Measurements At 12:16 p.m. on [DATE], a test tray containing a regular diet and a test tray containing a pureed diet was placed on the last meal cart to leave the kitchen for service. The meal cart contained resident meal trays for residents who had their noon meal in the Atrium of the facility. The cart containing the test trays left the kitchen at 12:17 p.m. on [DATE]. The last resident tray on the meal cart was served at 12:35 p.m., at which time the temperatures of the foods on the test trays were taken. The temperatures were taken by the Vice President (VP) of dining services, using a facility thermometer. The following temperatures were obtained and confirmed with the VP of dining services: Pureed Foods -- Fried Zucchini - 98 degrees F -- Baked Beans - 108 degrees F Regular Consistency Foods -- Baked Beans - 106 degrees F -- Fried Zucchini - 115 degrees F -- Beef Brisket - 110 degrees F In an interview with Employee #60 the vice president of resident services, on [DATE] at 9:00 a.m., she stated she has addressed complaints regarding the residents' food concerns along with the dietary manager. She said she investigates the concerns and follows up in writing with the residents, so she thought the issue had been taken care of. The vice president of dining services, Employee #10, was interviewed at 9:20 a.m. on [DATE] regarding the issues with the dietary department. She was aware residents had complained about food temperatures and the facility had purchased heated plate warmers. She verified she had not taken temperatures of the food at the time of services to ensure the plate warmers were effective. 5. Food Substitutions Seven (7) residents who disliked zucchini were not offered a substitute of similar nutritive value. Each of the residents had a previously identified dislike of zucchini. During the lunch meal on [DATE], these residents were not provided or offered another vegetable in place of the zucchini. Resident identifiers: #19, #64, #68, #3, #60 #23, and #42. d) Pharmacy Services 1. The facility, in coordination with the licensed pharmacist, failed to establish a system of medication records that enabled periodic accurate reconciliation, accounting for, and disposition of all controlled medications. The facility had no formal mechanisms in place to safely handle controlled medications, and to maintain accurate and timely medication records. The facility, in coordination with the pharmacist, failed to establish a means to ensure security and safeguarding of controlled medications. There was no system to account for the receipt, usage, disposition, and reconciliation of all controlled medications. The facility was not conducting periodic reconciliations of records of receipt, disposition, and inventory, for controlled medications to prevent or identify loss or diversion of these medications. There was no evidence the pharmacist evaluated the facility's systems regarding controlled medications to ensure the facility maintained an accurate accounting of all controlled medications and completed periodic reconciliations. Observation of the medication room, on [DATE] at 11:30 a.m., found a large amount of controlled medications (those which are known to be frequently misused/abused) in a double locked cabinet. Two (2) registered nurses (RNs), Employee #96 and Employee #133, were present during the observation. They stated they were not aware the controlled medications were being stored in the cabinet. Upon inquiry, the RNs said all nurses had access to the cabinet. No logs, indicating who had received these medications and in what dose, were observed in the cabinet. RNs #96 and #133 confirmed the absence of logs related to the medications in the cabinet. The facility had no method of accounting for any of the medications and no method to monitor for and/or recognize potential loss or diversion. All nurses had access to the controlled medications in the cabinet, without accountability of the medication Further observation revealed the controlled medications in the cabinet were those ordered for current residents, discontinued medications for current residents, and controlled medications for discharged and deceased residents. There were names and dosages on the labels for the current residents; however, no records were available to indicate when they were placed in the cabinet or when they were taken out for use. The controlled medications for discharged and deceased residents were intermingled with those for current residents. Some of these were labeled for individual residents; however, some had nothing on the bottle other than the manufacturer's label. The medications found in this cabinet were: [MEDICATION NAME] 97.2 milligram (mg) tablets- 60 tablets Tylenol with [MEDICATION NAME] #2 tablets- 174 tablets [MEDICATION NAME] 200 mg capsules- 30 capsules [MEDICATION NAME] 30 mg capsules- 120 capsules [MEDICATION NAME] 7XXX,[DATE] mg tablets- 2 tablets [MEDICATION NAME] 1 mg tablets-520 tablets [MEDICATION NAME] ER( extended release) 10 mg tablets- 30 tablets [MEDICATION NAME] 2 mg tablets- 38 tablets [MEDICATION NAME] injectable 1 mg per milliliters (ml)- 63 ml [MEDICATION NAME] 50 mg tablets- 512 tablets [MEDICATION NAME] 100 mg per 5 ml - 87.75 ml [MEDICATION NAME] 0.25 mg tablets- 150 tablets [MEDICATION NAME] 10 mg capsules- 60 capsules [MEDICATION NAME] 2 mg tablets- 76 tablets Ambien 5 mg tablets- 48 tablets [MEDICATION NAME] 1 mg tablets- 288 tablets [MEDICATION NAME] 0.5 mg tablets- 90 tablets [MEDICATION NAME] ,[DATE] mg tablets- 212 tablets [MEDICATION NAME] 2.5 mg tablets- 30 tablets [MEDICATION NAME] 2.5 mg tablets- 49 tablets [MEDICATION NAME] 5 mg tablets- 7 tablets [MEDICATION NAME] 15 mg capsules- 30 capsules Klonopin 2 mg tablets- 30 tablets [MEDICATION NAME] ,[DATE] mg tablets- 30 tablet Interview with the Chief Operating Officer (COO), on [DATE] at 1:00 p.m., revealed in April of 2014 there was a drug diversion involving [MEDICATION NAME]. According to the COO, an investigation was conducted. The information was taken to the Quality Assurance committee and a new process was initiated for the destruction of controlled medication. Under this new process, when a controlled medication was discontinued and/or a resident was discharged , the remaining amount of the medication, along with the Controlled Substance Record indicating the amount to be destroyed, would be placed in a locked box located on the wall in the medication room. Two (2) nurses would sign the Controlled Substance Record and place the medication and the record in the locked box. Only the pharmacist and the director of nursing would have the key to the box. The COO stated he thought this was happening and the issue with controlled medications was resolved. During an interview with the pharmacist, Employee #135, on [DATE] at 2:20 p.m., he stated he was not aware there was a large amount of controlled medications which were not being reconciled to prevent loss and/or diversion. Interview with the Vice President of Health Services (VPHS), Employee #90, on [DATE] at 11:30 a.m., revealed he was unaware of the controlled medication in the medication room, to which all nurses had access. He confirmed there was no process to do an accurate reconciliation and accounting for controlled medications. The VPHS agreed the facility had no means to determine if there had been a loss and/or a diversion of controlled medications. An interview was conducted with the attending physician, Employee #134 on [DATE] at 9:30 a.m When asked if he was aware of the large amount of controlled medications in the cabinet in the medication room, he stated, I knew the nurses had been calling for refills and I questioned as to why they were needing so much medication. I also told the nurses we need to check and see why so many refills were being required, although no one ever informed me as to why so many refills were needed. During a review of an Individual Resident's Controlled Substance Record, on [DATE] at 10:15 a.m., it was discovered Resident #50 had a vial of [MEDICATION NAME] 2 mg per milliliter (ml) with 29 ml remaining in the vial. A hand written note was on the bottom of the controlled substance sheet (typed as written): Wasted not refrigerated, (signatures of Employee #136, LPN and Employee #101, RN, charge nurse). Interview with Employee #101, on [DATE] at 10:20 a.m., confirmed she and the LPN destroyed the [MEDICATION NAME] because it was not refrigerated as required. Upon inquiry as to whether nurses were to destroy controlled medication, the RN said, No, but the pharmacist, Employee #135, threw it at me and told us to destroy it. In an interview with the pharmacist, Employee #135, on [DATE] at 11:00 a.m., he stated, I don't remember me telling the nurses to destroy [MEDICATION NAME]. I have to destroy all controlled medication with the DON present. Nurses are not allowed to destroy controlled medication. At 6:42 p.m. on [DATE] the vice president of health services was interviewed regarding the findings for pharmacy services. He stated the facility knew in [DATE] there was a problem with discontinued narcotics and the storage of the medications. He stated a locked box had been placed in the medication room and nursing staff had been in-serviced on the new procedure to place the medications in the box until the pharmacist could arrive to destroy the medications. He said he thought nursing staff were following through and he had no idea medications were not being placed in this box. He provided a copy of the in-service, dated [DATE] which directed, Any narcotics that will need to be destroyed must be placed in the narcotic box in the medication room. This box is mounted on the wall under the paper towel dispenser. Once the narcotics are placed in this box, you cannot retrieve them so make sure you have documented properly. A narcotic sheet must be accurately completed and 2 nurses must sign verifying the count No more narcs (narcotics) in cabinets. He had no explanation as to why staff had not followed through with the in-servicing and was unable to provide documentation the facility was monitoring to ensure compliance. An interview with Employee #60, the vice president of resident services, on [DATE] at 9:00 a.m., revealed she thought the issue with the storage of medications had been taken care of after the in-servicing in [DATE]. 2. The facility failed to ensure the safe storage of medications for residents temporarily residing in the long term care section, who would be returning to the assisted living section of the facility. This practice had the potential to affect any resident who was temporarily admitted to long term care from the assisted living section. Observation of the medication room, on [DATE] at 11:30 a.m., found a clear plastic trash bag which contained multiple medications. The bag contained [MEDICATION NAME] capsules, [MEDICATION NAME] tablets, Doxycline capsules, [MEDICATION NAME] inhaler, [MEDICATION NAME] lotion, [MEDICATION NAME] ointment, [MEDICATION NAME] cream, [MEDICATION NAME] tablets, Humlin N insulin, [MEDICATION NAME] mouthwash, Aspirin 81mg tablets, and Citracel Calcium [MEDICATION NAME] tablets. The medications in the bag belonged to multiple residents. Each medication had been opened and used. Two (2) registered nurses (RNs), Employee #96 and Employee #133, were present during the observation. They stated the medications belonged to residents from the assisted living section of the facility who were currently residents in the long term care section of the facility. The nurses explained the medications were going to be used when the residents returned to the assisted living floor. Upon inquiry, the RNs confirmed some of the medications from the trash bag were currently being used for those residents. They agreed the medications for the multiple residents should not be commingled, should be stored separately for each resident, and should not be stored in a trash bag. The nurses immediately destroyed the medications.",2018-05-01
5970,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,514,D,0,1,GK2611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain clinical records that were complete and accurately documented for three (3) of seventeen (17) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #89's physician order was incorrectly documented as a skin tear instead of a Stage II pressure ulcer. There was also a physician's order for wound treatment that did not indicate the location of the wound. In addition, the treatment was discontinued on 07/02/14 and was never removed from the physician's orders. Resident #46 had incorrect documentation on the wound assessment. It indicated the resident had a pressure ulcer, but the resident actually had a venous/arterial ulcer. Resident #40 refused to elevate her legs when she was up in the recliner. Staff failed to document this information in the resident's medical record. Resident identifiers: #89, #40, and #46. Facility census: 64. Findings include: a) Resident #89 1. A review of Resident #89's physician's orders, on 08/04/14 at 5:00 p.m., revealed an order dated 05/19/14 for [MEDICATION NAME] ointment (an antibiotic ointment). It was to be applied to a skin tear on the resident's right lower leg. The area was to be covered with [MEDICATION NAME] (a non-adhesive wound dressing) and Kling (used to secure the dressing in place) daily. On 08/04/14 at 5:05 p.m., review of Resident #89's nurse's progress note, dated 07/22/14, revealed the resident had a Stage II pressure ulcer on the right lower leg, not a skin tear. In an interview with registered nurse/charge nurse (RN-CN) #101, on 08/04/14 at 5:07 p.m., she was asked whether Resident #89 had a pressure ulcer or a skin tear. Employee #101 stated, . the right lower leg started out as a skin tear, but now the area is a Stage II pressure ulcer. She was asked to review the physician's order. After the review, she stated, . the physician order should have been updated to reflect the area is now a Stage II pressure ulcer. 2. A review of Resident #89's physician order on 08/04/14 at 5:17 p.m., revealed an order, dated 06/30/14, for calcium alginate (type of wound dressing) and border foam (absorbs, retains, and maintains a moist environment), and to cover the Stage II pressure ulcer with Kling as needed until healed. The physician's order did not indicate the location of the pressure ulcer. In an Interview with RN-CN #101, on 08/04/14 at 5:20 p.m., when asked where the Stage II pressure ulcer was located, she stated the order was for the resident's left heel. She said she must have forgotten to indicate where the pressure ulcer was located. RN-CN #101 also stated the order needed to be discontinued because, on 07/02/14, the order was changed to cleanse with [MEDICATION NAME] and apply Triple antibiotic ointment. b) Resident #46 Medical records, reviewed on 07/30/14 at 2:15 p.m., revealed a progress note completed by the attending physician on 03/18/14. This progress note was: (typed as written) Resident has a history of recurrent venous ulcers and was seen in surgical consult. A progress note, written on 05/18/14, by the attending physician was: (typed as written) The has recently been seen related to inconclusive noninvasive studies of his lower extremity arterial circulation. Vascular surgeon feels the resident is not a candidate for invasive procedures as the resident is a very poor surgical risk . Assessment: Chronic [MEDICAL CONDITION] and [MEDICAL CONDITIONS]. Review of the residents Minimum Date Set (MDS) with an assessment reference date (ARD) of 06/19/14 revealed Section M-1030 indicated the resident had six (6) venous and arterial ulcers present. Review of the weekly wound monitoring records found, on multiple dates, the wounds on the left and right heels were documented as pressure ulcers at various stages. An interview, on 07/31/14 at 3:00 p.m., with RN-CN #101, confirmed the weekly wound reports were inaccurate. She further confirmed the resident had six (6) vascular/arterial areas on his lower extremities. Employee #90, Vice President of Health Services, confirmed on 08/03/14 at 2:15 p.m., the wounds on Resident #46 were vascular/venous wounds. He further confirmed the weekly wound reports were inaccurate. c) Resident #40 On 07/30/2014 at 3:25 p.m., review of medical records revealed a physician's order, dated 03/6/14, which stated Elevate legs when up in recliner. An observation of Resident #40, on 07/29/2014 at 2:55 p.m., revealed her sitting in her recliner chair in an upright position. Her legs were not elevated and her feet were resting on the floor. Observation of Resident #40, on 07/30/14 at 10:05 a.m., revealed the resident's legs were not elevated. She was sleeping in her chair with her feet resting on the floor. An interview with RN #101, on 07/31/14 at 12:20 p.m., revealed the RN was aware of the physician's order for Resident #40 to elevate her legs when she was up in her recliner. The RN stated she encouraged the resident to elevate her feet; however, the resident refused to elevate her feet. The RN reported Resident #40 refused to have her feet elevated most of the time. Nursing notes contained no documentation staff encouraged the resident to elevate her feet. There was also no documentation to show the resident refused to comply with the physician's order for elevating her feet when in the recliner. Employee #101 reviewed the medical record and could find no documentation that staff made attempts to implement the physician's order for elevating the resident's feet, but the resident refused to allow them to do so. Employee #101 stated, The documentation here could be better.",2018-05-01
5971,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2014-08-05,520,F,0,1,GK2611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews, the facility failed to maintain an effective quality assurance (QA) program. The QA committee failed to act upon quality deficiencies during the daily operation of the facility in which it did have or should have had knowledge. Systemic problems were identified in the care areas of pressure ulcers, nutrition, and pharmacy. -- The QA committee failed to ensure the facility identified, assessed and/or provided treatments for Residents #23 and #19, who had pressure ulcers. -- The QA committee failed to ensure the facility provided food which was palatable and served at temperatures deemed acceptable by the residents. The QA committee also failed to ensure the facility provided nutritionally equivalent substitutions for residents' known food dislikes. -- The QA committee failed to ensure the facility, in coordination with the licensed pharmacist, maintained safe and secure storage of medications. The facility did not have a system for periodic accurate reconciliation and accounting of controlled medications. In addition, the facility did not have a system to identify loss or diversion of controlled medication. These practices had the potential to affect all residents. Facility census: 64. Findings include: a) Pressures Ulcers The facility failed to ensure two (2) of four (4) residents reviewed for pressure ulcers did not develop avoidable pressure ulcers and/or received services to promote healing of existing pressure ulcers. Resident #23 was assessed at high risk for the development of pressure ulcers. The resident had two (2) Stage II pressure ulcers which had not been identified, assessed, or addressed by the facility, resulting in a determination of actual harm to the resident. Resident #19 had bilateral Stage I pressure ulcers to her heels upon admission which were not treated or monitored until after identification during the survey. In addition, the resident expressed pain, associated with the pressure ulcers on her heels, which was not addressed by the facility. 1. Resident #23 In an interview with Registered Nurse (RN) #101, on [DATE] at 11:30 a.m., the nurse reported Resident #23 did not have any pressure ulcers. A review of Resident #23's medical record, at 11:00 a.m. on [DATE], revealed Resident #23 was readmitted to the facility on [DATE] after a hospitalization due to a fractured femur. The admission nursing assessment indicated Resident #23 had no skin breakdown and/or pressure ulcers upon readmission to the facility. The resident had a Braden Scale for Pressure Sore Risk assessment, completed on [DATE], which indicated the resident was at high risk for development of pressure ulcers. A nurse surveyor observed incontinence care for the resident, provided by Nurse Aide (NA) #113, on [DATE] at 2:20 p.m. Resident #23 was observed with a pressure ulcer on the left buttock and on the right buttock. NA #113 stated when she worked with the resident a week ago the resident had only a skin tear to his right buttock, which was caused by shearing. Registered Nurse (RN) #101 was requested to assess Resident #23's buttocks at 2:30 p.m. on [DATE]. The assessment by RN #101 was observed by the nurse surveyor. The resident had a wound to the right buttock measuring five (5) centimeters (cm)in length and four (4) cm in width. The outer edges of the wound on the right buttock were bright red, and the inner part of the wound was pink/red with one (1) cm of yellow tissue in the center of the wound. Additionally, the resident had a wound to the left buttock that was five (5) cm in length and two (2) cm in width. The outer wound edges were bright red, and the inner part of the wound was white. RN #101 indicated both wounds would be considered Stage II pressure ulcers. At 2:48 p.m. on [DATE], RN #101 stated she was not aware Resident #23 had the pressure areas to his buttocks. She stated she assessed the right buttock on [DATE] and found shearing, which was not considered a pressure ulcer. She stated the physician ordered, on [DATE], Hydrogel and border foam to shearing on right buttocks daily until healed. She indicated she had not reassessed the area because it was not a pressure ulcer. She said RNs only did weekly assessments on pressure ulcers. When asked if the wound to the right buttock looked worse today than it did on [DATE] she replied, Yes it is a lot worse. When asked if the nurses providing the daily treatments had reported to her the wound had become worse, she stated, The LPNs (Licensed Practical Nurses) have not reported the worsening of the wound to me. RN #101 said the LPNs were responsible for notifying the RN in charge of any worsening of an existing wound as well as the identification of any new areas of breakdown. This was supposed to occur on the day the areas were identified. She stated she was not made aware of the wound worsening or the development of the additional wound to the left buttock. RN #101 indicated if it had been reported to the RN as required, the wounds would have been assessed and treatment would have begun prior to this date. She stated it was likely the wound to left buttock started out as a reddened area and/or shearing like the wound to the right buttock, and then progressed to a Stage II pressure ulcer. RN #101 said it should have been identified prior to becoming a Stage II pressure ulcer. During this interview, RN #101 confirmed Resident #23 did not have any pressure ulcers to his buttocks upon readmission to the facility. She said he had a bruise to his right buttock; however, the pressure ulcer now noted was in a completely different part of the resident's buttock than the previously identified bruise. When asked what interventions were in place to prevent Resident #23 from developing pressure ulcers, she stated, He has a Maxi float mattress, he is to be turned and repositioned every two (2) hours, and he is to have zinc applied to his buttocks every eight hours. When asked if the Stage II pressure ulcers should have been identified prior to the observation of incontinence care, during the survey on [DATE], RN #101 stated the pressure ulcers should have been identified during the daily treatment (a bandage to the right buttock) provided by the LPNs and NAs should have noticed them during the application of zinc cream to the resident's buttocks three (3) times a day. Interview with the Coordinator of Quality Improvement RN #96, at 9:04 a.m. on [DATE], revealed the the NAs were to immediately report, to a LPN or the RN in charge, if skin break down was noticed or a wound was worsening. If noticed or reported to the LPN, the LPN was to immediately report the information to the RN so the area could be assessed, measured, and staged if necessary. She stated if the LPN was providing the treatment daily (bandage) and the NAs were applying the zinc cream three (3) times a day, as well as providing incontinence care, the pressure ulcers to Resident #23's buttocks should have been identified and reported to the RN prior to the identification of the wounds while observing incontinence care during the survey. An additional interview with RN #101, at 10:14 a.m. on [DATE], revealed Resident #23's physician had evaluated the resident's wounds. As the result of the evaluation, the physician ordered a treatment of [REDACTED]. RN #101 stated the physician was in agreement with the staging and the measurements of the wounds on the right and left buttock. 2. Resident #19 During a Stage 1 QIS interview with RN #101, at 4:33 p.m. on [DATE], she stated the resident was admitted with an unstageable DTI (deep tissue injury) to the right toe. Medical record review, during Stage 2 of the QIS, revealed the resident was admitted to the facility on [DATE]. The admission minimum data set (MDS) with an assessment reference date (ARD) of [DATE], indicated the resident was admitted with an unstageable pressure area and two (2) Stage I pressure areas. According to the MDS, the resident did not have any unstageable deep tissue injuries (DTI). Review of the admission nursing assessment, completed by the facility on [DATE] by a LPN, found the resident, .has multi bruised areas and discoloration on b/l (bilateral) legs . a black in color scabbed area on the left big toe . and a small bruise in the right side of her lower back right above her hip area . There was no mention of any other skin issues. Documentation was added to the admission nursing assessment by a RN, on [DATE], indicating the resident had a left great toe nail which was raised, black, and thick. It also noted the tip of the right great toe had an unstageable necrotic area measuring 0.4 cm by 0.5 cm, with no drainage noted. In addition, the note indicated the left and right heels were soft and boggy. The RN coordinator of quality improvement, Employee #96, was interviewed on [DATE] at 8:16 a.m. regarding the admission nursing assessment. She agreed the LPN who admitted the resident did not mention any area to the right great toe or any problems with the resident's heels. She was asked how the facility determined the pressure area was present on admission, when the admission assessment, completed on [DATE], did not mention the areas. RN #96 said the admitting nurse should have captured those areas during her assessment. An interview with RN #101, at 3:32 p.m. on [DATE], found the facility had an order for [REDACTED]. Employee #101 stated she was not aware of any issues with the resident's heels. She said she could find no documentation regarding the heels on the weekly wound sheets completed on [DATE], [DATE], [DATE], [DATE], and [DATE]. During an observation of the resident's bilateral feet with Employee #101, at 4:05 p.m. on [DATE], the resident stated her left heel was hurting. She said, I have been telling you all that since I got here. Employee #101 examined the left heel and stated her heel appeared to be covered with dry callus skin and was soft and boggy. An examination of the right heel by Employee #101 yielded the same conclusion. The RN stated she would contact the medical director today. According to the resident assessment instrument (RAI) manual, the definition of a stage I pressure ulcer is, An observable, pressure-related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. At 5:00 p.m. on [DATE], Employee #101 reviewed the physician's progress notes dated [DATE], [DATE], [DATE] and [DATE]. She was unable to find any documentation by the physician regarding the pressure areas on the resident's heels. An interview with Employee #101, at 11:00 a.m. on [DATE], found the physician examined the resident on [DATE] and ordered heel protectors while in bed and [MEDICATION NAME] external cream to be applied twice daily to the legs and feet for dryness. Employee #103, the MDS coordinator was interviewed, at 1:23 p.m. on [DATE], regarding the admission MDS. She was asked where the facility obtained the information for completion of the pressure ulcer information on the MDS. She said she did not complete the MDS and the employee who did was not at the facility. She said the employee who completed the MDS must have examined the resident and found the areas. She verified the weekly wound assessments did not mention the resident's heels. RN #103 provided a copy of the care area assessment (CAA) for pressure ulcers indicating the nurse who completed the admission MDS noted the resident was admitted with Stage I areas to the bilateral heels and an unstageable ulcer to the right great toe. She was unable to find any other documentation of the Stage I pressure areas to the bilateral heels. RN #103 concluded the facility had not addressed the Stage I pressure areas to the heels, and these areas were never described on any of the weekly wound sheets. She was unable to find any documentation to support the pressure areas to the heels were being monitored by the facility. An interview with the vice president of health services (VPHS), on [DATE] at 10:10 a.m., was conducted to discuss Resident #19's pressure areas and to determine how the facility addressed the resident's complaints of pain, which the resident expressed during observations of her feet on [DATE]. The VPHS provided copies of pain assessments completed on [DATE], [DATE], [DATE], [DATE], and [DATE]. These pain assessments indicated the resident did not have any pain and no interventions were necessary. The VPHS was again asked what the facility did regarding the resident's complaints of pain during the observation on [DATE]. On the evening of [DATE], at approximately 4:00 p.m., the VPHS was once again asked what interventions the facility implemented regarding the resident's complaints of pain on [DATE]. At 10:00 a.m. on [DATE], the VPHS was again asked about the provision of interventions for pain, related to the resident's complaints on [DATE]. At the close of the survey, on [DATE] at 2:00 p.m., no information had been provided regarding interventions to address Resident #19's complaints of pain to the left heel, which she expressed on [DATE]. 3. At 8:30 a.m. on [DATE], the chief operating officer (COO) stated the facility reviewed pressure areas weekly and at the bi-monthly quality assurance (QA) meetings. The COO stated during the review administrative staff looked at the number of pressure ulcers, the treatments being provided, and the progress of healing. When asked how the facility monitored to ensure new areas were reported, he stated the nursing assistants knew to report any changes in skin issues to the charge nurse. He was unsure why the facility had not recognized the pressure areas on Resident #23 and #19 before surveyor intervention. The COO was unable to provide evidence the facility monitored residents to ensure new pressure areas were recognized and treated. b) Nutrition The facility failed to ensure food was palatable, attractive, and served at temperatures which were acceptable to the residents. Hot foods were not served according to current professional standards and customary practice, which requires hot foods to be no less than 120 degrees Fahrenheit (F) at the time of receipt by the resident. In addition, the facility failed to ensure nutritionally equivalent food substitutions for know food dislikes. 1. Resident interviews During stage 1 of the Quality Indicator Survey (QIS), nine (9) of fifteen (15) interviewable residents complained of food temperatures and/or food taste. 2. Resident complaints Review of grievance / concern forms found eight (8) documented concerns regarding the food since [DATE]. Complaints included concerns about the menus, uncooked meats, the appearance of the meals, undercooked vegetables, portion sizes, and timely meal delivery. 3. Food Temperatures on Goodall Hall Observation of the noon meal delivery, on [DATE], found the meal cart arrived at 11:55 a.m. At 12:30 p.m., the registered dietitian and the dietary manager were asked to take the temperatures of the foods (with their thermometer) on the last tray on the food cart. The temperatures were: fried zucchini - 110 degrees F baked beans - 115 degrees F beef brisket - 112 degrees F 4. Atrium Food Temperature Measurements At 12:16 p.m. on [DATE], a test tray containing a regular diet and a test tray containing a pureed diet was placed on the last meal cart to leave the kitchen for service. The meal cart contained resident meal trays for residents who had their noon meal in the Atrium of the facility. The cart containing the test trays left the kitchen at 12:17 p.m. on [DATE]. The last resident tray on the meal cart was served at 12:35 p.m., at which time the temperatures of the foods on the test trays were taken. The temperatures were taken by the Vice President (VP) of dining services, using a facility thermometer. The following temperatures were obtained and confirmed with the VP of dining services: Pureed Foods -- Fried Zucchini - 98 degrees F -- Baked Beans - 108 degrees F Regular Consistency Foods -- Baked Beans - 106 degrees F -- Fried Zucchini - 115 degrees F -- Beef Brisket - 110 degrees F In an interview with Employee #60 the vice president of resident services, on [DATE] at 9:00 a.m., she stated she has addressed complaints regarding the residents' food concerns along with the dietary manager. She said she investigates the concerns and follows up in writing with the residents, so she thought the issue had been taken care of. The vice president of dining services, Employee #10, was interviewed at 9:20 a.m. on [DATE] regarding the issues with the dietary department. She was aware residents had complained about food temperatures and the facility had purchased heated plate warmers. She verified she had not taken temperatures of the food at the time of services to ensure the plate warmers were effective. 5. Food Substitutions Seven (7) residents who disliked zucchini were not offered a substitute of similar nutritive value. Each of the residents had a previously identified dislike of zucchini. During the lunch meal on [DATE], these residents were not provided or offered another vegetable in place of the zucchini. Resident identifiers: #19, #64, #68, #3, #60 #23, and #42. c) Pharmacy Services 1. The facility, in coordination with the licensed pharmacist, failed to establish a system of medication records that enabled periodic accurate reconciliation, accounting for, and disposition of all controlled medications. The facility had no formal mechanisms in place to safely handle controlled medications, and to maintain accurate and timely medication records. The facility, in coordination with the pharmacist, failed to establish a means to ensure security and safeguarding of controlled medications. There was no system to account for the receipt, usage, disposition, and reconciliation of all controlled medications. The facility was not conducting periodic reconciliations of records of receipt, disposition, and inventory, for controlled medications to prevent or identify loss or diversion of these medications. There was no evidence the pharmacist evaluated the facility's systems regarding controlled medications to ensure the facility maintained an accurate accounting of all controlled medications and completed periodic reconciliations. Observation of the medication room, on [DATE] at 11:30 a.m., found a large amount of controlled medications (those which are known to be frequently misused/abused) in a double locked cabinet. Two (2) registered nurses (RNs), Employee #96 and Employee #133, were present during the observation. They stated they were not aware the controlled medications were being stored in the cabinet. Upon inquiry, the RNs said all nurses had access to the cabinet. No logs, indicating who had received these medications and in what dose, were observed in the cabinet. RNs #96 and #133 confirmed the absence of logs related to the medications in the cabinet. The facility had no method of accounting for any of the medications and no method to monitor for and/or recognize potential loss or diversion. All nurses had access to the controlled medications in the cabinet, without accountability of the medication Further observation revealed the controlled medications in the cabinet were those ordered for current residents, discontinued medications for current residents, and controlled medications for discharged and deceased residents. There were names and dosages on the labels for the current residents; however, no records were available to indicate when they were placed in the cabinet or when they were taken out for use. The controlled medications for discharged and deceased residents were intermingled with those for current residents. Some of these were labeled for individual residents; however, some had nothing on the bottle other than the manufacturer's label. The medications found in this cabinet were: [MEDICATION NAME] 97.2 milligram (mg) tablets- 60 tablets Tylenol with [MEDICATION NAME] #2 tablets- 174 tablets [MEDICATION NAME] 200 mg capsules- 30 capsules [MEDICATION NAME] 30 mg capsules- 120 capsules [MEDICATION NAME] 7XXX,[DATE] mg tablets- 2 tablets [MEDICATION NAME] 1 mg tablets-520 tablets [MEDICATION NAME] ER( extended release) 10 mg tablets- 30 tablets [MEDICATION NAME] 2 mg tablets- 38 tablets [MEDICATION NAME] injectable 1 mg per milliliters (ml)- 63 ml [MEDICATION NAME] 50 mg tablets- 512 tablets [MEDICATION NAME] 100 mg per 5 ml - 87.75 ml [MEDICATION NAME] 0.25 mg tablets- 150 tablets [MEDICATION NAME] 10 mg capsules- 60 capsules [MEDICATION NAME] 2 mg tablets- 76 tablets Ambien 5 mg tablets- 48 tablets [MEDICATION NAME] 1 mg tablets- 288 tablets [MEDICATION NAME] 0.5 mg tablets- 90 tablets [MEDICATION NAME] ,[DATE] mg tablets- 212 tablets [MEDICATION NAME] 2.5 mg tablets- 30 tablets [MEDICATION NAME] 2.5 mg tablets- 49 tablets [MEDICATION NAME] 5 mg tablets- 7 tablets [MEDICATION NAME] 15 mg capsules- 30 capsules Klonopin 2 mg tablets- 30 tablets [MEDICATION NAME] ,[DATE] mg tablets- 30 tablet Interview with the Chief Operating Officer (COO), on [DATE] at 1:00 p.m., revealed in April of 2014 there was a drug diversion involving [MEDICATION NAME]. According to the COO, an investigation was conducted. The information was taken to the Quality Assurance committee and a new process was initiated for the destruction of controlled medication. Under this new process, when a controlled medication was discontinued and/or a resident was discharged , the remaining amount of the medication, along with the Controlled Substance Record indicating the amount to be destroyed, would be placed in a locked box located on the wall in the medication room. Two (2) nurses would sign the Controlled Substance Record and place the medication and the record in the locked box. Only the pharmacist and the director of nursing would have the key to the box. The COO stated he thought this was happening and the issue with controlled medications was resolved. During an interview with the pharmacist, Employee #135, on [DATE] at 2:20 p.m., he stated he was not aware there was a large amount of controlled medications which were not being reconciled to prevent loss and/or diversion. Interview with the Vice President of Health Services (VPHS), Employee #90, on [DATE] at 11:30 a.m., revealed he was unaware of the controlled medication in the medication room, to which all nurses had access. He confirmed there was no process to do an accurate reconciliation and accounting for controlled medications. The VPHS agreed the facility had no means to determine if there had been a loss and/or a diversion of controlled medications. An interview was conducted with the attending physician, Employee #134 on [DATE] at 9:30 a.m When asked if he was aware of the large amount of controlled medications in the cabinet in the medication room, he stated, I knew the nurses had been calling for refills and I questioned as to why they were needing so much medication. I also told the nurses we need to check and see why so many refills were being required, although no one ever informed me as to why so many refills were needed. During a review of an Individual Resident's Controlled Substance Record, on [DATE] at 10:15 a.m., it was discovered Resident #50 had a vial of [MEDICATION NAME] 2 mg per milliliter (ml) with 29 ml remaining in the vial. A hand written note was on the bottom of the controlled substance sheet (typed as written): Wasted not refrigerated, (signatures of Employee #136, LPN and Employee #101, RN, charge nurse). Interview with Employee #101, on [DATE] at 10:20 a.m., confirmed she and the LPN destroyed the [MEDICATION NAME] because it was not refrigerated as required. Upon inquiry as to whether nurses were to destroy controlled medication, the RN said, No, but the pharmacist, Employee #135, threw it at me and told us to destroy it. In an interview with the pharmacist, Employee #135, on [DATE] at 11:00 a.m., he stated, I don't remember me telling the nurses to destroy [MEDICATION NAME]. I have to destroy all controlled medication with the DON present. Nurses are not allowed to destroy controlled medication. At 6:42 p.m. on [DATE] the vice president of health services was interviewed regarding the findings for pharmacy services. He stated the facility knew in [DATE] there was a problem with discontinued narcotics and the storage of the medications. He stated a locked box had been placed in the medication room and nursing staff had been in-serviced on the new procedure to place the medications in the box until the pharmacist could arrive to destroy the medications. He said he thought nursing staff were following through and he had no idea medications were not being placed in this box. He provided a copy of the in-service, dated [DATE] which directed, Any narcotics that will need to be destroyed must be placed in the narcotic box in the medication room. This box is mounted on the wall under the paper towel dispenser. Once the narcotics are placed in this box, you cannot retrieve them so make sure you have documented properly. A narcotic sheet must be accurately completed and 2 nurses must sign verifying the count No more narcs (narcotics) in cabinets. He had no explanation as to why staff had not followed through with the in-servicing and was unable to provide documentation the facility was monitoring to ensure compliance. On [DATE] at 9:00 a.m., the vice president of resident services (Employee #60) stated she thought the issue with the storage of medications had been taken care of after the in-servicing in [DATE]. She added the QA committee had put measures in place to fix the situation, but she guessed they were not effective. 2. During review of the Individual Resident's Controlled Substance Records, on [DATE] at 10:15 a.m., it was discovered Resident #50 had a vial of [MEDICATION NAME] 2mg (milligram) per ml (milliliter); in which there were 29 ml remaining in the vial. Obervations found hand written on the bottom of the sheet, (typed as written) Wasted not refrigerated, (signatures of Employee #136, LPN and Employee #101, RN, charge nurse). Interview with Employee #101, RN charge nurse on [DATE] at 10:20 a.m., confirmed the two nurses destroyed the [MEDICATION NAME] due to it not being refrigerated. I asked if nurses were to destroy controlled medication, she said, No, but the pharmacist, Employee #135, threw it at me and told us to destroy it. Interview with the pharmacist, Employee #135, on [DATE] at 11:00 a.m., he stated, I don't remember me telling the nurses to destroy [MEDICATION NAME]. I have to destroy all controlled medication with the DON present. Nurses are not allowed to destroy controlled medication. 3. Observation of the medication room on [DATE] at 11:30 a.m., found a clear, plastic trash bag which contained multiple medications as follows: [MEDICATION NAME] capsules, [MEDICATION NAME] tablets, Doxycline capsules, [MEDICATION NAME] inhaler, [MEDICATION NAME] lotion, [MEDICATION NAME] ointment, [MEDICATION NAME] cream, [MEDICATION NAME] tablets, Humlin N insulin, [MEDICATION NAME] mouthwash, Aspirin 81mg tablets, and Citracel Calcium [MEDICATION NAME] tablets. The medication contained in this bag belonged to multiple residents and all had been opened and used. Interviews with two registered nurses, Employee #96 and Employee #133, whom was present during the observation on [DATE] at 11:30, confirmed the medication contained in the trash bag belonged to various different residents and all had been used. They further confirmed the medication should be stored separately. The medication was immediately destroyed by the two RNs.",2018-05-01
6408,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2014-04-17,157,D,0,1,YDCH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's standing orders, and staff interview, the facility failed to ensure the resident's physician was notified when a change in condition occurred. Residents #128 and #60 were transferred to the hospital as a result of a change in condition. The facility was unable to provide evidence the physician was aware of the significant changes in the residents' conditions resulting in the decision to transfer the residents to the hospital. This was true for two (2) of two (2) residents reviewed for changes in condition during Stage 2 of the Quality Indicator Survey. Resident identifiers: #128 and #60. Facility census: 114. Findings include: a) Resident #128 Review of the medical record on the afternoon of 04/16/14 found the resident was admitted to the facility on [DATE]. On 03/05/13 the resident was discharged to the hospital. Further review of all the nurses' notes, recorded on 03/05/13, found the following entries: - 03/05/14 at 2:25 p.m., Resident very lethargic this shift. This AM (morning) she was up ambulating hallway as she chose with steady gate observed. At lunch time resident was observed to be sleeping at table with head hung down and playing in her food. Residents vital signs are within normal range for this resident. Resident denies any pain at this time. Will continue to monitor. - 03/05/14 at 3:09 p.m., Resident more lethargic than she was. Resident now leaning sideways not at her baseline. Resident is normally up ambulating where ever she wants. I called the case manager and told her I was sending resident to (initials of the hospital) via (initials of the ambulance service) for evaluation. Called MPOA (medical power of attorney), (name of MPOA) left message for him to call the facility back. - 03/05/14 at 4:50 p.m., At 3:40 p.m. I called (initials of ambulance service) to transport resident to the (initials of hospital) ER (emergency room ) for evaluation. (Initials of ambulance service) in facility at 4:40 p.m. to transport to (initials of hospital) ER out of facility at 4:50 p.m. in route to (initials of hospital) I did try to call MPOA again but did not get any answer. Will continue to try to get in touch with MPOA. - 03/05/14 at 5:38 p.m., I called MPOA (name of MPOA) again and did get to speak with him I made him aware of residents condition and that I sent her to the ER for evaluation. I also gave (name of MPOA) the phone number to (initials of hospital) so he could call and check on her. Review of the hospital discharge summary, dated 03/07/14, found Resident #128 was admitted to the hospital on [DATE] for leukocytosis (elevated number of white cells in the blood) and was started on the antibiotic [MEDICATION NAME]. The resident returned to the facility on [DATE]. At 3:13 p.m. on 04/16/14, Employee #3, the director of nursing (DON), and Employee #97, the registered nurse case manager were interviewed. These employees were unable to provide evidence the resident's physician was notified of the transfer / admission to the hospital. Employee #3, the DON, provided a copy of the physician's standing orders which directed, All changes in the resident's condition must be reported to the physician, RN (registered nurse) on duty or RN on call and the resident's health care representative. . b) Resident #60 Review of Resident #60's medical record, on 04/17/14 at 1:00 p.m., revealed a nurse's note written by Employee #103, licensed practical nurse, (LPN) dated 04/13/14 at 11:11 p.m This note (typed as written) included, Staff observed resident's abdomen to be very distended and hard this shift. PEG (percutaneous endoscopic gastrostomy) tube placement checked, placement was good with no residual. Nurse gave resident medications through PEG tube and resident immediately vomited up the medications. Contacted POA and advised was sending resident to ER (emergency room ) to be checked out. Further record review found no evidence the physician was notified of the resident's change in condition. In an interview with Employee #3, the director of nursing (DON), 04/17/14 at 2:30 p.m., she verified there was no evidence the physician was notified of Resident #60's change in condition, or of her transfer to the emergency room .",2018-04-01
6409,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2014-04-17,241,E,0,1,YDCH11,"Based on observation and staff interview, the facility failed to provide care to four (4) residents in a manner and environment that maintained or enhanced the residents' dignity during the lunch meal on 04/14/14. A nurse aide (NA), stood over Residents #08, #24 and #58 while assisting the residents with eating. In addition, staff fed Resident #17 at a table that was too high for her to see her food. Resident identifiers: #8, #24, #58, and #17. Facility census: 114. Findings include: a) Residents #8, #24, and #58 On 04/14/14 at 12:45 p.m., observations in the South hall main dining room during the lunch meal noted a NA aide, Employee #112, standing over Residents #8, #24 and #58 while feeding them lunch. When asked about standing over the residents while assisting them to eat, the NA acknowledged she was supposed to sit when feeding residents. In an interview with Employee #128, licensed practical nurse (LPN), at 1:10 p.m. on 04/14/14, she confirmed the NAs were to sit while feeding the residents. Employee #128 confirmed, Employee #112 was standing while feeding Residents #08, #24, and #58. b) Resident # 17 On 04/14/14 at 12:30 p.m., a dining observation in the South hall main dining room during the lunch meal found staff failed to maintain Resident #17's dignity by feeding her at a table that was higher than her eyes. Employee #152, a NA was feeding the resident. She was reaching down in front of the table to reach the resident's mouth. Resident #17 was unable to see her food. The NA acknowledged the table was too high for the resident. An interview was conducted at 1:10 p.m. on 04/14/14 with Employee #128, licensed practical nurse (LPN). She confirmed the table was too high for Resident #17, and the resident was unable to see her food.",2018-04-01
6410,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2014-04-17,279,E,0,1,YDCH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident observations, the facility failed to develop a comprehensive care plan for three (3) of twenty-five (25) residents reviewed during Stage 2 of the Quality Indicator Survey. Resident #133 had a history of [REDACTED]. Resident #23 was receiving hospice services and did not have a comprehensive care plan which reflected the services he received. Resident #75 was identified as having a port-a-cath and as [MEDICAL CONDITION] related to a urinary tract infection [MEDICAL CONDITION], neither of which was addressed on his comprehensive care plan. Resident Identifiers: #133, #23, and #75. Facility Census: 114. Findings Include: a) Resident #133 Review of the resident's medical record, on 04/16/14 at 3:32 p.m., found an admission minimum data set (MDS), with an assessment reference date (ARD) of 03/18/14. This MDS contained a Care Area Trigger (CAT) worksheet related to the problem area of falls. The CAT worksheet contained the following statements, (typed as written) The resident was noted to have a fall prior to her admit to the facility. She has not had any falls since her admission. She does have mobility deficits from [MEDICAL CONDITION]. She has made attempts to get up unassisted and had fall interventions ordered on admit. The resident has confusion. Her positioning when up to the wheel chair is poor at times. Two assist is used for transfers. Long distance transfers require the wheelchair. Her balance is poor. The CAT worksheet also indicated Resident #133 would be care planned for falls due to her high risk for falls. Resident #133's physician orders [REDACTED]. Maintain chair pad alarm each shift. Maintain soft mat alarm at bedside each shift. All three (3) fall interventions were ordered on [DATE], which was the day Resident #133 was readmitted to the facility following a hospital stay. A review of the facility's incident and accident reports revealed Resident #133 was observed lying on the floor at her bed side. The facility classified this incident as a fall. Multiple observations of Resident #133, throughout the course of the Quality Indicator Survey, revealed the following fall interventions in place: low bed, alarming mat at bedside, and chair alarm in place when in chair. Review of the comprehensive care plan, which was based on the results of the comprehensive MDS assessment, with an ARD of 03/18/14, found the care plan did not contain any mention of history of falls, high risk for falls, or her actual fall on 04/13/14. In an interview with Employee #102, Registered Nurse (RN) MDS Coordinator, at 4:02 p.m. on 04/16/14, she confirmed she completed Resident #133's comprehensive care plan. She stated the resident's risk for falls and her actual fall should have been addressed in the comprehensive care plan. The RN reviewed Resident #133's care plan, and stated, I do not see where her risk for falls or her actual fall on 04/13/14 were addressed on the care plan. She reviewed the CAT worksheet for falls and stated, based on the CAT worksheet which she completed, Resident #133 should have a care plan for her risk for falls and her recent actual fall. The RN confirmed she was aware the resident was at risk for falls and was aware of all the interventions which were in place. She stated she had mistakenly left falls off Resident #133's care plan. b) Resident #23 Review of the resident's medical record, at 08:24 a.m. on 04/16/14, revealed Resident #23 had received hospice services at the facility since 02/20/14. Resident #23's care plan related to hospice was reviewed. It contained the following problem, goals and interventions: (typed as written) (Residents preferred name) family has chosen to receive hospice care. (Residents preferred name) will experience a peaceful and dignified death 06/04/14. (Residents preferred name) will remain comfortable throughout hospice care. Interventions included: 1. Assist (Residents preferred name) with Sitting up hospice care. 2. Coordinate (Residents preferred name) care with hospice team. 3. Coordinate with the Hospice team to assure (Residents preferred name) Experience as little pain as possible. 4. Provide(Residents preferred name) and family with grief and spiritual counseling if desired. 5. Hospice aide to visit with (another female resident's name) as ordered to provide additional ADL care. This care plan did not accurately reflect Resident #23 because it contained another resident's name in the last intervention. The care plan also did not indicate what days of the week the hospice aide would visit, nor did it indicate what care the resident would receive from the hospice aide. At 9:30 a.m. on 04/16/14, Employee #119, Registered Nurse (RN), was interviewed. Employee #119 was the nurse assigned to Resident #23 on this date. When asked when Resident #23's hospice aide came to visit the resident, she was not able to readily answer the question without searching through the computer system to see when the hospice aide had last visited. The RN then replied the hospice aide visited on Monday so she came on Monday, Wednesday and Friday. Employee #119 was not able to refer to Resident #23's care plan to answer when the hospice aide would visit the resident. During an interview on 04/16/14 at 10:05 a.m., Employee #102, the MDS coordinator, reviewed Resident #23's care plan and confirmed the wrong resident's name appeared in the last intervention on the Hospice Care Plan. She stated they used a template and changed the names in the care plan when they changed it from one resident to another resident. She stated it appeared they missed changing the name in Resident #23's care plan. She further confirmed the care plan did not specifically state when the hospice aide would visit and what the hospice aide would do when at the facility. c) Resident #75 Review of this resident's medical record, on 04/16/14 at 10:00 a.m., revealed the resident was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. the resident required parental medications of [MEDICATION NAME] (antibiotic) through a Port-A-Cath (an implantable venous access system for parental delivery of medications and fluids). Review of the resident's care plan revealed there were no goals or interventions for monitoring and/or management of the port-a-cath and/or the administration of the antibiotic. In addition, no goals or interventions were found that addressed the UTI and the risk for infection (sepsis). During an interview on 04/16/14 at 1:30 p.m., Employee #3, the director of nursing (DON), reviewed the resident's care plan. The DON confirmed Resident #75's care plan did not address the care and management of the port-a-cath and the resident's risk for UTIs.",2018-04-01
6411,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2014-04-17,280,D,0,1,YDCH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise the care plan of one (1) of twenty-five (25) residents whose care plan was reviewed during Stage 2 of the Quality Indicator Survey (QIS). The resident experienced an 8% weight loss within thirty (30) days. The care plan was not revised to address the resident's weight loss. Resident identifier: #98. Facility census: 114. Findings include: a) Resident #98 During Stage 1 of the QIS, the director of nursing (DON) stated all resident's weights could be located in the facility's electronic computerized medical record. The resident's weights were obtained from the facility's computerized medical record, under the tab entitled, Vital Signs. Medical record review found the resident was admitted to the facility on [DATE] and was discharged to her home on 12/20/13. Review of the electronic medical record on 04/17/14 found the resident's first weight was recorded as 129.8 pounds on 11/18/13, by Employee #165, the facility's contracted registered dietitian. On 11/19/13 at 10:10 a.m., Employee #165, entered a progress note, Nutrition evaluation. Resident transferred from (initials of hospital) s/p (status [REDACTED]. She eats well - 80% avg. (average) of meals. Drinks fairly well also - 1400 ml (milliliters) avg. - could increase oral fluids slightly. Recent issues with constipation - only 1 bm (bowel movement) X 1 wk. (week) at hospital. [MEDICATION NAME] added qd (every day). She is on a regular diet. Wt (weight) gain since admission to hospital. Was 118.8 # (pounds) on 11/9. CW (current weight) 129.8#. BMI (body mass index) = 24.5. Sign (significant) meds: [MEDICATION NAME]. Supplements: Omega 3 fatty acid, MVI (multivitamin), Vit (vitamin) C, vit D, Vit B-12. Stage I on back per nrsg (nursing) note. Regular diet is appropriate. Intake is good. BMI WNL (within normal limits) Expect adequate wound healing. Watch for constipation. The next recorded entry from the dietary department was entered by the dietary manager, Employee #13, on 11/21/13 at 2:48 p.m. The dietary manager wrote, Visited with resident and family during meal time in the solarium today. Resident's daughters and visitor stated the vegetable soup was delicious. I then asked resident if she liked it and she stated no. I've had better, mine is much better. She then went on to complain about the food. She then stated there is nothing wrong with the food, it's good but it's how y'all cook it. I use more seasoning than y'all do. Her daughter then intervened and told me she was hard to please with the food because she is Hispanic and likes lots of garlic and seasoning on her food. She then told me that her dentures doesn't fit as well due to losing weight and she had difficulty chewing some thing. Will continue to monitor. Further review of the facility's computerized medical record found the next weight was obtained on 12/02/13. Two (2) weights were recorded in the medical record by Employee #97, the registered nurse case manager. At 9:00 a.m. on 12/02/13 the weight was recorded as 119.4 pounds. At 9:05 a.m. on 12/02/13 the weight was recorded as 119.0 pounds. On 12/03/13 at 7:57 a.m., Employee #13 entered a progress note in the resident's medical record. The entry was, This is a 5 day Medicare Admission Care Plan Assessment Review. Current diet: Regular. Current weight 129.8# (pounds). Employee #13 entered a progress note in the electronic medical record on 12/05/13 at 9:45 a.m., Resident's family stated in care plan meeting that her last weight at the hospital was 115#. She weighed 118# at (name of hospital) on 11/15/13. Admission weight her (sic) at this facility is questionable due to resident's weight on 12/02/13. The resident's minimum data sets (MDSs) were reviewed on the morning of 04/17/14 and revealed: -- The admission MDS, with an assessment reference date (ARD) of 11/22/13, identified the resident's weight was 130 pounds. -- The fourteen (14) day MDS, with an ARD of 11/29/13, recorded the weight as 130 pounds. -- The thirty (30) day MDS, with an ARD of 12/13/13, recorded the weight as 119 pounds. These weights were consistent with the weights recorded found under the Vitals Tab in the electronic medical record. Review of the only care plan formulated during the resident's stay at the facility, from 11/16/14 through 12/20/14 (the date of discharge), found only the potential for weight loss was addressed on the care plan on 12/02/13. The facility was aware, or should have been aware, of the weight loss 18 days before the resident's discharge. There was no evidence to support the care plan was updated after the resident's weight loss. The dietary manager, Employee #13, was interviewed at 9:15 a.m. on 04/17/14. When asked if the facility had addressed the resident's weight loss, Employee #13 stated the admission weight was most likely incorrect. She stated, the facility did not have the weights to, back up, her statement that the admission weight was incorrect. She verified she had not addressed the resident's weight loss, Employee #13 was unable to provide any evidence the facility explored the reasons for the weight loss or updated the care plan to reflect the weight loss. During an interview at 10:45 a.m. on 04/17/14, the DON and Employee #13 verified the recorded weights in the electronic medical record were the weights used by facility staff to make assessments of the resident's nutritional status. At the close of the survey, no further information had been provided to verify the resident's 8% weight loss was addressed on the care plan by the facility.",2018-04-01
6412,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2014-04-17,282,D,0,1,YDCH11,"Based on observation, record review, and staff interview, the facility failed to implement the interventions established in the care plan for one (1) of twenty-five (25) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #37 was care planned for being at risk for falls. An intervention for fall prevention addressed the resident would wear shoes. Observations during the QIS found the resident was not wearing his shoes. Resident identifier: #37. Facility census: 114. Findings include: a) Resident #37 Observations of the resident, on 04/15/14 from 10:11 a.m. through approximately 1:30 p.m., found the resident resided on the South Wing of the facility. He was observed in both the activity room and the dining room and was not wearing his shoes. He was wearing only socks. Review of the resident's care plan, on 04/16/14, found a care plan problem, initiated on 06/12/13, addressing the resident was at risk for falls. The goal associated with this problem was, The resident will not experience any injuries related to falls. An intervention for prevention of falls was, The resident prefers wearing tennis shoes. Review of the resident's most recent minimum data set (MDS), with an assessment reference date (ARD) of 02/20/14, found the resident's skills for daily decision making were severely impaired. The Brief Interview for Mental Status (BIMS) could not be conducted with the resident due to his cognitive status. He also required extensive staff assistance of two (2) staff members for dressing. The only behavior recorded on the MDS was wandering. The resident was again observed on 04/16/14 at 10:15 a.m. in the lounge on the South Wing. He was wearing only regular socks. The resident's nurse, Employee #125, a licensed practical nurse was asked why the resident was not wearing his shoes. She stated, Maybe he wouldn't wear his shoes. The resident's assigned nursing assistant, Employee #134, was interviewed at 10:20 a.m. on 04/16/14. She stated the resident was up, dressed and in the lounge by the time she arrived for work on the day shift, so she did not know why he was not wearing shoes. She stated night shift employees would have dressed him. Observation of the resident's room and closet, with Employee #134, found the resident did not have tennis shoes. Employee #134 located his slippers, which had non-skid soles. The resident did not resist when Employee #134 asked him if he would wear his shoes. At 10:22 p.m. on 04/16/14, Employee #102, the registered nurse MDS coordinator, was asked if she could provide any evidence the resident had resisted care during the night shift which started on 04/15/14. Employee #102 provided a behavior report roster which identified the resident had no behaviors on the midnight shift. She was unable to provide any evidence the resident had refused to wear his shoes. Employee #97, the registered nurse care coordinator for the South Unit, was interviewed at 11:38 a.m. on 04/17/14. She stated she was the author of the care plan and she was already aware the resident was not wearing his shoes.",2018-04-01
6413,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2014-04-17,309,G,0,1,YDCH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's bowel management protocol, and staff interview, the facility failed to provide care and services to attain or maintain the highest practicable well-being for one (1) of twenty-five (25) residents reviewed in Stage 2 of the Quality Indicator Survey (QIS). There was no evidence the facility assessed and monitored Resident #60's bowel movements resulting in a transfer to the hospital. This practice resulted in actual harm for Resident #60. Resident identifier: #60. Facility census: 114. Findings include: a) Resident #60 Medical record review, on 04/17/14 at 2:15 p.m., revealed this resident was readmitted to the facility on [DATE]. Further review of records revealed on 04/13/14, the resident was had a hard and very distended abdomen. The resident experienced vomiting when given her medications at 11:11 p.m. on 04/13/14, and was transported to a local emergency room (ER) for treatment. During her visit to the local emergency room the resident received two (2) liters of fluid intravenously and had a radiology test (CT scan) of the abdomen. The CT resulted in the [DIAGNOSES REDACTED]. According to the hospital records, the resident had a large loose stool while in the ER. Review of Resident #60's bowel movement records, dated 03/01/14 through 04/17/14, found only two (2) bowel movements were recorded. A medium bowel movement was recorded on 03/14/14 and a large bowel movement on 04/16/14. A review of the No bowel movement report, dated 03/01/14 through 04/17/14, revealed Resident #60's name was not contained on the report. This report was generated by the evening shift nurses daily and was used to determine if the bowel protocol should be initiated for a resident. The facility's bowel protocol was to be initiated it a resident had no bowel movements for a period of three (3) days. Resident #60's medication administration records (MAR), for the time period of 03/01/14 through 04/17/14, were reviewed. This review found the bowel protocol was not initiated for the resident. Review of the facility's bowel protocol (standing orders) found it included, (typed as written): Constipation. Check bowel movement record for bowel elimination: If no bowel movement in three (3) days the administer: 1. Milk of Magnesia 30cc (cubic centimeters) po (by mouth) daily prn (as needed) x (times) 1 dose. If no results in 8 hrs (hours) . 2. [MEDICATION NAME] 15mg (Give 3 tabs of 5mg) po q (every) 3days or [MEDICATION NAME] 10mg R/S (rectal suppository) 10mg q3days x 1 if no results in in 8 hours . 3. May check for constipated stool, If present remove manually 4. [MEDICATION NAME] (Fleets) enema prn x 1. If no results after implementing steps 1-4 above, notify physician. Hemocult on any resident with dark/tarry stool or vomitus. At 6:10 p.m. on 04/17/14, the Director of Nursing (DON), Employee #5, Staff Development Coordinator, and Employee #102, Registered Nurse Minimum Data Set Coordinator (MDS Coordinator) were interviewed. This interview revealed they had determined why Resident #60's bowel movements had not been documented by the nurse aides (NAs). Employee #102 stated the bowel movement scheduled care task assignment had not been initiated. She stated the NAs where not prompted by the Kiosk to enter whether or not Resident #60 had a bowel movement. They confirmed the NAs were trained to enter every bowel movement into the computer system. They stated the NAs would have to select the task themselves and make the entry, if the computer did not prompt them to do so. Employee #5 stated all staff were trained on how to document bowel movements into the system when the system did not prompt them to do so. This could happen if a resident had more than one (1) bowel movement a shift. In this situation, the NAs would have to manually document that in the system. Employee #3 stated the reason Resident #60 did not pull to the No BM (bowel movement) report was because this report was driven by the bowel movement button which was not initiated for Resident #60. She confirmed they could not prove Resident #60 had a bowel movement, because there were none documented. She stated not all the NAs had the foresight to manually document a bowel movement when they were not prompted to do so. She confirmed they did not monitor Resident #60's bowel movement status due to this error in the computer.",2018-04-01
6414,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2014-04-17,323,E,0,1,YDCH11,"Based on observation and staff interview, the facility failed to ensure a safe environment was maintained for the residents residing on the South Unit, a locked unit. A screwdriver was left lying between the window and the hand rail near the door exiting the unit. It was discovered the screwdriver was there, unobserved by facility staff, for at least twenty (20) minutes. This had the potential to affect more than an isolated number of residents residing on the South Unit. Facility Census: 114. Findings include: a) Observations and Staff Interviews On 04/15/14 at 3:40 p.m., Employee #89, the Maintenance Supervisor, was observed in the south side of the building exiting the locked unit. Prior to exiting the unit, observation revealed he reached down and picked up a screwdriver which was lying in the window sill between the window and the hand rail. Employee #89 was interviewed. He stated about 15 minutes prior to the observation, he was notified he was needed to take water temperatures. He said he left the screwdriver in the window sill between the hand rail and the window. Employee #89 stated it should not have been left there. He said he just forgot. He laid it there while working on the door. He confirmed the screwdriver was there the entire time he was taking water temperatures. The first water temperature was obtained at 3:20 p.m. on 04/15/14 . Employee #3, the Director of Nursing (DON) was interviewed at 2:20 p.m. on 04/17/14. She stated it was definitely not safe to leave a screwdriver unattended on the South Unit for any period of time, due to the type of residents who resided on the South Unit.",2018-04-01
6415,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2014-04-17,325,D,0,1,YDCH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to evaluate and address the nutritional needs of one (1) of three (3) residents reviewed for the care area of nutrition during Stage 2 of the Quality Indicator Survey (QIS). The resident experienced an 8% weight loss in thirty (30) days. The facility failed to develop and implement interventions to stabilize or improve the resident's nutritional status when the weight loss was, or should have been, identified. Resident identifier: #98. Facility census: 114. Findings include: a) Resident #98 During Stage 1 of the QIS, the director of nursing (DON) stated all residents' weighs could be located in the facility's electronic computerized medical record. The resident's weights were obtained from the facility's computerized medical record, under the tab entitled, vital signs. Medical record review found the resident was admitted to the facility on [DATE] and was discharged to her home on 12/20/13. Review of the electronic medical record on 04/17/14 found the resident's first weight was recorded as 129.8 pounds on 11/18/13, by Employee #165, the facility's contracted registered dietician. On 11/19/13 at 10:10 a.m., Employee #165, entered a progress note, Nutrition evaluation. Resident transferred from (initials of hospital) s/p (status [REDACTED]. She eats well - 80% avg. (average) of meals. Drinks fairly well also - 1400 ml (milliliters) avg. - could increase oral fluids slightly. Recent issues with constipation - only 1 bm (bowel movement) X 1 wk. (week) at hospital. [MEDICATION NAME] added qd (every day). She is on a regular diet. Wt (weight) gain since admission to hospital. Was 118.8 # (pounds) on 11/9. CW (current weight) 129.8#. BMI (body mass index) = 24.5. Sign (significant) meds: [MEDICATION NAME]. Supplements: Omega 3 fatty acid, MVI, (multivitamin) Vit (vitamin) C, vit D, Vit B-12. Stage I on back per nrsg (nursing) note.Regular diet is appropriate. Intake is good. BMI WNL (within normal limits) Expect adequate wound healing. Watch for constipation. The next recorded entry from the dietary department was entered by the dietary manager, Employee #13, on 11/21/13 at 2:48 p.m., Visited with resident and family during meal time in the solarium today. Resident's daughters and visitor stated the vegetable soup was delicious. I then asked resident if she liked it and she stated no. I've had better, mine is much better. She then went on to complain about the food. She then stated there is nothing wrong with the food, it's good but it's how y'all cook it. I use more seasoning than y'all do. Her daughter then intervened and told me she was hard to please with the food because she is Hispanic and likes lots of garlic and seasoning on her food. She then told me that her dentures doesn't fit as well due to losing weight and she had difficulty chewing some thing. Will continue to monitor. Further review of the facility's computerized medical record found the next weight was obtained on 12/02/13. Two (2) weights were recorded in the medical record by Employee #97, the registered nurse case manager. At 9:00 a.m. on 12/02/13 the weight was recorded as 119.4 pounds. At 9:05 a.m. on 12/02/13 the weight was recorded as 119.0 pounds. On 12/03/13 at 7:57 a.m., Employee #13 entered a progress note in the resident's medical record. This is a 5 day Medicare Admission Care Plan Assessment Review. Current diet: Regular. Current weight 129.8# (pounds) Employee #13 entered a progress note in the electronic medical record on 12/05/13 at 9:45 a.m., Resident's family stated in care plan meeting that her last weight at the hospital was 115#. She weighed 118# at (name of hospital) on 11/15/13. Admission weight her (sic) at this facility is questionable due to resident's weight on 12/02/13. The resident's minimum data set's (MDSs) were reviewed on the morning of 04/17/14: --The admission MDS, with assessment reference date (ARD) of 11/22/13, found the resident's recorded weight was 130 pounds. --The fourteen (14) day MDS, with an ARD of 11/29/13, noted the resident's weight as 130 pounds. --The thirty (30) day MDS, with ARD of 12/13/13, had a recorded weight of 119 pounds. These weights were consistent with the recorded weights found under the, vitals tab, in the electronic medical record. Review of the only care plan formulated during the resident's stay at the facility, from 11/16/14 through 12/20/14 ( the date of discharge), found only the potential for weight loss was addressed on the care plan dated 12/02/13. The facility was aware, or should have been aware, of the weight loss 18 days before the resident's discharge. There was no evidence to support the care plan was updated after the resident's weight loss. The dietary manager, Employee #13, was interviewed at 9:15 a.m. on 04/17/14. When asked if the facility had addressed the resident's weight loss, Employee #13 stated the admission weight was most likely incorrect. She stated the facility did not have evidence to back up her statement that the admission weight was incorrect. She verified she had not addressed the resident's weight loss. Employed #13 was unable to provide any evidence the facility had explored the reasons for the weight loss. The DON and Employee #13 verified the recorded weights in the electronic medical record were the weights used by facility staff to make assessments of the resident's nutritional status during the interview at 10:45 a.m. on 04/17/14. The DON provided a copy of the facility's policy for, Weights, which directed: All new and readmissions will be weighted first 3 days upon admission, and then weekly for four weeks. If weight remains stable, then monthly weights will be obtained. If a significant weight change is recorded, staff will continue to weigh weekly until weight becomes stable. Monitor weekly weights. If a significant weekly change of 5# loss or gain is noted: a) Re-weigh to confirm accuracy, b) Review meal consumption record for meal and fluid intakes for past two weeks, c) Review any recent labs and medication changes that could affect nutritional status, d) Look back at last 3 weights recorded if available, e) Notify RD (registered dietician) for possible recommendations, f) Notify physician, g) Notify responsible party, h) Review and update care plan to include significant weight changes, corresponding goals, and interventions . There was no evidence the facility identified the resident's significant weight loss and/or implemented its protocols to address Resident #98's weight loss. At the close of the survey, no further information had been provided to verify the resident's 8 %weight loss was addressed by the facility.",2018-04-01
6416,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2014-04-17,333,D,0,1,YDCH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of manufacturer's specifications, and staff interview, the facility failed to ensure residents are free of significant medication errors. Resident #60 was given [MEDICATION NAME] ([MEDICATION NAME]) an anticonvulsant medication, through her gastrostomy tube ([DEVICE]) without holding her tube feeding for one (1) hour before administering the medication as directed by the manufacturer's specifications. Giving [MEDICATION NAME] ([MEDICATION NAME]) with the [DEVICE] feeding has the potential to reduce the effectiveness of the [MEDICATION NAME] ([MEDICATION NAME]) and could cause [MEDICAL CONDITION]. This was true for one (1) resident observed receiving medication through a feeding tube. Resident identifier: #60. Facility census: 114. Findings include: a) Resident #60 Medication administration for Resident #60 was observed at 12:00 p.m. on 04/16/14. Employee #138, a licensed practical nurse (LPN), was observed administrating the medication [MEDICATION NAME] ([MEDICATION NAME]), an anticonvulsant medication. The gastrostomy tube was paused just long enough to administer the medication and then the feeding was resumed. Review of the manufacturer's specifications revealed: Products that contain calcium (e.g., antacids, calcium supplements) and nutritional tube-feeding (enteral) products may decrease the absorption of [MEDICATION NAME]. Do not take these products at the same time as your [MEDICATION NAME] dose. Separate liquid nutritional products at least 1 hour before and 1 hour after your [MEDICATION NAME] dose, or as directed by your doctor. The Medication Administration Record [REDACTED]. An interview with Employee #3, the director of nursing (DON), was conducted on 04/16/14 at 2:00 p.m. The DON confirmed the tube feeding should be stopped for one (1) hour prior to the administration of [MEDICATION NAME] ([MEDICATION NAME]) and stopped for one (1) hour after the administration of the medication. She stated the information, related to holding the tube feeding for one (1) hour prior to and one (1) hour after the administration of [MEDICATION NAME] ([MEDICATION NAME]), was available on the computer. The DON said the information was provided by the consultant pharmacist/pharmacy for guidance when administering medications.",2018-04-01
6417,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2014-04-17,371,F,0,1,YDCH11,"Based on observation and staff interview, the facility failed to store foods under sanitary conditions. Foods were not labeled and dated. Equipment needed repaired, and some needed cleaning. In the locked unit nourishment pantry, employee food items were intermingled with the resident items. This practice had the potential to affect all residents who consumed foods by oral means. Facility census:114. Findings include: a) When completing the initial tour of the dietary department, on 04/14/14 at 11:20 a.m., with the dietary manager present, the following sanitation issues were observed: 1. The ice machine had a cracked lid along the left corner (if looking at the machine), creating a potential for improper sealing. This also prevented the machine from being easily cleanable. 2. In the reach-in refrigerator, a bag of opened pork ribs was observed without the date it was opened. 3. Also in the reach-in refrigerator, a bag of waffles was observed out of the original packaging, and did not have the date it was opened. b) At 12:20 p.m. on 04/14/14, a cook was observed using a gloved hand to handle hamburger bun packaging and menus, then handled the hamburger buns for Sloppy Joes. This created a potential for cross contamination of infectious organisms from the packaging and menus to the food items. c) The Nourishment pantry observations, conducted after lunch on 04/15/14, revealed the following sanitation issues: 1. The locked unit pantry had two (2) plastic McCafe cups containing liquid and a used Styrofoam cup with a straw sitting on a counter top. An opened can of diet Shasta cola was also on the counter top. In addition, a pimento cheese sandwich, dated 04/14/14, was not refrigerated. It was observed on the counter in a plastic baggie. 2. In the refrigerator, there were opened bottles of Dr. Pepper and Mt. Dew which belonged to staff, and not the residents. This refrigerator also did not contain an internal thermometer to enable monitoring to ensure food items were kept at the correct temperature. These issues were verified with Employee #90, the registered nurse of the unit, at the time of the observations.",2018-04-01
6418,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2014-04-17,428,D,0,1,YDCH11,"**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, were addressed in a timely manner. On 10/09/13, the pharmacist identified the resident did not have an accepted / appropriate [DIAGNOSES REDACTED]. The facility did not act on the recommendation for over three (3) months, until 01/31/14. This was true for one (1) of five (5) residents reviewed for unnecessary medications during Stage 2 of the Quality Indicator Survey, (QIS). Resident identifier: #97. Facility census: 114. Findings include: a) Resident #97 On 04/16/14 the resident's recapitulation (re-cap) orders, signed by the physician on 04/05/14, were reviewed. The re-cap contained an order for [REDACTED]. Review of the consultant pharmacist progress notes, on 04/16/14, found a note from the pharmacist, dated 10/09/13. It recommended: Need [DIAGNOSES REDACTED]. Avoid use unless threat to self or others Thanks. On 11/08/13, the pharmacist again recommended, See October note .need [DIAGNOSES REDACTED]. (diagnosis) for AP (antipsychotic) use. The director of nursing (DON) was interviewed on the afternoon of 04/16/14. The DON explained the facility asked for a [DIAGNOSES REDACTED]. The psychiatrist added the [DIAGNOSES REDACTED]. The DON confirmed the [DIAGNOSES REDACTED]. She further explained the facility failed to update the monthly re-cap physician's orders [REDACTED]. On 04/17/14 at 3:15 p.m., the facility provided a physician orders [REDACTED]. This order was dated 01/31/14, nearly three (3) months after the first recommendation on 10/09/13.",2018-04-01
6419,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2014-04-17,441,E,0,1,YDCH11,"Based on observations, staff interview, and review of the facility's policy for clean dressing technique, the facility failed to ensure residents' medications were administered in a sanitary manner for Residents #33 and #60. The facility also failed to ensure proper hand hygiene during a dressing change for Resident #75. In addition, the facility failed to ensure medication stored in the North hall refrigerator was stored in a sanitary manner. Food was stored in the refrigerator with resident medications. These practices had the potential to affect more than an isolated number of residents. Resident identifiers: #33, #60 and #75. Facility census: 114. Findings include: a) Resident #33 During medication administration observation, on 04/16/14 at 8:40 a.m., Employee #119, a registered nurse (RN) was observed dropping a pill on top of the medication cart. She picked up the pill with her bare hands, and placed the contaminated pill in the medication cup. The RN then administered the medication to Resident #33. An interview was conducted with Employee #119, RN, on 04/16/14 at 8:45 a.m., concerning this incident. She stated, The top of my medication cart is clean. Upon further discussion, she confirmed her hands were not clean, as she had touched and opened the medication cart drawer, and had removed containers from the cart. She agreed she should not have picked up the pill with her bare hands. Employee #3, director of nursing (DON) was informed Employee #119, RN, dropped a pill on top of the medication cart and picked it up with her bare hands. The DON agreed the nurse should not have picked up the pill with bare hands. b) Resident #60 Observation of the medication administration for Resident #60 was completed on 04/16/14 at 12:00 p.m. Employee #139, a licensed practical nurse (LPN), was observed preparing the resident's medication. The nurse entered the resident's room and pulled a table over to Resident #60's bedside and laid a wooden spoon on the table. The LPN picked up the wooden spoon and used the spoon to mix the resident's medication with water, then administered the medicine through the resident's gastrostomy tube. Following this observation, an Interview was conducted with Employee #139, LPN. When asked if she should have placed the wooden spoon on the table, then used it to mix the medication, she stated, No. During an interview, on 04/16/14 at 12:30 p.m., with the DON, she agreed the wooden spoon should not have been used, as it was contaminated when the nurse placed it on the table. c) Resident #75 During observation of a dressing change on 04/17/14 at 9:00 a.m., Employee #104, an LPN, removed soiled dressing from a pressure ulcer on the resident's right buttocks and proceeded to cleanse the area. She did not wash her hands prior to cleansing the area. The LPN then removed her gloves, washed her hands, applied new gloves, and placed a new dressing to the area. The facility's policy for Clean Dressing Technique was reviewed on 04/17/14 at 10:00 a.m. The policy read, Remove soiled dressing and place into plastic bag. Wash hands. Apply clean gloves. Apply treatment as ordered. An interview with Employee #104, LPN, was conducted on 04/17/14 at 10:35 a.m. Employee #104 confirmed she should have washed her hands after removing the soiled dressing before cleansing the area. d) Medication refrigerator on North hall The observation of the medication room on the North Hall, on 04/17/14 at 2:15 p.m., found two (2) mini cheeseburgers stored in the medication refrigerator. Employees #139 and #20, both LPNs were present during the observation of the medication storage room. Both LPNs agreed food was not to be placed in the medication refrigerator.",2018-04-01
6420,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,154,D,1,0,S2LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to inform one (1) of five (5) sampled residents of the healthcare status and treatment which necessitated medication changes. Resident #54 was receiving two (2) medications used to treat sexual behaviors. These medications had dosage adjustments of which Resident #54 was not informed. Resident Identifier: #54 Facility Census: 68. Findings Include: a) Resident #54 Review of Resident #54's medical record, at 3:17 p.m. on 03/03/15, found the resident had capacity to make medical decisions. The medical record contained one (1) capacity statement completed by the attending physician. The capacity statement indicated Resident #54 had the ability to appreciate the nature and implications of a health care decision, to make an informed choice regarding the alternatives presented, and to communicate the choice in an unambiguous manner. This form was completed on 05/31/14 and was still in effect at the time of this review. Further review of Resident #54's medical record found a physician's orders [REDACTED]. The nurse progress notes were reviewed. A note, dated 02/16/15, indicated Resident #54's spouse was notified of the medication change. There was no evidence in the medical record to suggest Resident #54 was notified of this medication change or was informed of the reason the medications were ordered and provided. Interview with the Director of Nursing (DON), at 12:23 p.m. on 03/06/15, confirmed there was no evidence to suggest Resident #54 was informed of the medication change on 02/16/15. She said staff called the spouse, but there was no evidence the resident was informed. The DON stated the physician was going to review the resident's capacity; however, at the time of the medication changes the resident was determined capable of making medical decisions.",2018-03-01
6421,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,157,E,1,0,S2LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the attending physician and healthcare decision makers were promptly notified when there was a change in the health status of two (2) of five (5) sampled residents. Resident #59 complained of pain on several occasions for which the attending physician and/or the healthcare decision maker were not promptly notified. Resident #7 had weight losses for which the attending physician and the healthcare decision maker were not promptly notified. Resident Identifiers: #59 and #7. Facility Census: 58. Findings Include: a) Resident #59 1. Review of Resident #59's medical record, at 12:33 p.m. on 03/02/15, found three (3) instances in August 2014 when Resident #59 made complaints of pain. On 08/20/14, 08/21/14, and 08/26/14, the resident complained of bilateral lower extremity pain. There was no evidence the attending physician and the healthcare decision maker were notified of the pain. 2. The medical record revealed Resident #59 had complaints of pain to the abdomen and/or right side daily from 09/03/14 through 09/08/14. There was no evidence Resident #59's attending physician was notified of the resident's daily pain until the morning of 09/08/14. In addition, there was no evidence Resident #59's healthcare decision maker was ever made aware of these daily complaints of pain. -- On 09/03/14 at 3:43 a.m., Licensed Practical Nurse (LPN) #60 noted Resident #59 received her prescribed as needed (PRN) pain medication twice that shift for complaints of abdominal pain. -- On 09/04/14 at 1:43 a.m., LPN #60 noted Resident #59 had complaints of abdominal pain and was given the PRN pain medication. -- On 09/05/14, Resident #59's Medication Administration Record [REDACTED]. -- On 09/06/14 at 5:11 p.m., LPN #5 noted Resident #59 was calling out from her bed stating, My belly is going to bust. -- On 09/07/14, Resident #59's MAR indicated [REDACTED]. -- On 09/08/14 at 4:02 a.m., Resident #59's MAR indicated [REDACTED]. -- On 09/08/14 at 10:38 a.m., Registered Nurse (RN) #61 noted Resident #59's attending physician was in to evaluate why Resident #59 had been complaining of abdominal pain. This was the first time there was evidence the physician was made aware of the resident's complaints of pain, which began on 09/03/14. -- On 09/08/14 at 1:36 p.m., the resident received a second dose of PRN [MEDICATION NAME] for complaints of pain to the right side. The medical record indicated the resident was crying at that time. 3. At 10:54 a.m. on 10/06/14, LPN #5 noted Resident #59 had constant complaints that her side hurt. LPN #5 indicated the resident had been medicated by the medication nurse. The note indicated the LPN spoke with the resident's healthcare decision maker about the resident's complaints of pain, but there was no evidence the physician was contacted. At 2:54 p.m. on 10/06/14, LPN #62 noted Resident #59 was administered pain medication for continued complaints of stomach pain. At 10:39 p.m. on 10/06/14, LPN #7, noted Resident #59 was guarding her stomach and crying in pain. The LPN noted this had been going on for the last two (2) nights. There was no evidence the physician or healthcare decision maker were notified of the resident's abdominal pain the last two (2) nights (10/04/14 and 10/05/14). LPN #7's note on 10/06/14 was the first mention Resident #59 experienced pain the nights of 10/04/14 and 10/05/14. The note dated 10/06/14 indicated a request was made for the physician to evaluate the resident's pain. The heath care decision maker also was not made aware of Resident #59's complaints of pain, on 10/04/14 and 10/05/14, until LPN #5 telephoned him at 10:54 a.m. on 10/06/14. 4. These failures to notify the physician and healthcare decision maker of Resident #59's pain were reviewed with the Director of Nursing and the Clinical Service Manager at 4:30 p.m. on 03/05/15. They were unable to provide evidence Resident #59's attending physician and healthcare decision maker were promptly notified of the resident's complaints of pain in August, September, and October 2014. b) Resident #7 A review of Resident #7's medical record, at 9:46 a.m. on 03/03/15, revealed the resident was admitted to the facility on [DATE]. She was discharged to the hospital on [DATE], then readmitted to the facility on [DATE], where she remained with no further discharges as of the time of the survey. Medical records contained several documented weights for Resident #7. The records indicated they were obtained at the facility through the use of a mechanical lift: -- 02/04/15 - 190.6 pounds (admission) to the facility). -- 02/09/15 - 191.8 pounds (the resident was in the hospital on this date) -- 02/11/15, 181.7 pounds (readmission weight) -- 02/20/15, 171.7 pounds (a severe weight loss of 5.5% in nine (9) days) -- 02/24/15, 158.4 pounds (a severe weight loss of 7.74% in four (4) days) -- 03/01/15, 153.2 pounds (a severe weight loss of 5.2% in five (5) days) On 03/03/15, review of the medical record found on 02/16/15, the physician and the medical power of attorney (MPOA) were notified the resident had a weight loss. There was no evidence the physician or the MPOA were notified the resident's weight records showed the resident had additional weight losses, each severe, recorded on 02/20/15, 02/24/15, and 03/01/15. In an interview with the Director of Nursing (DON) at 2:28 p.m. on 03/04/15, when asked if Resident #7's physician and MPOA were notified of the resident's continued weight losses since the notification on 02/16/15, the DON confirmed there was no evidence which indicated the physician and MPOA had been notified since 02/16/15. She confirmed Resident #7 had three (3) additional weights recorded since their notification on 02/16/15, which demonstrated additional weight losses. The DON confirmed the physician and Resident #7's MPOA should have been notified of each loss. .",2018-03-01
6422,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,224,H,1,0,S2LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident observation, resident interview, and staff interview, the facility failed to prohibit the neglect of two (2) of five (5) sampled residents. The facility neglected to ensure optimal management of Resident #59's pain to prevent undue pain and mental anguish. Since July 2014, facility staff had consistently neglected to assess Resident #59's pain for location, nature, and severity before the administration of medication and/or neglected to reassess her pain for the effectiveness of the pain medication after administration. This constituted actual harm for Resident #59. For Resident #7, the facility staff neglected to take appropriate actions to implement the Registered Dietitian's recommendations. The facility staff also neglected to notify the physician promptly of the resident ' s weight loss; therefore, delaying his ability to assess and/or provide interventions to prevent additional weight losses. As the facility failed to implement the dietitian ' s recommendations and failed did not promptly notify the physician to assess and/or provide interventions to prevent further weight loss, the weight loss could not be determined to be unavoidable. This represented actual harm to Resident #7. Additionally, the facility staff failed to adequately monitor Resident #7 ' s skin during weekly skin assessments and while providing treatments. Resident #7 developed an avoidable pressure ulcer, which also constituted actual harm for Resident #7. Resident Identifiers: #59 and #7. Facility Census: 58. Findings Include: a) Resident #59 A review of Resident #59's medical record, at 12:33 p.m. on 03/02/15, found Resident #59 had frequent complaints of abdominal pain, and pain in her left and right sides, since July 2014. She had a computerized tomography (CT), without contrast, of the abdomen and pelvis completed on 07/04/14 at a local hospital. The impression was, A possible tiny non-bstructive distal left [MEDICAL CONDITION] calculus is seen. A probable renal mass raising the possibility of renal cell [MEDICAL CONDITION] is also seen. A ventral Hernia containing a loop of colon is also identified. While out to the hospital on [DATE], she also had an ultrasound of both kidneys. The impression for this was, The examination is limited due to the patients large body habitus. A left renal mass is identified raising the possibility of renal cell [MEDICAL CONDITION]. She had another CT of the abdomen completed on 08/19/14. The impression for this was, A 3.4 CM left renal mass believe to [MEDICAL CONDITION] essentially the same as previous 07/23/14 exam. Ventral hernia with non-obstructed small bowel loop of the lower abdomen. Mild constipation. 3 cm (centimeter) uterine fibroid. On 09/08/14, she also had an X-ray of the abdomen which indicated, No acute Findings or Bowel Obstruction. They compared this to an x-ray of the abdomen taken on 12/30/12, which also indicated no bowel obstruction. Review of the resident's annual minimum data set (MDS) assessment, with an assessment reference date (ARD) of 06/10/14, found the resident was on a scheduled pain medication and an as needed (PRN) medication. At that time, the assessment indicated no non-pharmacologic interventions were utilized. The coding for pain indicated the resident had moderate intensity pain rarely. The quarterly MDS, with an ARD of 09/05/14, indicated the resident was not on scheduled pain medication, but did receive PRN [MEDICATION NAME]. The resident's pain interview indicated she had pain frequently that made it hard to sleep at night and limited her activities. Severe was checked for the resident's response for the intensity of her pain. Further review of the resident's medical record found the facility staff failed to ensure Resident #59 consistently received adequate pain management. At times, there was no evidence the resident's complaints of pain were treated. Staff also failed to assess Resident #59's pain for location, nature, and severity before the administration of medication, and/or neglected to reassess her pain for the effectiveness of the pain medication after administration. Staff also failed to implement non-pharmacological interventions in attempts to alleviate Resident #59's pain. No evidence was found to indicate staff monitored the resident for passage of the kidney stone. The failure of facility staff to effectively manage Resident #59's pain on an ongoing basis since July 2014 resulted in Resident #59 periodically suffering from pain for longer than necessary, which constituted physical harm for Resident #59. 1. July 2014 Review of Resident #59's medical record for July 2014 found the resident received ordered as needed (PRN) pain medication and/or complained of pain on the following instances in which Resident #59's pain was not assessed to determine the location, nature, and or severity, and the effectiveness of the pain medication was not determined unless otherwise noted. By not assessing the location, nature, and severity of the pain, information about the resident's pain was not available to communicate to the physician for evaluation. No non-pharmacological interventions were identified as being employed to address the resident's pain. a. 07/03/14 Review of Resident #59's medical record found she began complaining of left side pain on 07/03/14 at 10:00 p.m. Licensed Practical Nurse (LPN) #20 assessed the area and noted no bruising or redness on 07/03/14 at 10:00 p.m. LPN #20 did note administering pain medication at that time. A routine dose of of Tylenol 1000 milligrams (mg) was due at 10:00 p.m. There was no indication LPN #20 assessed whether the dose of Tylenol at 10:00 p.m. was effective in relieving Resident #59's pain. At that time, the resident also had an order for [REDACTED]. There was no indication the attending physician and/or Resident #59's healthcare decision maker were notified of Resident #59's complaints of pain on 07/03/14. b. 07/04/14 Resident #59 again complained of pain in her left side on 07/04/14 at 7:25 p.m. LPN #5 noted she wanted to go to the emergency room (ER) for an evaluation. The resident was sent to the ER, but prior to her leaving the facility, there was no indication her pain was assessed and/or treated. There was no evidence of attempts to obtain additional orders from the attending physician to treat Resident #59's pain prior to sending her to the ER. c. 07/05/14 Resident #59 returned from the ER at 2:44 a.m. on 07/05/14 with new orders for [MEDICATION NAME] 5/325 every 6 (six) hours as needed (PRN) for pain. It was also noted at this time, Resident #59 had a kidney stone and a three (3) centimeter mass. At 1:33 p.m. on 07/05/14, Resident #59's attending physician was notified of her visit to the ER and he gave a new order to discontinue her routine dose of Tylenol 1000 mg twice daily at 10:00 a.m. and 10:00 p.m. Resident #59's MAR indicated [REDACTED]. d. 07/06/14 LPN #20 noted, on 07/06/14 at 1:41 a.m., Resident #59 was medicated with [MEDICATION NAME] one (1) time for complaints of left sided pain with relief noted. Review of 07/06/14 MAR found it did not reflect administration of [MEDICATION NAME] as identified in the nurse's note. e. 07/07/14 LPN #32 noted, at 8:06 a.m. on 07/07/14, Resident #59 was given one (1) dose of [MEDICATION NAME] for complaints of left sided pain. LPN #32 noted the medication was effective. However, there was no indication LPN #32 assessed for the nature and severity of the resident's pain before the administration of medication and/or the effectiveness of the pain medication after administration. f. 07/08/14 - 07/09/14 Resident #59's MAR indicated [REDACTED]. g. 07/12/14 - 07/13/14 Resident #59's MAR indicated [REDACTED]. h. 07/15/14 Resident #59's MAR indicated [REDACTED]. i. 07/21/14 to 07/23/14 Resident #59's MAR indicated [REDACTED]. LPN #5, at 5:41 a.m. on 07/22/14, noted Resident #59 was complaining of stomach pain and headache. LPN #5 indicated she administered PRN Tylenol with relief. There was no indication LPN #5 assessed the severity of Resident #59's pain prior to and after the administration of the PRN Tylenol. Registered Nurse (RN) #58 noted at 10:04 a.m. on 07/22/14, Resident #59's attending physician was in the facility and notified of Resident #59's complaints of pain in her left side. There was no indication the physician assessed Resident #59 and he provided no new orders on that date. At 7:35 a.m., RN #59 telephoned Resident #59's health care decision maker and obtained permission to send Resident #59 out to the ER if the physician requested. RN #59 noted, at 7:45 a.m. on 07/23/14, Resident #59 was moaning and complaining of severe abdominal pain. RN #59 assessed the resident as having severe abdominal pain, rated a 10 (ten) plus on a scale of 0 - 10 with zero (0) being no pain and ten (10) being the worst. RN #59 noted a .large protrusion noted at the umbilicus (navel) area warm/tender to touch. At 9:41 a.m. on 07/23/14, RN #58 noted Resident #59 was sent to the ER for abdominal pain. The resident remained at the facility for nearly two (2) hours, until 9:41 a.m. on 07/23/14, at which time she left the facility via ambulance. During the two (2) hours she remained at the facility, she received no treatment for [REDACTED].#59 at 7:45 a.m. Review of Resident #59's MAR for 07/23/14 found no pain medications were administered to Resident #59. There was no further mention of the resident's ventral hernia found in subsequent nursing entries. j. 07/30/14 Resident #59's MAR indicated [REDACTED]. 2. August 2014 Review of Resident #59's medical record for August 2014 found the resident received ordered as needed pain medication and/or complained of pain on the following instances. Again, unless otherwise noted, there was not assessment of the location, nature, or severity of her pain and no assessment of the effectiveness of the medications. There were no non-pharmacological interventions identified. a. 08/07/14 LPN #20 noted a 5:10 a.m. on 08/07/14 that Resident #59 awoke and requested to go the ER for abdominal pain. At 5:23 a.m. on 08/07/14, LPN #20 noted Resident #59's healthcare decision maker was notified of Resident #59's complaint of abdominal pain and was advised Resident #59 was medicated with her as needed pain medication. LPN #20 noted the healthcare decision maker would prefer to give the medication time to work and if the resident continued with complaints of pain to call him back and he would come and talk with the resident. LPN #20 noted she explained the conversation to Resident #59 who was not happy with her brother's decision. Review of Resident #59's MAR found she was medicated with [MEDICATION NAME] 5/325 mg on 08/07/14. There was no indication LPN #20 assessed the severity/intensity of Resident #59's prior to administration of the as needed pain medication. There was also no evidence to suggest LPN #20 reassessed the resident after the PRN pain medication was administered and had time to be effective, as the resident ' s brother had requested. b. 08/15/14 Resident #59's MAR indicated [REDACTED]. c. 08/19/14 Resident #59's MAR indicated [REDACTED]. d. 08/20/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. It should be noted this administration note was linked to the administration of [MEDICATION NAME] 5/325, but [MEDICATION NAME] 5/325 was not administered on that date. There was no indication the nurse who administered this medication assessed the resident's pain for severity/intensity prior to administering the PRN Tylenol, and there was no indication the nurse reassessed the the resident to determine if the PRN medication was effective. e. 08/21/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. f. 08/24/14 Resident #59's MAR indicated [REDACTED]. g. 08/26/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. An additional administration note on the MAR indicated [REDACTED]. h. 08/28/14 to 08/30/14 Resident #59's MAR indicated [REDACTED]. i. On 08/20/14, 08/21/14, and 08/26/14 it was noted Resident #59 complained of bilateral lower extremity pain. There was no evidence to suggest the facility made any attempts to determine the cause of the pain in her bilateral lower extremities, nor evidence to suggest the attending physician and/or healthcare decision maker were notified of her bilateral lower extremity pain. 3. September 2014 Review of Resident #59's medical record for 09/2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: a. 09/01/14 Review of Resident #59's MAR for 09/01/14 found she was administered her PRN [MEDICATION NAME] 5/325 on 09/01/14. b. 09/03/14 - 09/08/14 On 09/03/14 at 3:43 a.m. LPN #60, noted Resident #59 received her PRN pain medication twice that shift for complaints of abdominal pain. LPN #60 noted Resident #59 had a bowel movement and her bowels sounds were present in all four (4) quadrants. On 09/04/14 at 1:43 a.m. LPN #60 noted Resident #59 had complaints of abdominal pain and was given PRN pain medication. On 09/05/14, Resident #59's MAR indicated [REDACTED]. On 09/06/14 at 5:11 p.m., LPN #5 noted Resident #59 was calling out from her bed stating, My belly is going to bust. LPN #5 noted the resident had received her PRN pain medication. There was no evidence to suggest LPN #5 assessed the severity of Resident #59's pain prior to administering the PRN pain medication, nor did she reassess her pain for severity to determine if the PRN pain medication was effective. On 09/07/14, Resident #59's MAR indicated [REDACTED] On 09/08/14 at 10:38 a.m., RN #61 noted Resident #59's attending physician was in to evaluate why Resident #59 had been complaining of abdominal pain and crying. He ordered to obtain a KUB to check for ileus disease. Further review of the record found this testing was obtained and ileus disease was not diagnosed . Additionally, on 09/08/14 Resident #59's MAR indicated [REDACTED]. Dhe received a second dose of PRN [MEDICATION NAME] at 1:36 p.m. on 09/08/14, for complaints of pain to the right side accompanied by crying On 09/09/14 at 2:24 a.m., Resident #59's MAR indicated [REDACTED]. It should be noted this information was contained in the Administration notes on the MAR; however, the dosage of [MEDICATION NAME] 5/325 was not initialed as given on the MAR. Resident #59 had complaints of pain to the abdomen and/or right side daily from 09/03/14 through 09/08/14, there was no evidence to suggest Resident #59's attending physician was notified of her daily pain until the morning of 09/08/14. There was also no evidence to suggest Resident #59's healthcare decision maker was made aware of her daily complaints of pain. c. 09/19/14 - 09/21/14 Review of Resident #59's MAR indicated [REDACTED]. The source of Resident #59's pain was only identified on one (1) of the three (3) days she received the PRN pain medication. On 09/21/14 the location of Resident #59's pain was identified as being in the abdomen d. On 09/19/14 and 09/20/14 there was no evidence to suggest Resident #59's pain was assessed for location, nature, and severity before the administration of medication and/or the effectiveness of the pain medication after administration. On 09/23/14 at 12:26 a.m. LPN #20 noted Resident #59 had some complaints of leg discomfort and was medicated with her PRN pain medication. She additionally noted that the Resident was screaming and keeping the residents on the hallway awake. LPN #20 noted there was no reasoning with the resident. At 12:46 a.m. LPN #20 noted resident continued to scream and was now complaining of shortness of breath even though her oxygen saturation was in the upper 90's. LPN #20 again noted she was unable to reason with the resident. At 1:00 a.m. LPN #20 noted she heard Resident #59 screaming as she has been since 12:30 a.m Upon entering Resident #59's room LPN #20 observed the resident laying in the floor beside her bed. LPN #20 indicated she had slid off the bed and continued to yell and scream. She again noted she was unable to reason with Resident #59. At 1:45 a.m. LPN #20 noted Resident #59 continued to yell and scream and disturb the other residents. She again indicated she was unable to reason with the resident. She noted the resident was screaming at staff instead of speaking to them in a normal tone. There was no mention by LPN #20 that she reassessed Resident #59 for pain after administering the PRN pain medication at 12:26 a.m., despite the fact Resident #59 continually screamed, yelled, and even slid off her bed. LPN #20 also failed to assess the severity of the Resident #59's pain prior to administering the PRN pain medication. At 8:18 a.m. on 09/23/14, LPN #5 noted she had spoken with Resident #59's healthcare decision maker and notified him about the resident sliding off the bed. She noted the resident's health decision maker indicated he and his wife would be in later today to speak with the resident about her behaviors. Resident #59's MAR indicated [REDACTED]. e. 09/26/14 to 09/28/14 Resident #59's MAR indicated [REDACTED]. Beginning on 09/15/14 the facility implemented a new pain observation tool. Nursing staff were to observe and/or question for pain every four (4) hours and PRN while awake. The documentation on this tool was inconsistent with the documentation contained in the rest of Resident #59's medical record. The documentation on this tool was reviewed and found Resident #59 was positive for pain on 09/16/14, 09/21/14, 09/22/14, 09/23/14, and 09/27/14. It should be noted Resident #59 was not medicated for identified pain on 09/16/14 and 09/22/14. Additionally, it should be noted that on 09/19/14, 09/20/14, 09/24/14, 09/26/14, and 09/28/14 Resident #59 was given PRN pain medication, but the pain observation tool was marked to indicate she was not having pain. Review of Resident #59's medical record for October 2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: 4) October 2014 a. 10/01/14 - 10/02/14 At 11:00 a.m. on 10/01/14 RN #49 noted that Resident #59 was complaining of abdominal pain at her hernia site. She noted her PRN pain medication had been administered about five (5) minutes prior to Resident #59's complaints. RN #49 noted the resident complained the pain medication was not helping her pain. RN #49 applied a warm compress to the abdomen and attempted to reach the resident's health care decision maker. RN #49 then spoke with the resident about waiting until her attending physician was able to visit to review her pain medication regimen before they sent her to the emergency room . RN #49 noted Resident #59 was in agreement with this plan. Review of Resident #59's MAR found she received a PRN dose of [MEDICATION NAME] on that date At 9:55 a.m. on 10/02/14, RN #41 noted Resident #59's attending physician was in and reviewed her pain medication regimen. The physician wrote a new order for [MEDICATION NAME] 5/325 as needed every four (4) hours instead of every six (6) hours. The physician also added a scheduled dose of [MEDICATION NAME] 5/325 three times a day at 10:00 a.m., 2:00 p.m. and 10:00 p.m. Resident #59 began receiving this routine scheduled dose of [MEDICATION NAME] at 10:00 a.m. on 10/02/14. b. 10/04/14 to 10/07/14 At 10:54 a.m. on 10/6/14, LPN #5 noted Resident #59 had constant complaints of her side hurting. LPN #5 indicated the resident had been medicated by the medication nurse. She noted she had spoken with Resident #59's health care decision maker and he did not want the resident sent out of the facility. LPN #5 noted that the healthcare decision maker stated, every time she is sent out they always send her right back because nothing is ever wrong with her. The health care decision maker stated he would come in and talk to the resident that day. LPN #5 noted Resident #59 was not happy about her brother not wanting her sent out of the facility. There was no mention of assessments to determine the severity of the pain Resident #59 was experiencing, or assessments to determine if scheduled doses of pain medication were effective in order to determine if resident needed to be medicated with the PRN [MEDICATION NAME] for which she had an order. Additionally there was no testing and or evaluations completed by facility staff to determine the cause of Resident #59's pain. At 2:54 p.m. on 10/06/14, LPN #62 noted Resident #59 had shown a decrease in the volume of complaints and she was administered pain medication for continued complaints of stomach pain. At 10:39 p.m. on 10/06/14, LPN #7 noted Resident #59 was guarding her stomach and crying in pain and she had done so for the last two (2) nights. She noted bowel sounds were present, were hypoactive in all four (4) quadrants, abdomen was distended in right lower quadrant and tender to touch. LPN #7 noted Resident #59 screamed in pain when she was turned on her stomach. She noted Resident #59 was medicated with scheduled [MEDICATION NAME] one (1) time that shift. She noted she had requested a physician evaluation for pain. There was no evidence in the medical record of Resident #59 to indicate she was having pain in her abdomen and guarding her stomach on 10/04/14 or 10/05/14 as indicated in the 10/06/14 entry by LPN #7. LPN #7's note on 10/06/14 was the first mention of Resident #59's pain which she had experienced on the previous two (2) nights. There was no evidence to suggest Resident #59's pain was assessed for severity and/or relief of pain upon administration of scheduled pain medication on 10/04/14 and 10/05/14, in order to determine the need for PRN pain medication, which was not administered at all on 10/05/14. There was no indication nursing staff assessed Resident #59 to determine the cause of her continued pain in her abdomen. LPN #7 noted she had requested the physician evaluate the resident for pain, but there was no indication nursing staff had called Resident #59's attending physician to notify him of her continued abdominal pain. The heath care decision maker was not made aware of Resident #59's complaints of pain on 10/04/14, 10/05/14 and 10/06/14 until LPN #5 phoned him at 10:54 a.m. on 10/06/14. Resident #59 received a dose of her PRN pain medication on 10/04/14 and 10/06/14. At 8:34 a.m. on 10/07/14, LPN #5 noted Resident #59 was being combative and yelling out at staff. She noted the medication nurse tried to give the resident her pain medication for her complaint of stomach pain and the resident refused stating, You all are not helping me, I want the police. She noted she explained to the resident they were trying to help her, but she would not let them. Resident #59 proceeded to kick over the bedside table and continued to yell out. LPN #5 noted she called the health care decision maker and he would be at the facility shortly to calm the resident down. At 8:46 a.m. on 10/07/14, LPN #5 noted Resident #59's brother was at the facility to see her. At 8:54 a.m. 10/07/14, LPN #5 noted the resident's brother wanted her sent to the ER for an evaluation. At 9:20 a.m. on 10/07/14, LPN #5 noted the resident was transported to the ER at 9:20 a.m. on 10/07/14. At 5:46 p.m. on 10/07/14 LPN #5 noted Resident #59 returned to the facility from the ER with [DIAGNOSES REDACTED]. Resident #59 had made multiple complaints of abdominal and side pain beginning 10/04/14 through 10/07/14. The facility failed to assess for the cause of the pain, failed to treat the pain effectively, and failed to assess for the severity of the pain prior to and after administration of PRN pain medications on 10/4/14 and 10/06/14. Staff also failed to assess for the effectiveness of her scheduled pain medication to determine if she needed further medicated with the PRN doses [MEDICATION NAME] to control her pain. Additionally, they failed to notify the attending physician of the continual complaints of pain, and failed to notify the healthcare decision maker of her complaints of pain until 10/06/14. This resulted in Resident #59 suffering undue pain as well as mental anguish. On 10/07/14 Resident #59 was noted to be combative with staff and was noted to state, You all aren't helping me, I want the police. Resident #59 had at that point endured pain for three (3) consecutive days and felt as if the facility staff was not helping her. It was not until her brother arrived at the facility and requested she be sent to the ER that Resident #59 was sent out of the facility for treatment for [REDACTED]. The facility was unable to show any evidence of attempts to manage and control her pain at the facility. They made no attempts to determine the cause pain and/or to treat the cause of the pain. b. 10/10/14: Resident #59's MAR indicated [REDACTED]. c. 10/16/14: Resident #59's MAR indicated [REDACTED]. Review of Resident #59's pain observation tool found the resident was identified as having pain on 10/04/14, 10/06/14, 10/08/14, and 10/13/14. Please note this report was again inconsistent with the rest of Resident #59's medical record. She was identified as having continual pain from 10/04/14 through 10/07/14 in the nursing progress notes, she received a PRN dose of [MEDICATION NAME] in addition to her scheduled pain medications on 10/10/14 and 10/16/14 and was identified as not having pain on these dates on the pain observation tool. Additionally, the pain observation tool identified she had pain on 10/08/14 and 10/13/14 with no mention of the pain in the progress notes or administration of any pain medication other than her scheduled [MEDICATION NAME] 5/325 three (3) times a day. This tool was ineffective in identifying when Resident #59 experienced pain. Review of Resident #59's medical record for 11/2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: 5) November 2014 a. 11/12/14: Resident #59's MAR indicated [REDACTED]. b. 11/16/14: Resident #59's MAR indicated [REDACTED]. c. 11/21/14: Resident #59's MAR indicated [REDACTED]. d. 11/28/14: Resident #59's MAR indicated [REDACTED]. h. Review of Resident #59's pain observation tool for the month of November 2014 again found inconsistent documentation between the pain monitoring tool and the MAR. Resident #59 received PRN pain medication on 11/12/14, 11/16/14, 11/21/14, and 11/28/14. The pain observation tool indicated Resident #59 was negative for pain on all of these dates. 6) December 2014 Review of Resident #59's medical record for December 2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: a. 12/08/14: Resident #59's MAR indicated [REDACTED]. b. 12/09/14: Resident #59's MAR indicated [REDACTED]. c. 12/22/14: Resident #59's MAR indicated [REDACTED]. d. 12/28/14: At 10:14 a.m. on 12/28/14, LPN #36 noted that Resident #59 had poured water on herself multiple times to get the staff to change her pants. She noted Resident #59 was complaining that her pants were too tight. LPN #36 noted, she told the resident her pants were not too tight and to quit being disruptive. She advised the resident that the nurse aides were busy feeding and bathing other residents and that she could not keep pouring water on herself just to get changed. LPN #36 then noted Resident #59 began to complain of stomach pain and nausea. She indicated she gave Resident #59 a [MEDICATION NAME] shot and the resident was noted to be resting about 30 minutes after the shot. There was no indication in Resident #59's medical record that LPN #36 had assessed the resident for pain upon her complaints that her pants were too tight. There was no mention of pain until after the staff had changed the resident's pants on several occasions and after LPN #36 had advised Resident #59 that she was being disruptive. At that time, Resident #59 mentioned pain when she complained of pain in her stomach. Once the resident complained of pain, LPN #36 failed to assess the severity of the pain and/or the possible causes of the stomach pain. LPN #36 proceeded to treat the complaints of nausea, but failed to assess and/or treat Resident #59's complaints of stomach pain. This note was entered into the medical record at 10:14 a.m., which was 14 minutes after Resident #59 had received her scheduled dose of [MEDICATION NAME]. LPN #36 failed to assess the severity of Resident #59's pain did not assess the effectiveness of the resident ' s scheduled pain medication to determine if a PRN dose [MEDICATION NAME] was needed. Resident #59 was not administered her PRN [MEDICATION NAME] on 12/28/14. e. 12/30/14: Resident #59's MAR indicated [REDACTED]. 7) January 2015 Review of Resident #59's medical record for January 2015 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: a. 01/18/15: Resident #59's MAR indicated [REDACTED]. b. 01/31/15: Resident #59's MAR indicated [REDACTED]. 8) February 2015 For the month of February 2015, Resident #59 received no doses of her PRN pain medication. Additionally, Resident #59 had not voiced any complaints of pain except on 02/09/15. On 02/09/15, Resident #59 complained of abdomin",2018-03-01
6423,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,225,D,1,0,S2LQ11,"Based on record review and staff interview, the facility failed to report an allegation of sexual abuse to appropriate State agencies, and failed to thoroughly investigate the allegation. This was discovered by a random opportunity for discovery while reviewing a resident's medical record. The medical record indicated an allegation of sexual abuse was made to a nurse aide and a licensed practical nurse (LPN). There was no evidence this allegation was reported to appropriate state agencies or thoroughly investigated. Resident Identifier: #59. Facility Census: 58. Findings Include: a) Resident #59 A review of Resident #59's medical record, at 4:00 p.m. on 03/04/15, found a nursing progress note, dated 07/15/14, written by Licensed Practical Nurse (LPN) #56. The note contained the following text (typed as written): Called residents room by CNA (Nurse Aide) to witness thing that the resident was stating. Resident stated that, 'Someone came in while I was asleep and was touching me down there and got me pregnant. They also took pictures of me naked. And since they touched me they made me start my period again. I went to the hospital last week and they had to remove a mass. It was a baby and it was born dead.' Charge nurse (Name of former employee), RN (Registered Nurse) was notified and so was social services. Resident was checked for bleeding and no bleeding noted. Resident will continue to be monitored. Call Bell within reach. An interview with the Vice President of Social Services, Employee #55, at 9:05 a.m. on 03/06/15, found this incident was not reported to the Office of Health Facility Licensure and Certification, Adult Protective Services, or the Ombudsman Program. She said she could not recall whether or not the allegation was reported to her by nursing staff. Employee #55 said she felt if it had been reported to her, she would have reported it immediately as an allegation of sexual abuse. She was asked about the process for situations in which a resident alleged abuse to nursing staff. Employee #55 stated nursing staff brought it to her attention, she reviewed it with the administrator, then a decision was made regarding whether it was a reportable allegation. She said to her knowledge, this process was not carried out for this allegation because she had no knowledge of the allegation Resident #59 made on 07/15/14. When asked if the allegation was investigated, Employee #55 stated the allegation of sexual abuse had not been thoroughly investigated.",2018-03-01
6424,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,241,D,1,0,S2LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of five (5) sampled residents was cared for in a manner which enhanced the resident's dignity and respect, in full recognition of the resident's individuality. A licensed practical nurse (LPN) dismissed the resident's complaints of discomfort and told the resident she was being disruptive. Resident identifier: #59. Facility census: 58. Findings Include: a) Resident #59 Review of Resident #59's medical record, at 12:33 p.m. on 03/02/15, found Resident #59 was not treated in a dignified and respectful manner on 12/28/14, when she complained that her pants were too tight. The medical record contained a nursing note, written by Licensed Practical Nurse (LPN) #36 on 12/28/14. The note read (typed as written): Resident has been seen to pour water on herself several times to get the CNA's (Nurse Aides) to change her clothing. Resident states, 'My pants are too tight, they need thrown away, im going to put them in the trash.' Every time the CNA's changed her pants she did the same thing. This nurse tried to redirect the resident and explain to her that her pants were not to tight, that she just got them on 12-25-14 (Christmas), and she was being disruptive. I explained to the her that the CNA's were trying to feed and bathe other patients and she couldn't keep pouring water on herself just to be changed. Resident stated she understood, but within 10 (ten) minutes she started yelling her pants were too tight and needed change again. Resident also started c/o (complaints of) stomach pain and nausea. Asked resident if she wanted a [MEDICATION NAME] injection and she said, 'Yes if it will make it go away.' Gave resident a PRN (as needed) [MEDICATION NAME] injection in the right hip. CNA's changed residents pants again and she asked to sit on her bed and color. Went to resident's room about 30 minutes after the injection was given and the resident was asleep in her bed. Call light within reach and will continue to monitor. When this documentation was brought to the attention of the director of nursing (DON), in an interview at 12:28 p.m. on 03/04/15, she confirmed LPN #36's actions regarding Resident #59's complaints on 12/28/14 were not appropriate. The DON stated the LPN should have handled the situation differently. She agreed the nurse should not have told Resident #59 her pants were not too tight, but should have assessed the situation to determine why the resident thought her pants were too tight. The DON also agreed the nurse should not have told the resident she was being disruptive. At 1:50 p.m. on 03/04/15, the Vice President of Social Services, Employee #55, was interviewed. Employee #55 confirmed LPN #36 did not treat Resident #59 with dignity and respect when she dismissed the resident's complaints and told the resident she was being disruptive. .",2018-03-01
6425,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,309,H,1,0,S2LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure two (2) of seven (7) sampled residents received the care and services needed to maintain each resident's highest practicable well-being. The facility consistently failed to implement non-pharmacological interventions in attempts to alleviate Resident #59's pain. The facility also failed to consistently assess Resident #59's pain for location, nature, and severity before the administration of medication and/or failed to reassess her pain for the effectiveness of the pain medication after administration. The failure to ensure optimal pain management for Resident #59 constituted actual harm. For Resident #7, the facility failed to evaluate the resident for the need and/or administered insulin coverage if required, according to physician's orders. Resident Identifiers: #59 and #7. Facility Census: 58. Findings Include: a) Resident #59 A review of Resident #59's medical record, at 12:33 p.m. on 03/02/15, found Resident #59 had frequent complaints of abdominal pain, and pain in her left and right sides, since July 2014. She had a computerized tomography (CT), without contrast, of the abdomen and pelvis completed on 07/04/14 at a local hospital. The impression was, A possible tiny non-obstructive distal left [MEDICAL CONDITION] calculus is seen. A probable renal mass raising the possibility of renal cell [MEDICAL CONDITION] is also seen. A ventral Hernia containing a loop of colon is also identified. While out to the hospital on [DATE], she also had an ultrasound of both kidneys. The impression for this was, The examination is limited due to the patients large body habitus. A left renal mass is identified raising the possibility of renal cell [MEDICAL CONDITION]. She had another CT of the abdomen completed on 08/19/14. The impression for this was, A 3.4 CM left renal mass believe to [MEDICAL CONDITION] essentially the same as previous 07/23/14 exam. Ventral hernia with non-obstructed small bowel loop of the lower abdomen. Mild constipation. 3 cm (centimeter) uterine fibroid. On 09/08/14, she also had an X-ray of the abdomen which indicated, No acute Findings or Bowel Obstruction. They compared this to an x-ray of the abdomen taken on 12/30/12, which also indicated no bowel obstruction. Review of the resident's annual minimum data set (MDS) assessment, with an assessment reference date (ARD) of 06/10/14, found the resident was on a scheduled pain medication and an as needed (PRN) medication. At that time, the assessment indicated no non-pharmacologic interventions were utilized. The coding for pain indicated the resident had moderate intensity pain rarely. The quarterly MDS, with an ARD of 09/05/14, indicated the resident was not on scheduled pain medication, but did receive PRN [MEDICATION NAME]. The resident's pain interview indicated she had pain frequently that made it hard to sleep at night and limited her activities. Severe was checked for the resident's response for the intensity of her pain. Further review of the resident's medical record found the facility staff failed to ensure Resident #59 consistently received adequate pain management. At times, there was no evidence the resident's complaints of pain were treated. Staff also failed to assess Resident #59's pain for location, nature, and severity before the administration of medication, and/or neglected to reassess her pain for the effectiveness of the pain medication after administration. Staff also failed to implement non-pharmacological interventions in attempts to alleviate Resident #59's pain. No evidence was found to indicate staff monitored the resident for passage of the kidney stone. The failure of facility staff to effectively manage Resident #59's pain on an ongoing basis since July 2014 resulted in Resident #59 periodically suffering from pain for longer than necessary, which constituted physical harm for Resident #59. 1. July 2014 Review of Resident #59's medical record for July 2014 found the resident received ordered as needed (PRN) pain medication and/or complained of pain on the following instances in which Resident #59's pain was not assessed to determine the location, nature, and or severity, and the effectiveness of the pain medication was not determined unless otherwise noted. By not assessing the location, nature, and severity of the pain, information about the resident's pain was not available to communicate to the physician for evaluation. No non-pharmacological interventions were identified as being employed to address the resident's pain. a. 07/03/14 Review of Resident #59's medical record found she began complaining of left side pain on 07/03/14 at 10:00 p.m. Licensed Practical Nurse (LPN) #20 assessed the area and noted no bruising or redness on 07/03/14 at 10:00 p.m. LPN #20 did note administering pain medication at that time. A routine dose of of Tylenol 1000 milligrams (mg) was due at 10:00 p.m. There was no indication LPN #20 assessed whether the dose of Tylenol at 10:00 p.m. was effective in relieving Resident #59's pain. At that time, the resident also had an order for [REDACTED]. There was no indication the attending physician and/or Resident #59's healthcare decision maker were notified of Resident #59's complaints of pain on 07/03/14. b. 07/04/14 Resident #59 again complained of pain in her left side on 07/04/14 at 7:25 p.m. LPN #5 noted she wanted to go to the emergency room (ER) for an evaluation. The resident was sent to the ER, but prior to her leaving the facility, there was no indication her pain was assessed and/or treated. There was no evidence of attempts to obtain additional orders from the attending physician to treat Resident #59's pain prior to sending her to the ER. c. 07/05/14 Resident #59 returned from the ER at 2:44 a.m. on 07/05/14 with new orders for [MEDICATION NAME] 5/325 every 6 (six) hours as needed (PRN) for pain. It was also noted at this time, Resident #59 had a kidney stone and a three (3) centimeter mass. At 1:33 p.m. on 07/05/14, Resident #59's attending physician was notified of her visit to the ER and he gave a new order to discontinue her routine dose of Tylenol 1000 mg twice daily at 10:00 a.m. and 10:00 p.m. Resident #59's MAR indicated [REDACTED]. d. 07/06/14 LPN #20 noted, on 07/06/14 at 1:41 a.m., Resident #59 was medicated with [MEDICATION NAME] one (1) time for complaints of left sided pain with relief noted. Review of 07/06/14 MAR found it did not reflect administration of [MEDICATION NAME] as identified in the nurse's note. e. 07/07/14 LPN #32 noted, at 8:06 a.m. on 07/07/14, Resident #59 was given one (1) dose of [MEDICATION NAME] for complaints of left sided pain. LPN #32 noted the medication was effective. However, there was no indication LPN #32 assessed for the nature and severity of the resident's pain before the administration of medication and/or the effectiveness of the pain medication after administration. f. 07/08/14 - 07/09/14 Resident #59's MAR indicated [REDACTED]. g. 07/12/14 - 07/13/14 Resident #59's MAR indicated [REDACTED]. h. 07/15/14 Resident #59's MAR indicated [REDACTED]. i. 07/21/14 to 07/23/14 Resident #59's MAR indicated [REDACTED]. LPN #5, at 5:41 a.m. on 07/22/14, noted Resident #59 was complaining of stomach pain and headache. LPN #5 indicated she administered PRN Tylenol with relief. There was no indication LPN #5 assessed the severity of Resident #59's pain prior to and after the administration of the PRN Tylenol. Registered Nurse (RN) #58 noted at 10:04 a.m. on 07/22/14, Resident #59's attending physician was in the facility and notified of Resident #59's complaints of pain in her left side. There was no indication the physician assessed Resident #59 and he provided no new orders on that date. At 7:35 a.m., RN #59 telephoned Resident #59's health care decision maker and obtained permission to send Resident #59 out to the ER if the physician requested. RN #59 noted, at 7:45 a.m. on 07/23/14, Resident #59 was moaning and complaining of severe abdominal pain. RN #59 assessed the resident as having severe abdominal pain, rated a 10 (ten) plus on a scale of 0 - 10 with zero (0) being no pain and ten (10) being the worst. RN #59 noted a .large protrusion noted at the umbilicus (navel) area warm/tender to touch. At 9:41 a.m. on 07/23/14, RN #58 noted Resident #59 was sent to the ER for abdominal pain. The resident remained at the facility for nearly two (2) hours, until 9:41 a.m. on 07/23/14, at which time she left the facility via ambulance. During the two (2) hours she remained at the facility, she received no treatment for [REDACTED].#59 at 7:45 a.m. Review of Resident #59's MAR for 07/23/14 found no pain medications were administered to Resident #59. There was no further mention of the resident's ventral hernia found in subsequent nursing entries. j. 07/30/14 Resident #59's MAR indicated [REDACTED]. 2. August 2014 Review of Resident #59's medical record for August 2014 found the resident received ordered as needed pain medication and/or complained of pain on the following instances. Again, unless otherwise noted, there was not assessment of the location, nature, or severity of her pain and no assessment of the effectiveness of the medications. There were no non-pharmacological interventions identified. a. 08/07/14 LPN #20 noted a 5:10 a.m. on 08/07/14 that Resident #59 awoke and requested to go the ER for abdominal pain. At 5:23 a.m. on 08/07/14, LPN #20 noted Resident #59's healthcare decision maker was notified of Resident #59's complaint of abdominal pain and was advised Resident #59 was medicated with her as needed pain medication. LPN #20 noted the healthcare decision maker would prefer to give the medication time to work and if the resident continued with complaints of pain to call him back and he would come and talk with the resident. LPN #20 noted she explained the conversation to Resident #59 who was not happy with her brother's decision. Review of Resident #59's MAR found she was medicated with [MEDICATION NAME] 5/325 mg on 08/07/14. There was no indication LPN #20 assessed the severity/intensity of Resident #59's prior to administration of the as needed pain medication. There was also no evidence to suggest LPN #20 reassessed the resident after the PRN pain medication was administered and had time to be effective, as the resident's brother had requested. b. 08/15/14 Resident #59's MAR indicated [REDACTED]. c. 08/19/14 Resident #59's MAR indicated [REDACTED]. d. 08/20/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. It should be noted this administration note was linked to the administration of [MEDICATION NAME] 5/325, but [MEDICATION NAME] 5/325 was not administered on that date. There was no indication the nurse who administered this medication assessed the resident's pain for severity/intensity prior to administering the PRN Tylenol, and there was no indication the nurse reassessed the the resident to determine if the PRN medication was effective. e. 08/21/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. f. 08/24/14 Resident #59's MAR indicated [REDACTED]. g. 08/26/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. An additional administration note on the MAR indicated [REDACTED]. h. 08/28/14 to 08/30/14 Resident #59's MAR indicated [REDACTED]. i. On 08/20/14, 08/21/14, and 08/26/14 it was noted Resident #59 complained of bilateral lower extremity pain. There was no evidence to suggest the facility made any attempts to determine the cause of the pain in her bilateral lower extremities, nor evidence to suggest the attending physician and/or healthcare decision maker were notified of her bilateral lower extremity pain. 3. September 2014 Review of Resident #59's medical record for 09/2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: a. 09/01/14 Review of Resident #59's MAR for 09/01/14 found she was administered her PRN [MEDICATION NAME] 5/325 on 09/01/14. b. 09/03/14 - 09/08/14 On 09/03/14 at 3:43 a.m. LPN #60, noted Resident #59 received her PRN pain medication twice that shift for complaints of abdominal pain. LPN #60 noted Resident #59 had a bowel movement and her bowels sounds were present in all four (4) quadrants. On 09/04/14 at 1:43 a.m. LPN #60 noted Resident #59 had complaints of abdominal pain and was given PRN pain medication. On 09/05/14, Resident #59's MAR indicated [REDACTED]. On 09/06/14 at 5:11 p.m., LPN #5 noted Resident #59 was calling out from her bed stating, My belly is going to bust. LPN #5 noted the resident had received her PRN pain medication. There was no evidence to suggest LPN #5 assessed the severity of Resident #59's pain prior to administering the PRN pain medication, nor did she reassess her pain for severity to determine if the PRN pain medication was effective. On 09/07/14, Resident #59's MAR indicated [REDACTED] On 09/08/14 at 10:38 a.m., RN #61 noted Resident #59's attending physician was in to evaluate why Resident #59 had been complaining of abdominal pain and crying. He ordered to obtain a KUB to check for ileus disease. Further review of the record found this testing was obtained and ileus disease was not diagnosed . Additionally, on 09/08/14 Resident #59's MAR indicated [REDACTED]. Dhe received a second dose of PRN [MEDICATION NAME] at 1:36 p.m. on 09/08/14, for complaints of pain to the right side accompanied by crying On 09/09/14 at 2:24 a.m., Resident #59's MAR indicated [REDACTED]. It should be noted this information was contained in the Administration notes on the MAR; however, the dosage of [MEDICATION NAME] 5/325 was not initialed as given on the MAR. Resident #59 had complaints of pain to the abdomen and/or right side daily from 09/03/14 through 09/08/14, there was no evidence to suggest Resident #59's attending physician was notified of her daily pain until the morning of 09/08/14. There was also no evidence to suggest Resident #59's healthcare decision maker was made aware of her daily complaints of pain. c. 09/19/14 - 09/21/14 Review of Resident #59's MAR indicated [REDACTED]. The source of Resident #59's pain was only identified on one (1) of the three (3) days she received the PRN pain medication. On 09/21/14 the location of Resident #59's pain was identified as being in the abdomen d. On 09/19/14 and 09/20/14 there was no evidence to suggest Resident #59's pain was assessed for location, nature, and severity before the administration of medication and/or the effectiveness of the pain medication after administration. On 09/23/14 at 12:26 a.m. LPN #20 noted Resident #59 had some complaints of leg discomfort and was medicated with her PRN pain medication. She additionally noted that the Resident was screaming and keeping the residents on the hallway awake. LPN #20 noted there was no reasoning with the resident. At 12:46 a.m. LPN #20 noted resident continued to scream and was now complaining of shortness of breath even though her oxygen saturation was in the upper 90's. LPN #20 again noted she was unable to reason with the resident. At 1:00 a.m. LPN #20 noted she heard Resident #59 screaming as she has been since 12:30 a.m Upon entering Resident #59's room LPN #20 observed the resident laying in the floor beside her bed. LPN #20 indicated she had slid off the bed and continued to yell and scream. She again noted she was unable to reason with Resident #59. At 1:45 a.m. LPN #20 noted Resident #59 continued to yell and scream and disturb the other residents. She again indicated she was unable to reason with the resident. She noted the resident was screaming at staff instead of speaking to them in a normal tone. There was no mention by LPN #20 that she reassessed Resident #59 for pain after administering the PRN pain medication at 12:26 a.m., despite the fact Resident #59 continually screamed, yelled, and even slid off her bed. LPN #20 also failed to assess the severity of the Resident #59's pain prior to administering the PRN pain medication. At 8:18 a.m. on 09/23/14, LPN #5 noted she had spoken with Resident #59's healthcare decision maker and notified him about the resident sliding off the bed. She noted the resident's health decision maker indicated he and his wife would be in later today to speak with the resident about her behaviors. Resident #59's MAR indicated [REDACTED]. e. 09/26/14 to 09/28/14 Resident #59's MAR indicated [REDACTED]. Beginning on 09/15/14 the facility implemented a new pain observation tool. Nursing staff were to observe and/or question for pain every four (4) hours and PRN while awake. The documentation on this tool was inconsistent with the documentation contained in the rest of Resident #59's medical record. The documentation on this tool was reviewed and found Resident #59 was positive for pain on 09/16/14, 09/21/14, 09/22/14, 09/23/14, and 09/27/14. It should be noted Resident #59 was not medicated for identified pain on 09/16/14 and 09/22/14. Additionally, it should be noted that on 09/19/14, 09/20/14, 09/24/14, 09/26/14, and 09/28/14 Resident #59 was given PRN pain medication, but the pain observation tool was marked to indicate she was not having pain. Review of Resident #59's medical record for October 2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: 4) October 2014 a. 10/01/14 - 10/02/14 At 11:00 a.m. on 10/01/14 RN #49 noted that Resident #59 was complaining of abdominal pain at her hernia site. She noted her PRN pain medication had been administered about five (5) minutes prior to Resident #59's complaints. RN #49 noted the resident complained the pain medication was not helping her pain. RN #49 applied a warm compress to the abdomen and attempted to reach the resident's health care decision maker. RN #49 then spoke with the resident about waiting until her attending physician was able to visit to review her pain medication regimen before they sent her to the emergency room . RN #49 noted Resident #59 was in agreement with this plan. Review of Resident #59's MAR found she received a PRN dose of [MEDICATION NAME] on that date At 9:55 a.m. on 10/02/14, RN #41 noted Resident #59's attending physician was in and reviewed her pain medication regimen. The physician wrote a new order for [MEDICATION NAME] 5/325 as needed every four (4) hours instead of every six (6) hours. The physician also added a scheduled dose of [MEDICATION NAME] 5/325 three times a day at 10:00 a.m., 2:00 p.m. and 10:00 p.m. Resident #59 began receiving this routine scheduled dose of [MEDICATION NAME] at 10:00 a.m. on 10/02/14. b. 10/04/14 to 10/07/14 At 10:54 a.m. on 10/6/14, LPN #5 noted Resident #59 had constant complaints of her side hurting. LPN #5 indicated the resident had been medicated by the medication nurse. She noted she had spoken with Resident #59's health care decision maker and he did not want the resident sent out of the facility. LPN #5 noted that the healthcare decision maker stated, every time she is sent out they always send her right back because nothing is ever wrong with her. The health care decision maker stated he would come in and talk to the resident that day. LPN #5 noted Resident #59 was not happy about her brother not wanting her sent out of the facility. There was no mention of assessments to determine the severity of the pain Resident #59 was experiencing, or assessments to determine if scheduled doses of pain medication were effective in order to determine if resident needed to be medicated with the PRN [MEDICATION NAME] for which she had an order. Additionally there was no testing and or evaluations completed by facility staff to determine the cause of Resident #59's pain. At 2:54 p.m. on 10/06/14, LPN #62 noted Resident #59 had shown a decrease in the volume of complaints and she was administered pain medication for continued complaints of stomach pain. At 10:39 p.m. on 10/06/14, LPN #7 noted Resident #59 was guarding her stomach and crying in pain and she had done so for the last two (2) nights. She noted bowel sounds were present, were hypoactive in all four (4) quadrants, abdomen was distended in right lower quadrant and tender to touch. LPN #7 noted Resident #59 screamed in pain when she was turned on her stomach. She noted Resident #59 was medicated with scheduled [MEDICATION NAME] one (1) time that shift. She noted she had requested a physician evaluation for pain. There was no evidence in the medical record of Resident #59 to indicate she was having pain in her abdomen and guarding her stomach on 10/04/14 or 10/05/14 as indicated in the 10/06/14 entry by LPN #7. LPN #7's note on 10/06/14 was the first mention of Resident #59's pain which she had experienced on the previous two (2) nights. There was no evidence to suggest Resident #59's pain was assessed for severity and/or relief of pain upon administration of scheduled pain medication on 10/04/14 and 10/05/14, in order to determine the need for PRN pain medication, which was not administered at all on 10/05/14. There was no indication nursing staff assessed Resident #59 to determine the cause of her continued pain in her abdomen. LPN #7 noted she had requested the physician evaluate the resident for pain, but there was no indication nursing staff had called Resident #59's attending physician to notify him of her continued abdominal pain. The heath care decision maker was not made aware of Resident #59's complaints of pain on 10/04/14, 10/05/14 and 10/06/14 until LPN #5 phoned him at 10:54 a.m. on 10/06/14. Resident #59 received a dose of her PRN pain medication on 10/04/14 and 10/06/14. At 8:34 a.m. on 10/07/14, LPN #5 noted Resident #59 was being combative and yelling out at staff. She noted the medication nurse tried to give the resident her pain medication for her complaint of stomach pain and the resident refused stating, You all are not helping me, I want the police. She noted she explained to the resident they were trying to help her, but she would not let them. Resident #59 proceeded to kick over the bedside table and continued to yell out. LPN #5 noted she called the health care decision maker and he would be at the facility shortly to calm the resident down. At 8:46 a.m. on 10/07/14, LPN #5 noted Resident #59's brother was at the facility to see her. At 8:54 a.m. 10/07/14, LPN #5 noted the resident's brother wanted her sent to the ER for an evaluation. At 9:20 a.m. on 10/07/14, LPN #5 noted the resident was transported to the ER at 9:20 a.m. on 10/07/14. At 5:46 p.m. on 10/07/14 LPN #5 noted Resident #59 returned to the facility from the ER with [DIAGNOSES REDACTED]. Resident #59 had made multiple complaints of abdominal and side pain beginning 10/04/14 through 10/07/14. The facility failed to assess for the cause of the pain, failed to treat the pain effectively, and failed to assess for the severity of the pain prior to and after administration of PRN pain medications on 10/4/14 and 10/06/14. Staff also failed to assess for the effectiveness of her scheduled pain medication to determine if she needed further medicated with the PRN doses [MEDICATION NAME] to control her pain. Additionally, they failed to notify the attending physician of the continual complaints of pain, and failed to notify the healthcare decision maker of her complaints of pain until 10/06/14. This resulted in Resident #59 suffering undue pain as well as mental anguish. On 10/07/14 Resident #59 was noted to be combative with staff and was noted to state, You all aren't helping me, I want the police. Resident #59 had at that point endured pain for three (3) consecutive days and felt as if the facility staff was not helping her. It was not until her brother arrived at the facility and requested she be sent to the ER that Resident #59 was sent out of the facility for treatment for [REDACTED]. The facility was unable to show any evidence of attempts to manage and control her pain at the facility. They made no attempts to determine the cause pain and/or to treat the cause of the pain. b. 10/10/14: Resident #59's MAR indicated [REDACTED]. c. 10/16/14: Resident #59's MAR indicated [REDACTED]. Review of Resident #59's pain observation tool found the resident was identified as having pain on 10/04/14, 10/06/14, 10/08/14, and 10/13/14. Please note this report was again inconsistent with the rest of Resident #59's medical record. She was identified as having continual pain from 10/04/14 through 10/07/14 in the nursing progress notes, she received a PRN dose of [MEDICATION NAME] in addition to her scheduled pain medications on 10/10/14 and 10/16/14 and was identified as not having pain on these dates on the pain observation tool. Additionally, the pain observation tool identified she had pain on 10/08/14 and 10/13/14 with no mention of the pain in the progress notes or administration of any pain medication other than her scheduled [MEDICATION NAME] 5/325 three (3) times a day. This tool was ineffective in identifying when Resident #59 experienced pain. Review of Resident #59's medical record for 11/2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: 5) November 2014 a. 11/12/14: Resident #59's MAR indicated [REDACTED]. b. 11/16/14: Resident #59's MAR indicated [REDACTED]. c. 11/21/14: Resident #59's MAR indicated [REDACTED]. d. 11/28/14: Resident #59's MAR indicated [REDACTED]. h. Review of Resident #59's pain observation tool for the month of November 2014 again found inconsistent documentation between the pain monitoring tool and the MAR. Resident #59 received PRN pain medication on 11/12/14, 11/16/14, 11/21/14, and 11/28/14. The pain observation tool indicated Resident #59 was negative for pain on all of these dates. 6) December 2014 Review of Resident #59's medical record for December 2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: a. 12/08/14: Resident #59's MAR indicated [REDACTED]. b. 12/09/14: Resident #59's MAR indicated [REDACTED]. c. 12/22/14: Resident #59's MAR indicated [REDACTED]. d. 12/28/14: At 10:14 a.m. on 12/28/14, LPN #36 noted that Resident #59 had poured water on herself multiple times to get the staff to change her pants. She noted Resident #59 was complaining that her pants were too tight. LPN #36 noted, she told the resident her pants were not too tight and to quit being disruptive. She advised the resident that the nurse aides were busy feeding and bathing other residents and that she could not keep pouring water on herself just to get changed. LPN #36 then noted Resident #59 began to complain of stomach pain and nausea. She indicated she gave Resident #59 a [MEDICATION NAME] shot and the resident was noted to be resting about 30 minutes after the shot. There was no indication in Resident #59's medical record that LPN #36 had assessed the resident for pain upon her complaints that her pants were too tight. There was no mention of pain until after the staff had changed the resident's pants on several occasions and after LPN #36 had advised Resident #59 that she was being disruptive. At that time, Resident #59 mentioned pain when she complained of pain in her stomach. Once the resident complained of pain, LPN #36 failed to assess the severity of the pain and/or the possible causes of the stomach pain. LPN #36 proceeded to treat the complaints of nausea, but failed to assess and/or treat Resident #59's complaints of stomach pain. This note was entered into the medical record at 10:14 a.m., which was 14 minutes after Resident #59 had received her scheduled dose of [MEDICATION NAME]. LPN #36 failed to assess the severity of Resident #59's pain did not assess the effectiveness of the resident's scheduled pain medication to determine if a PRN dose [MEDICATION NAME] was needed. Resident #59 was not administered her PRN [MEDICATION NAME] on 12/28/14. e. 12/30/14: Resident #59's MAR indicated [REDACTED]. 7) January 2015 Review of Resident #59's medical record for January 2015 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: a. 01/18/15: Resident #59's MAR indicated [REDACTED]. b. 01/31/15: Resident #59's MAR indicated [REDACTED]. 8) February 2015 For the month of February 2015, Resident #59 received no doses of her PRN pain medication. Additionally, Resident #59 had not voiced any complaints of pain except on 02/09/15. On 02/09/15, Resident #59 complained of abdominal pain and nausea, but refused her PRN pain medications. There was no evidence the facility had a process in place to consistently assess the resident's pain and to ensure each nurse followed a process to reassess and treat the pain. Since July 2014, Resident #59 had multiple trips to the emergency room related to pain. There were occasions where Resident #59 complained of pain for multiple days in a row, at which time the facility failed to provide interventions and/or treatment to attempt to alleviate the resident's pain in a timely manner. On multiple occasions, Resident #59 suffered for days with pain because of the facility's failure to implemen",2018-03-01
6426,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,314,G,1,0,S2LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide services to prevent the development of an avoidable pressure ulcer for one (1) of three (3) residents reviewed for pressure ulcers. Assessments indicated the resident was at risk for the development of pressure ulcers; however, the resident's skin was not observed and monitored during the provision of ordered treatments. In addition, each treatment was not performed as ordered. This constituted actual harm to the resident. Resident identifier: #7. Facility census: 58. Findings include: a) Resident #7 On 03/05/14 at 12:30 p.m., upon request, Nurse Aides (NAs) #46 and #44 removed Resident #7's socks to enable a visual inspection of the resident's heels. The observation of the resident's left heel revealed a circular, non-blanching, reddened area, the size of a quarter. Within the quarter size reddened area, was a brown area the size of a nickel. On 03/05/15 at 1:40 p.m., a review of the nurses' notes for Resident #7 revealed the following entries: -- An entry on 02/04/15 at 16:27 by LPN #5, containing an addition by Registered Nurse (RN) #49. The addition by RN #49 identified the resident as having bilateral heels that were mushy, red, and blanchable, and for the heels to be floated off the bed with pillows under the lower legs. -- An entry on 02/27/15 at 13:15 by LPN #36, indicated a new physician's orders [REDACTED]. -- On 03/01/15 at 14:52 by RN #39, the MDS coordinator, completing the 14-day minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/24/15, noted, . Anti-pressure measures in place, no breakdown is noted at this time At 1:50 p.m. on 03/05/15, in response to an regarding the manner in which the weekly skin assessments were completed, as well as the protocol when wounds were identified, RN #47 responded, If wounds were discovered by the NAs, they report to the nurse providing care for the resident on that day. If the wound was a pressure ulcer, it was reported to (RN #47) for monitoring and tracking. She stated LPN #4 was responsible for performing the weekly skin assessment for Resident #7. A review of the Treatment Administration Record (TAR) with the DON and RN #49 on 03/05/15 at 2:15 p.m., revealed a treatment for [REDACTED].#7, twice daily. The treatment was initialed as applied twice daily on 03/01/15, 03/02/15, 03/03/15, and 03/04/15. The 8:00 a.m. application of Skin Prep on 03/04/15 was initialed as completed by LPN #4. As of 2:15 p.m. on 03/05/15, the 8:00 a.m., the application of Skin Prep for 03/05/15 was not initialed as completed. At 2:20 p.m. on 03/05/15, inquiry was made of LPN #4, in the presence of the DON and RN #49, as to the application of the skin prep on 03/04/15. In response to an inquiry as to whether she observed any areas of concern on the resident's heels during the application of the Skin Prep, she replied, No. Her reply to further an inquiry as to whether she visualized the areas in which she applied the Skin Prep, was, No, I didn't actually get down and look at them. I just sort of wiped the skin barrier on. She then did a demonstration of how she held up a leg with one (1) hand and applied the skin prep with the other, demonstrating the areas receiving the treatments were not in her line of vision. Therefore, LPN #4, the nurse responsible for completing the weekly skin assessments and for providing Resident #7's treatment on the morning of 03/04/15, neglected to visualize the area in which she was providing a treatment. This led to the facility failing to identify a pressure ulcer on Resident #7's left heel on the morning of 03/04/15. This failure caused a delay treatment to the area. The pressure ulcer was identified by the surveyor at 12:30 p.m. on 03/05/15. On 03/05/15 at 2:23 p.m., when asked if they thought the manner in which LPN #4 applied the treatment for [REDACTED].#49 both replied, No. The DON agreed it would have been appropriate, as well as necessary, to visualize an area in which a treatment was being applied. At 2:25 p.m. on 03/05/15, The DON and RN #49 removed the socks from Resident #7, and observed her heels. Both agreed she had a pressure related area to her left heel. Both agreed the area was previously undetected by staff, and due to the coloring of the skin tissue, agreed it had most likely been there longer than 24 hours. They further agreed staff should have identified the area prior to surveyor intervention. A review of the weekly skin assessments for Resident #7, on 03/05/14 at 3:30 p.m., revealed no areas indicating pressure ulcers on the assessments dated 02/06/15, 02/13/15, and 02/17/15. The weekly skin assessment dated [DATE] indicated the resident had boggy heels. The skin assessment dated [DATE] indicated the resident had a healing abdominal incision, boggy heels, groin redness, and the resident's buttocks were red and blanchable. There was no mention of the suspected deep tissue injury to the left heel. The skin assessments had been completed by LPN #4. LPN #4 had completed a Skin Assessment for Resident #7 on 03/05/15, prior to the surveyor's observation at 12:30 p.m Upon completing this assessment, she neglected to identify the pressure related area to the resident's right heel rendering the skin assessment process ineffective due to her failure to adequately visualize and inspect the resident's skin to ensure no pressure related areas were present. At 3:30 p.m. on 03/05/15, after this issue was brought to her attention, RN #49 completed the weekly wound assessment and progress review for Resident #7. RN #49 identified a wound on the resident's left heel. The type of wound was indicated as pressure, measuring 1.5 cm x 1.5 cm x 0 cm, staged as a deep tissue injury (DTI). The nurse identified 03/05/15 as the date the wound was first noted. The treatment section of the wound assessment indicated the application of Skin Prep twice daily, with a start date of 02/27/15. Wound specifications section described the wound as dark red, non-blanchable color with brown colored dots inside of redness. It further described the area as tender to palpation with no signs or symptoms of discomfort when the area was not being palpated.",2018-03-01
6427,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,315,D,1,0,S2LQ11,"Based on observation, record review, policy review, and staff interview, the facility failed to ensure one (1) of three (3) residents observed for the provision of incontinence care was provided care in a manner to prevent, to the extent possible, urinary tract infections (UTIs). Resident identifier: #54. Facility census: 58. Findings Include: a) Resident #54 On 03/05/15 at 9:50 a.m., Nurse Aide #10 was observed providing incontinence care for Resident #54. The resident was observed lying in his bed, and had urinated in his brief. The brief was removed by NA #10. After removing the saturated brief, NA #10 used one (1) wet wash cloth (water only, no cleaner) and wiped in a straight line, from the resident's anal area up and between the buttocks. There were visible smears of fecal matter on the washcloth. She folded the washcloth and repeated the process several more times, in the same manner. No cleansing was performed to the resident's buttocks, or his frontal perineal area, including his penis. The resident was an uncircumcised male. NA #10 left the room for a short period of time, to get another NA to assist her with the provision of care. NA #10 returned to the resident's room with NA #44 and continued with the provision of care. No further cleansing of the resident occurred prior to the application of a new incontinence brief. Neither the resident's buttocks, nor the front of the resident was cleansed, in any manner, after the resident was incontinent of urine. At 1:00 p.m. on 03/05/15, when asked about the provision of incontinence care for Resident #54, NA #44 verified she had not provided any perineal care, and she had not observed any perineal care provided by NA #10. At 1:10 p.m. on 03/05/15, a review of the care plan revealed a focus area indicating the resident was at risk for UTIs due to a history of UTIs. The onset date for this focus area was 06/09/14, with an edited date of 01/27/15. The goal for this focus area was for the resident to remain free of signs or symptoms of UTI through the next review, with a target date of 04/27/15. On 03/05/15 at 1:50 p.m., the Director of Nursing (DON) and Registered Nurse #49 were informed of the observations during the provision of incontinence care for Resident #54. Both agreed Resident #54 was not been provided incontinence care in a manner to prevent UTIs. At this time, a copy of the facility's incontinence care policy was requested. At 10:00 a.m. on 03/06/15, review of the facility's Incontinence Care policy found it included the following steps which had not been implemented when incontinence care was provided to Resident #54: -- Step 5. Wash hands and don gloves (hands not washed by NA #10 prior to the start of care) -- Step 20. c. Gently grasp the penis with one hand, if the resident is not circumcised draw foreskin back with the other hand. (Not completed by NA #10 or NA #44) -- Step 20. e. If using warm wet wash cloths, spray approved perineal cleanser on the wash cloth and gently cleanse the tip of the penis with a circular motion, moving down the shaft to the scrotal area. (Place dirty wash cloth in a plastic bag.) (Not completed by NA #10 or NA #44) -- Step 20. f. Be sure to replace the foreskin for uncircumcised males after cleaning. (Not completed by NA #10 or NA #44) -- Step 20 g. and h. If the resident has had a bowel movement,with wipes or wash cloths and perineal cleanser, wash scrotum and perineum, wiping back toward the rectal area. Make sure peri-rectal area and surrounding skin is free of urine and feces. (Place dirty linens and wipes in a plastic bag.) (Not completed by NA #10 or NA #44) On 03/06/15 at 12:00 p.m., upon inquiry, the DON confirmed she expected care be provided in accordance with standards of practice and facility policy.",2018-03-01
6428,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,323,K,1,0,S2LQ11,"Based on record review, staff interview, and observation, the facility failed to ensure the resident environment, over which it had control, was as free of accident hazards as possible. The tri-fold door on the health care unit, which is used by ambulance crews to enter and exit the facility, was found to not be closing properly. When facing the door, the left side of the tri-fold door would close automatically as it was intended to do; however, the right side of the tri-fold door would stick in the open position and would have to be closed manually by facility staff. The tri-fold door was not maintained in constant view of facility staff, nor did the WanderGuard system alarm if a resident wearing a WanderGuard passed through the opened half of the door way. This created the potential for serious harm and/or death related to the risk of elopement. Residents #48, #34, #45, and #3 were identified by facility staff as being at risk for elopement. Each resident wore a WanderGuard on their person. The purpose of the WanderGuard was to lock exit doors if the resident was within a certain amount of space of the door, and to alarm should the resident attempt to open the door. Additionally, the WanderGuard should alarm and alert staff if a resident left the facility through an open doorway equipped with the WanderGuard system. It was confirmed the tri-fold door was equipped with the WanderGuard system, but when the right side of the door (the right side identified when standing facing the door) would stick and not close properly, the WanderGuard system did not alarm when a resident wearing a WanderGuard passed through the open half of the door. This placed four (4) of four (4) residents (Residents #48, #34, #45, and #3), identified by the facility at risk for elopement in an immediate jeopardy situation. The facility's Executive Director and the Director of Nursing were notified of the immediate jeopardy on 03/03/15 at 7:10 p.m The Immediate Jeopardy began at 5:20 p.m. on 03/03/15, when the door was observed standing open. Facility staff had no idea how long the door had been open. The WanderGuard system was found to not alarm when a WanderGuard was passed through the door at 5:40 p.m. on 03/03/15. The facility provided a plan of correction to the state agency at 7:40 p.m. on 03/03/15. The plan of correction read as follows: The tri fold door across from the nurses' station in health care was found to be sticking. The DON (Director of Nursing) had a head count performed between 5:48 p.m. and 6:00 p.m. on 03/03/15 to determine no elopement of residents. The DON at 6:45 p.m. on 03/03/15 stood watch by the door until staff was secured to continuously watch the door to prevent elopements. At 6:55 p.m. on 03/03/15 the Executive Director instructed the staff not to leave the door. There will be an employee posted at the door continuously until the door is fixed. The Director of Maintenance was called in to work on the door. The maintenance person on duty began working on the door at 7:10. At 7:42 p.m. on 03/03/15 the Surveyors; (Name of Surveyors), (Name of Executive Director), Executive Director, (Name of DON), DON, (Name of Maintenance Director), Dir of Maintenance, and (Name of Maintenance Worker), Maintenance observed the door opening and closing several times. The DON tested the WanderGuard alarm system as well. The door would not open and when she went through the door with the WanderGuard the alarm sounded. The DON and Executive Director posted staff at the door for a 24 hour period as a further safety measure at 7:42 p.m. on 03/03/15. The state agency observed for implementation of the plan of correction and found it properly implemented. At 7:52 p.m. on 03/03/15, the state agency accepted the plan of correction and abated the immediate jeopardy. Resident Identifiers: #48, #34, #45, and #3. Facility Census: 58. Findings Include: a) At approximately 5:20 p.m. on 03/03/15, the right side (right side identified when standing facing the door) tri- fold door on the healthcare unit (the door used by ambulance crews when picking up and returning residents) was observed open. Employee #35, Licensed Practical Nurse, was asked if the door should be open. She stated it should not be, and closed the door. At approximately 5:30 p.m. on 03/03/15, the Director of Nursing (DON) confirmed the door was not working properly. She was asked if the door would alarm if a resident who was wearing a WanderGuard walked out the open door. The DON said she felt it would alarm. She was asked to provide a WanderGuard, and was asked to open the door. At approximately 5:40 p.m. on 03/13/15, a surveyor walked through the right side of the tri-fold door with a WanderGuard in her hand. No alarm sounded to alert facility staff that someone with a WanderGuard had walked out the open door. The DON was advised to ensure they could account for all of the facility's residents. This process began at 5:48 p.m. on 03/03/15 and ended at approximately 6:00 p.m. All residents were accounted for. During this process, the DON stated she was unable to determine how long the door had been open. She indicated she did not know who the last person was to go out the door, so she did not know how long it remained open. Observation revealed the door had a sign taped to it which indicated the door had been sticking, and to make sure the door closed. The door was also observed open earlier in the day, on 03/03/15 at 9:30 a.m. At this time it was promptly closed by facility staff. (During this observation the door was kept in view by the surveyor the entire time). The door was also observed standing open on 03/02/15 at approximately 2:25 p.m. It was kept in view by the surveyor until it was closed by facility staff at approximately 2:30 p.m. on 03/02/15. Maintenance was asked to come and look at the door shortly after every resident was accounted for, at approximately 6:00 p.m. on 03/03/15. The maintenance worker who came to look at the door indicated he was not aware of any problems with the door. He looked at the sign posted on the door, and asked why the sign was there. He denied having any knowledge of the door not working properly until that time. On 03/06/15 at 11:15 a.m., the Executive Director (ED) was asked to enter the nurses' station to see if she could visualize the right side of the door (the right side when standing facing the door). She confirmed she could not. The ED indicated, from the nurses' station, she could not see the side of the door which was not closing properly.",2018-03-01
6429,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,325,G,1,0,S2LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and resident interview, the facility failed to ensure one (1) of five (5) sampled residents maintained acceptable parameters of nutritional status. The resident had three (3) severe weight losses, between 02/11/15 and 03/01/15, which were not identified and addressed by the facility. These weight losses resulted in a cumulative weight loss of 15.69% of the resident's total body weight in fourteen (14) days, representing actual harm to the resident. Resident Identifier #7. Facility Census: 58 Findings Include: a) Resident #7 Medical record review revealed Resident #7 experienced the following weight losses: -- From 02/11/15 to 02/20/15, the resident lost 5.50% of her body weight, -- From 02/20/15 to 02/24/15, the resident lost 7.75 % of her body weight, and -- From 02/24/15 to 03/01/15, the resident lost 3.28 % of her body weight. These weight losses combined for a cumulative weight loss since readmission on 02/11/15 to the last available weight on 03/01/15 of 15.69 % of her body weight. A review of Resident #7's medical record at 9:46 a.m. on 03/03/15, revealed Resident #7 was admitted to the facility on [DATE]. She went back to the hospital on [DATE] and returned to the facility on [DATE], where she remained with no further discharges. Resident #7 had the following weights recorded in her medical record (all weights were obtained using a mechanical manual lift): -- 02/04/15 - 190.6 pounds (admission to the facility) -- 02/09/15 - 191.8 pounds (Resident #7 was in the hospital when the facility allegedly obtained this weight) -- 02/11/15 - 181.7 pounds (readmission to the facility). -- 02/20/15 - 171.7 pounds -- 02/24/15 - 158.4 pounds -- 03/01/15 - 153.2 pounds The resident's percentage of weight loss from 02/11/15 to 02/20/15, 02/20/15 to 02/24/15, from 02/24/15 to 03/01/15, and from 02/11/15 to 03/01/15 were calculated using the following formula % of body weight loss = (usual weight - actual weight) / (usual weight) X 100. -- From 02/11/15 to 02/20/15, the resident lost 5.50% of her body weight -- From 02/20/15 to 02/24/15, the resident lost 7.75% of her body weight -- From 02/24/15 to 03/01/15, the resident lost 3.28% of her body weight -- Her cumulative weight loss since readmission on 02/11/15 to the last available weight on 03/01/15 is 15.69% of her body weight. Further review of the medical record found a Comprehensive Nutritional assessment dated [DATE] completed by Registered Dietitian (RD) #50. Review of the assessment revealed Resident #7 had the following disease/conditions: [MEDICAL CONDITION], Arthritis, Cardiovascular Disease, Diabetes, Gastrointestinal Problems, and Hypertension. RD #50 indicated in the assessment that Resident #7 had no significant [MEDICAL CONDITION]. RD #50 also indicated on the nutritional assessment Resident #7 had the following nutritional concerns: inadequate food/fluid intake and involuntary weight loss. RD #50 wrote the following narrative on the nutritional assessment (typed as written), Readmission and recent new admission. 87 yof (year old female) dx (diagnosis): Upper GIB ([MEDICAL CONDITION]), PUD ([MEDICAL CONDITION] ulcer disease) w (with)/ hemorrhage, Dementia, UTI (urinary tract infection),[MEDICAL CONDITION] [MEDICAL CONDITION], DM2 (Diabetes Mellitus Type II), OA ([MEDICAL CONDITION]),[MEDICAL CONDITION](hypertension). PO (by mouth) intake varies R (refused) X 2 (two) meals; 0 (zero) - 25% X 2 meals, 26 - 50 % X 5 meals, 51-75 % X 1 meal. Visited resident during evening meal and she states appetite fine and that there are no food she doesn't like. Poor PO intake observed. Wt. (weight) loss x 1 week and note further wt. changes may occur d/t (due to) generalized [MEDICAL CONDITION]. Therapeutic diet d/t dx. BMI (body mass index) indicates obesity; no interventions warranted d/t age and dx. skin: surgical wound abdomen. Rec. (recommendation) House Shake 2 p (p.m.) daily. Will fup (follow up) prn (as needed). Review of Resident #7's physician orders [REDACTED]. Review of the documentation of the percentage of the supplement consumed found Resident #7 was offered her supplement 12 out of 14 times since it was ordered on [DATE]. Of the 12 times it was offered, she consumed 100% of the supplement six (6) times, consumed 75% once, consumed 50% three (3) times, and consumed 25% twice. RD #50 again assessed Resident #7 on 02/25/25. RD #50's note dated 02/25/15, contained the following text (typed as written): PO (by mouth) intake varies R (refused) X 5 meals; 0 - 25 % X 8 meals; 26 - 50 % X 4 meals; 51 - 75 % x 2 meals. Visited resident during evening meal and resident states eating good no new food pref (preferences) but poor intake observed. Spoke to CNA (Nurse Aide) and they reported poor intake recently. Wt. (weight) history: 2/24 (2015) 158.4 # (pounds), 2/20 171.7#, 2/11 181.7#, 2/9 191.5#, 2/4 190.6# - sig (significant) wt. (weight) loss X 1, 3, & (and) 6 meals. Rec. (Recommend) house shakes bid (twice a day) @ (at) 10 a (a.m.) and 2 p (p.m.) Staff to feed resident prn (as needed) If poor intake continues consider appetite stimulant. Will fuo (follow up) prn (as needed). Further review of the medical record on 03/03/15 found no evidence the physician was notified of RD #50's recommendation on 02/25/15. There was also no evidence this recommendation was ever implemented and/or addressed by the physician. An interview with the Director of Nursing (DON) at 2:28 p.m. on 03/03/15, revealed the nursing department had no knowledge of the dietary recommendation to increase the House Shake to twice daily. She stated the RD did not communicate this recommendation to nursing. The DON stated the RD should have sent a form with her recommendation on it to nursing so the physician could be notified and the recommendations could be implemented. She confirmed this process failed in this instance. When asked if Resident #7's physician had been notified of the resident's continued weight loss since his notification on 02/16/15, she confirmed she had no documentation to suggest Resident #7's physician had been notified since 02/16/15. She confirmed Resident #7 had three (3) additional weights in which she demonstrated a weight loss and the physician and/or Resident #7's Medical Power of Attorney (MPOA) were not notified. An additional interview with the DON, at 4:07 p.m. on 03/03/15, found that after the earlier conversation on 03/03/14 at 2:28 p.m., Licensed Practical Nurse (LPN) #5 telephoned Resident #7's physician to notify him of Resident #7's weight loss. She indicated, the physician agreed with the RD's recommendation to increase the House Shakes to two (2) times daily and to feed the resident at all meals. The DON indicated the information about Resident #7's weight loss was on the physician's board for him to address prior to our conversation, but the physician failed to address the weight loss, so they called him to make sure he had seen the information. Interview with LPN #5 at 5:00 p.m. on 03/03/15 found she had spoken with Resident #7's attending physician earlier about the resident's weight loss. She stated he agreed to increase the house shakes to two (2) times daily and to assist the resident with eating as needed. She stated she asked him about the appetite stimulant and he indicated he would wait until he was able to come to the facility and review her medication regimen, which would likely be 03/04/15. At 5:10 p.m. on 03/03/15, during the evening meal, Resident #7 was asked if she was going to eat her dinner. She stated, I am going to eat what I can - I am not that hungry. When asked if she was served foods she liked, she stated, I guess I am just not hungry. Resident #7 then pushed her food away. An interview with RD #50 at 4:26 p.m. on 03/4/15 revealed she had seen Resident #7 on 02/25/15 to address her continued weight loss. She stated, when she made a recommendation she would send an email to the Certified Dietary Manager (CDM) who would then share the recommendation with nursing. She indicated on 02/25/15 she tried to use a new form in the computer and had thought she had sent the recommendation to the CDM, but the message had failed to send and the recommendation was never implemented. She confirmed she saw the resident again today and recommended fortified foods for Resident #7 and if poor by mouth intakes continued, to consider an appetite stimulant if medically appropriate. An additional interview with RD #50 by telephone at 2:28 p.m. on 03/05/15, found RD #50 felt fortified foods were an appropriate intervention for Resident #7's weight loss. When asked how fortified foods would help a resident with such poor by mouth intake she stated, It will increase the calories in what she does eat, even though she does not eat well. After the initial conversation with the DON at 2:28 p.m. on 03/03/15, the following physician orders [REDACTED].#7's medical record: -- Order dated 03/03/15 4:15 p.m. 4 oz (ounce) house shake BID (twice daily). D/C (discontinue) house shakes once daily. Feed all meals. -- Order dated 03/05/15 (no time specified) Increase house shake to TID (three times daily) between meals. Add fortified foods to diet with meals. -- Order dated 03/05/15 (no time specified) CBC (comprehensive blood count), comp metabolic (comprehensive metabolic panel) . weight loss Additionally, the following social service and nursing progress notes were entered into Resident #7's medical record after the initial conversation with the DON at 2:28 p.m. on 03/03/15 (all notes typed as written): -- Nursing progress note on 03/03/15 at 3:52 p.m., Dr. (name of physician) has been informed about 30 lb (pound) weight loss. Agrees with dietician recommendation to increase 4 (four) ounce house shakes bid (two times daily) and order to provide feeding assistance prn (as needed). -- Dietary progress note at 4:44 p.m. on 03/03/15, Added 4 oz (ounce) shake to 10am snack for resident to address weight loss (resident currently receives 4 oz shake at 2pm). Recommend adding fortified foods to diet. Will follow. -- Nursing Progress note at 1:16 p.m on 03/05/15, New order to increase house shake TID (three times a day) between meals and to add fortified foods to diet with meals . -- Nursing Progress Note at 12:27 p.m. on 03/06/15, (Name of physician) in for acute visit for resident losing weight, per labs her [MEDICATION NAME] is increasing and for now we will continue to monitor resident and her labs. Additionally, Resident #7's attending physician dictated the following physician's progress note on 03/05/15 and it was transcribed into the medical record on 03/06/15. The note contained the following text (typed as written), Resident, who has undergone recent gastric surgery in early February related to GI (gastrointestinal) bleeding, was subsequently rehospitalized and again returned to the facility. Since her return less than a month ago the resident has demonstrated a significant weight change. Interestingly laboratory studies performed on 02/16/15 failed to reveal an obvious etiology for the resident's weight loss but where consistent with profound nutritional deficiency likely related to the resident's significant recent hospital stays and surgery. The attending physician identified his plan for Resident #7 as, The resident has already had diet supplementation ordered between two and three weeks ago. Unfortunately the resident continues to manifest weight loss has had some recent nutritional modifications again and we will reassess lab work as it is now slightly more than two weeks old. After surveyor intervention on 03/03/15, the facility notified Resident #7's attending physician of her weight loss, and began to implement interventions to address Resident #7's weight loss as they had previously failed to do. '",2018-03-01
6430,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,329,E,1,0,S2LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure the medication regimens for four (4) of seven (7) sampled residents were free from unnecessary medications. Resident #59 received excessive doses of an antibiotic. Resident #7 received excessive doses of an antibiotic and the resident's sliding scale insulin coverage was not monitored. Resident #54's sliding scale insulin was also not monitored, and Resident #16 received excessive doses of potassium. Resident Identifiers: #59, #7, #54 and #16. Facility Census: 58. Findings include: a) Resident #59 Review of Resident #59's medical record, at 12:33 p.m. on 03/02/15, found a physician's orders [REDACTED]. Resident #59 was to receive a total of 30 doses of this medication. Review of Resident #59's Medication Administration Record [REDACTED]. The Director of Nursing (DON), in an interview at 12:29 p.m. on 03/04/15, confirmed Resident #59 should have only received 30 doses of the [MEDICATION NAME], and received three (3) extra doses of the medication. Later in the afternoon on 03/04/15, the DON stated the nurse who took the order had apparently not counted 01/04/15 as day one and entered the end date in the computer as 01/14/15. She stated this error caused Resident #59 to receive the medication for one (1) extra day for a total of three (3) extra doses. b) Resident #7 1. A review of Resident #7's medical record, at 9:46 a.m. on 03/03/15, found a physician's orders [REDACTED]. The resident was admitted to the facility the evening of 02/11/15, This medication was to start on 02/12/15. Resident #7 should have received her last dose of Cairo on 02/16/15. The resident's MAR for February 2015 indicated Resident #7 received Cairo 250 mg twice daily from 02/12/15 through 02/18/15, once daily from 02/19/15 through 02/21/15, and daily from 02/23/15 through 02/26/15. The MAR indicated [REDACTED]. There was a large X on the MAR indicated [REDACTED]. Review of Resident #7's nursing progress notes found documentation the resident continued on the antibiotic on 02/17/15, 02/18/15, 02/19/15, 02/21/15, 02/22/15, 02/23/15, 02/24/15, and 02/26/15. An interview with the DON, at 1:13 p.m. on 03/03/15, confirmed facility documentation indicated Resident #7 received 12 extra doses of Cairo. 2. A review of Resident #7's medical record, at 9:46 a.m. on 03/03/15, also found a February 2015 MAR indicated [REDACTED]. 251 - 300 give 6 units. 301 - 350 give 8 units. 351 - 400 give 10 units. 401 - 450 give 14 units. 451 - 500 give 20 units. Above 500 send to ER (emergency room ) for eval (evaluation ). Review of Resident #7's MAR indicated [REDACTED]. This resulted in an inability to monitor the administration of Resident #7's sliding scale insulin coverage. The manner in which the MAR indicated [REDACTED]. c) Resident #54 Review of Resident #54's medical record, at 3:17 p.m. on 03/03/15, found an order for [REDACTED].#54 should have received this medication at 6:45 a.m., 11:30 a.m., 4:45 p.m. and 9:00 p.m. daily. Page two (2) of Resident #54's MAR indicated [REDACTED]. 151-200 give 3 units. 201-250 give 6 units. 251 - 300 give 9 units. 301 - 350 give 12 units. 351- 400 give 15 units. 401 - 450 give 18 units. 451- 500 give 21 units. If greater than 500 give 21 units and notify the physician. The only other order on page two (2) of the MAR indicated [REDACTED]. It was (typed as written): [MEDICATION NAME]- [MEDICATION NAME] Oral tablet 7.5-325 mg (milligrams) po (by mouth) Q (every) 4 (four) hours as needed for pain. Review of Resident #54's MAR indicated [REDACTED]. This resulted in an inability to monitor the administration of Resident #54's sliding scale insulin coverage. The manner in which the MAR indicated [REDACTED]. In addition, on several occasions, nursing staff documented information related to the resident's sliding scale insulin administration in the section of the MAR indicated [REDACTED]. This made the MAR indicated [REDACTED]. d) An interview was conducted with the DON, at 11:36 a.m. on 03/04/15, regarding the sliding scale coverage for Residents #7 and #54. She confirmed the documentation on the residents' MARs regarding sliding scale insulin was ineffective in monitoring each resident's needs for insulin coverage. She confirmed it could not be determined when the residents received sliding scale coverage, what the blood sugar was prior to administration of sliding scale insulin, which nurse administered the medications, the time the sliding scale insulin coverage was administered, or on what day it was administered. e) Resident #16 At 8:45 a.m. on 03/03/15, observation revealed Licensed Practical Nurse (LPN) #35, administered three (3) 10 milliequivalent (meq) [MEDICATION NAME] capsules (a potassium supplement), for a total of 30 meq, to Resident #16. On 03/03/15 at 10:00 a.m., review of the physician's orders [REDACTED]. This was a total of 10 meq at each medication administration. At 11:30 a.m. on 03/03/15, a reconciliation of the physician's orders [REDACTED].#16 was completed with the DON. She verified Resident #16 received an excessive dose of the [MEDICATION NAME] at 8:45 a.m. on 03/03/15. Upon review of the resident's medical record, the DON verified the resident received an excessive dose of [MEDICATION NAME] on four (4) occasions. The resident received 30 meq of the medication, instead of 10 meq, on 03/01/15 at 8:00 p.m., 03/02/15 at both 8:00 a.m. and 8:00 p.m., and again on 03/03/15 at 8:00 a.m.",2018-03-01
6431,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,332,E,1,0,S2LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of medication administration, reconciliation of the observed medication administrations with medical records, staff interviews, and review of the Centers for Medicare and Medicaid Services (CMS) guidance to surveyors, the facility failed to ensure it was free of a medication error rate of five (5) percent or greater. Eleven (11) errors were identified during thirty one (31) observed opportunities, making the facility's medication error rate 30.56%. This affected four (4) of nine (9) residents observed during medication administration observations. Resident identifiers: #59, #12, #16, and #33. Facility census: 58. Findings include: a) Resident #59 During the 2:00 p.m. medication pass observation on 03/02/15, Licensed Practical Nurse (LPN) #36, was observed administering medications to Resident #59. Reconciliation of the observed medications administered with the resident's medical record revealed three (3) medication errors. Error #1: Both the physician's orders [REDACTED]. Ordered administration times were 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m. LPN #36 administered the 12:00 p.m. dose at 1:40 p.m., more than 100 minutes after the scheduled time. This resulted in the potential for administration of the [MEDICATION NAME] again in three (3) hours and twenty (20) minutes, rather than the ordered six (6) hours. Given the medication administration parameters, as referenced in the Centers for Medicare and Medicaid Services (CMS) guidance to surveyors, of sixty (60) minutes earlier or later than the scheduled dose, the smallest duration of time between doses should have been no less than four (4) hours. Error #2: [MEDICATION NAME] 0.2 mg/milliliter (ml) solution, one (1) unit dose via a nebulizer with [MEDICATION NAME] (a medication given for shortness of breath), scheduled at 2:00 p.m., was omitted. It was initialed as administered; however, observation during the medication pass revealed it was not administered. Error #3: [MEDICATION NAME] was omitted. The order, written on 03/02/15 and transcribed on the resident's MAR, was for [MEDICATION NAME] 250 mg every six (6) hours for ten (10) days, with the first dose to be given at 12:00 p.m. on 03/02/15. On 03/02/15 at 3:20 p.m., upon inquiry as to the timing of the administration of the [MEDICATION NAME] for Resident #59, LPN #36 stated, I was late passing the noon medications today, so I gave them with the 2:00 p.m. medications. Upon inquiry as to the omission of [MEDICATION NAME] and [MEDICATION NAME], LPN #36 said, I just forgot to give the breathing treatment, and the antibiotic is not here from the pharmacy yet. At 4:00 p.m. on 03/02/15, a review of the medications available in the emergency medication box, located at the nurses' station, with the Director of Nursing (DON), revealed the medication [MEDICATION NAME] 250 mg was available in the emergency medication box. The DON was then made aware of the findings regarding the medication errors identified for Resident #59 during the medication administration observation. The DON verified the 12:00 p.m. ordered medications should not have been given with the 2:00 p.m. ordered medications. She further verified the [MEDICATION NAME] should have been signed out of the emergency medication box and administered to Resident #59 at 12:00 p.m. b) Resident #12 At 1:45 p.m. on 03/02/15, during a medication pass observation, LPN #36 was observed administering medications to Resident #12. Reconciliation of the observed medications administered with the resident's medical record revealed four (4) medication errors. Error #1: Both the physician's orders [REDACTED]. The administration times were 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m. LPN #36 administered the 12:00 p.m. dose at 1:45 p.m., more than 105 minutes after the scheduled time. The administration of the 12:00 p.m., dose of [MEDICATION NAME] at 1:45 p.m., resulted in a potential for the medication to be administered again in three (3) hours and fifteen (15) minutes, rather than the ordered six (6) hours. Given the medication administration parameters, as referenced in the CMS guidance to surveyors, of 60 minutes earlier or later than the scheduled dose, the smallest duration of time between doses should have been no less than four (4) hours. Error #2: [MEDICATION NAME] (a medication given for shortness of breath) 100 mg/five (5) ml syrup, was ordered for 12:00 a.m., 6:00 a.m., 12:00 p.m,, and 6:00 p.m. At 1:45 p.m., LPN #36 initialed the MAR, indicating she gave the [MEDICATION NAME] at 12:00 p.m. Observation revealed she did not give the [MEDICATION NAME] during the observed medication pass. LPN #36 previously stated she had not given the 12:00 p.m. medications, and was giving them with the 2:00 p.m. medications. Errors #3 and #4: Refresh unit dose eye drops were ordered to instill one (1) drop into each eye, four (4) times daily (10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m.), due to dry eyes. Observation revealed the eye drops were not administered during the medication pass; however, the LPN initialed, on the MAR, that they were administered. On 03/02/15 at 3:20 p.m., upon inquiry as to the timing of the administration of the [MEDICATION NAME] for Resident #12, LPN #36 stated, I was late passing the noon medications today, so I gave them with the 2:00 p.m. medications. Upon further inquiry as to the omissions of the [MEDICATION NAME] and the Refresh eye drops, LPN #36 said, I just forgot to give the eye drops and the syrup. LPN #36 stated there had been so many recent changes in the facility, and it was hard to keep up with everything. She said the nurses were used to using an electronic system when administering medications. LPN #36 said for the month of March 2015, the facility had reverted back to the use of paper MARs. At 4:00 p.m. on 03/02/15, the DON was made aware of the medication errors identified for Resident #12 during the medication administration observation. The DON verified the 12:00 p.m. ordered medications should not have been given with the 2:00 p.m. ordered medications. She further verified the medications [MEDICATION NAME] and the Refresh eye drops should have been administered to Resident #12 at the ordered times. c) Resident #16 On 03/03/15 at 8:30 a.m., during the 8:00 a.m. medication pass observation, LPN #36 was observed administering medications to Resident #16. Reconciliation of the observed medications administered with the resident's medical record revealed two (2) medication errors. Error #1: LPN # 35 was observed as she administered [MEDICATION NAME], a gastro [MEDICAL CONDITION] reflux disorder (GERD) medication, ordered for administration at 8:00 a.m. The resident was seated in a chair. Her breakfast tray was observed on the over-the-bed table beside her. A small portion of the meal had been consumed by the resident. Reconciliation of the observed medications administered with the medical record revealed the [MEDICATION NAME] was ordered to be given on an empty stomach. The instructions, Give on an empty stomach, had not been carried forward on the hand written MAR for Resident #16. Error #2: While preparing the medications for administration, LPN #35 questioned Resident #16's MAR, in regards to the order for [MEDICATION NAME] (a potassium supplement). She said the order on the MAR indicated [REDACTED]. The LPN stated the resident had always received three (3) capsules for a total of thirty (30) meq, twice a day. The LPN reviewed the physician's orders [REDACTED]. After reviewing the physician's recapitulation orders, she stated, She does get three (3) capsules, the order was carried forward wrong. LPN #35 then changed the order on the resident's MAR. She discontinued the order which indicated [MEDICATION NAME] (ten) 10 meq, give one (1) by mouth twice a day, then transcribed a new order on the resident's MAR indicated [REDACTED]. At 8:45 a.m. on 03/03/15, LPN #35, opened three (3) ten (10) meq [MEDICATION NAME] capsules, for a total of thirty (30) meq, and mixed their contents with applesauce. She was then observed administering the medication to Resident #16. Upon inquiry as to the discrepancy of the orders, the LPN stated, It feels like we have gone back in time, we have a new pharmacy and are using paper MARs this month. On 03/03/15 at 10:00 a.m., a review of the physician's orders [REDACTED]. The new orders instructed to give [MEDICATION NAME] 10 meq, one (1) tablet by mouth twice daily (BID) for [DIAGNOSES REDACTED]. At 11:30 a.m. on 03/03/15, a reconciliation of the physician's orders [REDACTED]. She verified, Resident #16 received an incorrect dose of [MEDICATION NAME]. She further verified the [MEDICATION NAME] should have been administered on an empty stomach. The DON said she would ensure the order for the [MEDICATION NAME] would be clarified, indicating the correct dosage. She also said the time for the administration of the [MEDICATION NAME] would be changed on the MAR. d) Resident #33 On 03/04/15 at 9:40 a.m., during the 8:00 a.m. medication pass observation, LPN #12 was observed administering medications to Resident #33. Observation and reconciliation of the observed medications administered, revealed two (2) medication errors. Error #1: At 9:40 a.m., observation revealed LPN #12 crushed [MEDICATION NAME]-[MEDICATION NAME]-Enta 31.25-125 mg (a medication used for [MEDICAL CONDITION]) and mixed the medication with applesauce. The medication card contained a Black Box Warning which stated, DO NOT CRUSH OR CHEW. The LPN was then informed she had a telephone call at the nurses' station. She labeled the medication cup with Resident #33's name and placed it in the top drawer of her medication cart. She stated, I have to take this call. LPN #12 returned at 9:50 a.m., retrieved the medication cup, and administered the medication to the resident. Error #2: LPN #12 was observed at 9:55 a.m. as she administered eye drops, Natural Balance Tears 0.4 percent (%) drops, to Resident #33. The resident was seated in a semi-reclined position in her geri-chair. She was lying on her left side, with her head facing in a downward position. LPN #12 unsuccessfully attempted to reposition the resident onto her back, in order to instill the eye drops. The resident remained lying on her left side in the chair with her head in a downward position. The LPN instilled a single drop into the resident's right eye. She then, attempted to instill a drop into the resident's left eye. The resident's head remained in the same downward position. The surveyor was kneeling down to ensure a clear view of the instillation. The tip of the instillation dropper touched the resident's upper eyelashes, and the drop of medication rolled down the resident's left temporal area. The drop of medication did not come in contact with the resident's left eye. During the administration of both the right and left eye drop, the nurse was standing up and over the resident. The nurse's position prevented the visualization of the left eye, to ensure instillation of the drop. At 9:55 a.m. on 03/04/15, an inquiry was made regarding the resident's positioning and the effective instillation of the eye drop into the resident's left eye. The LPN said, I saw it go in. Upon inquiry as to the black box warning on the [MEDICATION NAME]-[MEDICATION NAME]-Enta, of DO NOT CRUSH OR CHEW, the LPN said, What else am I supposed to do, she can't swallow pills, and this is what she always gets. On 03/04/15 at 11:00 a.m., the Director of Operations, South, was made aware of the observations regarding LPN #12's administration of Resident #33's eye drops. She agreed the positioning of the resident during the eye drop instillation would have made it virtually impossible for the drop to have entered the resident's left eye. At 2:05 p.m. on 03/04/15, the DON was made aware of the findings regarding the administration of the medication [MEDICATION NAME]-[MEDICATION NAME]-Enta. She agreed a medication with a warning of DO NOT CRUSH OR CHEW, should not have been crushed. She stated she would notify the physician. On 03/04/15 at 4:30 p.m., the DON provided a copy of the new physician orders [REDACTED]. The new order was to discontinue the [MEDICATION NAME]-[MEDICATION NAME] 3.25-125 mg and to start [MEDICATION NAME] 25/100 mg dissolvable tablets, by mouth three (3) times a day, along with Comton 200 mg (crushable) by mouth three (3) times a day.",2018-03-01
6432,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,356,C,1,0,S2LQ11,"Based on observation and staff interview, the facility failed to post nurse staffing data in a clear and readable format and in a prominent place that was readily accessible to residents and visitors. This had the potential to affect all residents currently residing in the facility. Facility Census: 58. Findings Include: a) At 9:15 a.m. on 03/05/15, the Executive Director was asked where the nurse staff posting was located. She indicated she did not know, and indicated nursing staff would know. The Director of Nursing (DON) was asked where the nurse staff posting could be located at 9:20 a.m. on 03/05/15. She stated it should be posted outside of the nurses' station. At 9:25 a.m. on 03/05/15, the assistant Director of Nursing (ADON) and the Executive Director verified there was not a nurse staff posting anywhere on the health care unit.",2018-03-01
6433,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,441,F,1,0,S2LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to maintain an Infection Control Program to prevent, to the extent possible, the onset and spread of infections. A nasal cannula was removed from the floor and was reconnected to the oxygen canister. Medications in medication cups, for various residents, were stacked inside each other. A prepared crushed medication in applesauce was stored uncovered in a medication cart drawer with other residents' poured medications. Omissions of hand washing and the improper use of gloves were observed during a medication administration observation and observation of the provision of incontinence care. Incontinence and perineal care were not provided in a manner to prevent potential infections and disease transmission. These infection control practices affected two (2) of nine (9) residents two (2) residents identified through random opportunities for discovery, and had the potential to affect all residents. Resident identifiers: #33, #36, #48, and #54. Facility Census: 58 Findings Include: a) Resident #33 On 03/04/15 at 9:15 a.m., during the medication administration observation, with LPN #12, the LPN was observed changing the portable oxygen canister for Resident #33. The LPN disconnected the resident's nasal cannula from the empty oxygen canister, and the connecting end fell to the floor. The LPN exchanged the empty oxygen canister for a full canister. After the canisters had been exchanged, the LPN picked up the connecting end of the resident's nasal cannula, and reconnected the cannula to the oxygen canister. The connector end of the cannula was observed in direct contact with the floor since it was disconnected from the oxygen canister. The LPN did not wash her hands or use hand sanitizer before returning to the medication cart and resuming preparation of the resident's medication. At 9:40 a.m. on 03/04/15, after LPN #12 prepared Resident #33's medications for administration, she was informed, she had a telephone call at the nurses' station. The LPN stated she had to take the call. Using a permanent marker, she wrote the resident's name on the pill cup which contained the resident's prepared medications. The LPN placed the cup in the top drawer of the medication cart. While the drawer was open, other pill cups containing medications were observed in the drawer, each labeled with resident names. The LPN returned from her telephone call at 9:50 a.m. to resume the medication administration. She did not wash her hands or use hand sanitizer after her telephone call. The LPN donned a pair of gloves prior to the administration of Resident #33's medications. She retrieved the resident's medications from the drawer of the medication cart. The resident was sitting in a geri-chair, in a semi-reclined position. The resident was positioned on her left side, with her head in a downward manner. The LPN attempted to reposition the resident to instill ordered eye drops. The resident remained on her left side, with her head in a downward The LPN, still wearing the same pair of gloves which she donned prior to the administration of the oral medications and the attempt to reposition the resident, instilled one (1) eye drop into the resident's right eye. While still wearing the same gloves, she attempted to instill one (1) drop into the resident's left eye. After administering all of Resident #33's medications, the LPN returned to the medication cart and removed the soiled gloves. She did not wash her hands or use hand sanitizer after removing the soiled gloves. b) Resident #36 At 9:55 a.m. on 03/04/15, upon request, LPN #12 opened the top drawer of the medication cart. Observed was a [MEDICATION NAME] which was opened and dated. Sitting directly on top of the patch, was a medication cup containing one (1) pill. Stacked inside of the medication cup containing the pill, was another medication cup, containing several medications. The bottom of the top stacked cup was in direct contact with the pill that was in the lower stacked medication cup. The patch and the two (2) stacked medication cups were labeled with Resident #36's name. c) Resident #48 The observation of the medication cart on 03/04/15 at 9:55 a.m. revealed a medication cup to the right side of the cups for Resident #36. This cup contained crushed medications mixed with applesauce, and had a small wooden spoon placed in the center of the mixture. The cup was labeled with Resident #48's name. An inquiry was made as to the prepared labeled medications stored in the drawer of the medication cart. The LPN said when she went to administer the medications to those residents, she was unable to locate the residents and had placed the medications in the drawer until she could find the residents. Upon inquiry as to the practice of placing prepared medication cups in the drawer, she replied, We do it all the time, have you not seen any other nurses do it? She then said, What else am I supposed to do with them, is this illegal or something? At that time, the LPN was asked if she could see any potential problems or concerns regarding oxygen cannula tubing in direct contact with the floor or the pill that was in direct contact with the bottom of the other medication cup. She replied, They all had the potential to be contaminated by germs. Further inquiry regarding hand washing, and the appropriate time to do so was made. The LPN stated she should have washed her hands between residents and after her telephone call. On 03/04/15 at 11:00 a.m., the Director of Operations South was informed of the observations made during the medication pass. She said she would promptly notify the Director of Nursing (DON). She said LPN #12 would receive needed education regarding infection control. d) Resident #54 On 03/05/15 at 9:50 a.m., the provision incontinence care for Resident #54, provided by Nurse Aide (NA) #10, was observed. The NA donned a pair of gloves without first washing her hands, and wet and warmed several wash cloths. She placed the wash cloths directly onto the resident's over-the-bed table. Resident #54 was observed wearing a wet brief, as discerned by the wetness indicator line on the brief. NA #10 attempted to roll the resident onto his left side. The resident was having difficulty maintaining the position on his left side. The NA folded the brief under the resident in order to provide care. She used one (1) of the wet wash cloths, with no cleanser, and began to wipe in a straight line from the anal area upward between the buttocks. Observed on the cloth were smears of fecal matter. She folded the wash cloth, and again wiped upward in the same line. She repeated this same action, using the same cloth, until there was no longer smears of fecal matter. The NA placed the soiled cloth in a plastic bag for disposal and was about to remove the soiled brief. The NA was asked to position the resident more on to his left side so the skin integrity of resident's coccyx area could be observed. When the NA had difficulty maintaining the resident's position on his left side, she said she needed to get another NA to assist her. She removed her gloves, disposed of them in the trash can, and exited the room. She did not wash her hands. NA #10 returned to the resident's room and started to don a new pair of gloves. She was followed into the room by NA #44. NA #44 went directly into the bathroom and began washing her hands. Upon seeing this action, NA #10 removed the gloves she was donning and said, I better go do that. She then went to the bathroom and washed her hands. After positioning the resident on his left side, and the resident's skin integrity was observed, NA #10 removed the resident's saturated brief and placed it in a plastic bag for disposal. A new brief was placed under the resident. He was rolled onto his back and the new brief was secured on the resident. The resident was observed to be an uncircumcised male. There had been no attempts to cleanse the resident's perineal area by the two (2) NAs, prior to securing the brief. NA #44 noticed the resident's gray sweatshirt was wet. She asked the resident if they could change his shirt, and he agreed. After the removal of the sweatshirt, observation revealed it was wet from the waistband up the back of the shirt and on the left side. The resident was then dressed in a clean shirt. The resident's back and left side, which came in contact with the urine soaked sweatshirt, was not cleansed. NA #44 observed that the incontinence pad beneath the resident was also wet with urine. NA #44 and NA #10 removed the wet pad and placed a clean and dry pad beneath the resident. NA #44 removed her soiled gloves, disposed of them in the trash can, washed her hands, and left the resident's room. While wearing the same soiled gloves she had worn while providing incontinence care, NA #10 adjusted the resident's bed height with the remote control, and secured the control to the resident's side rail. She then retrieved the resident's call light from the floor and secured it to the opposite side rail. NA #10 then removed the remaining unused, wet wash cloths from the resident's over-the-bed table and placed them in a plastic bag. She then removed her soiled left glove, gathered the plastic bags containing the soiled linens and the soiled brief, in her gloved right hand, and exited the resident's room. She had worn the same pair of soiled gloves from start to finish after returning to the room with NA #44, only washing her hands the one (1) time. At 1:00 p.m. on 03/05/15, upon inquiry as to the provision of incontinence care for Resident #54, NA #44 verified the resident's skin, which had been in contact with urine soaked materials, had not been cleansed. She verified she had not provided perineal care, and she had not observed any perineal care provided by NA #10. On 03/05/15 at 1:50 p.m., the DON and Registered Nurse #49 were informed of the observations during the provision of incontinence care for Resident #54. Both agreed proper hand washing did not occur, nor was Resident #54 provided adequate incontinence care. At this time, the facility's Incontinence Care and Hand washing policies were requested. At 10:00 a.m. on 03/06/15, review of the facility's Incontinence Care policy found it included the following steps which had not been implemented when incontinence care was provided to Resident #54: -- Step 5. Wash hands and don gloves (hands not washed by NA #10 prior to the start of care) -- Step 20. c. Gently grasp the penis with one hand, if the resident is not circumcised draw foreskin back with the other hand. (Not completed by NA #10 or NA #44) -- Step 20. e. If using warm wet wash cloths, spray approved perineal cleanser on the wash cloth and gently cleanse the tip of the penis with a circular motion, moving down the shaft to the scrotal area. (Place dirty wash cloth in a plastic bag.) (Not completed by NA #10 or NA #44) -- Step 20 g. and h. If the resident has had a bowel movement,with wipes or wash cloths and perineal cleanser, wash scrotum and perineum, wiping back toward the rectal area. Make sure peri-rectal area and surrounding skin is free of urine and feces. (Place dirty linens and wipes in a plastic bag.) (Not completed by NA #10 or NA #44) On 03/06/15 at 12:00 p.m., upon inquiry, the DON confirmed she expected care be provided in accordance with standards of practice and facility policy.",2018-03-01
6434,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,465,D,1,0,S2LQ11,"Based on observation and staff interview, the facility failed to provide a functional, safe resident environment for one (1) of five (5) residents. It was not possible to turn on the over-the-bed light, making the illumination in the room unsuitable for the provision of care. Resident identifier: #7. Facility Census: 58. Findings Include: a) Resident #7 During an observation of incontinence care for Resident #7, on 03/05/15 at 12:30 p.m., the resident's side of the room was dark. The resident's bed was along the wall, in front of the window. The window blinds were closed to provide privacy, as the room was located at ground level, next to a sidewalk. The lack of functional lighting made it difficult to observe the condition of the resident's skin. In response to a request for the light to be turned on, Nurse Aide (NA) #46, stated, We can't turn it on, there is no cord. Observation of the light confirmed the cord was missing, and the light had no other means to turn it on or off. Upon inquiry as to how long the cord had been missing, NA #46 said she was not sure. The NA said she had looked for a maintenance slip earlier in the shift, in order to report the missing cord. NA #46 verified the lack of adequate lighting in the room made the provision of care a difficult task.",2018-03-01
6435,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,490,F,1,0,S2LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, resident interviews, and staff interviews, the facility was not administered in an efficient and effective manner which ensured each resident maintained the highest practicable well-being. During the facility's Quality Indicator Survey (QIS) conducted 07/28/14 through 08/05/14, the facility received deficiencies related to quality of care. Those deficiencies were specifically related to provision of the care and services needed to enable residents to attain and/or maintain the highest practicable, physical, mental and psychosocial well being. These areas included pressure ulcers, weight loss, and unnecessary medications. During the QIS survey which ended 08/05/14, the facility was cited at the level of actual harm related to Pressure Ulcers. This required a revisit to determine compliance. The revisit was conducted on 11/03/14 to 11/04/14, at which time the facility was found in substantial compliance in the above mentioned areas. The complaint survey, conducted 03/02/15 through 03/06/15, found the facility again had deficient practices in the area of quality of care. The facility failed to provided optimal pain management for Resident #59 which constituted physical harm. The facility also failed to address a severe weight loss for Resident #7 and failed to provide care and services to prevent an avoidable pressure ulcer. Both of these deficits constituted physical harm for Resident #7. As well, Resident #7's need for insulin coverage was not monitored. Finally, the facility failed to ensure Residents #59's, #7's, #54's and #16's medication regimens were as free as possible from unnecessary medications as possible. Facility administration failed to ensure continued compliance in deficient areas which were previously identified for them. Review of the facility's Plan of Correction for each identified deficient practice found the QA & A committee was responsible for the monitoring of the corrective actions to maintain compliance. Facility administration failed to ensure this committee fulfilled this responsibility. The identified issues specifically affected four (4) of nine (9) sample residents, Residents #59, #7, #54, and #19; however, the failure to ensure continued compliance with identified deficient practices in the area of Quality of Care had the potential to affect all residents currently residing at the facility. Resident Identifiers: #59, #7, #54, and #19. Facility Census: 58. Findings Include: a) Care and Services to maintain and/or Attain the Highest Practicable Physical Mental and psychosocial well being. 1. Resident #59 (Pain) A review of Resident #59's medical record, at 12:33 p.m. on 03/02/15, found Resident #59 had frequent complaints of abdominal pain, and pain in her left and right sides, since July 2014. She had a computerized tomography (CT), without contrast, of the abdomen and pelvis completed on 07/04/14 at a local hospital. The impression was, A possible tiny non-obstructive distal left [MEDICAL CONDITION] calculus is seen. A probable renal mass raising the possibility of renal cell [MEDICAL CONDITION] is also seen. A ventral Hernia containing a loop of colon is also identified. While out to the hospital on [DATE], she also had an ultrasound of both kidneys. The impression for this was, The examination is limited due to the patients large body habitus. A left renal mass is identified raising the possibility of renal cell [MEDICAL CONDITION]. She had another CT of the abdomen completed on 08/19/14. The impression for this was, A 3.4 CM left renal mass believe to [MEDICAL CONDITION] essentially the same as previous 07/23/14 exam. Ventral hernia with non-obstructed small bowel loop of the lower abdomen. Mild constipation. 3 cm (centimeter) uterine fibroid. On 09/08/14, she also had an X-ray of the abdomen which indicated, No acute Findings or Bowel Obstruction. They compared this to an x-ray of the abdomen taken on 12/30/12, which also indicated no bowel obstruction. Review of the resident's annual minimum data set (MDS) assessment, with an assessment reference date (ARD) of 06/10/14, found the resident was on a scheduled pain medication and an as needed (PRN) medication. At that time, the assessment indicated no non-pharmacologic interventions were utilized. The coding for pain indicated the resident had moderate intensity pain rarely. The quarterly MDS, with an ARD of 09/05/14, indicated the resident was not on scheduled pain medication, but did receive PRN [MEDICATION NAME]. The resident's pain interview indicated she had pain frequently that made it hard to sleep at night and limited her activities. Severe was checked for the resident's response for the intensity of her pain. Further review of the resident's medical record found the facility staff failed to ensure Resident #59 consistently received adequate pain management. At times, there was no evidence the resident's complaints of pain were treated. Staff also failed to assess Resident #59's pain for location, nature, and severity before the administration of medication, and/or neglected to reassess her pain for the effectiveness of the pain medication after administration. Staff also failed to implement non-pharmacological interventions in attempts to alleviate Resident #59's pain. No evidence was found to indicate staff monitored the resident for passage of the kidney stone. The failure of facility staff to effectively manage Resident #59's pain on an ongoing basis since July 2014 resulted in Resident #59 periodically suffering from pain for longer than necessary, which constituted physical harm for Resident #59. 1. July 2014 Review of Resident #59's medical record for July 2014 found the resident received ordered as needed (PRN) pain medication and/or complained of pain on the following instances in which Resident #59's pain was not assessed to determine the location, nature, and or severity, and the effectiveness of the pain medication was not determined unless otherwise noted. By not assessing the location, nature, and severity of the pain, information about the resident's pain was not available to communicate to the physician for evaluation. No non-pharmacological interventions were identified as being employed to address the resident's pain. a. 07/03/14 Review of Resident #59's medical record found she began complaining of left side pain on 07/03/14 at 10:00 p.m. Licensed Practical Nurse (LPN) #20 assessed the area and noted no bruising or redness on 07/03/14 at 10:00 p.m. LPN #20 did note administering pain medication at that time. A routine dose of of Tylenol 1000 milligrams (mg) was due at 10:00 p.m. There was no indication LPN #20 assessed whether the dose of Tylenol at 10:00 p.m. was effective in relieving Resident #59's pain. At that time, the resident also had an order for [REDACTED]. There was no indication the attending physician and/or Resident #59's healthcare decision maker were notified of Resident #59's complaints of pain on 07/03/14. b. 07/04/14 Resident #59 again complained of pain in her left side on 07/04/14 at 7:25 p.m. LPN #5 noted she wanted to go to the emergency room (ER) for an evaluation. The resident was sent to the ER, but prior to her leaving the facility, there was no indication her pain was assessed and/or treated. There was no evidence of attempts to obtain additional orders from the attending physician to treat Resident #59's pain prior to sending her to the ER. c. 07/05/14 Resident #59 returned from the ER at 2:44 a.m. on 07/05/14 with new orders for [MEDICATION NAME] 5/325 every 6 (six) hours as needed (PRN) for pain. It was also noted at this time, Resident #59 had a kidney stone and a three (3) centimeter mass. At 1:33 p.m. on 07/05/14, Resident #59's attending physician was notified of her visit to the ER and he gave a new order to discontinue her routine dose of Tylenol 1000 mg twice daily at 10:00 a.m. and 10:00 p.m. Resident #59's MAR indicated [REDACTED]. d. 07/06/14 LPN #20 noted, on 07/06/14 at 1:41 a.m., Resident #59 was medicated with [MEDICATION NAME] one (1) time for complaints of left sided pain with relief noted. Review of 07/06/14 MAR found it did not reflect administration of [MEDICATION NAME] as identified in the nurse's note. e. 07/07/14 LPN #32 noted, at 8:06 a.m. on 07/07/14, Resident #59 was given one (1) dose of [MEDICATION NAME] for complaints of left sided pain. LPN #32 noted the medication was effective. However, there was no indication LPN #32 assessed for the nature and severity of the resident's pain before the administration of medication and/or the effectiveness of the pain medication after administration. f. 07/08/14 - 07/09/14 Resident #59's MAR indicated [REDACTED]. g. 07/12/14 - 07/13/14 Resident #59's MAR indicated [REDACTED]. h. 07/15/14 Resident #59's MAR indicated [REDACTED]. i. 07/21/14 to 07/23/14 Resident #59's MAR indicated [REDACTED]. LPN #5, at 5:41 a.m. on 07/22/14, noted Resident #59 was complaining of stomach pain and headache. LPN #5 indicated she administered PRN Tylenol with relief. There was no indication LPN #5 assessed the severity of Resident #59's pain prior to and after the administration of the PRN Tylenol. Registered Nurse (RN) #58 noted at 10:04 a.m. on 07/22/14, Resident #59's attending physician was in the facility and notified of Resident #59's complaints of pain in her left side. There was no indication the physician assessed Resident #59 and he provided no new orders on that date. At 7:35 a.m., RN #59 telephoned Resident #59's health care decision maker and obtained permission to send Resident #59 out to the ER if the physician requested. RN #59 noted, at 7:45 a.m. on 07/23/14, Resident #59 was moaning and complaining of severe abdominal pain. RN #59 assessed the resident as having severe abdominal pain, rated a 10 (ten) plus on a scale of 0 - 10 with zero (0) being no pain and ten (10) being the worst. RN #59 noted a .large protrusion noted at the umbilicus (navel) area warm/tender to touch. At 9:41 a.m. on 07/23/14, RN #58 noted Resident #59 was sent to the ER for abdominal pain. The resident remained at the facility for nearly two (2) hours, until 9:41 a.m. on 07/23/14, at which time she left the facility via ambulance. During the two (2) hours she remained at the facility, she received no treatment for [REDACTED].#59 at 7:45 a.m. Review of Resident #59's MAR for 07/23/14 found no pain medications were administered to Resident #59. There was no further mention of the resident's ventral hernia found in subsequent nursing entries. j. 07/30/14 Resident #59's MAR indicated [REDACTED]. 2. August 2014 Review of Resident #59's medical record for August 2014 found the resident received ordered as needed pain medication and/or complained of pain on the following instances. Again, unless otherwise noted, there was not assessment of the location, nature, or severity of her pain and no assessment of the effectiveness of the medications. There were no non-pharmacological interventions identified. a. 08/07/14 LPN #20 noted a 5:10 a.m. on 08/07/14 that Resident #59 awoke and requested to go the ER for abdominal pain. At 5:23 a.m. on 08/07/14, LPN #20 noted Resident #59's healthcare decision maker was notified of Resident #59's complaint of abdominal pain and was advised Resident #59 was medicated with her as needed pain medication. LPN #20 noted the healthcare decision maker would prefer to give the medication time to work and if the resident continued with complaints of pain to call him back and he would come and talk with the resident. LPN #20 noted she explained the conversation to Resident #59 who was not happy with her brother's decision. Review of Resident #59's MAR found she was medicated with [MEDICATION NAME] 5/325 mg on 08/07/14. There was no indication LPN #20 assessed the severity/intensity of Resident #59's prior to administration of the as needed pain medication. There was also no evidence to suggest LPN #20 reassessed the resident after the PRN pain medication was administered and had time to be effective, as the resident's brother had requested. b. 08/15/14 Resident #59's MAR indicated [REDACTED]. c. 08/19/14 Resident #59's MAR indicated [REDACTED]. d. 08/20/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. It should be noted this administration note was linked to the administration of [MEDICATION NAME] 5/325, but [MEDICATION NAME] 5/325 was not administered on that date. There was no indication the nurse who administered this medication assessed the resident's pain for severity/intensity prior to administering the PRN Tylenol, and there was no indication the nurse reassessed the the resident to determine if the PRN medication was effective. e. 08/21/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. f. 08/24/14 Resident #59's MAR indicated [REDACTED]. g. 08/26/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. An additional administration note on the MAR indicated [REDACTED]. h. 08/28/14 to 08/30/14 Resident #59's MAR indicated [REDACTED]. i. On 08/20/14, 08/21/14, and 08/26/14 it was noted Resident #59 complained of bilateral lower extremity pain. There was no evidence to suggest the facility made any attempts to determine the cause of the pain in her bilateral lower extremities, nor evidence to suggest the attending physician and/or healthcare decision maker were notified of her bilateral lower extremity pain. 3. September 2014 Review of Resident #59's medical record for 09/2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: a. 09/01/14 Review of Resident #59's MAR for 09/01/14 found she was administered her PRN [MEDICATION NAME] 5/325 on 09/01/14. b. 09/03/14 - 09/08/14 On 09/03/14 at 3:43 a.m. LPN #60, noted Resident #59 received her PRN pain medication twice that shift for complaints of abdominal pain. LPN #60 noted Resident #59 had a bowel movement and her bowels sounds were present in all four (4) quadrants. On 09/04/14 at 1:43 a.m. LPN #60 noted Resident #59 had complaints of abdominal pain and was given PRN pain medication. On 09/05/14, Resident #59's MAR indicated [REDACTED]. On 09/06/14 at 5:11 p.m., LPN #5 noted Resident #59 was calling out from her bed stating, My belly is going to bust. LPN #5 noted the resident had received her PRN pain medication. There was no evidence to suggest LPN #5 assessed the severity of Resident #59's pain prior to administering the PRN pain medication, nor did she reassess her pain for severity to determine if the PRN pain medication was effective. On 09/07/14, Resident #59's MAR indicated [REDACTED] On 09/08/14 at 10:38 a.m., RN #61 noted Resident #59's attending physician was in to evaluate why Resident #59 had been complaining of abdominal pain and crying. He ordered to obtain a KUB to check for ileus disease. Further review of the record found this testing was obtained and ileus disease was not diagnosed . Additionally, on 09/08/14 Resident #59's MAR indicated [REDACTED]. Dhe received a second dose of PRN [MEDICATION NAME] at 1:36 p.m. on 09/08/14, for complaints of pain to the right side accompanied by crying On 09/09/14 at 2:24 a.m., Resident #59's MAR indicated [REDACTED]. It should be noted this information was contained in the Administration notes on the MAR; however, the dosage of [MEDICATION NAME] 5/325 was not initialed as given on the MAR. Resident #59 had complaints of pain to the abdomen and/or right side daily from 09/03/14 through 09/08/14, there was no evidence to suggest Resident #59's attending physician was notified of her daily pain until the morning of 09/08/14. There was also no evidence to suggest Resident #59's healthcare decision maker was made aware of her daily complaints of pain. c. 09/19/14 - 09/21/14 Review of Resident #59's MAR indicated [REDACTED]. The source of Resident #59's pain was only identified on one (1) of the three (3) days she received the PRN pain medication. On 09/21/14 the location of Resident #59's pain was identified as being in the abdomen d. On 09/19/14 and 09/20/14 there was no evidence to suggest Resident #59's pain was assessed for location, nature, and severity before the administration of medication and/or the effectiveness of the pain medication after administration. On 09/23/14 at 12:26 a.m. LPN #20 noted Resident #59 had some complaints of leg discomfort and was medicated with her PRN pain medication. She additionally noted that the Resident was screaming and keeping the residents on the hallway awake. LPN #20 noted there was no reasoning with the resident. At 12:46 a.m. LPN #20 noted resident continued to scream and was now complaining of shortness of breath even though her oxygen saturation was in the upper 90's. LPN #20 again noted she was unable to reason with the resident. At 1:00 a.m. LPN #20 noted she heard Resident #59 screaming as she has been since 12:30 a.m Upon entering Resident #59's room LPN #20 observed the resident laying in the floor beside her bed. LPN #20 indicated she had slid off the bed and continued to yell and scream. She again noted she was unable to reason with Resident #59. At 1:45 a.m. LPN #20 noted Resident #59 continued to yell and scream and disturb the other residents. She again indicated she was unable to reason with the resident. She noted the resident was screaming at staff instead of speaking to them in a normal tone. There was no mention by LPN #20 that she reassessed Resident #59 for pain after administering the PRN pain medication at 12:26 a.m., despite the fact Resident #59 continually screamed, yelled, and even slid off her bed. LPN #20 also failed to assess the severity of the Resident #59's pain prior to administering the PRN pain medication. At 8:18 a.m. on 09/23/14, LPN #5 noted she had spoken with Resident #59's healthcare decision maker and notified him about the resident sliding off the bed. She noted the resident's health decision maker indicated he and his wife would be in later today to speak with the resident about her behaviors. Resident #59's MAR indicated [REDACTED]. e. 09/26/14 to 09/28/14 Resident #59's MAR indicated [REDACTED]. Beginning on 09/15/14 the facility implemented a new pain observation tool. Nursing staff were to observe and/or question for pain every four (4) hours and PRN while awake. The documentation on this tool was inconsistent with the documentation contained in the rest of Resident #59's medical record. The documentation on this tool was reviewed and found Resident #59 was positive for pain on 09/16/14, 09/21/14, 09/22/14, 09/23/14, and 09/27/14. It should be noted Resident #59 was not medicated for identified pain on 09/16/14 and 09/22/14. Additionally, it should be noted that on 09/19/14, 09/20/14, 09/24/14, 09/26/14, and 09/28/14 Resident #59 was given PRN pain medication, but the pain observation tool was marked to indicate she was not having pain. Review of Resident #59's medical record for October 2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: 4) October 2014 a. 10/01/14 - 10/02/14 At 11:00 a.m. on 10/01/14 RN #49 noted that Resident #59 was complaining of abdominal pain at her hernia site. She noted her PRN pain medication had been administered about five (5) minutes prior to Resident #59's complaints. RN #49 noted the resident complained the pain medication was not helping her pain. RN #49 applied a warm compress to the abdomen and attempted to reach the resident's health care decision maker. RN #49 then spoke with the resident about waiting until her attending physician was able to visit to review her pain medication regimen before they sent her to the emergency room . RN #49 noted Resident #59 was in agreement with this plan. Review of Resident #59's MAR found she received a PRN dose of [MEDICATION NAME] on that date At 9:55 a.m. on 10/02/14, RN #41 noted Resident #59's attending physician was in and reviewed her pain medication regimen. The physician wrote a new order for [MEDICATION NAME] 5/325 as needed every four (4) hours instead of every six (6) hours. The physician also added a scheduled dose of [MEDICATION NAME] 5/325 three times a day at 10:00 a.m., 2:00 p.m. and 10:00 p.m. Resident #59 began receiving this routine scheduled dose of [MEDICATION NAME] at 10:00 a.m. on 10/02/14. b. 10/04/14 to 10/07/14 At 10:54 a.m. on 10/6/14, LPN #5 noted Resident #59 had constant complaints of her side hurting. LPN #5 indicated the resident had been medicated by the medication nurse. She noted she had spoken with Resident #59's health care decision maker and he did not want the resident sent out of the facility. LPN #5 noted that the healthcare decision maker stated, every time she is sent out they always send her right back because nothing is ever wrong with her. The health care decision maker stated he would come in and talk to the resident that day. LPN #5 noted Resident #59 was not happy about her brother not wanting her sent out of the facility. There was no mention of assessments to determine the severity of the pain Resident #59 was experiencing, or assessments to determine if scheduled doses of pain medication were effective in order to determine if resident needed to be medicated with the PRN [MEDICATION NAME] for which she had an order. Additionally there was no testing and or evaluations completed by facility staff to determine the cause of Resident #59's pain. At 2:54 p.m. on 10/06/14, LPN #62 noted Resident #59 had shown a decrease in the volume of complaints and she was administered pain medication for continued complaints of stomach pain. At 10:39 p.m. on 10/06/14, LPN #7 noted Resident #59 was guarding her stomach and crying in pain and she had done so for the last two (2) nights. She noted bowel sounds were present, were hypoactive in all four (4) quadrants, abdomen was distended in right lower quadrant and tender to touch. LPN #7 noted Resident #59 screamed in pain when she was turned on her stomach. She noted Resident #59 was medicated with scheduled [MEDICATION NAME] one (1) time that shift. She noted she had requested a physician evaluation for pain. There was no evidence in the medical record of Resident #59 to indicate she was having pain in her abdomen and guarding her stomach on 10/04/14 or 10/05/14 as indicated in the 10/06/14 entry by LPN #7. LPN #7's note on 10/06/14 was the first mention of Resident #59's pain which she had experienced on the previous two (2) nights. There was no evidence to suggest Resident #59's pain was assessed for severity and/or relief of pain upon administration of scheduled pain medication on 10/04/14 and 10/05/14, in order to determine the need for PRN pain medication, which was not administered at all on 10/05/14. There was no indication nursing staff assessed Resident #59 to determine the cause of her continued pain in her abdomen. LPN #7 noted she had requested the physician evaluate the resident for pain, but there was no indication nursing staff had called Resident #59's attending physician to notify him of her continued abdominal pain. The heath care decision maker was not made aware of Resident #59's complaints of pain on 10/04/14, 10/05/14 and 10/06/14 until LPN #5 phoned him at 10:54 a.m. on 10/06/14. Resident #59 received a dose of her PRN pain medication on 10/04/14 and 10/06/14. At 8:34 a.m. on 10/07/14, LPN #5 noted Resident #59 was being combative and yelling out at staff. She noted the medication nurse tried to give the resident her pain medication for her complaint of stomach pain and the resident refused stating, You all are not helping me, I want the police. She noted she explained to the resident they were trying to help her, but she would not let them. Resident #59 proceeded to kick over the bedside table and continued to yell out. LPN #5 noted she called the health care decision maker and he would be at the facility shortly to calm the resident down. At 8:46 a.m. on 10/07/14, LPN #5 noted Resident #59's brother was at the facility to see her. At 8:54 a.m. 10/07/14, LPN #5 noted the resident's brother wanted her sent to the ER for an evaluation. At 9:20 a.m. on 10/07/14, LPN #5 noted the resident was transported to the ER at 9:20 a.m. on 10/07/14. At 5:46 p.m. on 10/07/14 LPN #5 noted Resident #59 returned to the facility from the ER with [DIAGNOSES REDACTED]. Resident #59 had made multiple complaints of abdominal and side pain beginning 10/04/14 through 10/07/14. The facility failed to assess for the cause of the pain, failed to treat the pain effectively, and failed to assess for the severity of the pain prior to and after administration of PRN pain medications on 10/4/14 and 10/06/14. Staff also failed to assess for the effectiveness of her scheduled pain medication to determine if she needed further medicated with the PRN doses [MEDICATION NAME] to control her pain. Additionally, they failed to notify the attending physician of the continual complaints of pain, and failed to notify the healthcare decision maker of her complaints of pain until 10/06/14. This resulted in Resident #59 suffering undue pain as well as mental anguish. On 10/07/14 Resident #59 was noted to be combative with staff and was noted to state, You all aren't helping me, I want the police. Resident #59 had at that point endured pain for three (3) consecutive days and felt as if the facility staff was not helping her. It was not until her brother arrived at the facility and requested she be sent to the ER that Resident #59 was sent out of the facility for treatment for [REDACTED]. The facility was unable to show any evidence of attempts to manage and control her pain at the facility. They made no attempts to determine the cause pain and/or to treat the cause of the pain. b. 10/10/14: Resident #59's MAR indicated [REDACTED]. c. 10/16/14: Resident #59's MAR indicated [REDACTED]. Review of Resident #59's pain observation tool found the resident was identified as having pain on 10/04/14, 10/06/14, 10/08/14, and 10/13/14. Please note this report was again inconsistent with the rest of Resident #59's medical record. She was identified as having continual pain from 10/04/14 through 10/07/14 in the nursing progress notes, she received a PRN dose of [MEDICATION NAME] in addition to her scheduled pain medications on 10/10/14 and 10/16/14 and was identified as not having pain on these dates on the pain observation tool. Additionally, the pain observation tool identified she had pain on 10/08/14 and 10/13/14 with no mention of the pain in the progress notes or administration of any pain medication other than her scheduled [MEDICATION NAME] 5/325 three (3) times a day. This tool was ineffective in identifying when Resident #59 experienced pain. Review of Resident #59's medical record for 11/2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: 5) November 2014 a. 11/12/14: Resident #59's MAR indicated [REDACTED]. b. 11/16/14: Resident #59's MAR indicated [REDACTED]. c. 11/21/14: Resident #59's MAR indicated [REDACTED]. d. 11/28/14: Resident #59's MAR indicated [REDACTED]. h. Review of Resident #59's pain observation tool for the month of November 2014 again found inconsistent documentation between the pain monitoring tool and the MAR. Resident #59 received PRN pain medication on 11/12/14, 11/16/14, 11/21/14, and 11/28/14. The pain observation tool indicated Resident #59 was negative for pain on all of these dates. 6) December 2014 Review of Resident #59's medical record for December 2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: a. 12/08/14: Resident #59's MAR indicated [REDACTED]. b. 12/09/14: Resident #59's MAR indicated [REDACTED]. c. 12/22/14: Resident #59's MAR indicated [REDACTED]. d. 12/28/14: At 10:14 a.m. on 12/28/14, LPN #36 noted that Resident #59 had poured water on herself multiple times to get the staff to change her pants. She noted Resident #59 was complaining that her pants were too tight. LPN #36 noted, she told the resident her pants were not too tight and to quit being disruptive. She advised the resident that the nurse aides were busy feeding and bathing other residents and that she could not keep pouring water on herself just to get changed. LPN #36 then noted Resident #59 began to complain of stomach pain and nausea. She indicated she gave Resident #59 a [MEDICATION NAME] shot and the resident was noted to be resting about 30 minutes after the shot. There was no indication in Resident #59's medical record that LPN #36 had assessed the resident for pain upon her complaints that her pants were too tight. There was no mention of pain until after the staff had changed the resident's pants on several occasions and after LPN #36 had advised Resident #59 that she was being disruptive. At that time, Resident #59 mentioned pain when she complained of pain in her stomach. Once the resident complained of pain, LPN #36 failed to assess the severity of the pain and/or the possible causes of the stomach pain. LPN #36 proceeded to treat the complaints of nausea, but failed to assess and/or treat Resident #59's complaints of stomach pain. This note was entered into the medical record at 10:14 a.m., which was 14 minutes after Resident #59 had received her scheduled dose of [MEDICATION NAME]. LP (TRUNCATED)",2018-03-01
6436,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,498,D,1,0,S2LQ11,"Based on observation, record review, facility policy review, and staff interviews, the facility failed to ensure the nurse aides providing care for residents demonstrated competency and techniques necessary to care for residents. Nurse aides did not show competency in the areas of personal care, basic nursing skills, and infection control in providing care for one (1) of three (3) residents reviewed for the provision of incontinence care. Resident Identifier: #54. Facility census: 58. Findings include: a) Resident #54 On 03/05/15 at 9:50 a.m., Nurse Aide #10 was observed providing incontinence care for Resident #54. The resident was observed lying in his bed, and had urinated in his brief. The brief was removed by NA #10. After removing the saturated brief, NA #10 used one (1) wet wash cloth (water only, no cleaner) and wiped in a straight line, from the resident's anal area up and between the buttocks. There were visible smears of fecal matter on the washcloth. She folded the washcloth and repeated the process several more times, in the same manner. No cleansing was performed to the resident's buttocks, or his frontal perineal area, including his penis. The resident was an uncircumcised male. NA #10 left the room for a short period of time, to get another NA to assist her with the provision of care. NA #10 returned to the resident's room with NA #44 and continued with the provision of care. No further cleansing of the resident occurred prior to the application of a new incontinence brief. Neither the resident's buttocks, nor the front of the resident was cleansed, in any manner, after the resident was incontinent of urine. At 1:00 p.m. on 03/05/15, when asked about the provision of incontinence care for Resident #54, NA #44 verified she had not provided any perineal care, and she had not observed any perineal care provided by NA #10. At 1:10 p.m. on 03/05/15, a review of the care plan revealed a focus area indicating the resident was at risk for UTIs due to a history of UTIs. The onset date for this focus area was 06/09/14, with an edited date of 01/27/15. The goal for this focus area was for the resident to remain free of signs or symptoms of UTI through the next review, with a target date of 04/27/15. On 03/05/15 at 1:50 p.m., the Director of Nursing (DON) and Registered Nurse #49 were informed of the observations during the provision of incontinence care for Resident #54. Both agreed Resident #54 was not been provided incontinence care in a manner to prevent UTIs. At this time, a copy of the facility's incontinence care policy was requested. At 10:00 a.m. on 03/06/15, review of the facility's Incontinence Care policy found it included the following steps which had not been implemented when incontinence care was provided to Resident #54: -- Step 5. Wash hands and don gloves (hands not washed by NA #10 prior to the start of care) -- Step 20. c. Gently grasp the penis with one hand, if the resident is not circumcised draw foreskin back with the other hand. (Not completed by NA #10 or NA #44) -- Step 20. e. If using warm wet wash cloths, spray approved perineal cleanser on the wash cloth and gently cleanse the tip of the penis with a circular motion, moving down the shaft to the scrotal area. (Place dirty wash cloth in a plastic bag.) (Not completed by NA #10 or NA #44) -- Step 20. f. Be sure to replace the foreskin for uncircumcised males after cleaning. (Not completed by NA #10 or NA #44) -- Step 20 g. and h. If the resident has had a bowel movement,with wipes or wash cloths and perineal cleanser, wash scrotum and perineum, wiping back toward the rectal area. Make sure peri-rectal area and surrounding skin is free of urine and feces. (Place dirty linens and wipes in a plastic bag.) (Not completed by NA #10 or NA #44) On 03/06/15 at 12:00 p.m., upon inquiry, the DON confirmed she expected care be provided in accordance with standards of practice and facility policy.",2018-03-01
6437,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,514,E,1,0,S2LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain complete, accurate, and/or organized medical records for four (4) of nine (9) sampled residents. Resident #54's and #7's sliding scale insulin documentation on the medication administration record (MAR) did not provide sufficient information to indicate the care provided and/or required. Resident #7's nutritional assessment did not accurately reflect the medication the resident received. Resident #12's MAR indicated she received a medication which she did not receive while in the facility, and reflected she received a medication during a time she was out of the facility. Resident #19 received a medication for which parameters for administration were indicated. These parameters were not reflected on the resident's current MAR. Resident Identifiers: #54, #7, #12, and #19. Facility Census: 58. Findings Include: a) Resident #54 Review of Resident #54's medical record, at 3:17 p.m. on 03/03/15, found an order for [REDACTED]. Review of the facility's medication schedule found Resident #54 should have received this medication at 6:45 a.m., 11:30 a.m., 4:45 p.m. and 9:00 p.m. daily. Page two (2) of Resident #54's MAR revealed the following medications which were scheduled for administration (typed as written): [MEDICATION NAME] R Injection Solution 100 unit/sliding scale AC (before meals) and HS (at bedtime) prn (as needed) for Accu Check: 0-150 give 0 units. 151-200 give 3 units. 201-250 give 6 units. 251 - 300 give 9 units. 301 - 350 give 12 units. 351- 400 give 15 units. 401 - 450 give 18 units. 451- 500 give 21 units. If greater than 500 give 21 units and notify the physician. The only other order on page two (2) of the MAR was listed directly below the sliding scale. It was (typed as written): [MEDICATION NAME]- [MEDICATION NAME] Oral tablet 7.5-325 mg (milligrams) po (by mouth) Q (every) 4 (four) hours as needed (PRN)for pain. Review of Resident #54's MAR revealed it was not possible to determine when the resident received the sliding scale insulin coverage, who administered the sliding scale insulin, how much insulin he received, and what her blood sugar reading was prior to the administration of the sliding scale insulin coverage. This resulted in an inability to monitor the administration of Resident #54's sliding scale insulin coverage. The manner in which the MAR was documented rendered it impossible for facility staff, the pharmacist, and the physician to accurately assess and monitor Resident #54's sliding scale insulin coverage and/or to determine if the resident received the appropriate doses of insulin coverage. In addition, on several occasions, nursing staff documented information related to the resident's sliding scale insulin administration in the section of the MAR which was dedicated for documentation related to the administration of the [MEDICATION NAME]. This made the MAR ineffective in monitoring the resident's PRN use of [MEDICATION NAME]. b) Resident #7 (Sliding Scale Insulin) A review of Resident #7's medical record, at 9:46 a.m. on 03/03/15, found a February 2015 MAR which contained the following order (typed as written): Accu check BID (two (2) times a day) cover with Humbling R insulin subcutaneously 200-250 give 4 units. 251 - 300 give 6 units. 301 - 350 give 8 units. 351 - 400 give 10 units. 401 - 450 give 14 units. 451 - 500 give 20 units. Above 500 send to ER (emergency room ) for eval (evaluation ). Review of Resident #7's MAR revealed it was not possible to determine when the resident received the sliding scale insulin coverage, who administered the sliding scale insulin, how much insulin she received, and what her blood sugar reading was prior to the administration of the sliding scale insulin coverage. This resulted in an inability to monitor the administration of Resident #7's sliding scale insulin coverage. The manner in which the MAR was documented rendered it impossible for facility staff, the pharmacist, and the physician to accurately assess and monitor Resident #7's sliding scale insulin coverage and/or to determine if the resident received the appropriate doses of insulin coverage. c) An interview was conducted with the Director of Nursing (DON), at 11:36 a.m. on 03/04/15, regarding the sliding scale coverage for Residents #7 and #54. She confirmed the documentation on the residents' MARs regarding sliding scale insulin did not clearly indicate when the residents received sliding scale coverage, what the blood sugar was prior to administration of sliding scale insulin, which nurse administered the medications, the time the sliding scale insulin coverage was administered, or on what day it was administered. d) Resident #7 (Nutritional Assessment) A review of Resident #7's medical record, at 9:46 a.m. on 03/03/15, found a Comprehensive Nutritional Assessment with an effective date of 02/13/15. Review of this assessment found, under the section titled Medications, Antipsychotics was checked to indicate Resident #7 received an antipsychotic medication. Further review of Resident #7's medical record found no evidence the resident received an antipsychotic medication. An interview with Registered Dietitian (RD) #50 at 5:00 p.m. on 03/04/15, confirmed she completed Resident #7's nutritional assessment on 02/13/15. She additionally confirmed, after reviewing the resident's medical record, she had marked the antipsychotic use by mistake. The RD confirmed the resident's medical record contained no evidence Resident #7 had received antipsychotic medications since her admission to the facility on [DATE], or on her previous admission on 02/04/15. She indicated she must have meant to mark anti-hypertensive and hit the wrong button. e) Resident #12 During reconciliation of the medication administration pass observations on 03/02/15 for Resident #12, the following inaccuracies were identified on the medication administration record (MAR), a part of the resident's medical record: -- Refresh eye drops were documented as administered at 2:00 p.m. on 03/02/15. Upon inquiry on 03/02/15 at 3:20 p.m., licensed practical nurse (LPN) #36 verified she had not administered the eye drops. She stated she forgot to give them. -- The medication [MEDICATION NAME] (a medication given for shortness of breath) was documented as administered at 2:00 p.m. on 03/02/15. Upon inquiry, on 03/02/15 at 3:20 p.m., LPN #36 verified she did not administer the medication. She stated she forgot to give it. Further review of the March 2015 MAR, on 03/03/15 at 10:00 a.m., found another inaccuracy. Refresh eye drops were documented as administered at 6:00 p.m. on 03/02/15. The resident was not in the facility at 6:00 p.m. on 03/02/15. She was admitted to the hospital earlier that afternoon, with no readmission to the facility on [DATE]. f) Resident #19 Review, on 03/03/15 at 1:15 p.m., of the physician's orders [REDACTED].#19 found an inconsistency. Both the MAR and the physician's orders [REDACTED]. The order was to administer [MEDICATION NAME] XL 100 milligrams (mg) by mouth every day, and included pulse parameters. The parameters instructed the medication be held if the resident's pulse was below 55 beats per minute. The order had a start date of 12/18/13. Also reviewed, at 1:15 p.m. on 03/03/15, were the MAR and the physician's orders [REDACTED]. Both contained the order for the [MEDICATION NAME] XL, but did not indicate the pulse parameters. Further review of the physician's orders [REDACTED]. On 03/03/15 at 2:30 p.m., the DON was made aware of the findings regarding the pulse parameters prior to the administration of the [MEDICATION NAME] XL. She responded by saying the month of March had been proving to be a difficult month due to changes with the pharmacy, the use of paper MARs, and the changes from one electronic medical record company to another electronic medical record company. She agreed the parameters should have been carried forward onto the March 2015 order recapitulation as well as the MAR. She verified there was not a physician's orders [REDACTED].",2018-03-01
6438,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,520,F,1,0,S2LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, resident interviews, and staff interviews, the quality assessment and assurance (QA & A) committee failed to address quality deficiencies of which they were aware, or should have been aware. These practices had the potential to affect all residents. During the facility's Quality Indicator Survey (QIS) conducted 07/28/14 through 08/05/14, the facility received deficiencies related to quality of care. Those deficiencies were specifically related to provision of the care and services needed to enable residents to attain and/or maintain the highest practicable, physical, mental and psychosocial well being. These areas included pressure ulcers, weight loss, and unnecessary medications. During the QIS survey which ended 08/05/14, the facility was cited at the level of actual harm related to Pressure Ulcers. This required a revisit to determine compliance. The revisit was conducted on 11/03/14 to 11/04/14, at which time the facility was found in substantial compliance in the above mentioned areas. The complaint survey, conducted 03/02/15 through 03/06/15, found the facility again had deficient practices in the area of quality of care. The facility failed to provided optimal pain management for Resident #59 which constituted physical harm. The facility also failed to address a severe weight loss for Resident #7 and failed to provide care and services to prevent an avoidable pressure ulcer. Both of these deficits constituted physical harm for Resident #7. As well, Resident #7's need for insulin coverage was not monitored. Finally, the facility failed to ensure Residents #59's, #7's, #54's and #16's medication regimens were as free as possible from unnecessary medications as possible. The facility's QA & A committee failed to ensure continued compliance in deficient areas which were previously identified for them. Review of the facility's Plan of Correction for each identified deficient practice found the QA & A committee was responsible for the monitoring of the corrective actions to maintain compliance. These identified issues specifically affected four (4) of nine (9) sample residents, Residents #59, #7, #54, and #19; however, the failure to ensure continued compliance with identified deficient practices in the area of Quality of Care had the potential to affect all residents currently residing at the facility. Resident Identifiers: #59, #7, #54, and #19. Facility Census: 58. Findings Include: a) Care and Services to maintain and/or Attain the Highest Practicable Physical Mental and psychosocial well being. 1. Resident #59 (Pain) A review of Resident #59's medical record, at 12:33 p.m. on 03/02/15, found Resident #59 had frequent complaints of abdominal pain, and pain in her left and right sides, since July 2014. She had a computerized tomography (CT), without contrast, of the abdomen and pelvis completed on 07/04/14 at a local hospital. The impression was, A possible tiny non-obstructive distal left [MEDICAL CONDITION] calculus is seen. A probable renal mass raising the possibility of renal cell [MEDICAL CONDITION] is also seen. A ventral Hernia containing a loop of colon is also identified. While out to the hospital on [DATE], she also had an ultrasound of both kidneys. The impression for this was, The examination is limited due to the patients large body habitus. A left renal mass is identified raising the possibility of renal cell [MEDICAL CONDITION]. She had another CT of the abdomen completed on 08/19/14. The impression for this was, A 3.4 CM left renal mass believe to [MEDICAL CONDITION] essentially the same as previous 07/23/14 exam. Ventral hernia with non-obstructed small bowel loop of the lower abdomen. Mild constipation. 3 cm (centimeter) uterine fibroid. On 09/08/14, she also had an X-ray of the abdomen which indicated, No acute Findings or Bowel Obstruction. They compared this to an x-ray of the abdomen taken on 12/30/12, which also indicated no bowel obstruction. Review of the resident's annual minimum data set (MDS) assessment, with an assessment reference date (ARD) of 06/10/14, found the resident was on a scheduled pain medication and an as needed (PRN) medication. At that time, the assessment indicated no non-pharmacologic interventions were utilized. The coding for pain indicated the resident had moderate intensity pain rarely. The quarterly MDS, with an ARD of 09/05/14, indicated the resident was not on scheduled pain medication, but did receive PRN [MEDICATION NAME]. The resident's pain interview indicated she had pain frequently that made it hard to sleep at night and limited her activities. Severe was checked for the resident's response for the intensity of her pain. Further review of the resident's medical record found the facility staff failed to ensure Resident #59 consistently received adequate pain management. At times, there was no evidence the resident's complaints of pain were treated. Staff also failed to assess Resident #59's pain for location, nature, and severity before the administration of medication, and/or neglected to reassess her pain for the effectiveness of the pain medication after administration. Staff also failed to implement non-pharmacological interventions in attempts to alleviate Resident #59's pain. No evidence was found to indicate staff monitored the resident for passage of the kidney stone. The failure of facility staff to effectively manage Resident #59's pain on an ongoing basis since July 2014 resulted in Resident #59 periodically suffering from pain for longer than necessary, which constituted physical harm for Resident #59. 1. July 2014 Review of Resident #59's medical record for July 2014 found the resident received ordered as needed (PRN) pain medication and/or complained of pain on the following instances in which Resident #59's pain was not assessed to determine the location, nature, and or severity, and the effectiveness of the pain medication was not determined unless otherwise noted. By not assessing the location, nature, and severity of the pain, information about the resident's pain was not available to communicate to the physician for evaluation. No non-pharmacological interventions were identified as being employed to address the resident's pain. a. 07/03/14 Review of Resident #59's medical record found she began complaining of left side pain on 07/03/14 at 10:00 p.m. Licensed Practical Nurse (LPN) #20 assessed the area and noted no bruising or redness on 07/03/14 at 10:00 p.m. LPN #20 did note administering pain medication at that time. A routine dose of of Tylenol 1000 milligrams (mg) was due at 10:00 p.m. There was no indication LPN #20 assessed whether the dose of Tylenol at 10:00 p.m. was effective in relieving Resident #59's pain. At that time, the resident also had an order for [REDACTED]. There was no indication the attending physician and/or Resident #59's healthcare decision maker were notified of Resident #59's complaints of pain on 07/03/14. b. 07/04/14 Resident #59 again complained of pain in her left side on 07/04/14 at 7:25 p.m. LPN #5 noted she wanted to go to the emergency room (ER) for an evaluation. The resident was sent to the ER, but prior to her leaving the facility, there was no indication her pain was assessed and/or treated. There was no evidence of attempts to obtain additional orders from the attending physician to treat Resident #59's pain prior to sending her to the ER. c. 07/05/14 Resident #59 returned from the ER at 2:44 a.m. on 07/05/14 with new orders for [MEDICATION NAME] 5/325 every 6 (six) hours as needed (PRN) for pain. It was also noted at this time, Resident #59 had a kidney stone and a three (3) centimeter mass. At 1:33 p.m. on 07/05/14, Resident #59's attending physician was notified of her visit to the ER and he gave a new order to discontinue her routine dose of Tylenol 1000 mg twice daily at 10:00 a.m. and 10:00 p.m. Resident #59's MAR indicated [REDACTED]. d. 07/06/14 LPN #20 noted, on 07/06/14 at 1:41 a.m., Resident #59 was medicated with [MEDICATION NAME] one (1) time for complaints of left sided pain with relief noted. Review of 07/06/14 MAR found it did not reflect administration of [MEDICATION NAME] as identified in the nurse's note. e. 07/07/14 LPN #32 noted, at 8:06 a.m. on 07/07/14, Resident #59 was given one (1) dose of [MEDICATION NAME] for complaints of left sided pain. LPN #32 noted the medication was effective. However, there was no indication LPN #32 assessed for the nature and severity of the resident's pain before the administration of medication and/or the effectiveness of the pain medication after administration. f. 07/08/14 - 07/09/14 Resident #59's MAR indicated [REDACTED]. g. 07/12/14 - 07/13/14 Resident #59's MAR indicated [REDACTED]. h. 07/15/14 Resident #59's MAR indicated [REDACTED]. i. 07/21/14 to 07/23/14 Resident #59's MAR indicated [REDACTED]. LPN #5, at 5:41 a.m. on 07/22/14, noted Resident #59 was complaining of stomach pain and headache. LPN #5 indicated she administered PRN Tylenol with relief. There was no indication LPN #5 assessed the severity of Resident #59's pain prior to and after the administration of the PRN Tylenol. Registered Nurse (RN) #58 noted at 10:04 a.m. on 07/22/14, Resident #59's attending physician was in the facility and notified of Resident #59's complaints of pain in her left side. There was no indication the physician assessed Resident #59 and he provided no new orders on that date. At 7:35 a.m., RN #59 telephoned Resident #59's health care decision maker and obtained permission to send Resident #59 out to the ER if the physician requested. RN #59 noted, at 7:45 a.m. on 07/23/14, Resident #59 was moaning and complaining of severe abdominal pain. RN #59 assessed the resident as having severe abdominal pain, rated a 10 (ten) plus on a scale of 0 - 10 with zero (0) being no pain and ten (10) being the worst. RN #59 noted a .large protrusion noted at the umbilicus (navel) area warm/tender to touch. At 9:41 a.m. on 07/23/14, RN #58 noted Resident #59 was sent to the ER for abdominal pain. The resident remained at the facility for nearly two (2) hours, until 9:41 a.m. on 07/23/14, at which time she left the facility via ambulance. During the two (2) hours she remained at the facility, she received no treatment for [REDACTED].#59 at 7:45 a.m. Review of Resident #59's MAR for 07/23/14 found no pain medications were administered to Resident #59. There was no further mention of the resident's ventral hernia found in subsequent nursing entries. j. 07/30/14 Resident #59's MAR indicated [REDACTED]. 2. August 2014 Review of Resident #59's medical record for August 2014 found the resident received ordered as needed pain medication and/or complained of pain on the following instances. Again, unless otherwise noted, there was not assessment of the location, nature, or severity of her pain and no assessment of the effectiveness of the medications. There were no non-pharmacological interventions identified. a. 08/07/14 LPN #20 noted a 5:10 a.m. on 08/07/14 that Resident #59 awoke and requested to go the ER for abdominal pain. At 5:23 a.m. on 08/07/14, LPN #20 noted Resident #59's healthcare decision maker was notified of Resident #59's complaint of abdominal pain and was advised Resident #59 was medicated with her as needed pain medication. LPN #20 noted the healthcare decision maker would prefer to give the medication time to work and if the resident continued with complaints of pain to call him back and he would come and talk with the resident. LPN #20 noted she explained the conversation to Resident #59 who was not happy with her brother's decision. Review of Resident #59's MAR found she was medicated with [MEDICATION NAME] 5/325 mg on 08/07/14. There was no indication LPN #20 assessed the severity/intensity of Resident #59's prior to administration of the as needed pain medication. There was also no evidence to suggest LPN #20 reassessed the resident after the PRN pain medication was administered and had time to be effective, as the resident's brother had requested. b. 08/15/14 Resident #59's MAR indicated [REDACTED]. c. 08/19/14 Resident #59's MAR indicated [REDACTED]. d. 08/20/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. It should be noted this administration note was linked to the administration of [MEDICATION NAME] 5/325, but [MEDICATION NAME] 5/325 was not administered on that date. There was no indication the nurse who administered this medication assessed the resident's pain for severity/intensity prior to administering the PRN Tylenol, and there was no indication the nurse reassessed the the resident to determine if the PRN medication was effective. e. 08/21/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. f. 08/24/14 Resident #59's MAR indicated [REDACTED]. g. 08/26/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. An additional administration note on the MAR indicated [REDACTED]. h. 08/28/14 to 08/30/14 Resident #59's MAR indicated [REDACTED]. i. On 08/20/14, 08/21/14, and 08/26/14 it was noted Resident #59 complained of bilateral lower extremity pain. There was no evidence to suggest the facility made any attempts to determine the cause of the pain in her bilateral lower extremities, nor evidence to suggest the attending physician and/or healthcare decision maker were notified of her bilateral lower extremity pain. 3. September 2014 Review of Resident #59's medical record for 09/2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: a. 09/01/14 Review of Resident #59's MAR for 09/01/14 found she was administered her PRN [MEDICATION NAME] 5/325 on 09/01/14. b. 09/03/14 - 09/08/14 On 09/03/14 at 3:43 a.m. LPN #60, noted Resident #59 received her PRN pain medication twice that shift for complaints of abdominal pain. LPN #60 noted Resident #59 had a bowel movement and her bowels sounds were present in all four (4) quadrants. On 09/04/14 at 1:43 a.m. LPN #60 noted Resident #59 had complaints of abdominal pain and was given PRN pain medication. On 09/05/14, Resident #59's MAR indicated [REDACTED]. On 09/06/14 at 5:11 p.m., LPN #5 noted Resident #59 was calling out from her bed stating, My belly is going to bust. LPN #5 noted the resident had received her PRN pain medication. There was no evidence to suggest LPN #5 assessed the severity of Resident #59's pain prior to administering the PRN pain medication, nor did she reassess her pain for severity to determine if the PRN pain medication was effective. On 09/07/14, Resident #59's MAR indicated [REDACTED] On 09/08/14 at 10:38 a.m., RN #61 noted Resident #59's attending physician was in to evaluate why Resident #59 had been complaining of abdominal pain and crying. He ordered to obtain a KUB to check for ileus disease. Further review of the record found this testing was obtained and ileus disease was not diagnosed . Additionally, on 09/08/14 Resident #59's MAR indicated [REDACTED]. Dhe received a second dose of PRN [MEDICATION NAME] at 1:36 p.m. on 09/08/14, for complaints of pain to the right side accompanied by crying On 09/09/14 at 2:24 a.m., Resident #59's MAR indicated [REDACTED]. It should be noted this information was contained in the Administration notes on the MAR; however, the dosage of [MEDICATION NAME] 5/325 was not initialed as given on the MAR. Resident #59 had complaints of pain to the abdomen and/or right side daily from 09/03/14 through 09/08/14, there was no evidence to suggest Resident #59's attending physician was notified of her daily pain until the morning of 09/08/14. There was also no evidence to suggest Resident #59's healthcare decision maker was made aware of her daily complaints of pain. c. 09/19/14 - 09/21/14 Review of Resident #59's MAR indicated [REDACTED]. The source of Resident #59's pain was only identified on one (1) of the three (3) days she received the PRN pain medication. On 09/21/14 the location of Resident #59's pain was identified as being in the abdomen d. On 09/19/14 and 09/20/14 there was no evidence to suggest Resident #59's pain was assessed for location, nature, and severity before the administration of medication and/or the effectiveness of the pain medication after administration. On 09/23/14 at 12:26 a.m. LPN #20 noted Resident #59 had some complaints of leg discomfort and was medicated with her PRN pain medication. She additionally noted that the Resident was screaming and keeping the residents on the hallway awake. LPN #20 noted there was no reasoning with the resident. At 12:46 a.m. LPN #20 noted resident continued to scream and was now complaining of shortness of breath even though her oxygen saturation was in the upper 90's. LPN #20 again noted she was unable to reason with the resident. At 1:00 a.m. LPN #20 noted she heard Resident #59 screaming as she has been since 12:30 a.m Upon entering Resident #59's room LPN #20 observed the resident laying in the floor beside her bed. LPN #20 indicated she had slid off the bed and continued to yell and scream. She again noted she was unable to reason with Resident #59. At 1:45 a.m. LPN #20 noted Resident #59 continued to yell and scream and disturb the other residents. She again indicated she was unable to reason with the resident. She noted the resident was screaming at staff instead of speaking to them in a normal tone. There was no mention by LPN #20 that she reassessed Resident #59 for pain after administering the PRN pain medication at 12:26 a.m., despite the fact Resident #59 continually screamed, yelled, and even slid off her bed. LPN #20 also failed to assess the severity of the Resident #59's pain prior to administering the PRN pain medication. At 8:18 a.m. on 09/23/14, LPN #5 noted she had spoken with Resident #59's healthcare decision maker and notified him about the resident sliding off the bed. She noted the resident's health decision maker indicated he and his wife would be in later today to speak with the resident about her behaviors. Resident #59's MAR indicated [REDACTED]. e. 09/26/14 to 09/28/14 Resident #59's MAR indicated [REDACTED]. Beginning on 09/15/14 the facility implemented a new pain observation tool. Nursing staff were to observe and/or question for pain every four (4) hours and PRN while awake. The documentation on this tool was inconsistent with the documentation contained in the rest of Resident #59's medical record. The documentation on this tool was reviewed and found Resident #59 was positive for pain on 09/16/14, 09/21/14, 09/22/14, 09/23/14, and 09/27/14. It should be noted Resident #59 was not medicated for identified pain on 09/16/14 and 09/22/14. Additionally, it should be noted that on 09/19/14, 09/20/14, 09/24/14, 09/26/14, and 09/28/14 Resident #59 was given PRN pain medication, but the pain observation tool was marked to indicate she was not having pain. Review of Resident #59's medical record for October 2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: 4) October 2014 a. 10/01/14 - 10/02/14 At 11:00 a.m. on 10/01/14 RN #49 noted that Resident #59 was complaining of abdominal pain at her hernia site. She noted her PRN pain medication had been administered about five (5) minutes prior to Resident #59's complaints. RN #49 noted the resident complained the pain medication was not helping her pain. RN #49 applied a warm compress to the abdomen and attempted to reach the resident's health care decision maker. RN #49 then spoke with the resident about waiting until her attending physician was able to visit to review her pain medication regimen before they sent her to the emergency room . RN #49 noted Resident #59 was in agreement with this plan. Review of Resident #59's MAR found she received a PRN dose of [MEDICATION NAME] on that date At 9:55 a.m. on 10/02/14, RN #41 noted Resident #59's attending physician was in and reviewed her pain medication regimen. The physician wrote a new order for [MEDICATION NAME] 5/325 as needed every four (4) hours instead of every six (6) hours. The physician also added a scheduled dose of [MEDICATION NAME] 5/325 three times a day at 10:00 a.m., 2:00 p.m. and 10:00 p.m. Resident #59 began receiving this routine scheduled dose of [MEDICATION NAME] at 10:00 a.m. on 10/02/14. b. 10/04/14 to 10/07/14 At 10:54 a.m. on 10/6/14, LPN #5 noted Resident #59 had constant complaints of her side hurting. LPN #5 indicated the resident had been medicated by the medication nurse. She noted she had spoken with Resident #59's health care decision maker and he did not want the resident sent out of the facility. LPN #5 noted that the healthcare decision maker stated, every time she is sent out they always send her right back because nothing is ever wrong with her. The health care decision maker stated he would come in and talk to the resident that day. LPN #5 noted Resident #59 was not happy about her brother not wanting her sent out of the facility. There was no mention of assessments to determine the severity of the pain Resident #59 was experiencing, or assessments to determine if scheduled doses of pain medication were effective in order to determine if resident needed to be medicated with the PRN [MEDICATION NAME] for which she had an order. Additionally there was no testing and or evaluations completed by facility staff to determine the cause of Resident #59's pain. At 2:54 p.m. on 10/06/14, LPN #62 noted Resident #59 had shown a decrease in the volume of complaints and she was administered pain medication for continued complaints of stomach pain. At 10:39 p.m. on 10/06/14, LPN #7 noted Resident #59 was guarding her stomach and crying in pain and she had done so for the last two (2) nights. She noted bowel sounds were present, were hypoactive in all four (4) quadrants, abdomen was distended in right lower quadrant and tender to touch. LPN #7 noted Resident #59 screamed in pain when she was turned on her stomach. She noted Resident #59 was medicated with scheduled [MEDICATION NAME] one (1) time that shift. She noted she had requested a physician evaluation for pain. There was no evidence in the medical record of Resident #59 to indicate she was having pain in her abdomen and guarding her stomach on 10/04/14 or 10/05/14 as indicated in the 10/06/14 entry by LPN #7. LPN #7's note on 10/06/14 was the first mention of Resident #59's pain which she had experienced on the previous two (2) nights. There was no evidence to suggest Resident #59's pain was assessed for severity and/or relief of pain upon administration of scheduled pain medication on 10/04/14 and 10/05/14, in order to determine the need for PRN pain medication, which was not administered at all on 10/05/14. There was no indication nursing staff assessed Resident #59 to determine the cause of her continued pain in her abdomen. LPN #7 noted she had requested the physician evaluate the resident for pain, but there was no indication nursing staff had called Resident #59's attending physician to notify him of her continued abdominal pain. The heath care decision maker was not made aware of Resident #59's complaints of pain on 10/04/14, 10/05/14 and 10/06/14 until LPN #5 phoned him at 10:54 a.m. on 10/06/14. Resident #59 received a dose of her PRN pain medication on 10/04/14 and 10/06/14. At 8:34 a.m. on 10/07/14, LPN #5 noted Resident #59 was being combative and yelling out at staff. She noted the medication nurse tried to give the resident her pain medication for her complaint of stomach pain and the resident refused stating, You all are not helping me, I want the police. She noted she explained to the resident they were trying to help her, but she would not let them. Resident #59 proceeded to kick over the bedside table and continued to yell out. LPN #5 noted she called the health care decision maker and he would be at the facility shortly to calm the resident down. At 8:46 a.m. on 10/07/14, LPN #5 noted Resident #59's brother was at the facility to see her. At 8:54 a.m. 10/07/14, LPN #5 noted the resident's brother wanted her sent to the ER for an evaluation. At 9:20 a.m. on 10/07/14, LPN #5 noted the resident was transported to the ER at 9:20 a.m. on 10/07/14. At 5:46 p.m. on 10/07/14 LPN #5 noted Resident #59 returned to the facility from the ER with [DIAGNOSES REDACTED]. Resident #59 had made multiple complaints of abdominal and side pain beginning 10/04/14 through 10/07/14. The facility failed to assess for the cause of the pain, failed to treat the pain effectively, and failed to assess for the severity of the pain prior to and after administration of PRN pain medications on 10/4/14 and 10/06/14. Staff also failed to assess for the effectiveness of her scheduled pain medication to determine if she needed further medicated with the PRN doses [MEDICATION NAME] to control her pain. Additionally, they failed to notify the attending physician of the continual complaints of pain, and failed to notify the healthcare decision maker of her complaints of pain until 10/06/14. This resulted in Resident #59 suffering undue pain as well as mental anguish. On 10/07/14 Resident #59 was noted to be combative with staff and was noted to state, You all aren't helping me, I want the police. Resident #59 had at that point endured pain for three (3) consecutive days and felt as if the facility staff was not helping her. It was not until her brother arrived at the facility and requested she be sent to the ER that Resident #59 was sent out of the facility for treatment for [REDACTED]. The facility was unable to show any evidence of attempts to manage and control her pain at the facility. They made no attempts to determine the cause pain and/or to treat the cause of the pain. b. 10/10/14: Resident #59's MAR indicated [REDACTED]. c. 10/16/14: Resident #59's MAR indicated [REDACTED]. Review of Resident #59's pain observation tool found the resident was identified as having pain on 10/04/14, 10/06/14, 10/08/14, and 10/13/14. Please note this report was again inconsistent with the rest of Resident #59's medical record. She was identified as having continual pain from 10/04/14 through 10/07/14 in the nursing progress notes, she received a PRN dose of [MEDICATION NAME] in addition to her scheduled pain medications on 10/10/14 and 10/16/14 and was identified as not having pain on these dates on the pain observation tool. Additionally, the pain observation tool identified she had pain on 10/08/14 and 10/13/14 with no mention of the pain in the progress notes or administration of any pain medication other than her scheduled [MEDICATION NAME] 5/325 three (3) times a day. This tool was ineffective in identifying when Resident #59 experienced pain. Review of Resident #59's medical record for 11/2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: 5) November 2014 a. 11/12/14: Resident #59's MAR indicated [REDACTED]. b. 11/16/14: Resident #59's MAR indicated [REDACTED]. c. 11/21/14: Resident #59's MAR indicated [REDACTED]. d. 11/28/14: Resident #59's MAR indicated [REDACTED]. h. Review of Resident #59's pain observation tool for the month of November 2014 again found inconsistent documentation between the pain monitoring tool and the MAR. Resident #59 received PRN pain medication on 11/12/14, 11/16/14, 11/21/14, and 11/28/14. The pain observation tool indicated Resident #59 was negative for pain on all of these dates. 6) December 2014 Review of Resident #59's medical record for December 2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: a. 12/08/14: Resident #59's MAR indicated [REDACTED]. b. 12/09/14: Resident #59's MAR indicated [REDACTED]. c. 12/22/14: Resident #59's MAR indicated [REDACTED]. d. 12/28/14: At 10:14 a.m. on 12/28/14, LPN #36 noted that Resident #59 had poured water on herself multiple times to get the staff to change her pants. She noted Resident #59 was complaining that her pants were too tight. LPN #36 noted, she told the resident her pants were not too tight and to quit being disruptive. She advised the resident that the nurse aides were busy feeding and bathing other residents and that she could not keep pouring water on herself just to get changed. LPN #36 then noted Resident #59 began to complain of stomach pain and nausea. She indicated she gave Resident #59 a [MEDICATION NAME] shot and the resident was noted to be resting about 30 minutes after the shot. There was no indication in Resident #59's medical record that LPN #36 had assessed the resident for pain upon her complaints that her pants were too tight. There was no mention of pain until after the staff had changed the resident's pants on several occasions and after LPN #36 had advised Resident #59 that she was being disruptive. At that time, Resident #59 mentioned pain when she complained of pain in her stomach. Once the resident complained of pain, LPN #36 failed to assess the severity of the pain and/or the possible causes of the stomach pain. LPN #36 proceeded to treat the complaints of nausea, but failed to assess and/or treat Resident #59's complaints of stomach pain. This note was entered into the medical record at 10:14 a.m., which was 14 minutes after Resident #59 had received her scheduled dose of [MEDICATION NAME]. LPN #36 failed to asse (TRUNCATED)",2018-03-01
6439,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-27,272,D,1,0,F3KE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the accuracy of the comprehensive minimum data set (MDS) assessment for one (1) of five (5) residents reviewed. The resident's admission MDS was not accurate. It did not identify the resident's behaviors, which significantly impacted the privacy and activities of others or his rejection of care. Resident identifiers: #46. Facility census: 54. Findings include: a) Resident #46 On 03/26/15 at 7:00 p.m., review of Resident #46's admission MDS, with an assessment reference date (ARD) of 03/10/15, found the coding for the resident's behaviors indicated his behaviors did not significantly intrude on the privacy or activity of others. The section related to the presence and frequency of rejection of care indicated the resident did not exhibit this behavior. A review of the nursing progress notes, for the assessment's seven (7) day look back period revealed a note written on 03/05/15. It described the resident had picked up several items of clothing that belonged to a resident in room [ROOM NUMBER]A. When staff asked the resident to put the clothes back into the chair, the resident tossed them on the floor. On that same day, Licensed Practical Nurse (LPN) #20 offered the resident his medications, but the resident refused stating, I don't want them and I don't need them. Another nursing progress note revealed that on 03/06/15, Resident #46 refused all of his medications and he had refused to take a shower/bath. In an interview, on 03/27/15 at 10:10 p.m., Social Worker (SW) #59 was asked if the admission MDS was accurately coded related to the resident's intruding on the privacy or activities of others and related to rejection of care. The SW reviewed the MDS and the nursing progress notes for the seven (7) day look back period. He stated he had inaccurately coded these areas on the MDS. The SW stated a correction request would be completed due to the inaccuracies.",2018-03-01
6440,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-27,282,G,1,0,F3KE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to provide services in accordance with the written care plan for one (1) of five (5) sample residents reviewed. The facility failed to implement the interventions in Resident #46's care plan related to elopement. This failure resulted in actual harm to the resident when he eloped from the facility, was missing for several hours, and was injured during the elopement. Resident identifier: #46. Facility census: 54. Findings include: a) Resident #46 1. Medical record review, on 03/25/15 at 1:00 p.m., found on 03/24/15 at 10:00 p.m., Licensed Practical Nurse (LPN) #30 documented Resident #46 was dressed and ambulating in the hallway. According to the note, the resident was, Alert and verbal but is confused, which is normal for resident. Resident approached this nurse and stated, 'I want out of here. ' The nurse noted she told the resident it was 10:00 p.m., dark, and chilly outside, and that the staff would be here with him throughout the night. The nurse noted she asked the resident if there was anything she could get for him, to which the resident replied again, I want out of here. According to the note, the resident turned and walked down the hallway. LPN #30 noted she then went into room [ROOM NUMBER]-C to continue with her medication pass. 2. Documentation in the nursing progress notes, at 11:20 p.m. on 03/24/15, revealed a nursing assistant (NA) reported to LPN #30 that Resident #46 was not in his room, and the resident's window was open. A review of the nursing progress note, dated 03/25/15 at 9:00 a.m., written by LPN #22, revealed a staff member located the resident outside of the facility. The local ambulance service was already on-site and they transported Resident #46 to an acute-care hospital emergency room for evaluation of his condition. 3. A review of a staff member's statement on the evident/incident report revealed NA #56 came on duty at 10:00 p.m. on 03/24/15, and started his rounds at 10:45 p.m. NA #56 wrote that he reached Resident #46's room at about 11:20 p.m., and the resident was not in his room. The window was open, and the window shade was moved to the side. The NA noticed the cold air was coming through the window. Review of NA #18's statement of the event/incident report, found NA #56 came and showed NA #18 that Resident #46 was not in his room. NA #18 told NA #56 to start looking in all the rooms for Resident #46. She told NA #56, she would go and notify the nurses. The report revealed NA #18 reported to the nurses that Resident #46 was missing. LPN #30 notified administrative staff and called nine -one-one ( 911). 4. A review of the resident's care plan, on 03/25/15 at 1:44 p.m., revealed an initial care plan was written on 03/04/15, created on 03/20/15, and revised on 03/25/15. The focus indicated the resident was an elopement risk/wanderer as evidence by (AEB) disoriented to place. The goal was the resident would not leave the facility unattended through the review date. The resident's safety was to be maintained through the review date. The care plan interventions were: -- Assess for fall risk, -- Distract the resident from wandering by offering pleasant diversion, structured activities, food, conversation, television, and books. -- Provide intervention like having a conversation with him about his family, cars, and coffee. The care plan directed staff to document wandering behaviors and attempted diversion interventions in the behavioral log, and Identify whether the pattern of wandering was purposeful, aimless, or escapist? Is resident looking for something? Provide structured activities, toileting, walking inside and outside, reorientation strategies, including signs and pictures. On 03/25/15 at 1:10 p.m., the director of nursing (DON) was asked to provide Resident #46's behavior log. In an interview on 03/27/15 at 9:10 a.m., the DON stated she had looked for the behavior log documentation and found that none of her staff was implementing the care plan interventions related to elopement. She confirmed she had no evidence to provide. The DON stated she did an in-service immediately with her staff on 03/25/15. 5. In an interview with Acute-Care Hospital-Registered Nurse (ACHRN) #58 on 03/25/15 at 7:10 p.m., she stated the resident had an elevated Troponin level, probably related to the resident lying down, as this could cause high Troponin levels. The ACHRN stated the resident was diagnosed with [REDACTED]. He had the [DIAGNOSES REDACTED]. She stated the resident continued to be confused. He had a petechiae (pinpoint-sized hemorrhages of small capillaries) rash on his back. The RN said the resident was receiving [MEDICATION NAME] (an antibiotic) two (2) grams intravenously, and receiving normal saline (an intravenous fluid). In an interview with the ACHRN #57 on 03/26/15 at 8:45 a.m., the ACHRN stated the resident had bilateral bruises and abrasions on the backs of his hands, a laceration to his left elbow, and the 4th digit (toe) on his foot was [MEDICAL CONDITION] and blue. 6. Observation of Resident #46 in the acute-care hospital, on 03/26/15 at 8:50 a.m., revealed the resident was lying in bed. He had bruising/abrasions on the backs of both hands. Abrasions were noted on his upper forearms and his left elbow had a dressing that was intact. Observation of the 4th digit of his right foot found it was blue and [MEDICAL CONDITION] (swollen). The resident also had abrasions on both lower legs. 7. Resident #46's hospital information was reviewed on 03/26/15 at 11:16 p.m. On 03/25/15, the physician's primary impression was acute rhabdomyolysis, acute exacerbation of dementia, a three (3) centimeter (cm) laceration to the left elbow with delayed presentation. The physician wrote, . laceration appears to be more than 10 -12 hours old. There is granulation tissue throughout the entire borders of the laceration. This is very deep and the bony structure of the olecranon (bony projection of the ulna) is visualized. The physician wrote, I do not feel that I need to close the left elbow. This is a delayed closure and there may be contaminants that I currently do not see. The area may need to be evaluated by a surgeon or orthopedic surgeon at this time . The physician also noted, Patient has significant scratches all over the upper and lower extremities. He is only complaining of left elbow pain. The left elbow has sanguinous drainage . There is a petechiae rash of the trunk as well as the extremities. The resident had to undergo conscious sedation in order for a lumbar puncture to be performed. The lab report revealed a white blood cell (WBC)(WBC - fight off infection) count of 15.4 (normal WBC is 4.0-10.5), A high WBC count indicated infection, inflammation, trauma. The resident's Troponin I was .10, normal is 0.00- 0.05. Troponin I are proteins in the blood. Trauma causes the Troponin to be elevated. Resident's CK-MB ([MEDICATION NAME] kinase [MEDICAL CONDITION] band) was 20.1 ng (nanogram - is one billionth of a gram) /ml (milliliter) normal is 0.1 - 6.3 ng/ml. This test determines whether there is heart damage or skeletal muscle damage 8. In an interview with LPN #30, on 03/26/15 at 12:48 p.m., she stated Resident #46 was dressed in his day clothes, and he ambulated to where her medication cart was at 10:00 p.m. She stated the resident told her, I want out of here. The LPN stated she told the resident it was dark, chilly outside, and that staff would be with him throughout the night. She said, I asked the resident if he wanted anything. The LPN said the resident stated again, I want out of here. She said after that, the resident turned and walked down the hallway. When asked what she did next, she stated, I went into room [ROOM NUMBER]- C to continue with my med pass. When asked if she identified that Resident #46 might be going to elope, she stated she did not identify that he was going to leave. When asked if she implemented any of the care plan interventions related to elopement when the resident said, I want out of here, the LPN said she did not attempt any interventions related to elopement. She stated, I continued with my medication pass. 9. In an interview with Maintenance Supervisor (MS) #55 on 03/27/15 at 10:00 a.m., he described how he found Resident #46 in the woods. He stated he had gone out to help search for Resident #46 at 8:00 a.m. on 03/25/15. The MS said he had gone to the upper employee parking lot and noticed the resident when the resident stood up, at approximately 9:00 a.m. The MS stated he went to where the resident was in the woods. When asked about the resident's condition, the MS said the resident had no shoes on, had scratches on his upper and lower extremities, and had a cut on his left elbow. The MS stated he walked with the resident out of the woods, where there was an all-terrain vehicle (ATV) waiting to take the resident to a ambulance, which was waiting to take the resident to the hospital for evaluation.",2018-03-01
6594,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2016-06-01,309,D,0,1,8JZH12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to follow physician's orders for one (1) of five (5) residents reviewed for medication administration. The physician ordered specific parameters related to when to hold an anti-hypertensive medication. Resident #46's medication was held on three (3) occasions in contradiction of the physician's order. Resident identifier: #46. Facility census: 116. Findings include: a) Resident #46 Review of the medical record on 08/02/16 at 10:30 a.m. found the physician ordered [MEDICATION NAME] 3.125 milligram (mg), one half of a tablet, twice daily. The physician ordered the blood pressure medication to be held for a systolic blood pressure less than 105 mm/hg., or the pulse rate less than sixty (60) beats per minute. Review of the Medication Administration Record [REDACTED] 1. On 07/17/16 at 9:00 p.m. the resident's blood pressure was 113/56 mm/hg., and the pulse rate 63. 2. On 0729/16 at 9:00 p.m. the resident's blood pressure was 112/51 mm/hg., and the pulse rate 67. 3. On 07/30/16 at 9:00 p.m. the resident's blood pressure was 110/50 mm/hg., and the pulse rate 69. An interview was conducted with the director of nursing (DON) on 08/02/16 at 1:40 p.m. She reviewed progress notes and the MAR indicated [REDACTED]. The only rationale the nurse wrote was nursing judgment. The DON said she did not know why the nurse did not follow the physician's order and administer the [MEDICATION NAME] on those three (3) dates.",2018-01-01
7587,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2013-03-21,167,C,0,1,OKIC11,"Based on observation and staff interview, the facility did not ensure the residents had the opportunity to examine the results of the most recent survey of the facility conducted by the State surveyors. The facility had not posted the results of their most recent complaint investigation. This practice had the potential to affect all residents in the facility. Facility census: 60. Findings include: a) On 03/19/13 at 9:50 a.m., an observation of the facility's survey results book revealed the book did not contain the results of the most recent complaint investigation. The facility had a complaint investigation on 08/24/11 that resulted in four (4) D level deficiencies. The facility had not posted the statement of deficiencies associated with this complaint. On 03/19/13 at 10:00 a.m., the senior vice president (Employee #11) confirmed the survey results book did not contain the results of the 08/21/11 complaint investigation.",2017-03-01
7588,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2013-03-21,225,D,0,1,OKIC11,"Based on resident interview, staff interview, and review of reportable incidents, the facility failed to report to the appropriate State officials (Office of Heath Facility License and Certification, Adult Protective Services, and Regional Ombudsman) and investigate an allegations of verbal abuse as required. This was found for one (1) of twelve (12) reportable files reviewed. Resident identifier: #90. Facility census: 60. Findings include: a) Resident #90 During Stage I of the Quality Indicator Survey (QIS), an interview was conducted with this resident on 03/19/13 at 9:27 a.m. When the resident was asked, Have you ever been treated rough by staff? and Have staff yelled or have they been rude to you?, the resident's responses to these questions was, That black girl in therapy was very rough and hateful with me yesterday (03/18/13) when getting on the bike, she kept saying put your hands on the handles and quit letting them fall off. She was very rude and hateful. The resident was then asked, Did you report this to anyone? The resident's response was no, I just got tired of listening to her and quit working. Employee #44, the Social Worker (SW) was informed of the alleged incident of verbal abuse on 03/19/13 at 9:42 a.m. He stated, I will report it to Employee #45, Vice-President (VP) Resident Services. Employee #44 (SW) was interviewed on 03/20/13 at 3:35 p.m. related to the reporting of the allegation made by Resident #90. He brought the resident's chart and said, Employee #45 did not report it to the State. She went and interviewed the resident and he said; 'no one was mean to him.' When asked why it was not reported? He responded, I will get Employee #45 to talk with you. Employee #45, the VP Resident Services, came to the conference room on 03/20/13 at 4:30 p.m. During this interview, Employee #45, stated, I did not report this to the State because when I went and asked Resident #90 about the allegation, he said: 'no one was mean to him.' This employee was informed at this time that all allegations of abuse were to be reported to all required State agencies and investigated. On 03/20/13 at 5:00 p.m., Employee # 44 (SW) requested the surveyor's statement of the allegation made by Resident #90 on 03/19/13. This report was completed and returned immediately. On 03/20/13 at 6:09 p.m., the Office of Health Facility Licensure and Certification (OHFLAC), at 6:24 p.m., Adult Protective Services (APS), and at 6:26 p.m. the Regional Ombudsman were all notified by fax. On 03/21/13 at 10:00 a.m., an interview was conducted with Employee #11, the Senior Vice-President of Corporate Compliance. It was confirmed the reported allegation of verbal abuse by Resident #90 had not been submitted or investigated until after the surveyor inquired about the progress of the investigation. b) On 03/20/13 at 10:00 a.m., a review of the facility's personnel files revealed they had not completed a thorough background check on one (1) of ten (10) employees. Employee #71 (licensed practical nurse) began working at the facility on 08/19/10. The facility had not completed a nurse aide registry check for this employee. On 03/20/13 at 10:30 a.m., Employee #2 (human resource assistant) verified the facility had not completed a nurse aide registry check for Employee #71.",2017-03-01
7589,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2013-03-21,226,D,0,1,OKIC11,". Based on a review of the abuse, neglect, and misappropriation of property policy, review of reportable allegations of abuse/neglect, and staff interview, the facility failed to thoroughly investigate the background of one (1) of ten (10) employees at the time the employee began working in the facility. a) Employee #71 On 03/21/13 at 1:00 p.m., Employee #11 provided a copy of the abuse, neglect, and misappropriation of property policy. The facility's abuse, neglect and misappropriation of property policy, reviewed on 03/21/13, revealed a section titled Criminal history record checks. This section stated By law, all residential care facilities, day care centers, and home care service providers authorized to operate in West Virginia shall contact the abuse registry to verify that applicants selected for employment or other contractual relationship are not listed on the abuse registry prior to the time the individual begins employment or begins providing services to children or incapacitated adults. On 03/21/13 at 2:00 p.m., the senior vice president (Employee #11) indicated the facility required all applicants be checked against the nurse aide abuse registry. She confirmed the facility had not completed this check for Employee #71 (licensed practical nurse) in accordance with its policy.",2017-03-01
7590,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2013-03-21,241,E,0,1,OKIC11,"Based on observations and staff interviews, the facility failed to promote care for residents in a manner that maintained each resident's dignity. During the dining room observations, five (5) of twenty-two (22) residents were not treated in a dignified manner during the lunch meal. Five (5) of the eight (8) residents were not served their meals although others at the same table were already eating. Resident identifiers: #16, #40, #36, #24, and #77. Facility census: 60. Findings include: a) Resident #16, #40, #36, #24, and #77 During observation of the lunch meal, on 03/19/13 at 12:15 p.m., these five (5) residents were observed sitting at tables with other residents who had been served and were already eating their meals. Resident #16 was not served until 12:40 p.m. She was seated at a table with another resident being fed by staff. Resident #40 also received her meal at 12:40 p.m. She too was seated at a table with another resident being fed by staff. Resident #36 was not served until 12:46 p.m. She was seated at a table with one (1) resident who had been fed by family. She received her meal after the resident at her table had consumed all of her food. Resident #36 repeatedly asked for her tray during the observation. Resident #24 was not served until 12:40 p.m. She was seated at a table with one (1) resident who had already been fed by staff and had consumed most of her food. Resident #77 received her meal fifteen (15) minutes after the other residents at her table had been fed by staff. During an interview, on 03/19/13 at 12:55 p.m., with Employee #77 (registered nurse), it was confirmed three (3) residents in dining room during lunch were assisted by staff and family while (5) residents had to sit and watch them being fed.",2017-03-01
7591,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2013-03-21,279,D,0,1,OKIC11,"**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 a resident on [MEDICAL CONDITION] medications. This was found for one (1) of ten (10) residents reviewed in Stage II of the sample. Resident Identifier: #4. Facility Census: 60. Findings Include: a) Resident #4 Review of the care plan for Resident #4 was conducted on 03/21/2013 at 8:20 a.m The resident was currently taking [MEDICATION NAME], and [MEDICATION NAME]. Review of the care plan revealed the care plan did not address the rationale for the use of this number of [MEDICAL CONDITION] medications, to include the use of three (3) Benzodiazepines, nor was the use of antianxiety or antidepressant medications addressed in the care plan. There no nonpharmacologic interventions identified relative to the conditions for which these medications were ordered. An interview with the Care Plan Coordinator, a Registered Nurse (RN), Employee #84, was conducted at 8:47 a.m. on 03/21/13. She reviewed the care plan and confirmed she had not care planned for the use of the [MEDICATION NAME], and [MEDICATION NAME] (the conditions for which they were ordered). nor had the care plan addressed the needed monitoring of these medications, and/or nonpharmacologic interventions that might be employed.",2017-03-01
7592,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2013-03-21,329,E,0,1,OKIC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, staff interview, and family interview, the facility failed to ensure each resident's drug regimen was free of unnecessary medications. The facility did not ensure the rationale for not attempting dose reductions was documented and failed to ensure appropriate monitoring of [MEDICAL CONDITION] medications for four (4) of ten (10) residents reviewed for unnecessary medication use. Resident identifiers: #4, #78, #2, and #90. Facility census: 60. Findings include: a) Resident #4. Medical record review for Resident #4 was conducted at 8:05 a.m. on 03/20/13. This review revealed the resident was receiving multiple [MEDICAL CONDITION] medications which included [MEDICATION NAME] and [MEDICATION NAME]. Further review revealed there had been no attempt at gradual dose reduction for any of these medications, with the exception of one (1) dose reduction on the [MEDICATION NAME] on 07/06/12. At that time, the pharmacist recommended reducing the 4:00 p.m. dose of [MEDICATION NAME] from 2 mg to 1.5 mg. This dose reduction was implemented. Interview with a registered nurse (RN), Employee #77, at 8:15 a.m. on 03/20/13 was conducted. Employee #77 advised the resident's guardian made all of the resident's care decisions. Employee #77 advised the guardian was a nurse, and she was closely involved with the resident's care. Employee #77 further stated the guardian would not allow any gradual dose reductions (GDR), or change to the resident's medications, as the medication regimen had been set by the resident's neurologist at a university hospital. She did allow only the one (1) dose reduction of [MEDICATION NAME] from 2 mg at 4:00 p.m. to 1.5 mg at 4:00 p.m. on 07/06/12. A telephone conversation was conducted with the guardian at 8:45 a.m. on 03/20/13. The guardian stated she did not allow any changes to the resident's medications because of the severity of the resident's symptoms secondary to his [MEDICAL CONDITION] (TBI). The mother advised she took care of the resident at home after the motor vehicle accident that resulted in the TBI in 2000. She further stated that the resident was on these medications prior to admission to the facility, and this regimen barely controls his symptoms. She advised if any changes were made they would be made only by the neurologist, and she would obtain a letter from the neurologist if necessary. Following the conversation with the resident's guardian, the medical record was reviewed once again at 9:00 a.m. on 03/20/13. The review revealed the physician had made no documentation regarding the rationale for the absence of gradual dose reductions in the resident's medical record. The chart was reviewed at that time by Employee #77, and this was confirmed. ==== b) Resident #78 Review of the medical record for Resident #78 was conducted at 10:52 a.m. on 03/20/13. 1) The last gradual dose reduction (GDR) evaluation for [MEDICATION NAME] 10 mg everyday and [MEDICATION NAME] 25 mg twice daily was done on 02/12/13. On that date, the pharmacist documented a GDR was needed for both [MEDICATION NAME] and [MEDICATION NAME]. On the pharmacist's Note to Attending Physician/Prescriber, dated 02/24/13, the pharmacist requested evaluate the use of [MEDICATION NAME]. The physician checked the response The resident had good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh risks for this patient at this time and a reduction is likely to impair the resident's function and/or cause psychiatric instability. (Please elaborate with patient specific information). No patient specific information was documented. Although the physician signed the form, he did not note whether he agreed, disagreed, or make a comment under Other. There was no evidence the physician had evaluated the use of [MEDICATION NAME]. ==== c) Resident #2 Review of medical records, on 03/19/13 at 11:00 a.m., found the resident was ordered an antipsychotic medication ([MEDICATION NAME]) for treatment of [REDACTED]. Review of the pharmacist's monthly drug regimen review revealed the consultant pharmacist had reviewed the chart on 03/14/13 and written (typed as written) No monitoring beh (behaviors) or SE (side-effects). Review of Behavior Monitoring Sheets, revealed monitoring of behaviors and side-effects began on 03/18/13. Interview with Employee #96, a registered nurse (RN), on 03/19/13 at 1:00 p.m. confirmed behavior monitoring had not been initiated on 03/14/13. The facility's policy for [MEDICAL CONDITION] drug monitoring included, Objective: To adequately monitor behaviors and side-effects related to [MEDICAL CONDITION] drug use. Procedure: 1) All residents receiving [MEDICAL CONDITION] medications will be monitored for behaviors and side-effects, related to their specific [MEDICAL CONDITION] medications, on an ongoing basis. ==== d) Resident #90 Review of medical records on 03/19/13 at 12:40 p.m., found the resident was ordered the antipsychotic medications [MEDICATION NAME] and [MEDICATION NAME] for treatment of [REDACTED]. Review of the physician's orders [REDACTED]. [MEDICATION NAME] 20 milligrams (mg) by mouth (Po) daily, pending psy (psychiatric) dr (doctor) eval (evaluation). Interview with Employee #96, a registered nurse (RN), on 03/19/13 at 1:00 p.m., confirmed behavior monitoring had not been initiated on 03/05/13. The facility's policy for [MEDICAL CONDITION] drug monitoring included, Objective: To adequately monitor behaviors and side-effects related to [MEDICAL CONDITION] drug use. Procedure: 1) All residents receiving [MEDICAL CONDITION] medications will be monitored for behaviors and side-effects, related to their specific [MEDICAL CONDITION] medications, on an ongoing basis.",2017-03-01
7593,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2013-03-21,428,D,0,1,OKIC11,"Based on medical record review, staff interview, and family interview, the facility failed to ensure the pharmacist reported all irregularities to the attending physician and director of nursing. Additionally, the facility failed to ensure the pharmacist's recommendations for evaluation for the continued use of psychoactive medications were acted upon. The facility also failed to ensure laboratory studies recommended by the pharmacist, and agreed to by the physician, were completed. Resident identifiers: #78 and #4. Facility census: 60 Findings include: a) Resident #78. Review of the medical record for Resident #78 was conducted at 10:52 a.m. on 03/20/13. On 02/12/13, the pharmacist noted on the Drug Regimen Review sheet GDR Paxil, Seroquel. On 02/24/13, a Note to Attending Physician/Prescriber, by the pharmacist, requested an evaluation of the use of Paxil. The pharmacist made no written recommendation to the physician for an evaluation of the Seroquel. The pharmacist reviewed the medications again on 03/12/13, with no irregularity noted for the Seroquel. An interview regarding the Seroquel was conducted with Employee #77, a registered nurse (RN), at 12:40 p.m. on 03/20/13. Employee #77 contacted the facility pharmacist via telephone regarding the Seroquel at 12:45 p.m. on 03/20/13. At that time, the pharmacist requested copies of his notes from the medical record be faxed to him. At 12:55 p.m. on 03/20/13, the pharmacist contacted Employee #77 back via telephone. Employee #77 confirmed the pharmacist stated he had missed the GDR on the Seroquel. b) Resident #4. Review of the medical record for Resident #4 was conducted at 8:05 a.m. on 03/20/13. This review revealed the resident was currently on Dilantin for seizure activity, secondary to traumatic brain injury (TBI). Further review of the medical record revealed there was no order in place for Dilantin levels to be evaluated on this resident. Continued review of the medical record revealed the facility's pharmacist had made the recommendation for Phenytoin (Dilantin) serum levels every six (6) months to help monitor adverse reactions and toxicities on 07/06/12. The recommendation had been signed off as agreed by the Physician on 07/06/12. However, further review revealed there had been no Dilantin levels drawn on this resident as of that date. Interview with Employee #77, a registered nurse, (RN) was conducted at 8:15 a.m. on 03/20/13. Employee #77 advised the guardian for the resident did not allow any lab work on the resident other than yearly lab work. She also advised the guardian had given the facility clear instructions that they were to call her if the resident had any order for any blood draws outside of these yearly labs, for her approval. A telephone interview was completed with the resident's guardian at 8:45 a.m. on 03/20/13. During this conversation, the resident's medications, as well as required labs, were discussed. The mother did advise that she does not want extra sticks done on the resident unless absolutely necessary, and preferred that only his yearly labs be drawn. She also advised that she was to be contacted for permission outside of any of these routine yearly labs. The mother was asked specifically about the serum Dilantin levels recommended by the pharmacist and approved by the physician. The mother stated she knew that was necessary, and had not stated objections to those being drawn. The facility was unable to produce any evidence that the mother previously objected to the Dilantin levels, specifically. Employee #77, telephoned the physician following the above noted conversation with the resident's guardian, and was overheard stating, The Dilantin levels you ordered for (Resident #4), we didn't get those. Employee #77 received an order from the physician at that time to draw the Dilantin Level.",2017-03-01
8359,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2012-12-07,157,D,0,1,X9QJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to notify the physician of the results from an abnormal laboratory test report for one of ten sampled residents (Resident #17), who was reviewed for unnecessary medications. Findings include: Resident # 17 was originally admitted to facility on 7/01/2011 and was re-admitted on [DATE]. The resident had multiple [DIAGNOSES REDACTED]. The most recent full minimum data set (MDS) assessment dated [DATE], indicated that Resident # 17 received antipsychotic, anti anxiety, and anti-depressants medications. The MDS assessment did not list the anti-coagulants medications but added the following statement: See MD orders for current meds and consults, and that the resident is at risk for side effects associated with medications . The physicians orders dated 11/11/2012 included an order for [REDACTED]. Further review of the physicians monthly recapitulation orders dated 11/08/2012 through 12/06/2012 revealed a laboratory order for weekly monitoring of the anticoagulant via [MEDICATION NAME]/INR (International Normalized Ratio) QWK (every week) .[MEDICATION NAME] therapy. The plan of care dated 4/06/2012 through 1/02/2013 was also reviewed and listed as a problem area Potential for complications, injury related to anticoagulants medication. The care plan goal indicated that the resident Will be free from complications, bleeding, injury related to [MEDICATION NAME] thru next 90 days. The care plan also listed the following pertinent nursing interventions: 1). Administer medications as ordered and monitor effects ([MEDICATION NAME]) The care giver was listed as the licensed nurse. 2). Obtain and monitor lab/diagnostics work as ordered. Report results to MD (doctor of medicine) and follow up as indicated. The care giver was listed as the Nursing Department. A review of the clinical record revealed a laboratory report dated 11/29/2012. The laboratory report was initialed and dated by the RN coordinator on the same date 11/29/2012. There were no other initials, signatures, or comments noted on the report. The results of the laboratory report revealed the following abnormal lab values: The PT (pro [MEDICATION NAME] time) level was flagged as high at 42.5 seconds with a normal reference range of 10.1 -11.6 seconds. The high level was indicated on the report by the letter (H) next to the result. The INR was listed at 4.0 with no normal reference ranges noted on the report. The same lab report also indicated that the resident's potassium and chloride levels were abnormally low. The potassium level was noted on the report as 3.2. mEq/L (milliequivalents per liter). The normal reference range of potassium 3.6-5.1 mEq/L. The chloride level was also flagged as low indicated by an L on the report at 100 meq/L with a normal reference range of 101-111 mEq/L. An interview was conducted on 12/06/2012 at approximately 3:45 PM with the direct care nurse (staff member #35) that regularly provided care for resident #17. The licensed nurse voiced that she had not notified the physician of the abnormal lab results from 11/29/2012. The licensed nurse stated there was no documentation that she could find to support that the physician had been notified by anyone, An interview was also conducted on 12/06/2012 at approximately 3:55 PM with the Nurse coordinator (staff member # 103) who regularly monitors the facility's laboratory results. The nurse coordinator stated that she had signed the abnormal PT/INR laboratory report dated 11/29/2012 with a PT/INR result of 44.3/4.0, but stated that she had not notified the physician of the abnormal results. The nurse coordinator stated that instead of notifying the physician she followed the parameters and guidelines from a document she provided entitled Table 6 Recommendations for managing elevated INR's or bleeding in patients receiving VKA's (vitamin K agonists). The nurse coordinator further stated that the facility did not have a specific protocol for when to notify and when not to notify the physician of abnormal lab results. The nurse coordinator stated that the physician has a note book at the nurse's station that contained several documents like Table 6 referenced above, but no specific facility protocol as to when it would and would not be necessary to notify the physician of the abnormal lab results. The nurse coordinator stated, This (referring to Table 6) is what I go by, but there is no order that says don't call. The nurse coordinator did not address the abnormal potassium or chloride results on the same report. An interview was conducted with the director of nursing (DON) on 12/06/2012 at approximately 4:10 PM regarding the abnormal lab results from 11/29/2012. The DON stated that she had just been made aware by the RN coordinator that she had not notified the physician of the PT/INR results. The DON further stated that the facility did not have a written policy on when to report abnormal laboratory values to the physician, but stated that the facility uses the statement at the top of the facility's physicians standing orders which indicated, All changes in condition must be reported to the physician, RN on duty or RN on call and the residents health care representative. The standing orders document did not address when to report abnormal laboratory results or abnormal anticoagulant therapy laboratory results. The PT/INR results from the previous weeks results dated 11/21/2012 were also abnormal with PT/INR levels noted of 35.9/3.4. The physician was made aware of those results by the RN coordinator who in addition to signing the lab report and also noted the following comment, Message left for Dr. _____ (attending physician's name) 12:10 PM, 11/21/12. The lab report from 11/21/2012 was also signed and dated by the physician. The most recent MD progress note in the clinical record was dated September 30, 2012. There was no indication in the clinical record that the physician was aware of the abnormal lab results from 11/29/2012.",2016-07-01
8360,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2012-12-07,272,D,0,1,X9QJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review the facility failed to accurately assess one resident (#133) out of three residents reviewed who had expressed oral dental concerns during resident interview. Findings include: -Observation and interview with resident #133 was not consistent with information provided on the current Minimum Data Set (MDS). Review of the admission MDS dated [DATE] revealed resident #133 was coded as a 14 out of 15 for cognitive skills for daily decision making. In the dental section, nothing was checked indicating resident #133 did not have any dental issues. One of the options in the dental section was a box for No natural teeth (edentulous). The box was not checked as applicable. Observation of resident #133 at 4:25 PM on 12/3/12 revealed she did not have any teeth or dentures. On 12/3/12 Resident #133 was interviewed at 4:25 PM. She stated she had to gum her food (because she did not have any teeth) but only had trouble with bacon. She stated she had dentures but didn't want to wear them. On 12/5/12 at 12:00 noon resident #133 was asked again about dentures. She again stated she did not want new dentures--she didn't want to wear the ones she had. Also on 12/5/12 at 12:00 noon, resident #133's family also stated resident #133 did not want dentures. I have her old ones at home she won't wear them. The case manager #99 for resident #133 was interviewed on 12/6/12 at 10:00 AM. She was asked about the accuracy of the admission comprehensive assessment. She checked her computer and stated, The MDS is not accurate, I will do a correction now. She (resident #133) is edentulous. She has dentures but refuses to wear them. The case manager changed the information in the MDS from None present to edentulous.",2016-07-01
8361,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2012-12-07,280,D,0,1,X9QJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to revise a care plan regarding [MEDICAL CONDITION] medications for one resident (#91) out of 21 residents whose care plans were reviewed. Findings include: Resident #91 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the recapitulation of physician orders [REDACTED]. On July 13, 2012, a physician's orders [REDACTED]. On July 30, 2012, a physician's orders [REDACTED]. Review of the current recapitulation of physician orders [REDACTED]. There were no current physician orders [REDACTED]. Review of the current care plan for antipsychotic medications, initiated on November 17, 2010, with a review date of December 19, 2012, and signed by the interdisciplinary team that attended the care conference on September 26, 2012, included the approach to observe for drug related complications for [MEDICATION NAME] and [MEDICATION NAME], medications that had been discontinued in July. Further review of the care plan failed to reveal approaches related to the current orders for [MEDICATION NAME] and [MEDICATION NAME]. An interview was conducted on December 4, 2012, with Registered Nurse, staff #99, who is responsible for revision of the care plan, and with the Director of Nurses, staff #3. Both staff confirmed that the care plan should have been revised to reflect the resident's current status and that it was missed.",2016-07-01
8362,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2012-12-07,431,E,0,1,X9QJ11,"Based on observation, interview, and record review the facility failed to ensure medications were not expired in two of two medication rooms and four of four medication carts. Findings include: During observation of medication storage, medications were randomly checked for expiration dates. Of the randomly selected medications, numerous medications were found be in Opus System boxes with expiration dates. The following medications were observed: -Nitro stat for resident #66 had an expiration date of 7/12. -KCL 20 mEq for resident #78 had an expiration date of 2/11. -KCL 20 mEq for resident #36 had an expiration date of 2/12. -KCL 20 mEq for resident #22 had an expiration date of 8/12, -KCL 20 mEq for resident # 56 had an expiration date of 8/12, -APAP with codeine 300/30 mg for resident #8 had an expiration date 8/11 for the first box. The 2nd box expired in 8/12, the 3rd box had an expiration date of 8/12. -Phenobarb 20 mg/5 ml for resident #74 did not have any expiration date. -Xanax (2 boxes) 0.5 mg PRN for resident #76 had an expiration date of 2/12. -Lortab 5/500 (2 boxes) for resident #60 had an expiration date of 8/12. -Meclizine 12.5 mg (2 boxes) for resident # 113 had an expiration date of 8/12. -Lovaza 1 gm for resident # 130, 1 of 2 boxes had no expiration date the other box expired on 8/12. -Atenolol 25 mg for resident # 132 did not have an expiration date. -Ativan 0.5 mg for resident #37 had an expiration date of 2/12. -Glutose 15 --2 tubes expired in 7/12. Fortunately, the facility had Glucagon which was current. Review of the contract with the pharmacy providing the medications to the facility, read in pertinent part the responsibility of the pharmacy was: -Supervise compliance with Pharmacy Laws to include a). Inspect labels for legibility and legality. 1). Includes appropriate accessory and cautionary instructions, as well as expiration date when applicable. The Director of Nursing #3 (DON) was interviewed about the expired medications on 12/6/12 at approximately 3:00 PM. The DON stated she had already contacted the pharmacy and the pharmacy informed her they would replace all the expired labels. She stated she did not know the process the pharmacy used when labeling the Opus System boxes with the expiration dates. The DON stated she had requested a plan of correction from the pharmacy to ensure the pharmacy was not sending medications with expired dates. The DON acknowledged the ultimate responsibility was with her nurses to ensure they were not administering expired medications to the residents.",2016-07-01
9338,PRINCETON CENTER LLC,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-06-30,225,E,0,1,QU2H11,"Based on review of sampled personnel files, review of the facility's abuse policy, and staff interview, the facility failed to make reasonable efforts to uncover past histories of individuals prior to employing them, in an effort to uncover any past criminal convictions that would indicate the individuals are unsuited to work in a nursing home. Criminal background checks were not conducted outside the State of West Virginia (WV) for eight (8) individuals who identified on their employment applications having lived, worked, or attended school outside of WV. This practice has the potential to affect more than an isolated number of residents. Employee identifiers: #76, #100, #49, #42, #47, #142, #123, and #48. Facility census: 65. Findings include: a) Employees #76, #100, #49, #42, #47, #142, #123, and #48 On 06/28/11, sampled employee personnel files were reviewed. This review revealed eight (8) employees who had listed past employment, residency, or college attendance in States other than WV. Employee #42 (activities coordinator) listed residency and employment in Ohio (OH) and North Carolina (NC). Employee #76 (registered nurse) listed employment in Virginia (VA). Employee #47 (nurse aide) listed employment, residency ,and school attendance in OH. Employee #48 listed college attendance in VA. Employee #49 listed employment and residency in VA. Employee #100 (registered nurse) listed employment in VA. Employee #142 listed employment and residency in VA. Employee #123 (dietary aide) listed employment in MD and residency in Rhode Island (RI) and Maryland (MD). - The facility's abuse policy, when reviewed on 06/30/11, revealed the following: 5. All requests for Criminal History Record Checks under the Central Abuse Registry are to be directed to the West Virginia State Police. - On 06/29/11 at approximately 10:00 a.m., Employee #11 (vice president of resources) reported the facility had not conducted any criminal background searches outside of the State of West Virginia for the employees listed above. Employee #11 agreed the facility needed to perform a more thorough search into the criminal backgrounds of applicants who list residency and/or employment outside of West Virginia.",2015-11-01
9339,PRINCETON CENTER LLC,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-06-30,226,E,0,1,QU2H11,"Based on review of sampled personnel files, review of the facility's abuse policy, and staff interview, the facility failed to develop and implement a policy which ensures the facility made reasonable efforts to uncover past histories of individuals prior to employing them, in an effort to uncover any past criminal convictions that would indicate the individuals are unsuited to work in a nursing home. Criminal background checks were not conducted outside the State of West Virginia (WV) for eight (8) individuals who identified on their employment applications having lived, worked, or attended school outside of WV, and the facility's policy did not address the need to do so. This practice has the potential to affect more than an isolated number of residents. Employee identifiers: #76, #100, #49, #42, #47, #142, #123, and #48. Facility census: 65. Findings include: a) Employees #76, #100, #49, #42, #47, #142, #123, and #48 On 06/28/11, sampled employee personnel files were reviewed. This review revealed eight (8) employees who had listed past employment, residency, or college attendance in States other than WV. Employee #42 (activities coordinator) listed residency and employment in Ohio (OH) and North Carolina (NC). Employee #76 (registered nurse) listed employment in Virginia (VA). Employee #47 (nurse aide) listed employment, residency ,and school attendance in OH. Employee #48 listed college attendance in VA. Employee #49 listed employment and residency in VA. Employee #100 (registered nurse) listed employment in VA. Employee #142 listed employment and residency in VA. Employee #123 (dietary aide) listed employment in MD and residency in Rhode Island (RI) and Maryland (MD). - The facility's abuse policy, when reviewed on 06/30/11, revealed the following: 5. All requests for Criminal History Record Checks under the Central Abuse Registry are to be directed to the West Virginia State Police. - On 06/29/11 at approximately 10:00 a.m., Employee #11 (vice president of resources) reported the facility had not conducted any criminal background searches outside of the State of West Virginia for the employees listed above. Employee #11 agreed the facility needed to perform a more thorough search into the criminal backgrounds of applicants who list residency and/or employment outside of West Virginia.",2015-11-01
9340,PRINCETON CENTER LLC,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-06-30,280,D,0,1,QU2H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, and medical record review, the facility failed to assure one (1) of twenty-one (21) Stage II sampled residents was afforded the right to participate in the care and treatment provided. Resident #89 (who was alert and oriented) was placed on a diet consisting only of spoonfuls of thickened water without consulting her or obtaining her consent. Resident identifier: #89. Facility census: 65. Findings include: a) Resident #89 During random observations of the evening meal beginning at 5:10 p.m. on 06/27/11, it was noted that staff members did not deliver a meal tray to Resident #89. At 6:00 p.m., Resident #89 had still not been provided a meal tray. The nursing assistant (NA) assigned to care for the resident that shift (Employee #73) was interviewed at 6:00 p.m. on 06/27/11. When asked if Resident #89 received a tray for the evening meal, the NA stated the resident did not get a meal tray due to being NPO (nothing by mouth). The NA stated he had not been in the resident's room during his shift. Review of the medical record found a 06/23/11 physician's orders [REDACTED]. The medical record contained no evidence that the resident was notified of this change in diet, nor that she was allowed to participate in this decision. Further review found, on 03/19/11 and on 03/22/11, the physician determined the resident retained the capacity to make her own informed medical decisions. Review of the minimum data set (MDS) with an assessment reference date (ARD) of 05/15/11 found the assessor noted Resident #89 to be usually able to make herself understood and usually able to understand verbal content. In the area of activities of daily living, the resident was assessed as requiring the total assistance of staff for eating. The resident's room was entered at 6:30 p.m. on 06/27/11. Resident #89 was alert and answered questions appropriately by nodding her head in the positive or negative. The resident's lips and mouth appeared dry. She was asked if she was thirsty. The resident nodded her head indicating an affirmative answer. When asked if she was aware that the physician had determined that she would not be given any food, she indicated a negative answer by shaking her head from left to right. When asked if anyone had been in to speak with her about this decision, she again indicated a negative answer by shaking her head left and right and whispering no. When asked if she did want breakfast, lunch, and dinner, she indicated an affirmative answer by nodding her head up and down and whispering yes. A registered nurse (RN - Employee #76) was informed, at 6:45 p.m. on 06/27/11, that Resident #89 had been given no liquids as of the beginning of Employee #73's shift. Both she and Employee #73 entered the resident's room. the RN spoon-fed the resident honey thickened water. The resident swallowed the thickened water with no apparent difficulty. The resident informed the RN that she did want breakfast, lunch, and dinner even if it made her choke. Employee #76 contacted the physician, who ordered the resident to be placed back on a pureed diet. Further review of the medical record found a speech / language pathology weekly note which documented the following: . Resident may have honey thickened water via spoon if alert to retrieve bolus from spoon. The note further documented, POA (power of attorney) in agreement with decision by SLP (speech / language pathologist). Neither this note, nor any other document in the resident's medical record, contained evidence that the resident was consulted or notified of the decision to deprive her of food.",2015-11-01
9341,PRINCETON CENTER LLC,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-06-30,309,G,0,1,QU2H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to adequately assess / monitor and obtain timely medical intervention for one (1) of twenty-one (21) Stage II sample residents who was experiencing an acute change in condition. Resident #10, who was assessed upon admission on [DATE] as being continent of bowel, had twenty-seven (27) bowel movements (BMs) between her date of admission on [DATE] (with the first loose stool recorded on [DATE]) and until she expired on the early morning of [DATE]. Of those, twenty-one (21) BMs were described as loose and fourteen (14) of them were described as incontinent. There was no evidence of any recognition by licensed nurses of the resident's frequent episodes of diarrhea until it was brought to their attention by therapy staff on [DATE], and no evidence of any assessment / monitoring of the resident's bowel elimination status (after it was identified by the therapy staff) until [DATE], when a nurse noted the resident had a recurrent fever and episodes of diarrhea and the physician gave orders for a stool culture and sensitivity. When the lab results came back positive for [MEDICAL CONDITION] (C diff) in her stool on [DATE], Resident #10 was placed in contact isolation and started on an antibiotic ([MEDICATION NAME]) to treat the infection. This lack of assessment / monitoring resulted in a delay in treatment for [REDACTED]. Facility census: 65. Findings include: a) Resident #10 Record review revealed this [AGE] year old female resident was admitted to the nursing facility [DATE] and expired [DATE]. Her [DIAGNOSES REDACTED]. The resident had been hospitalized for [REDACTED]. The antibiotic therapy continued at the nursing facility until [DATE]. According to her hospital history and physical examination [REDACTED]. There was no mention of any diarrhea or hyperactive bowel sounds in her hospital discharge summary dictated by the physician on [DATE]. According to the hospital discharge summary, her (p)rognosis for further functional improvement is fair. -- Review of the admission nursing assessment dated [DATE] at 11:55 a.m., the nurse assessed Resident #10 as being continent of both bowel and bladder, and the nurse did not mark the assessment tool to indicate the resident was experiencing diarrhea. On a bowel incontinence assessment and progress notes form dated [DATE], a registered nurse (RN) wrote: [DATE] Resident has been frequently incontinence of bowel through ARD (assessment reference date). (Note the ARD referred to a seven-day period of time ending on [DATE].) Also on the form, the RN noted Resident #10 had been incontinent of bowel two (2) to three (3) times weekly, the stool was soft and brown, and section for recording the reason for the incontinence was marked through with a diagonal line. -- A review of care tracker reports for bowel and bladder detail showed Resident #10's first bowel movement (BM), following her admission to the facility on [DATE], was recorded at 10:44 p.m. on [DATE] and it was described as loose. Of the twenty-seven (27) BMs recorded during her stay at the facility, twenty-one (21) of them were described as loose and fourteen (14) were described as being incontinent. There were twenty-one (21) episodes of loose stool during a 16-day period from [DATE] to [DATE]. This was discussed with the vice president of health services (Employee #67), who provided the care tracker sheets, on the morning of [DATE]. -- Review of the medication administration record (MAR) for [DATE] found the resident was receiving [MEDICATION NAME] 17 grams in 8 ounces of water daily (in the morning) for constipation, as well as Power Pudding 1 ounce by mouth twice daily for constipation, both of which had been ordered on admission. The nurses' initials for all scheduled doses of the [MEDICATION NAME] from [DATE] to [DATE] were circled (to indicate they were not given). The nurses' initials for the Power Pudding were circled for the following scheduled doses: 10:00 a.m. on [DATE], 10:00 a.m. on [DATE], 10:00 a.m. on [DATE], 10:00 a.m. on [DATE], 10:00 a.m. and 10:00 p.m. on [DATE], and 10:00 a.m. on [DATE]. Documentation explaining why these doses of [MEDICATION NAME] and Power Pudding were not administered was absent from the reverse side of the MAR and the nursing notes except for the missed doses of [MEDICATION NAME] and Power Pudding due to have been administered at 10:00 a.m. [DATE]; the explanation written on the reverse side of the MAR for not administering these doses was (quoted as written): held due to residents c/o loose stools. -- Review of the nursing notes in Resident #10's medical record revealed the following entries (quoted as written): - [DATE] at 1:10 a.m. - VS (vital signs) - ,[DATE] (blood pressure), 99.8 (temperature), 64 (pulse), 20 (respirations). Resting in bed /c (with) eyes closed. Requires assist /c ADLs (activities of daily living), transfers & mobility. Therapy ordered. - [DATE] at 1:20 a.m. - VS - ,[DATE], 99.6, 81, 17. Resting in bed /c eyes closed, Requires assist /c ADLs, transfers & mobility. Therapy ordered. - [DATE] at 2:50 a.m. - Temp. re-(checkmark) still 99.6. Tylenol 650 po (by mouth) given per S.O. (standing orders). - [DATE] at 6:00 a.m. - Temp. re-(checkmark) 98.2. - [DATE] at 7:00 a.m. - Wt. (weight) ,[DATE] - 94.0 (pounds). Wt. ,[DATE] - 87.1 (pounds). 6.9lb wt loss. No IBW (ideal body weight) available. Dietician notified. Will re wt (reweigh) tomorrow. - [DATE] at 8:10 a.m. - Dr. (name) in facility. Made aware of 6.9lbs wt. loss since admission. - [DATE] at 10:10 a.m. - Resident needs assistance /s ADLs, mobility and transfers. Works /c therapy as ordered. Therapy reports resident had loose, incontinent stools this morning. - [DATE] - Notified Dr. (name) of Residents sporadic diarrhea episodes. No new orders received. - [DATE] at 6:00 p.m. - ,[DATE], 99.1 - 62 - 24. OOB (out of bed) to w/c (wheelchair). No C/Os (complaints) voiced needs assist /c ADLs, transfers & bed mobility. Call bell within reach. - [DATE] at 1:50 a.m. - VS - ,[DATE], 100.6, 82, 22. Resting in bed /c eyes closed. Requires assist /c ADLs, transfers & mobility. Therapy ordered. - [DATE] at 4:00 a.m. - Temp. re-(checkmark) 100.1. - [DATE] at 7:00 a.m. - Tem. re-(checkmark) 98.7. (Note these entries are out of chronological sequence, as the above entry was recorded on the bottom of a page of progress notes, while earlier entries beginning at 11:00 a.m. on [DATE] were recorded at the top of a new page of progress notes.) - [DATE] at 2:10 a.m. - VS - ,[DATE], 100.2, 94, 18. Was given [MEDICATION NAME] @ 12:30 A. Resting in bed /c eyes closed. Requires assist /c ADLs, transfers & mobility. Therapy ordered. - [DATE] at 5:00 a.m. - Temp. re-(checkmark) 98.9. - [DATE] at 1:25 a.m. - VS - ,[DATE], 100.2, 93, 24. [MEDICATION NAME] was given @ 12:30 A. Resting in bed /c eyes closed. Requires assist /c ADLs, transfers & mobility. Therapy ordered. - [DATE] at 5:00 a.m. - Temp. re-(checkmark) 98.6. - [DATE] at 9:00 a.m. - Resident has recurrent fever & diarrhea. Dr. (name) informed. New orders received. - [DATE] at 11:05 a.m. - Dr. (name) in to see residents mouth. See physicians orders for new orders. - [DATE] at 1:00 p.m. - (name) from PCH lab called and reported to report positive [MEDICAL CONDITION] culture on recent stool specimen. - [DATE] at 3:30 p.m. - New order received to move to room (#) and for contact isolation d/t (due to) (+) (positive) [MEDICAL CONDITION]. MPOA informed and Resident informed of room move & (+) [MEDICAL CONDITION] - verbalized understanding. - [DATE] at 6:30 p.m. - See new orders. - [DATE] at 8:00 a.m. - . [MEDICATION NAME] for [MEDICAL CONDITION]. Afebrile 97.9. Refused AM (morning) mouth care, refused breakfast. Remains in contact isolation. - [DATE] at 8:00 a.m. - Dr. (name) informed that resident is refusing meds. New order for labs received. - [DATE] at 9:40 a.m. - (Name) MPOA informed residents is refusing meds & of new orders. MPOA states she does not want resident sent to ER (emergency room ) @ this time. Resident also states she does not want to go to ER @ this time. - [DATE] at 5:50 p.m. - Resident refusing meds. No C/O (complaints of) pain at this time. Resident also refused dinner. Call bell in reach. [DATE] at 12:25 a.m. - Called to resident's room by CNA (certified nursing assistant). Noted to have no heartbeat, no VS X 2 nurses. There were no nursing notes between [DATE] and [DATE] addressing findings of loose stool or diarrheal episodes. There was no intervention until [DATE] when the physician ordered lab testing to rule out[DIAGNOSES REDACTED]. When the lab results came back positive for[DIAGNOSES REDACTED] on [DATE], the resident was placed in contact isolation and the physician started [MEDICATION NAME] (an antibiotic) to treat this infection. -- Review of the nutritional assessment completed by the registered dietician on [DATE] and dietary progress notes entered between [DATE] and [DATE], found no mention of the resident's frequent episodes of diarrhea and no recognition of the impact this diarrhea could have on the resident's nutrition and hydration needs. The assessment did, however, identify that constipation (not diarrhea) placed the resident at risk for dehydration. -- Review of Resident #10's physician orders [REDACTED]. - [DATE] - Tylenol 650 by mouth every four (4) hours as needed for elevated temperature - [DATE] - Discontinue [MEDICATION NAME] ,[DATE] mg every six (6) hours as needed for pain and administered [MEDICATION NAME] ,[DATE] mg every (6) hours for pain (scheduled doses instead of as needed) - [DATE] - Check stool for CDT (C diff toxin) and culture and sensitivity - [DATE] - [MEDICATION NAME] oral suspension 5 cc four-times-daily swished for fourteen (14) days - [DATE] at 3:30 p.m. - Move to Room (#) due to positive[DIAGNOSES REDACTED]. Contact isolation due to[DIAGNOSES REDACTED]. - [DATE] at 6:15 p.m. - [MEDICATION NAME] 500 mg every eight (8) hours for fourteen (14) days for[DIAGNOSES REDACTED] - [DATE] - Move to Room (#) - [DATE] - CBC (complete blood count), CMP (comprehensive metabolic panel) - decreased po (oral) intake - on [DATE] - [DATE] - May release body to (Name) Funeral Home -- In an interview with the physician at 10:35 a.m. on [DATE], he had no further information about why intervention(s) were not started prior to [DATE] to address Resident #10's loose stools, given that the resident was known to have been receiving antibiotics for an extended period of time and that antibiotic use is a contributing factor to the development of[DIAGNOSES REDACTED] infections. -- The assessor encoded the re-entry minimum data set assessment (MDS) with an ARD of [DATE] to indicate the resident was frequently incontinent for bowel. An MDS with an ARD of [DATE] also indicated the resident was frequently incontinent of bowel. A care plan based on the MDS of [DATE] stated the resident had a [DIAGNOSES REDACTED]. Interventions included: Observe, document and report s/s UTI i.e.: dysuria, polyuria, fever, increased confusion, lower flank pain, hematuria and etc. to notify MD prn (as needed). On [DATE], the care plan was revised to reflect the positive culture for[DIAGNOSES REDACTED]. Interventions were to observe and report signs and symptoms such as diarrhea, abdominal cramping, and distinct bowel movement odor and to implement contact isolation per order. -- The above was discussed with the senior vice president (Employee #5) on the afternoon of [DATE], to allow the facility to obtain and present any additional information to the survey team. No additional information was provided as of the time of exit.",2015-11-01
9342,PRINCETON CENTER LLC,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-06-30,314,D,0,1,QU2H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to assure one (1) of three (3) Stage II sampled residents with pressure ulcers received care and treatment necessary to promote healing and prevent infection. Resident identifier: #31. Facility census: 65. Findings include: a) Resident #31 Review of the medical record noted Resident #31 developed Stage III and Stage IV pressure ulcers to her left heel, right heel, and right ankle. Review of physician's orders [REDACTED]. Review of the treatment administration record (TAR) noted the nurses were documenting utilizing tender wet dressings with non-bordered foam to the wounds to the resident's right outer ankle and left heel. The order for the resident's right inner heel had been defaced in such a manner as to render the order indecipherable. An observation of the wound treatment was conducted with a licensed practical nurse (LPN - Employee #97) at 9:26 a.m. on 06/30/11. The LPN was noted to prepare a clean field and place supplies for the wound dressings on it. She then removed a pair of scissors from her right uniform pocket and placed them on the clean field without cleansing or sanitizing them. She utilized the contaminated scissors to cut the non-bordered foam utilized on two (2) of the resident's wounds. The nurse dressed the wound to the resident's left heel with a tender wet dressing covered with the contaminated non-bordered foam. She dressed the wound to the resident's right outer ankle utilizing the tender wet dressing covered with the contaminated non-bordered foam. She utilized the correct treatment of [REDACTED]. After completing the treatments, the nurse returned the scissors to her right uniform pocket without cleaning or sanitizing them. The discrepancy noted between the physician's orders [REDACTED].#76) at 10:05 a.m. on 06/30/11. The RN called the wound treatment center to clarify the treatment for [REDACTED]. She agreed that she could not decipher the last order on page 2 of the TAR. Employee #97 failed to apply the correct treatment to the resident's wounds and placed the resident at risk of infection by utilizing contaminated supplies to dress the resident's wounds.",2015-11-01
9343,PRINCETON CENTER LLC,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-06-30,327,G,0,1,QU2H12,Deficiency Text Not Available,2015-11-01
9344,PRINCETON CENTER LLC,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-06-30,371,E,0,1,QU2H11,"Based on observation and staff interview, the facility failed to ensure snack foods were stored in safe and sanitary conditions. The thermometer in the nourishment pantry refrigerator was not working, which did not allow for monitoring to ensure foods were stored in safe temperature range. This had the potential to affect more than an isolated number of residents. Facility census: 65. Findings include: a) On 06/28/11 at approximately 3:00 p.m., Employee #15 (environmental services supervisor) accompanied this surveyor during the tour of the building's general environment. Observation of the nourishment pantry refrigerator revealed the thermometer did not function properly. Employee #15 took the thermometer out of the refrigerator and replaced it with one (1) that worked. The facility used this refrigerator to store perishable food items for resident consumption.",2015-11-01
9345,PRINCETON CENTER LLC,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-06-30,431,F,0,1,QU2H11,"Based on observation and staff interview, the facility failed to assure that only authorized personnel were provided access to drugs and biologicals stored in the locked medication room. This deficient practice had the potential to affect all residents residing and receiving medication in the facility. Facility census: 65. Findings include: a) During observations of the nursing station on 06/29/11 at 8:00 a.m., two (2) members of the housekeeping staff were noted to enter the closed door of the nursing station. A member of the housekeeping staff (Employee #34) asked this surveyor to step out of the nursing station. She stated that everyone had to leave the nursing station so that housekeeping could clean. When asked how housekeeping cleaned the medication storage room, she stated the nurses leave the keys for them. The vice president of health services (Employee #67) was immediately informed of the housekeeper's statement and assisted this surveyor to identify what areas of the medication storage room allowed unsupervised access to members of the housekeeping staff. Employee #67 utilized the set of keys left by the nurse for the housekeeping staff to utilize and determined that the housekeepers would have access to cabinets full of medications as well as the controlled substances slated for destruction by the pharmacist.",2015-11-01
9346,PRINCETON CENTER LLC,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-06-30,441,F,0,1,QU2H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy review, the facility failed to establish and maintain an infection control program designed to help prevent the development and transmission of disease and infection. The facility failed to utilize a cleaning solution effective in killing Clostridium difficile (C diff) spores, failed to assure a nurse provided wound care free from contamination, failed to assure staff members washed their hands when indicated, and failed to assure staff members were educated concerning isolation procedures for equipment utilized in[DIAGNOSES REDACTED] isolation rooms. These deficient practices affected Residents #65 and #67, when nursing staff members failed to wash their hands prior to instilling eye drops, and had the potential to affect all residents residing in the facility. Resident identifiers: #65 and #67. Facility census: 65. Findings include: a) During the initial tour of the facility on 06/21/11 at 1:50 p.m., observation found Rooms #10 and #11 displayed signs on the doors directing visitors to go to the nursing station prior to entering the rooms. The registered nurse (RN - Employee #76), when asked why the signs were posted on the doors, stated the residents in both rooms were on contact isolation for[DIAGNOSES REDACTED]. Review of the medical records for each of the two (2) residents found that both were receiving treatment for [REDACTED]. The resident in room [ROOM NUMBER] was assessed as being always incontinent of bowel. In an interview on 06/21/11 at 2:04 p.m., a member of the housekeeping staff (Employee #20) stated she cleaned Rooms #10 and #11 and was aware that they were isolation rooms. When asked to describe the procedure she utilized in order to clean the rooms, Employee #20 stated she utilized a particular cleaning agent for all surfaces and floors in both rooms. In a subsequent interview conducted at 2:30 p.m. on 06/21/11, the vice president of environmental services (Employee #15) was asked to provide information to show the cleaning agent utilized by the housekeeping staff was effective in killing[DIAGNOSES REDACTED] spores. She relayed that she had contacted her supplier and was informed that the only cleaning solution approved for cleansing environmental surfaces contaminated with[DIAGNOSES REDACTED] spores was a 10% bleach solution. She stated this procedure would be changed immediately. A subsequent observation, conducted on 06/28/11 at 3:00 p.m., found another member of the housekeeping staff (Employee #28) cleaning room [ROOM NUMBER]. Employee #28 took into room [ROOM NUMBER] a spray bottle, an empty four (4) quart bucket and rags. When asked what solution was in the spray bottle, she stated that it was the 10% bleach solution. She was observed to pour approximately six (6) ounces of the 10% bleach solution into the empty bucket and fill it 1/2 full with tap water from the resident's sink. She then utilized the overly diluted bleach solution to clean all the surfaces in the resident's room. When asked why she had further diluted the 10% bleach solution, she stated she did not want the bleach to be too strong. This observation was reported to Employee #15, who stated she would assure that all housekeeping staff members were properly trained in cleaning rooms contaminated with[DIAGNOSES REDACTED] spores. -- b) During an interview with an RN (Employee #100) at 2:15 p.m. on 06/21/11, she was asked what preventative measures had been put into place to prevent the spread of infection related to the two (2) residents on contact isolation for[DIAGNOSES REDACTED] infection. She stated that each resident was provided dedicated equipment, with each having a blood pressure cuff, thermometer, and stethoscope in their rooms. She was then asked to check the rooms to assure the equipment was present. After checking the rooms, she stated each room only had a blood pressure cuff. Neither room contained a thermometer or stethoscope dedicated to that resident's use. She further relayed that she had provided an inservice for direct care staff members on 06/02/11. At 2:20 p.m. on 06/21/11, a nursing assistant (NA - Employee #82) was noted to be walking by. When asked if she provided care for either residents in Rooms #10 or #11, Employee #82 stated she provided care for the resident in room [ROOM NUMBER], who required a mechanical lift for transfers. When asked to describe the procedure utilized following the transfer by mechanical lift of the resident in room [ROOM NUMBER], she described the procedure. When asked what she would do with the lift after transferring the resident, she stated that, if the lift was not visibly soiled, she would take it back to the utility room and plug it in. When asked what she would utilize to clean the mechanical lift if it was visibly soiled, she stated she would use the solution from housekeeping. Following this interview with Employee #82 while Employee #100 was present, a request was made for documentation of the inservice given to direct care staff members. Employee #100 provided a copy of a the direct care staff members who attended the 06/02/11 inservice. Review of the document found that only seven (7) NAs and three (3) LPNs had attended. Employee #82 had not attended the inservice. -- c) Resident #65 During observation of the medication administration pass on 06/29/11 at 10:49 a.m., a licensed practical nurse (LPN - Employee #66) was observed to not wash her hands prior to touching the resident's lower eye lid while instilling eye drops into Resident #65's eyes. -- d) Resident #67 During random observations conducted on 06/21/11 at 5:35 p.m., an LPN (Employee #97) was observed to prepare to place drops into Resident #67's eyes. She was observed to touch the medication administration record, the locking mechanism on the medication cart, and her key ring prior to touching the finger portion of the gloves she donned. She then utilized these contaminated gloves to touch the resident's lower eye lids to instill the drops. -- e) Resident # 31 An observation of wound treatments on Resident #31's left and right heels and right ankle was conducted with Employee #97 at 9:26 a.m. on 06/30/11. The LPN prepared a clean field and placed supplies for the wound dressings on it. She then removed a pair of scissors from her right uniform pocket and placed them on the clean field without cleansing or sanitizing them. She utilized these contaminated scissors to cut the non-bordered foam utilized on two (2) of the resident's wounds. This practice placed the resident at risk of infection from the contaminated dressing. -- f) During dietary observations at 5:00 p.m. on 06/21/11, a dietary staff member (Employee #131) washed her hands, dried her hands with a paper towel, and then used the same paper towel to turn off the water faucet. This same procedure was noted again on 06/29/11 at 10:38 a.m., when another dietary staff member (Employee #129) washed hands, dried them, and then proceeded to use this same used wet towel to turn off the water faucet. This was discussed with the dietary supervisor (Employee #124) at the time of observation. The surveyor was provided with a copy of the facility's hand washing policy on 06/28/11, which stated: 10. Turn off water with dry paper towel. Avoid touching handles with hands. (The policy had a date of R3/2011.) Dietary staff did not adhere to the facility's hand washing policy.",2015-11-01
9347,PRINCETON CENTER LLC,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-06-30,502,D,0,1,QU2H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility did not ensure one (1) of twenty-one (21) Stage II sample residents received timely laboratory services. The physician had ordered a laboratory test in May 2011, which had not been obtained by the facility as of 06/27/11. Resident identifier: #62. Facility census: 65. Findings include: a) Resident #62 On 06/27/11 at approximately 9:00 a.m., review of the medical record for Resident #62 revealed a physician's orders [REDACTED]. The resident had a [DIAGNOSES REDACTED]. The vice president of health services (Employee #67) verified the facility had not obtained the laboratory test.",2015-11-01
9348,PRINCETON CENTER LLC,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-06-30,514,D,0,1,QU2H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized for three (3) Stage II sample residents. The facility did not complete documentation each month regarding Resident #72's behaviors which necessitated the use of antipsychotic and benzodiazepine medication. The facility did not ensure physician's orders [REDACTED].#31. The nurses did not record explanations on the reverse side of the medication administration record (MAR) or the nursing notes to explain when medications were not administered as ordered by the physician for Resident #10. Resident identifiers: #72, #31, and #10. Facility census: 65. Findings include: a) Resident #72 The medical record review for Resident #72 conducted on 06/30/11 at approximately 11:00 a.m. revealed the resident received [MEDICATION NAME] 0.25 for agitation and [MEDICATION NAME] .25 for anxiety. Resident #72 had a [DIAGNOSES REDACTED]. Employee #83 (registered nurse) reviewed the resident's medical record and determined the facility had not documented the resident's behaviors of attempting elopement and crying in May 2011. The behavior tracking form for May 2011 had not been filled out. -- b) Resident #31 Review of physician's orders [REDACTED]. Review of the treatment administration record (TAR) noted that licensed nurses were documenting utilizing tender wet dressings with non-bordered foam to the wounds to the resident's right outer ankle and left heel. The order for the resident's right inner heel had been defaced in such a manner as to render the order indecipherable (last order on page 2 of the TAR). The discrepancy noted between the physician's orders [REDACTED].#76) at 10:05 a.m. on 06/30/11. The RN called the wound treatment center to clarify the treatment for [REDACTED]. She also agreed that she could not decipher the last order on page 2 of the TAR. -- c) Resident #10 Review of Resident #10's MAR for May 2011 found the resident was receiving [MEDICATION NAME] 17 grams in 8 ounces of water daily (in the morning) for constipation, as well as Power Pudding 1 ounce by mouth twice daily for constipation, both of which had been ordered on admission. The nurses' initials for all scheduled doses of the [MEDICATION NAME] from 05/06/11 to 05/23/11 were circled (to indicate they were not given). The nurses' initials for the Power Pudding were circled for the following scheduled doses: 10:00 a.m. on 05/10/11, 10:00 a.m. on 05/15/11, 10:00 a.m. on 05/19/11, 10:00 a.m. on 05/20/11, 10:00 a.m. and 10:00 p.m. on 05/21/11, and 10:00 a.m. on 05/22/10. Documentation explaining why these doses of [MEDICATION NAME] and Power Pudding were not administered was absent from the reverse side of the MAR and the nursing notes except for the missed doses of [MEDICATION NAME] and Power Pudding due to have been administered at 10:00 a.m. 05/10/11; the explanation written on the reverse side of the MAR for not administering these doses was (quoted as written): held due to residents c/o loose stools.",2015-11-01
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
10722,"GLEN WOOD PARK, INC.",515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-08-24,329,D,1,0,HTIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assess one (1) of six (6) sampled residents for possible underlying causes of the resident's behavior prior to administering a psychoactive medication ([MEDICATION NAME]). Resident identifier: #60. Facility census: 59. Findings include: a) Resident #60 Review of the nurses' notes from [DATE] through [DATE] revealed the following entries (quoted as written): - On [DATE] at 3:55 p.m.: ""Vitals were taken temperature 97.3, pulse 107, Respirations 26, blood pressure ,[DATE]."" - On [DATE] at 8:00 p.m.: ""she took her medications without problems no distress was noted. The resident was taking off her oxygen and the nurse instructed her to leave it on. Her oxygen saturation was 93%."" - On [DATE] at 8:30 p.m.: ""Resident in bed call light in reach. Took meds with no problems or distress. Taking oxygen off face. Instructed to leave on face. Resident stated, 'I don't want that on my face.' oxygen saturation was 93%. Lung sounds clear. Will continue to monitor."" - On [DATE] at 10:00 p.m.: ""Resident hollering to be turned. Staff goes in to turn resident when leaving she wants to be turned again. Continues to remove oxygen. Vitals 97.3, 107, 26, ,[DATE]."" - On [DATE] at 12:00 a.m.: ""Resting in bed - call light within reach. Yelling out to be turned - before nursing assistant can leave room pt in yelling again. Pt. yelling, 'God Help me.' When ask if she was hurting pt. states, 'no' VS (vital signs) WNL (within normal limits). oxygen saturation 94% Lungs clear. oxygen in use as ordered. - cont to remove oxygen tubing from nostril."" - On [DATE] at 1:20 a.m.: ""cont to yell out and move around in bed - [MEDICATION NAME] given per prn order. cont. to remove oxygen from nostrils - lungs clear. nursing assistant sitting at bedside to give comfort to pt."" - On [DATE] at 2:00 a.m.: ""remains in bed. quiet at present. Requires assist with ADL's, foley patent and draining dark yellow urine."" - On [DATE] at 2:40 a.m.: ""Had light on - nursing assistant went into room - resident asked to be pulled up in bed. oxygen off - replaced pat. was trying to remove oxygen when nursing assistant was putting it on patient stated, 'I don't want this on my face - get this off me.' When nursing assistants were leaving patient yelled out to be turned again on her side. Which was done."" - On [DATE] at 3:00 p.m. (should have been ""a.m.""; error in documentation): ""nursing assistant went into room and sat with pt. per pt. request. some relief noted from [MEDICATION NAME] being given."" - On [DATE] at 4:40 a.m.: ""nursing assistants entered resident's room and found resident unresponsive and came to get nurses. Upon examining resident - no pulse or heartbeat noted no breathe sounds notes. Tongue hanging out of mouth - head turned to L (left) side Body cold and stiff. Resident obviously expired."" - Employee #64 administered [MEDICATION NAME] at 1:20 a.m. on [DATE], without providing non-pharmacological interventions and without making efforts to identify possible underlying causes of the resident's behavior. - Employee #64, when interviewed on [DATE] at 10:30 a.m., related the following: ""She (the resident) was very anxious. I was filling in for an 8 hour shift. When I came in she was screaming and yelling. I checked her oxygen level and her lung sounds. I didn't try to call her husband. I didn't call the doctor, because she already had the [MEDICATION NAME] ordered. After I gave her the [MEDICATION NAME], she calmed down. I don't remember how long the aide sit with her. The aide went to lunch, and she calmed down. I just thought maybe she was anxious. The other nurse did not say she was having any problems before I got her. I thought she was comfort care when she was admitted ; I never looked it up. We have two hour rounds, and she was resting. The [MEDICATION NAME] was effective, so I felt no need to go back. If the [MEDICATION NAME] had not been effective, I would have called the doctor and did something else. I don't usually work night shifts, so I didn't really know the resident."" She further stated, ""I would do things differently now.""",2014-12-01
10723,"GLEN WOOD PARK, INC.",515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-08-24,157,D,1,0,HTIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview and record review the facility failed to immediately notify the physician of one (1) of six (6) sampled resident's death. Resident #60 was a full code. She was found by nursing staff with no pulse and no respirations on [DATE]. Resident identifier: #60. Facility census: 59. Findings include: a) Resident #60 Resident #60 had elected to be a full code. Review of the nurses' notes for [DATE] revealed the following entries (quoted as written): - On [DATE] at 4:40 a.m.: ""nursing assistants entered resident's room and found resident unresponsive and came to get nurses. Upon examining resident - 0 pulse or heartbeat noted no breathe sounds notes. Tongue hanging out of mouth - head turned to L side Body cold and stiff. Resident obviously expired."" - On [DATE] at 4:41 a.m.: ""Family was notified of death."" - On [DATE] at 4:42 a.m.: ""Funeral Home was notified of death."" - On [DATE] at 4:44 a.m.: ""Senior vice president was notified of death."" - On [DATE] at 4:45 a.m.: ""Vice president of resident services was notified of death."" - On [DATE] at 5:00 a.m.: ""RN on call was notified of death."" Review of the nursing notes found no evidence that the physician was notified. - On [DATE], interviews were conducted with the following employees: - Employee #52 (certified nursing assistant), when interviewed at 1:30 p.m., stated he had entered the room at 4:40 a.m. to reposition the roommate of Resident #60. At this time, he noticed Resident #60 was turned sideways and ""... her tongue was drooped and purplish colored."" He stated he told Employee #73 (certified nursing assistant), ""She looks like she passed away."" He left the room to tell the nurse (Employee #64). - Employee #73, when interviewed at 2:30 p.m., verified she and Employee #52 found Resident #60 around 4:00 a.m. She stated, ""She felt cold and her tongue was hanging out of her mouth."" - Employee #64 (licensed practical nurse) was interviewed at 10:30 a.m. When asked if she knew the code status prior to Resident #60's death, Employee #64 replied, ""No, I thought she was comfort measures."" Employee #64 further stated, ""I didn't call the doctor."" - On [DATE] at 9:24 a.m., the director of nursing (Employee #80) stated, ""We do not have to call the physician, we tell him on his next round."" She further stated, ""They do not have to call him if they are a full code."" .",2014-12-01
10724,"GLEN WOOD PARK, INC.",515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-08-24,281,D,1,0,HTIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide care to one (1) of (6) sampled residents in accordance with the physician's orders [REDACTED]. Resident #60 had orders to monitor her blood pressure and pulse prior to administering antihypertensive medications; a nurse failed to obtain and record the resident's blood pressure and pulse prior to administering these medications as ordered by the physician. The nurse also failed to record the resident's blood sugar level as indicated on the physician's orders [REDACTED].#60. Facility census: 59. Findings include: a) Resident #60 Review of the Medication Administration Record [REDACTED]. The physician's orders [REDACTED]. No evidence could be found that Employee #70 followed the physician's orders [REDACTED]. Further review of the MAR found initials indicating a nurse obtained Resident #60's blood sugar at 8:00 p.m. on 07/29/11, but there was no record of the blood sugar level itself. Interview with the director of nursing, at 1:00 p.m. on 08/24/11, confirmed Employee #70 did not document a blood sugar, pulse, or blood pressure of Resident #60 for this date and time. .",2014-12-01
10725,"GLEN WOOD PARK, INC.",515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-08-24,282,D,1,0,HTIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure qualified nursing staff had knowledge of a resident's code status, for one (1) of six (6) sampled residents. Resident identifier: #60. Facility census: 59. Findings include: a) Resident #60 Record review revealed Resident #60 had elected to be a full code. Review of the nurses' notes from [DATE] through [DATE] revealed the following entries (quoted as written): - On [DATE] at 8:30 p.m.: ""Resident in bed call light in reach. Took meds with no problems or distress. Taking oxygen off face. Instructed to leave on face. Resident stated, 'I don't want that on my face.' oxygen saturation was 93%. Lung sounds clear. Will continue to monitor."" - On [DATE] at 10:00 p.m.: ""Resident hollering to be turned. Staff goes in to turn resident when leaving she wants to be turned again. Continues to remove oxygen. Vitals 97.3, 107, 26, ,[DATE]."" - On [DATE] at 12:00 a.m.: ""Resting in bed - call light within reach. Yelling out to be turned - before nursing assistant can leave room pt in yelling again. Pt. yelling, 'God Help me.' When ask if she was hurting pt. states, 'no' VS (vital signs) WNL (within normal limits). oxygen saturation 94% Lungs clear. oxygen in use as ordered. - cont to remove oxygen tubing from nostril."" - On [DATE] at 1:20 a.m.: ""cont to yell out and move around in bed - [MEDICATION NAME] given per prn (as needed) order. cont. to remove oxygen from nostrils - lungs clear. nursing assistant sitting at bedside to give comfort to pt."" - On [DATE] at 2:00 a.m.: ""remains in bed. quiet at present. Requires assist with ADL's (activities of daily living), foley (indwelling urinary catheter) patent and draining dark yellow urine."" - On [DATE] at 2:40 a.m.: ""Had light on - nursing assistant went into room - resident asked to be pulled up in bed. oxygen off - replaced pat. was trying to remove oxygen when nursing assistant was putting it on patient stated, ""I don't want this on my face - get this off me."" When nursing assistants were leaving patient yelled out to be turned again on her side. Which was done."" - On [DATE] at 3:00 p.m. (should have been ""a.m.""; error in documentation): ""nursing assistant went into room and sit with pt. per pt. request. some relief noted from [MEDICATION NAME] being given."" - On [DATE] at 4:40 a.m.: ""nursing assistants entered resident's room and found resident unresponsive and came to get nurses. Upon examining resident - 0 pulse or heartbeat noted no breathe sounds notes. Tongue hanging out of mouth - head turned to L side Body cold and stiff. Resident obviously expired."" Review of the facility's self-reporting of the incident revealed a statement taken on [DATE] from Employee #95, the registered nurse (RN) on call the night of the incident. According to this statement, a licensed practical nurse (LPN - Employee #64) called Employee #95 at 5:00 a.m. on [DATE]. Employee #95 questioned Employee #64 about the resident's code status. Employee #64 stated, ""I forgot to look."" Employee #95's statement also revealed she ""... did not feel comfortable on giving her instructions on what to do since mistake already made. ..."" Employee #95 recommended Employee #64 call the director of nursing (DON). The following staff interviews were conducted: - Employee #64 (LPN) was interviewed at 10:30 a.m. on [DATE]. When asked if she knew the code status prior to Resident #60's death, Employee #64 replied, ""No, I thought she was comfort measures. I had no clue that she was going to die. I knew her condition was not good, but I had no idea she was going to die. I thought she was comfort care when she was admitted . I never looked it up."" - Employee #52 (certified nursing assistant), when interviewed on [DATE] at 1:30 p.m., stated he had entered the room at 4:40 a.m. to reposition the roommate of Resident #60. At this time, he noticed Resident #60 was turned sideways and, ""... Her tongue was drooped and purplish colored."" He stated he told told employee #73, ""She looks like she passed away."" He left the room to tell the nurse, employee #64. - Employee #73 (certified nursing assistant), when interviewed on [DATE] at 2:30 p.m., stated, ""I checked the resident every two hours after starting my shift. I was in and out of the room because (Resident #60) seemed nervous. Prior to lunch, I sat with her holding her hand; she was calming down and seemed fine. I sat with her probably ten minutes before lunch."" She verified she and Employee #52 found Resident #60 around 4:00 a.m., stating, ""She felt cold and her tongue was hanging out of her mouth. It was probably 45 minutes since I had been in the room."" - Employee #80 (director of nursing), when interviewed on [DATE] at 9:42 a.m., stated, ""The facility reported the incident, because they did not perform CPR on a resident who was a full code."" - Employee #95 (RN on call), when interviewed on [DATE] at 11:06 a.m., stated Employee #64 had called her on the night of the incident, and she verified the statement previously given on [DATE] was correct. .",2014-12-01
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
11158,"GLEN WOOD PARK, INC.",515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-03-10,309,G,1,0,LH7B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of facility protocol, staff interview, physician interview, and review of information published by the American Diabetic Association, the facility failed to provide clear and precise instructions to nursing staff concerning when to notify the physician of elevated blood glucose levels for residents with diabetes. This deficient practice resulted in repeated untreated episodes of [MEDICAL CONDITION] for two (2) of four (4) sampled residents, with one (1) of these residents requiring hospitalization . Residents #65 and #49 were both ordered Accu-checks four-times-a-day (qid); prior to meals and at bedtime. Both residents displayed pre-meal blood glucose levels greater than 200 mg/dl on multiple occasions with no evidence of physician notification. Resident #65's [MEDICATION NAME] was discontinued shortly after her admission in response to the pharmacist's recommendation. This antiglycemic medication was not replaced with an alternate form of treatment. The resident suffered harm when her blood glucose level reached 512 mg/dl and she required hospitalization . This resident's blood glucose level was recorded to be greater than 300 mg/dl on three (3) occasions immediately prior to her hospitalization . The facility could provide no evidence that clear and precise instructions were provided to nursing staff members to ensure the physician was notified of these increased blood glucose levels. Resident #49 experienced multiple episodes of [MEDICAL CONDITION] prior to the physician being notified. Resident identifiers: #65 and #49. Facility census: 64. Findings include: a) Resident #65 Resident #65 was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of her medical record found her admission physician orders [REDACTED]. She was also ordered Accu-checks qid to be administered prior to meals and at bedtime. Review of her documented glucose levels found she was admitted with a blood glucose of 118 mg/dl. Review of the medication regimen review, dated 01/19/11, found the pharmacist recommended the resident's [MEDICATION NAME] be discontinued due to laboratory results indicating decreased renal function. He further recommended adding [MEDICATION NAME] if needed. The recommendation was agreed to by the physician, and her [MEDICATION NAME] was discontinued on 01/21/11. The physician did not order [MEDICATION NAME] or any other antiglycemic medication. The medical record contained no orders, parameters, or instructions to nursing staff members to inform the physician of hyperglycemic episodes. Review of the American Diabetic Association 2011 guidelines found [MEDICAL CONDITION] was defined as a blood glucose level great than or equal to 200 mg/dl at any time. Further review of the diabetic monitoring documentation found the resident's blood glucose was recorded as follows: - 291 mg/dl at 11:45 a.m. on 01/29/11, - 285 mg/dl at 8:00 p.m. on 01/29/11, - 308 mg/dl at 11:45 a.m. on 01/30/11, - 324 mg/dl at 8:45 p.m. on 01/30/11, - 265 mg/dl at 6:45 a.m. on 01/31/11, and - 361 mg/dl at 4:45 p.m. on 01/31/11. The facility could provide no evidence that staff notified the physician concerning these hyperglycemic episodes. A nursing note, at 9:05 a.m. on 01/31/11, documented the resident's blood glucose reading to be 512 mg/dl. The resident was transported to the hospital where she was determined to be suffering from a urinary tract infection. She was returned to the facility with orders for insulin injections of [MEDICATION NAME] 5 mg to be administered at bedtime. In an interview on 03/09/11 at 1:00 p.m., the resident's physician agreed the facility did not have procedures in place to contact him when a resident's blood glucose level reached defined parameters. He stated a protocol would be developed for nursing staff to follow. -- b) Resident #49 Review of the medical record found this resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the diabetic monitoring record found the resident's blood glucose levels were greater than 200 mg/dl on 02/10/11, 02/11/11, 02/12/11, 02/13/11, and reached 296 mg/dl at 11:45 a.m. on 02/14/11. The physician was not notified of these episodes of [MEDICAL CONDITION] until 02/15/11. He ordered the resident's [MEDICATION NAME] to be increased to 10 mg bid on 02/15/11. Review of the resident's blood glucose levels following the increase in medication noted documentation of [MEDICAL CONDITION] with levels above 200 mg/dl on a daily basis from 02/15/11 until the physician was notified on 03/01/11. The resident's blood glucose was documented to be: - 315 mg/dl on 02/19/11 at 11:45 a.m., - 305 mg/dl on 02/19/11 at 4:45 p.m., - 322 mg/dl on the morning of 02/24/11, and - 398 mg/dl on 02/25/11 at 4:45 p.m. After notification on 03/01/11, the physician ordered Actos 15 mg to be added to her medication regimen. In an interview on 03/07/11 at 2:00 p.m., a registered nurse (RN - Employee #84) confirmed that nursing staff members were provided no orders or parameters instructing nursing staff to contact the physician for episodes of [MEDICAL CONDITION].",2014-07-01
11292,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2011-03-10,246,D,1,0,MHV411,". Based on record review and staff interview, the facility failed to provide reasonable accommodations related to the physical environment and staff behaviors for one (1) of ten (10) residents. Review of the facility's call light report revealed, when Resident #78 rang her call bell for assistance on 02/05/11, the call light went unanswered for 57 minutes. Resident identifier: #78. Facility census: 115. Findings include: a) Resident #78 Review, on 03/07/11, of the facility's records of self-reported events found Resident #78 had been fallen to the floor on 01/23/11, after being left unattended on a bedside commode. Included in the facility's internal was a call light log, which recorded the following response times by staff to Resident #78's call light once activated: - 02/05/11 at 7:39 p.m., the call bell was answered after 22.6 minutes - 02/05/11 at 8:03 p.m., the call bell was answered after 57.9 minutes - 02/19/11 at 7:06 p.m., the call bell was answered after 13.0 minutes. - 02/22/11 at 6:35 p.m., the call bell was answered after 15.9 minutes. - 02/23/11 at 7:15 p.m., the call bell was answered after 16.0 minutes. Interview with the director of nursing (DON - Employee #6), at 2:00 p.m. on 03/08/11, revealed the facility had a new nurse call system. According to the DON, the call system first rings into a pager worn by the nursing assistants on the resident's hall. If unanswered after 3 minutes, it rings into a system to notify nursing assistants on the next hall. If not answered after 3 minutes, it then rings into the pager carried by the unit charge nurse. This system continues to carry over to various members of staff if not answered in intervals of 3 minutes. On 03/09/11 at 12:00 p.m., the director of nursing (Employee #6) could offer no explanation why it would take 57.9 minutes to answer Resident #78's call bell on the evening of 02/05/11. She further stated the facility had contacted a repairman to verify the call system was working properly. A report subsequently provided by the DON revealed the repairman serviced the system on 03/03/11, and no problems were found affecting the 100 hall (the hall on which Resident #78 resided). .",2014-07-01
11293,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2011-03-10,280,D,1,0,MHV411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and review of the facility's fall prevention program, the facility failed to revise the care plan and update the nursing assistant worksheet for one (1) of ten (10) sampled residents when the resident returned from a hospital stay and was assessed as requiring additional staff assistance with activities of daily living (ADLs). Resident #78 was readmitted to the facility after a hospital stay following a [MEDICAL CONDITION]. Upon readmission to the facility, she was identified as having poor sitting balance and needing increased physical assistance from staff with transfers and toilet use. The facility also assessed Resident #78 as being at high risk for falls, for which there was no evidence of an updated care plan. On 01/23/11, Resident #78 was placed on the bedside commode and left unattended; she subsequently fell and suffered a concussion and abrasions to both knees. Resident identifier: #78. Facility census: 115. Findings include: a) Resident #78 1. Record review revealed Resident #78 was an [AGE] year old female who was transferred to the hospital on [DATE] for [MEDICAL CONDITION], and she was readmitted from the hospital on [DATE]. [DIAGNOSES REDACTED]. Further record review revealed, on 01/23/11, Resident #78 was placed by staff on a bedside commode and left unattended. Staff later found her in the floor. She was sent to the hospital and diagnosed with [REDACTED]. - 2. According to an abbreviated quarterly MDS with an ARD of 12/06/10, in Section G0300 (balance during transitions and walking), the assessor encoded Resident #78's performance on Items A, D, and E (moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer, respectively) as ""2"", meaning she was ""not steady, only able to stabilize with human assistance"". Elsewhere in Section G, the assessor noted Resident #78 required the limited assistance of two (2) or more persons with transferring and toilet use. When assessing the resident's sitting balance using a form titled ""Tinetti Assessment Tool: Balance"" (completed on 01/06/11), the assessor scored Resident #78 as ""1"", indicating she ""(l)eans or slides in chair"". According to a significant change in status MDS with an ARD of 01/12/11, in Section G0300, the assessor again encoded Resident #78's performance on Items A, D, and E as ""2"", meaning she was ""not steady, only able to stabilize with human assistance"". Elsewhere in Section G, the assessor noted Resident #78 now required the extensive physical assistance of two (2) or more persons with transferring and toilet use. On 01/14/11, the assessment coordinator (Employee #85) completed a falls risk assessment on Resident #78, resulting in a score of ""16"". (Note: A score above ""10"" indicates the resident is at risk for falls.) On her last fall risk assessment dated [DATE], she scored ""9"", indicating she was not at high risk for falls at that time. She had experienced a decline since her previous fall risk assessment. - 3. According to the facility's fall prevention program, once the falls risk assessment is complete, interventions should be set in place and the resident's should be care plan updated. Review of the resident's care plan revealed the following problem statement dated 06/16/09 - 04/19/11: ""Decrease in physical mobility due to left sided weakness, tremors, deconditioning."" The goal associated with this problem statement, dated 06/16/09 - 04/19/11, was: ""Will remain free of complications related to decreased mobility, including contractures, thrombus formation, skin breakdown, fall related injury thru next 90 days."" Interventions to achieve this goal were: ""Observe, report to MD prn (as needed) s/sx (signs and symptoms) of immobility (contractures, forming of (sic) worsening, thrombus formation, skin breakdown, fall related injury. PT/OT referrals as indicated. Provide supportive care, assistance with mobility as needed. Document assistance needed. Keep items within easy reach of functional side (right), if one sided weakness is present. Administer medications and treatments as ordered and monitor for side effects."" Only after the resident's fall on 01/23/11 was a plan developed to specifically address falls. The following problem statement was added on 01/24/11: ""At risk for falls related to antidepressant, weakness, and past history of falls."" The goal associated with this problem was: ""Resident will not have any additional falls with injury thru the next 90 days."" The interventions to achieve this goal were: ""Ensure resident has on footwear with non-skid soles prior to getting up. Resident is two assist for transfers, up to C/V chair for mobility. Observe fatigue level: do not tire resident, report C/O (complaints of) weakness / intolerance, dizziness, pain or confusion. Allow for rest periods during the day. Resident is not to be left unassisted while toileting. Observe for side effects associated with medication use. PT treatment as ordered to improve functional status."" - 4. In an interview on 03/09/11 at 10:00 a.m., Employee #85 confirmed she had not updated Resident #78's care plan upon her readmission to the facility, to reflect her need for additional staff assistance with ADLs, especially her need for staff supervision during toilet use. The care plan was updated on 01/24/11, the day after the fall. .",2014-07-01
11294,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2011-03-10,323,G,1,0,MHV411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and review of the facility's fall prevention program, the facility failed to provide adequate supervision to prevent avoidable accidents for one (1) of ten (10) sampled residents. Review of her minimum data set (MDS) assessments, with assessment reference dates (ARDs) of 12/06/10 and 01/12/11, revealed Resident #78 was ""not steady, only able to stabilize with human assistance"" when moving from a seated to a standing position, moving on and off the toilet, and completing surface-to-surface transfers. Review of the resident's fall risk assessment dated [DATE] revealed a score of 9. Persons receiving a score of 10 or greater are considered at high risk for falling; Resident #78 was not considered to be at high risk for falls at that time. Resident #78 was hospitalized from [DATE] until 01/05/11. On 01/06/11, Resident #78 was assessed as having poor sitting balance. On 01/14/11, she scored 16 on the fall risk assessment, indicating she was now at high risk for falls. Safety measures were not implemented to promote fall prevention in accordance with the facility's fall prevention program, and neither Resident #78's care plan nor the nursing assistant worksheet was revised to address her high risk for falling. On 01/23/11, Resident #78 was placed on the bedside commode and left unattended. She was later found on the floor. She was sent to the hospital and diagnosed with [REDACTED]. Resident #78's care plan and nursing assistant worksheet were not revised, to address the need for staff to remain with her when using the toilet, until after she fell and sustained injuries requiring medical intervention. Resident identifier: #78. Facility census: 115. Findings include: a) Resident #78 1. Record review revealed Resident #78 was an [AGE] year old female who was transferred to the hospital on [DATE] for cardiac arrest, and she was readmitted from the hospital on [DATE]. [DIAGNOSES REDACTED]. Further record review revealed, on 01/23/11, Resident #78 was placed by staff on a bedside commode and left unattended. Staff later found her in the floor. She was sent to the hospital and diagnosed with [REDACTED]. Review of the facility's internal investigation into the 01/23/11 fall revealed the following (quoted verbatim): ""... LSW (licensed social worker - Employee #62) spoke with various staff, from all 3 shifts, answered varied on whether or not resident should or could be left alone on toilet. For example, (name of Employee #100), LPN did not know that resident should be assisted by staff 'once on toilet, staff had left alone several times that night'. (Name of Employee #97) stated '(she) was aware had had to stay with resident. CNA's statements also varied between shifts. CNA worksheets had not been updated from time resident had been readmitted following prior hospital stay on 1/05/2011, as to change from w/c to c/v chair, or 2 assist during toileting. ..."" The internal investigation contained the following statement from a nursing assistant (Employee #119) related to the incident on 01/23/11 (quoted verbatim), ""... I was not told I could not leave her in her room alone nor do we receive report half the time. Our worksheets are wrong more than half the time too so there isn't much to go by ..."" - 2. According to an abbreviated quarterly MDS with an ARD of 12/06/10, in Section G0300 (balance during transitions and walking), the assessor encoded Resident #78's performance on Items A, D, and E (moving from seated to standing position, moving on and off toilet, and surface-to-surface transfer, respectively) as ""2"", meaning she was ""not steady, only able to stabilize with human assistance"". Elsewhere in Section G, the assessor noted Resident #78 required the limited assistance of two (2) or more persons with transferring and toilet use. When assessing the resident's sitting balance using a form titled ""Tinetti Assessment Tool: Balance"" (completed on 01/06/11), the assessor scored Resident #78 as ""1"", indicating she ""(l)eans or slides in chair"". According to a significant change in status MDS with an ARD of 01/12/11, in Section G0300, the assessor again encoded Resident #78's performance on Items A, D, and E as ""2"", meaning she was ""not steady, only able to stabilize with human assistance"". Elsewhere in Section G, the assessor noted Resident #78 now required the extensive physical assistance of two (2) or more persons with transferring and toilet use. On 01/14/11, the assessment coordinator (Employee #85) completed a falls risk assessment on Resident #78, resulting in a score of ""16"". (Note: A score above ""10"" indicates the resident is at risk for falls.) On her last fall risk assessment dated [DATE], she scored ""9"", indicating she was not at high risk for falls at that time. She had experienced a decline since her previous fall risk assessment. - 3. According to the facility's fall prevention program, once the falls risk assessment is complete, interventions should be set in place and the resident's should be care plan updated. Review of the resident's care plan revealed the following problem statement dated 06/16/09 - 04/19/11: ""Decrease in physical mobility due to left sided weakness, tremors, deconditioning."" The goal associated with this problem statement, dated 06/16/09 - 04/19/11, was: ""Will remain free of complications related to decreased mobility, including contractures, thrombus formation, skin breakdown, fall related injury thru next 90 days."" Interventions to achieve this goal were: ""Observe, report to MD prn (as needed) s/sx (signs and symptoms) of immobility (contractures, forming of (sic) worsening, thrombus formation, skin breakdown, fall related injury. PT/OT referrals as indicated. Provide supportive care, assistance with mobility as needed. Document assistance needed. Keep items within easy reach of functional side (right), if one sided weakness is present. Administer medications and treatments as ordered and monitor for side effects."" Only after the resident's fall on 01/23/11 was a plan developed to specifically address falls. The following problem statement was added on 01/24/11: ""At risk for falls related to antidepressant, weakness, and past history of falls."" The goal associated with this problem was: ""Resident will not have any additional falls with injury thru the next 90 days."" The interventions to achieve this goal were: ""Ensure resident has on footwear with non-skid soles prior to getting up. Resident is two assist for transfers, up to C/V chair for mobility. Observe fatigue level: do not tire resident, report C/O (complaints of) weakness / intolerance, dizziness, pain or confusion. Allow for rest periods during the day. Resident is not to be left unassisted while toileting. Observe for side effects associated with medication use. PT treatment as ordered to improve functional status."" - 4. In an interview on 03/09/11 at 10:00 a.m., Employee #85 confirmed she had not updated Resident #78's care plan upon her readmission to the facility, to reflect her need for additional staff assistance with ADLs. The care plan was updated on 01/24/11, the day after the fall. Employee #85 also stated the nursing assistant worksheet (a tool used to inform nurse aides of resident-specific care needs) was not updated until 01/28/11.",2014-07-01
11478,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2010-10-06,285,D,,,4XPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and review of the WV Medicaid program manual for nursing facilities, the facility failed to coordinate their assessments with the preadmission screening and resident review (PASRR) program under Medicaid as required. The facility readmitted a resident from an inpatient psychiatric stay prior to receiving approval by the State-designated reviewing agency - West Virginia Medical Institute (WVMI), which resulted in the resident having no payer source to cover his continued stay at the facility when it was determined by WVMI that he was no longer medical eligible for nursing home placement under WV Medicaid criteria. Resident identifier: #56. Facility census: 112. Findings include: a) Resident #56 Record review revealed Resident #56 came to the facility on [DATE] with a pre-admission screening form (PAS-2000) signed by the physician on 01/18/10, who indicated his primary [DIAGNOSES REDACTED]. This PAS-2000 was reviewed by WVMI on 01/20/10, at which time the reviewer determined Resident #56 was medically eligible, under the WV Medicaid criteria, for nursing facility services and that a Level II evaluation was necessary. A Level II evaluator determined Resident #56 did not require specialized services for mental illness or mental [MEDICAL CONDITION] on 01/22/10. Resident #56's initial PAS-2000 indicated he was appropriate for nursing home placement for a period of up to six (6) months, after which another PAS-2000 would have to be completed for his nursing home stay to continue to be paid for by WV Medicaid. During this six-month period, Resident #56 was admitted for inpatient psychiatric services from 05/28/10 until 06/09/10, when he was readmitted to the nursing home. A second PAS-2000, signed by a physician on 06/15/10, indicated Resident #56 needed nursing home services and was not likely to eventually return home. On 06/17/10, a reviewer from WVMI denied the request for nursing home admission for Resident #56, stating he was ""ineligible for long-term care (nursing home) admission based upon WV Medicaid criteria."" This determination was made after Resident #56 had already been readmitted to the nursing facility, which resulted in the resident having no payer source to pay for his continued stay in the nursing home. In an interview on 10/06/10 at approximately 2:30 p.m., the social worker (Employee #1), director of nursing (Employee #2), and administrator (Employee #3) all indicated they did not know the resident needed an approved PAS-2000 prior to his readmission at the facility from an inpatient psychiatric stay. The nursing facility manual, Chapter 514 Section - 514.8.2 states: ""To qualify medically for the nursing facility Medicaid benefit, an individual must need direct nursing care twenty-four (24) hours a day, seven (7) days a week. The Bureau has designated a tool known as the Pre-Admission Screening form (PAS) to be utilized for physician certification of the medical needs of individuals applying for Medicaid benefit .... ""Each nursing facility must have an original pre-admission screening tool to qualify the individual for Medicaid and to meet the federal PASRR requirements. Should the receiving nursing facility fail to obtain an approved assessment prior to admission of a Medicaid eligible individual, the Medicaid program cannot pay for services. The individual cannot be charged for the cost of care during this non-covered period. ""A Medicaid recipient who converts from Medicare Part A coverage to Medicaid does not need a new assessment to receive the Medicaid benefit. Medicaid coverage can be reinstated as long as a Medicaid denial letter has been issued. ""A new medical assessment must be done for Medicaid eligibility for the nursing facility resident for all of the following situations: ""- Application for the Medicaid nursing facility benefit; ""- Transfer from one nursing facility to another; ""- Previous resident returning from any setting other than an acute care hospital; ""- Resident transferred to an acute care hospital, then to a distinct skilled nursing unit, and then returns to the original nursing facility; and ""- Resident converts from private pay to Medicaid."" As Resident #56 was returning from a setting other than an acute care hospital, a new PAS-2000 was required prior to his re-admission to the nursing facility.",2014-02-01
3545,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2017-06-22,241,D,0,1,150411,"Based on observation and staff interview, the facility failed to ensure Residents #5 and #37 had a dignified dining experience during the meal on 06/19/17. Residents #5 and #37 were served fifteen (15) minutes after other residents in the dining room. This was a random opportunity for discovery during the observation of the meal on 06/19/17. Resident identifiers: #5 and #37. Facility Census: 38. Findings include: a) Residents #5 and #37 Observation of the meal on 06/19/17 beginning at 11:00 a.m. found twelve (12) residents in the main dining room. The staff served ten (10) of the twelve (12) residents by 11:10 a.m. on 06/19/17. Nursing staff brought Residents #5 and #37's meals at 11:25 a.m. on 06/19/17. This was fifteen (15) minutes after the other residents in the dining room had been served. An interview with the Director of Nursing (DoN), at 11:30 a.m. on 06/19/17, confirmed Residents #5 and #37 were not served at the same time as the other residents in the main dining room.",2020-09-01
3546,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2017-06-22,272,D,0,1,150411,"Based on record review and staff interview, the facility failed to ensure Resident #17's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/15/17 was accurately completed to reflect the medications Resident #17 received during the seven (7) day look back period. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #17. Facility Census: 38. Findings Include: a) Resident #17 A review of the MDS with an ARD of 02/15/17, on 06/21/17 at 4:02 p.m., under the medications section revealed the following: Insulin Injections: 5. Antipsychotic: 6 days Antianxiety: 4 days Anticoagulant: 0 days A review of the Medication Administration Record (MAR) for the look back period of 02/09/17 through 02/15/17 found Resident #17 received an insulin injection on seven (7) days, received an antipsychotic medication on seven (7) days, received an antianxiety medication on six (6) days, and received an anticoagulant medication on seven (7) days during the seven (7) day look back period. An interview with the Director of Nursing at 10:59 a.m. on 06/22/17 confirmed the admission MDS with an ARD of 02/15/17 was inaccurately completed in the area of medications. She reviewed the MAR and the MDS and agreed the medication sections of the MDS were inaccurately completed.",2020-09-01
3547,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2017-06-22,278,D,0,1,150411,"Based on record review and staff interview, the facility failed to ensure Resident #4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/18/17 was accurately completed to reflect what medications Resident #4 received during the seven (7) day look back period. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #4. Facility Census: 38. Findings Include: a) Resident #4 A review of Resident #4's medical record, beginning at 1:26 p.m. on 06/20/17, found a Quarterly MDS with an ARD of 03/18/17. A review of this MDS found under the Medication section, the following, Medications Received - Indicated the number of DAYS the resident received the following medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. Enter 0 if medication was not received by the resident during the last 7 days. Days: Diuretic: 7, indicating Resident #4 received a diuretic medication (fluid pill) on seven (7) of the seven (7) days during the look back period. A review of the medication administration record (MAR) for the seven (7) day look back period from 03/12/17 through 03/18/17 found Resident #4 received no diuretic medication. An interview with the Director of Nursing at 06/20/17 at 2:55 p.m. confirmed Resident #4's quarterly MDS with an ARD of 03/18/17 was inaccurately completed. She reviewed the MDS and the MAR and indicated Resident #4 did not receive a diuretic medication on seven (7) of the seven (7) days during the look back period as indicated by the MDS.",2020-09-01
3548,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2017-06-22,279,D,0,1,150411,"Based on staff interview and record review, the facility failed to develop a comprehensive care plan which included Resident #12's behavior of resisting care daily. This was true for one (1) of three (3) residents reviewed for the care area of behavioral and emotional status during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #12. Facility census: 38. Findings include: a) Resident #12 Review of the most recent significant change minimum data set (MDS), with an assessment reference date (ARD) of 03/01/17, found the resident rejected care daily. Review of the current care plan, initialed by Registered Nurse (RN) #59 as being updated on 03/10/17, found the care plan did not specifically detail what type of care the resident resisted daily and the facility's plan to address the behaviors. The care plan addressed past behaviors such as: -resident drains her peg tube into her brief, -resident has occasional episodes of wanting to smoke and attempts to exit the facility, -past episodes of crying, cursing, screaming, hallucinating, etc. The director of nursing (DoN) was interviewed at 3:08 p.m. on 06/20/17. A review of the nursing notes with the DoN found the resident had been refusing her meals daily. The DoN reviewed the care plan and confirmed the care plan did not address the resident's daily refusal of her meals or how the facility would address the resident's refusal of meals.",2020-09-01
3549,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2017-06-22,280,D,0,1,150411,"Based on record review and staff interview, the facility failed to update the resident's care plan related to inappropriate behaviors for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #40. Facility census: 38. Findings include: a) Resident #40 On 04/19/17, the resident was witnessed rubbing a female resident's leg. The incident was reported and investigated per Federal regulations. On 05/11/17, the resident began receiving one on one monitoring, 7 days a week, 24 hours a day for a second act of unwanted sexual advances to another female resident. The facility reported and investigated this incident per regulations. The facility's plan of correction to prevent a re-occurrence of these behaviors and to safeguard other residents, was to provide a designated staff member, who provides one on one monitoring to only this resident at all times. Review of the resident's current care plan, was initialed by Registered Nurse (RN) #59, as being reviewed on 06/17, found the care plan addressed the problem of the resident's inappropriate sexual behaviors. The goal was the resident would demonstrate effective coping behavior and participate in activities. The interventions for accomplishment of this goal did not include the one on one continuous monitoring. At 11:09 a.m., on 06/21/17, RN #59 and the Director of Nursing (DoN) confirmed the continuous one on one monitoring was not included on the care plan. The DoN said she had updated the former care plan to include the monitoring but this intervention did not get carried over to the current care plan.",2020-09-01
3550,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2017-06-22,309,E,0,1,150411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #17 received [MEDICATION NAME] (bulk laxative) according to the physician's orders from 03/27/17 to 06/21/17. This was true for one (1) of five (5) residents reviewed for unnecessary medications during Stage 2 of the Quality Indicator Survey. Resident identifier: #17. Facility census: 38. Findings include: a) Resident #17 A review of Resident #17's medical record, at 4:02 p.m. on 06/21/17, found a pharmacy drug regimen review recommendation dated 03/24/17. This review recommended Resident #17's order for [MEDICATION NAME] mixed with six (6) milliliters (ml) of water be clarified and be administered with at least six (6) ounces (oz) of water. On the recommendation was a hand written note which read as follows, 8 oz added. This recommendation was signed by the attending physician. Further review of the record found a physician order dated, 03/27/17 which read, Polyethylene [MEDICATION NAME] (generic name for [MEDICATION NAME]) 3350 Powder 510/527 gm (gram) 1 capful PO (by mouth) daily 0900 (9:00 a.m. ) Dx (diagnosis) Constipation. Mix in 8 ml of water. This order had a start date of 03/27/17. A review of the Medication Administration Record [REDACTED]. An interview with the Director of Nursing (DoN) at 10:59 a.m. on 06/22/17 confirmed the physician ordered [MEDICATION NAME] mixed in 8 oz of water not 8 ml. She stated this was a medication error. She indicated the physician's order was entered incorrectly into the computer, on 03/27/17. She stated the [MEDICATION NAME] should have been administered in 8 oz of water as written on the pharmacy recommendation and signed by the attending physician.",2020-09-01
3551,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2017-06-22,371,F,0,1,150411,"Based on observation and staff interview, the facility failed to ensure food was stored in a safe and sanitary manner to prevent food borne illness. One food item in the walk-in refrigerator was not dated by the kitchen staff as to the date the item was opened, in addition the food item did not contain a manufactures expiration date. Two additional food items in the walk-in refrigerator had expired and had not been discarded. This had the potential to affect all residents who receive nourishment from the kitchen. Facility census: 38. Findings include: a) Initial tour of the kitchen The initial tour of the kitchen began at 11:00 a.m. on 06/19/17, with the Kitchen Manager. An opened gallon jug of mayonnaise was found in the walk-in refrigerator with no date to indicate when opened by the facility and no date stamped by the manufacture to indicate the expiration date. A pan of raspberry jello was prepared on 06/10/17 and had an expiration date of 06/17/17. In addition, an opened gallon jug of Barbeque sauce was stamped with a manufactures expiration date of 02/28/17. The Kitchen Manager said she would discard the items immediately.",2020-09-01
3552,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2017-06-22,514,E,0,1,150411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the medical record for Resident #4 and #41 was complete and accurate. Resident #4's Medication Administration Record [REDACTED]. Resident #41's medical record did not contain the pressure ulcer record from a previous admission. This record was maintained in the Director of Nursing's (DoN) office in a file cabinet instead of the medical record. This was true for two (2) of 15 medical records reviewed. Resident identifiers: #4 and #41. Facility census: 38. Findings Include: a) Resident #4 A review of Resident #4's medical record, at 1:26 p.m., on 06/20/17 found a physician's orders [REDACTED]. A review of Resident #4's MAR, from 01/01/17 through 06/20/17, found the following occasions when Resident #4's [MEDICATION NAME] was documented as administered in the morning hours between 8:00 a.m. and 10:00 a.m., but the resident's pulse was not documented until hours later: -- 01/02/17 medication administered at 8:58 a.m., pulse recorded at 10:27 a.m. -- 01/13/17 medication administered at 8:04 a.m., pulse recorded at 9:48 a.m. -- 01/19/17 medication administered at 8:06 a.m., pulse recorded at 11:02 a.m. -- 01/28/17 medication administered at 8:49 a.m., pulse recorded at 2:30 p.m. -- 01/30/17 medication administered at 8:32 a.m., pulse recorded at 2:30 p.m. -- 02/05/17 medication administered at 8:50 a.m., pulse recorded at 2:22 p.m. -- 02/13/17 medication administered at 8:40 a.m., pulse recorded at 9:52 a.m. -- 02/18/17 medication administered at 8:11 a.m., pulse recorded at 10:02 a.m. -- 02/26/17 medication administered at 8:54 a.m., pulse recorded at 2:24 p.m. -- 02/27/17 medication administered at 8:38 a.m., pulse recorded at 2:10 p.m. -- 03/07/17 medication administered at 8:16 a.m., pulse recorded at 2:09 p.m. -- 03/08/17 medication administered at 9:27 a.m., pulse recorded at 1:55 p.m. -- 03/12/17 medication administered at 8:13 a.m., pulse recorded at 11:18 a.m. -- 03/20/17 medication administered at 9:48 a.m., pulse recorded at 1:48 p.m. -- 03/21/17 medication administered at 9:19 a.m., pulse recorded at 11:22 a.m. -- 03/22/17 medication administered at 8:24 a.m., pulse recorded at 11:21 a.m. -- 03/24/17 medication administered at 8:57 a.m., pulse recorded at 1:55 p.m. -- 04/02/17 medication administered at 9:59 a.m., pulse recorded at 12:05 p.m. -- 04/05/17 medication administered at 8:50 a.m., pulse recorded at 11:26 a.m. -- 04/08/17 medication administered at 9:36 a.m., pulse recorded at 2:04 p.m. -- 04/12/17 medication administered at 8:31 a.m., pulse recorded at 4:55 p.m. -- 04/24/17 medication administered at 8:17 a.m., pulse recorded at 10:03 a.m. -- 05/09/17 medication administered at 8:09 a.m., pulse recorded at 10:43 a.m. -- 05/12/17 medication administered at 9:26 a.m., pulse recorded at 2:46 p.m. -- 05/14/17 medication administered at 8:10 a.m., pulse recorded at 2:09 p.m. -- 05/21/17 medication administered at 8:44 a.m., pulse recorded at 1:23 p.m. -- 05/25/17 medication administered at 8:03 a.m., pulse recorded at 11:07 a.m. -- 05/26/17 medication administered at 8:59 a.m., pulse recorded at 10:13 a.m. -- 05/29/17 medication administered at 8:03 a.m., pulse recorded at 06/07/17 at 8:41 p.m. -- 06/01/17 medication administered at 8:41 a.m., but pulse recorded at 1:07 p.m. -- 06/08/17 medication administered at 8:42 a.m., but pulse recorded at 3:36 p.m. -- 06/10/17 medication administered at 8:15 a.m., but pulse recorded at 1:54 p.m. -- 06/15/17 medication administered at 8:01 a.m., but pulse recorded at 9:33 a.m. -- 06/16/17 medication administered at 8:29 a.m., but pulse recorded at 1:15 p.m. -- 06/17/17 medication administered at 8:35 a.m., but pulse recorded at 5:18 p.m. -- 06/18/17 medication administered at 8:19 a.m., but pulse recorded at 1:53 p.m. An interview with the DoN at 11:16 a.m. on 06/21/17 confirmed on these dates Resident #4's pulse was entered into the MAR indicated [REDACTED]. She indicated likely the nurse obtained the pulse and wrote it down but did not enter it into the computer until later. It looked like the time the pulse was taken hours later than the time the medication was administered. During an interview with Licensed Practical Nurse (LPN ) #60 at 12:19 p.m. on 06/21/17 (who was the nurse who administered all, but one of the medications listed above.) she stated the reason it showed up like that on the MAR indicated [REDACTED]. She stated the time that shows up on the MAR indicated [REDACTED]. b) Resident #41 A review of Resident #41's medical record, on 06/21/17 at 11:00 a.m., during Stage 1 of the Quality Indicator Survey, found the resident was admitted to the facility on [DATE] with an unstageable pressure ulcer to the left heel. This information was located on the nursing admission assessment dated [DATE]. No other information pertaining to this wound could be found in Resident #41's medical record. At 12:00 p.m. on 06/21/17, the DoN was asked where the pressure ulcer documentation was kept for each resident. She stated, If they are still here I have a book that I keep the weekly wound assessments in. When asked where those assessments go after the resident was discharged as in the case of Resident #41 she stated, I take them out of the book and file them in this folder. She then removed a file folder from her filing cabinet in her office. When asked if this pressure ulcer record was scanned into Resident #41's medical record she stated, I don't think that they are. She agreed the pressure ulcer records should be scanned in and she would have them all scanned in as soon as possible.",2020-09-01
3553,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2017-06-22,520,F,0,1,150411,"Based on record review and staff interview, the facility failed to ensure the Medical Director attended quarterly Quality Assessment and Assurance (QA&A) Committee Meetings. This practice has the potential to affect all residents currently residing at the facility. Facility Census: 38. Findings Include: a) QA&A A review of the QA&A sign in sheets and/or attendance logs for the previous twelve months at 1:30 p.m. on 06/22/17, found the facility held a QA&A committee meeting on 05/25/16, 08/22/16, 02/21/17, and 04/24/17. Review of the sign in sheets and/or attendance log for each meeting found the Medical director did not attend the meetings held on 02/21/17 and 04/24/17. An interview with the Director of Nursing (DoN) at 1:46 p.m. on 06/22/17 confirmed the Medical Director did not attend these meetings. She stated, He was probably tied up in surgery and did not make it to the meetings.",2020-09-01
3554,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2018-08-17,550,E,0,1,1R7V11,"Based on observation and staff interview, the facility failed to provide a home-like dining experience for residents. There were no tableclothes on the tables, no beverages were offered, no hand wipes offered for resident to wash their hands before meals. Also there was a concern with how staff positioned and fed a resident who received a pureed diet. This was evident for 10 of 10 residents observed at meal time. This was also noted in two different dining areas on the unit. Census: 34. Findings included: a) On 08/13/18 04:47 PM surveyors watched the evening meal in the main dining area. Seven residents were present with 2 staff members in the area at the time. The TV was playing for stimulation but there were no tableclothes on tables, no beverages being offered to residents while they waited for meals, nor hand wipe offered to wash their hands before the meal. The television was then turned off once food trays came to the dining area and trays were passed. This did not enhance the dining experience and make it homelike for the residents eating in the dining area. b) Resident #13 During an observation on 08/13/18 at 5:21 PM, Resident # 13 was in a Geri chair in the reclined position. Licensed Practical Nurse (LPN) #28 was standing over him while she fed him dinner. She was putting heaping spoonfuls of green pureed food in his mouth, then using the spoon to scrap off the food that did not fit into his mouth, and not allowing much time for him to swallow. LPN # 24 was asked if she was supposed to be standing while feeding him, she shrugged her shoulders and said, I don't know. LPN #28 was asked if she always stood to feed him and she said, no and I feed him all the time and I always sit. She was asked why she was standing today to feed him and she said, I don't know. Resident #13 was offered one drink of which he did not get any of the orange colored drink more than halfway up the straw before LPN#28 took it away. LPN #28 took his tray out of the room at 5:30 PM and stated to Nurse Aide (NA) #7 that she was taking him back to his room because he was getting choked. During an interview on 08/15/18 at 10:40 AM, Administrator was informed of observation during dining. He said he will have to do some re-educating. This facility uses the Lippincott's Nursing Procedures Sixth Edition. published date 2013, for the nurses and nurse aides to follow for direction as a policy. Some of the points for feeding a resident are as follows: -conduct the feeding in a friendly, unhurried manner for dignity -Fowler's or semi-Fowler's (Sitting upright) position makes swallowing easier and reduces the risk of aspiration and choking -before trays arrive provide the resident with soap and water and a dry towel to clean their hands -position a chair next to the patient -During the meal, wipe the patient's mouth and chin as needed with a napkin or soft towel -Don't feed a patient too quickly because this can cause anxiety and impair digestion - Choking and aspiration of food can occur if the patient is fed too quickly or is given excessively large mouthfuls",2020-09-01
3555,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2018-08-17,558,D,0,1,1R7V11,"Based on observation, staff interview, and resident interview, the facility failed to ensure accommodations were offered to residents as needed. This was evident for one (1) of 34 residents who were reviewed in during the initial tour of the facility. Resident identifier: #28. Facility census: 34. Findings included: a) Resident #28 During the initial tour resident #28 was found to have a call bed cord stretched across the bed. When the surveyor tried to activate the call bell it would not work. The surveyor then summoned staff to come and assist in trying to see if the bell would work. There was another type call bell which was built into the side rail of the bed which would call for the nurse, activate the televison, etc. The staff determined the call cord across the bed was the roommates call cord. Staff then tried to place that call cord back on the roommate's bed and place the unit on the side rail close to the resident. The resident did not wish to use that call system and requested the other type back. Staff needed to accommodate the residents needs with a type of system she preferred.",2020-09-01
3556,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2018-08-17,640,D,0,1,1R7V11,"Based on record review and staff interview, the facility failed to ensure all Minimum Data Set (MDS) records were transmitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days of completion. This was true for three (3) of six (6) residents reviewed for the facility task of resident assessments during the Long Term Care Survey Process. Resident identifiers: #4, #5, and #6. Facility census: 34. Findings included: a) Resident #4, #5, and #6 A review of resident #4, #5, and #6's MDS records at 11:25 AM on 08/14/18 found the following: --Resident #4's last MDS with an assessment reference date (ARD) of 07/10/18 had not been transmitted to CMS at the time of this review. --Resident #5's last MDS with an ARD of 07/10/18 had not been transmitted to CMS at the time of this review. --Resident #6's last MDS with an ARD of 07/11/18 had not been transmitted to CMS at the time of this review. An interview with Registered Nurse (RN) #32 at 11:50 a.m. on 08/14/18 confirmed that all three MDS's noted above should have been transmitted by now and they must have just missed sending them.",2020-09-01
3557,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2018-08-17,641,D,0,1,1R7V11,"Based on record review and staff interview, the facility failed to ensure Resident #23's Quarterly Minimum data set with an Assessment Reference Date (ARD) of 07/03/18 was accurately completed to represent Resident #23's status. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during the Long Term Care Survey Process. Resident Identifier #23. Facility Census: 34. Findings Included: a) Resident #23 A review of resident #23's MDS with an ARD of 07/03/18 at 9:57 AM on 08/15/18 found section N0350B. Orders for insulin was coded with a seven (7) to indicate Resident #23 had seven (7) insulin orders during the seven (7) day look back period. Further review of the MDS found section N0410A Antipsychotic was coded with a seven (7) to indicate that Resident #23 received and antipsychotic medication on seven (7) of the seven days during the look back period. Further review of the record found no new insulin orders during the seven (7) day look back period and found Resident #23 received no antipsychotic medication during the seven (7) day look back period. During interviews with Registered Nurse (RN) #32 at 1:49 PM and 2:45 PM on 08/15/18 she confirmed resident #23 had no new orders for insulin during the seven (7) day look back period and that he received no antipsychotic medications during the seven (7) look back period.",2020-09-01
3558,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2018-08-17,675,D,0,1,1R7V11,"Based on observation, policy review and staff interview, the facility failed to properly and safely provide a dependent resident lunch. This was true for one (1) of two (2) residents observed being fed. Resident identifier: #13. Facility census: 34. Finding included: a) Resident #13 During an observation on 08/13/18 at 5:21 PM, Resident # 13 was in a Geri chair in the reclined position. Licensed Practical Nurse (LPN) #28 was standing over him feeding him. She is putting heaping spoonsful of pureed food in his mouth, then using the spoon to scrap off the food that did not fit into his mouth, and not allowing much time for him to swallow. LPN # 24 was asked if LPN was supposed to be standing while feeding him, she shrugged her shoulders and said, I don't know. LPN #28 was asked if she always stood to feed him and she said, no and I feed him all the time and I always sit. She was asked why she was standing today to feed him and she said, I don't know. Resident #13 was offered one drink of which he did not get any of the orange colored drink more than halfway up the straw before LPN#28 took it away. LPN #28 took his tray out of the room at 5:30 PM and stated to Nurse Aide (NA) #7 that she was taking him back to his room because he was getting choked. His chair was never changed from the reclining position. Placing him in an upright position would be optimal for eating. During an interview on 08/15/18 at 10:40 AM, Administrator was informed of observation during dining. He said he will have to do some re-educating. This facility uses the Lippincott's Nursing Procedures Sixth Edition. published date 2013, for the nurses and nurse aides to follow for direction as a policy. Some of the high points for feeding a resident are as follows: -conduct the feeding in a friendly, unhurried manner for dignity -Fowler's or semi-Fowler's (Sitting upright) position makes swallowing easier and reduces the risk of aspiration and choking -before trays arrive provide the resident with soap and water and a dry towel to clean their hands -position a chair next to the patient -During the meal, wipe the patient's mouth and chin as needed with a napkin or soft towel -Don't feed a patient too quickly because this can cause anxiety and impair digestion -Choking and aspiration of food can occur if the patient is fed too quickly or is given excessively large mouthfuls",2020-09-01
3559,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2018-08-17,686,D,0,1,1R7V11,"Based on observation and staff interview, the facility failed to provide treatment and services to promote the healing of pressure ulcers. This was true for one of one resident reviewed for the care area of pressure ulcers. Resident identifier: #15. Facility census: 34. Findings included: a) Resident #15 During an interview on 08/13/18 at 11:54 AM, Resident # 15 said he had pressure ulcers on his bottom. During an observation on 08/14/18 at 12:00 PM, Licensed Practical Nurse (LPN) #24 and LPN #34 changed the dressing to the pressure ulcers on the coccyx. There were three pressure ulcers on the coccyx, including one that was very large. Last measurement was on 08/08/18 was as follows: --Coccyx Stage IV, 8.5 centimeters (cm) width, 7 cm length, 2 cm depth. --Left Ischial Tuberosity Stage III (Gluteal fold) 11 cm width, 2cm length, 1.5 cm depth. --Right Ischial Tuberosity Stage III 3cm width, 1.75 cm length, 0.5 cm depth. He also had a pressure ulcer on his right heal, Stage II, 3 cm width, 1.75 cm length, 0.1 depth with sloughing. He was admitted with two of these pressure ulcers, the one on the coccyx and heal on 11/03/17 with measurements of: --Coccyx, Stage IV, 9 cm width, 7 cm length, 2 cm depth. --Right Heel, Stage III, 5 cm width, 4 cm length, 0.6 depth. Nursing notes indicate the pressure ulcer to the left Ischial Tuberosity was first observed on 02/09/18: --Stage II, 1cm width, 2 cm length, 1 cm depth. On 07/16/18 was the first note about the pressure ulcer on the right Ischial Tuberosity: --Stage III, 2.8 cm width, 1.8 cm length, 0.6 cm depth. During an interview on 08/14/18 at 1:04 PM, RN#8 was to provide more information and documentation for his pressure ulcers. No documentation of consults for wound specialist or pressure prevention bed or mattress. During an interview on 08/15/18 at 2:30 PM, Administrator said that they were aware of his pressure ulcers worsening and acquiring new ones. He said maybe they should have had him sent to a wound clinic, but he is on a softer mattress then the others but not a specialty mattress made for the prevention and the promote healing of pressure ulcers for high risk residents.",2020-09-01
3560,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2018-08-17,697,D,0,1,1R7V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #136's pain status was adequately monitored on a consistent basis. This was true for one (1) of one (1) residents reviewed for the care area of Pain during the Long Term Care Survey process. Resident Identifier #136. Facility Census: 34 Findings included: a) Resident #107 A review of Resident #107's medical record at 2:21 p.m. on 08/15/18 found Resident #107 was admitted to hospice services on 07/28/18 for end stage Lewey Body Dementia. Further review of the record found a physician's orders [REDACTED]. Monitor for non - verbal signs and symptoms of pain. A review of the treatment administration record (TAR) found that on the 3:00 p.m. to 11:00 p.m. shift on 08/01/18, 08/02/18, 08/03/18, 08/04/18, 08/05/18, 08/09/18, 08/10/18, and 08/12/18 the nurses did not document the residents pain level. An interview with Licensed Practical Nurse (LPN ) #25 at 10:08 a.m. 08/15/18 confirmed a number from 0-10 should be documented on the TAR to indicate the residents pain level. She confirmed on these dates a pain level was not documented. An interview with Registered Nurse (RN) # 59 at 1:16 p.m. on 08/15/18, confirmed that a pain level was not documented on the TAR for the above mentioned date. She stated that since they did not have a pain level documented that she could not say for sure if he had pain or not. She stated that she would check for further documentation. At 2:00 p.m. office assistant (OA) #55 brought in a note from RN #59 which stated they could find no more documentation related to Resident # 136's pain management.",2020-09-01
3561,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2018-08-17,812,E,0,1,1R7V11,"Based on observation and staff interview, the facility failed to label stored foods with date opened, maintain a clean kitchen, did not document dishwasher temperatures, and did not have a functioning internal refridgerator thermometer. This had the potential to affect all the residents who are served from this central location. Facility census: 34. Findings included: a) During initial tour with dietary staff on 08/13/18 at 12:06 PM the following issues were observed: 1. The drip pan under the range top was found to have lots of food debris and residue. It was in need of cleaning. 2. There was no working internal thermometer in the refrigerator. There was an internal thermometer inside but staff could not read what temperature the device was displaying. 3. In a reach in-refrigerator there was an opened gallon of 2% milk that did not have the date opened on the container. This did not allow dietary staff to ensure the milk was still safe to consume. 4. The dishmachine temperature log documentation for (MONTH) contained many days that were blank. This practice did not allow dietary staff to keep track if the dishmachine had reached the correct temperature to sanitize the dishware appropriately. Dietary staff was present and verified the issues at the time of the observations. These were additinally reviewed with the administrator on 08/15/18 at midmorning.",2020-09-01
3562,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2018-08-17,842,D,0,1,1R7V11,"Based on record review and staff interview, the facility failed to ensure Resident #18's medical record was complete and accurate. The facility did not document all of Resident #18's blood sugars in his medical record. This was true for one (1) of 12 resident records reviewed during the long term care survey process. Resident identifier #18. Facility census: 34. Findings included: a) Resident #18 A review of Resident #18's medical record at 9:00 AM on 08/15/18 found a physicians order dated 03/11/17 which read, Accu Check Finger Sticks daily at 6:30 a.m. and document. Further review of the record found that Resident #18's blood sugars were documented in the electronic medical record (EMR) under the heading WVLTC Diabetic Monitoring (Parent). Review of this documentation from 06/01/18 through current found no blood sugars documented for the following. For the month of (MONTH) (YEAR): --06/02/18 , 06/08/18, 06/13/18, 06/16/18, 06/23/18, 06/24/18, 06/25/18, and 06/27/18. For the month of (MONTH) (YEAR): --07/02/18, 07/03/18, 07/04/18, 07/05/18, 07/07/18, 07/08/18, 07/11/18, 07/12/18, 07/13/18, 07/15/18, 07/16/18, 07/19/18, 07/20/18, 07/23/18, 07/27/18, 07/28/18 , 07/29/18, and 07/31/18. For the month of (MONTH) (YEAR): --08/01/18, 08/02/18, 08/03/18, 08/05/18, 08/10/18, 08/11/18, 08/12/18, and 08/14/18. An interview with Registered Nurse (RN) #8 at 10:00 AM on 08/15/18 confirmed not all the blood sugars were documented in the Medical Record. She stated, They may be on the report sheet I will have to check. Later in the day RN #8 provided a report sheet for each day the blood sugar was not listed in the Medical Record. She indicated the staff wrote them on the report sheet but did not enter them into the record. She confirmed the report sheet listed multiple residents names and was not part of the medical record.",2020-09-01
3563,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2018-08-17,880,E,0,1,1R7V11,"Based on observation, staff interview and policy review, the facility failed to promote and maintain an infection prevention program to reduce the spread of infection and/or disease. For two (2) of two (2) residents reviewed in the care area of catheter and/or peri care. Resident identifiers: #15 and #25. Facility census: 34. Findings included: a) Resident #15 During an interview on 08/13/18 at 2:04 PM, Resident #15 stated he had a catheter. During an observation on 08/14/18 at 3:15 PM, Nurse Aide (NA) #42 was asked to empty the Catheter bag for Resident #15. NA #15 repeatedly tapping the draining spout on the collection bag on the side of the urinal which was being used to empty the urine out of the collection bag. During an interview on 08/15/18 at 1:11 PM, Registered Nurse (RN) #59 was asked why the policy for Foley catheter care did not address the care of the drain spout on the Foley collection bag. She reviewed the policy and said they will have to fix the policy. She agreed that the drainage spout should not touch anything and be wiped off before being replaced into the sleeve on the collection bag to prevent contamination of the closed sterile system. b) Resident #25 During a phone interview on 08/13/18 at 2:22 PM, with the Medical Power of Attorney for Resident #25 stated the resident keeps getting a urinary tract infection. During an observation on 08/15/18 at 1:19 PM, NA # 37 was doing peri-care for Resident #25, she used three (3) wash clothes one (1) with soap she washed the pubic area then without opening the vagina she did one wipe over the vagina this was repeated with the other two (2) wash clothes without soap then the resident was rolled to her side and her buttock washed and dried. NA# 37 was asked if that was her normal routine for peri care and she answered yes. She was informed that she only cleaned the pubic area and the outside of the vagina. She agreed that by not opening the vaginal folds this could cause the resident to get urinary tract infections and could cause skin break down. The facility Policy titled, NURSING DEPARTMENT PR[NAME]EDURE FOR CATHETER CARE States the following: -For female patients, open the labia and cleanse using a washcloth wiping from front to back with downward stokes, using a new washcloth with each stroke, cleaning the innermost surface outward. During an interview on 08/15/18 at 1:39 PM, Administrator was informed of findings during the observation. He agreed that re-educating the staff is necessary.",2020-09-01
3564,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2018-08-17,881,D,0,1,1R7V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Medical record review and staff interview, the facility failed to implement a antibiotic stewardship program that included antibiotic use protocols. This was true for four (4) of 34 residents reviewed. Resident identifiers: #33, #24, #29 and #12. Facility census: 34. Findings included: a) Resident #33 Review of records revealed that Resident #33 was given [MEDICATION NAME] (antibiotic) even though the, Urinary Tract Infection - Minimum Criteria for Initiation of an Antibiotic or Loeb assessment form was checked NO for all questions, which would indicate this resident does not meet criteria to receive antibiotics. b) Resident #24 Record review revealed this resident received [MEDICATION NAME] for seven (7) days. On the Loeb assessment form the only question answered was No for the question asking if the resident had an indwelling Foley Catheter. c) Resident #29 Record review of the Loeb assessment form for lower Respiratory infection revealed Resident #29 received [MEDICATION NAME] (antibiotic) for nine (9) days. There was a line with an arrow drawn from top to bottom in the NO column. To indicate this resident did not meet criteria to receive antibiotics. d) Resident #12 Record review of the Loeb Skin and Soft Tissue infection assessment form for this resident had all Nos marked on the form, which would indicate Resident #12 did not meet the criteria to receive antibiotics. In the space for Nurse Observation: was wrote, Hemorrhoid. However Resident #12 was [MEDICATION NAME](antibiotic). e) Interviews During an interview on 08/15/18 at 1:15 PM, Registered Nurse (RN) #59 agreed that the antibiotic stewardship is not being followed for Resident #33, #24, #29, #12. During an interview on 08/15/18 at 3:04 PM, Administrator was informed of finding regarding the Antimicrobial Stewardship not being followed and he said, So much using the Loeb for the Antimicrobial Stewardship.",2020-09-01
3565,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2018-08-17,883,E,0,1,1R7V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Medical record review and staff interview the facility, failed to provide pneumonia immunizations. This was true for 5 of 5 residents randomly chosen to be reviewed for influenza and pneumococcal vaccines. Resident identifiers: #4, #5, #19, #21 and #17. Facility census: 34. Findings included: a) Resident #4 Record review revealed Resident #4 had no records to indicate when or what pneumococcal vaccine was offered or given. This Resident was admitted on [DATE]. b) Resident #5 Resident #5 was admitted on [DATE], and after a record review there was no record of when or what pneumococcal vaccine was ever offered or given. c) Resident #19 Resident #19 was admitted on [DATE]. At that time, it was recorded that this resident received a pneumonia vaccine on 11/20/14. There was no other record of this resident being offered or receiving any other pneumococcal vaccines. d) Resident #21 Resident #21 was admitted on [DATE]. The facility had no record of this resident being offered or giving the pneumococcal vaccine. e) Resident #17 Resident #17 was admitted on [DATE]. There was a record of this resident being in a local hospital and received a pneumococcal vaccine on 11/04/10. Record review revealed the facility could not provide any record to indicate that the pneumococcal vaccine was offered or given to this resident. During an interview on 08/15/18 at 1:15 PM, Registered Nurse (RN)#59 stated that she was not aware of the Centers for Disease Control (CDC) guidelines for the pneumococcal vaccines. During an interview on 08/15/18 at 2:22 PM, RN #59 said she could not provide any consents or documentation regarding the pneumococcal vaccines for Residents #4, #5, #19, #21 and #17. During an interview on 08/15/18 at 3:04 PM, Administrator was informed of finding regarding the no consents for the influenza and pneumonia vaccines, plus no documentation to show that the pneumococcal vaccine was offered or given. He said, It's probably not a very good practice but the social worker normally meet with the Resident or their family and she would get a onetime consent for the Flu and pneumonia shots. I guess it's not good because they could change their minds from year to year. He agreed that the current practice is not in compliance and states he is going to change it. He also stated that the infection control nurse should have known about the CDC recommendations. The CDC recommends that adults [AGE] years old or older receive Pneumococcal Conjugate (PCV13) and Pneumococcal [MEDICATION NAME] (PPSV23) one (1) year apart.",2020-09-01
3566,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2019-08-28,558,D,0,1,EC8V11,"Based on observation, resident interview and staff interview, the facility failed to ensure each resident received reasonable accommodation of needs and preferences. Resident #5's clean clothes were hung in the Resident's bathroom on the shower rod. When asked if she wanted clothes hung up in her bathroom, she stated she would rather have a wardrobe to hang her clothes. This was a random opportunity for discovery. Resident identifier: #5. Facility census: 23. Findings included: a) Resident #5 Observations of Resident #5's room at 2:57 PM on 08/26/19 found her clean clothes were hanging in her bathroom on the shower rod above the bathtub. An interview with Resident #5 at 4:06 PM 08/26/19, revealed she did not want her clothes hung up in the bathroom. Furthermore, she stated she would like to have a wardrobe in her room to hang her clothes. She stated the facility was supposed to get her one when she was admitted in (MONTH) and they have not got her one yet. Additional observations of Resident #5's room at 1:35 PM on 08/27/19 confirmed her clothes were still hanging on the shower rod above the bath tub. When asked if she wanted her clothes stored in the restroom she stated, No I really would like to have wardrobe to hang them in. The Administrator was present during this observation and interview he stated, We have some in storage. She will have one by the end of the day.",2020-09-01
3567,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2019-08-28,577,C,0,1,EC8V11,"Based on observation and staff interview, the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. Review of posted survey results found no results from a recent complaint investigation that was conducted in (MONTH) 2019. This practice has the potential to affect all residents and visitors to the facility. Facility census: 23. Findings included: Observations at 1:00 PM on 08/27/19, found the survey results from the most recent complaint investigation completed on 01/17/19 was not in the three ring binder labeled Survey Result Posting. An interview with the Administrator at 1:23 PM on 08/27/19, confirmed the results from the complaint survey completed on 01/17/19 were not posted as required.",2020-09-01
3568,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2019-08-28,580,D,0,1,EC8V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the physician and/or the family/responsible party of the development of pressure ulcers. This was true for 2 of 3 residents reviewed for the care area of pressure ulcers. Resident identifiers: #23 and #18. Facility census: 23. Finding included: a) Resident #23 Review of Resident #23's medical records found the resident was admitted to the facility on [DATE] with no skin breakdown. Nurses note written on 08/11/19 at 10:31 AM by Employee #106, licensed practical nurse (LPN) revealed, Resident has a round blood blister area on the ball of right foot and a round like area on the ball of left foot. Resident stated both feet are sore. Will have (attending physician's name) evaluate tomorrow (08/12/19). No indication the family and/or the physician was notified of the pressure ulcers on both feet. On 08/21/19 at 5:02 PM, the physician evaluated the pressure ulcers. Nurses note revealed, Doctor in to assess resident's right foot blister on bottom and 2nd right toe pressure ulcer. Resident states, It is from my blue shoes and laces, they are new and tight. Area to the bottom of right foot intact, dark purplish in color, dry like and hard. Blister like area on top of the right 2nd toe. Encourage resident to not wear the same blue shoes. Record review revealed there was no mention of the area on the bottom (ball) of left foot assessed by the physician on 08/21/19. Observation of Resident #23's feet, on 08/28/19 at 10:10 AM, found an area on the bottom (ball) of both feet discolored (dark red/purple) and intact and top of right great toe open. Record review revealed the facility did not initiate a pressure ulcer record for Resident #23 as of 08/21/19. No further observation and measurement could be located in the resdient's record. Interview with the Nursing Home Administrator (NHA), on 08/27/19 at 3:45 PM, confirmed no documentation the family and/or family representative was notified of the pressure ulcer development. b) Resident #18 Review of Resident #18's medical records found a note dated 07/19/19 at 12:31 PM for a Stage 2 pressure ulcer on the right coccyx. No indication the family or the physician were notified. As of 08/16/19, Resident #18 continues to have a Stage 2 pressure ulcer on the right coccyx. Interview with the Nursing Home Administrator (NHA), on 08/27/19 at 3:45 PM, confirmed the family and/or family representative was notified of the pressure ulcer development.",2020-09-01
3569,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2019-08-28,623,D,0,1,EC8V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the resident or the resident's representative of a transfer and the reasons for the move in writing for 2 of 3 residents reviewed for the care area of hospitalization . Resident identifiers: #11 and #4. Facility census: 23. Findings included: a) Resident #11 Review of Resident #11's medical records revealed she was transferred to the hospital on [DATE] due to fever. The medical records did not contain a Notice of Transfer or Discharge, which notifies the resident or the resident's representative of the transfer, the reasons for the move, the resident's right to appeal the transfer. On 08/28/19 at 8:53 AM, Administrative Secretary #52 stated she was unable to locate a Notice of Transfer or Discharge for Resident #11 for 07/07/19. On 08/28/19 at 9:53 AM, Social Worker #200 confirmed a Notice of Transfer or Discharge was not completed for Resident #11 on 07/07/19. On 08/28/19 at 12:36 PM, the Administrator was informed of this situation. He had no additional information regarding the matter. No further information was provided through the completion of the survey. b) Resident #4 Review of Resident #4s medical record found she was transferred to the emergency room for lethargy and confusion on 08/20/19. No indication the family and/or responsible party was notified of the transfer on 08/20/19. Interview with the Nursing Home Administrator (NHA) on 08/27/19 at 2:30 PM, confirmed no notification could be located for Resident #4's 08/20/19 transfer.",2020-09-01
3570,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2019-08-28,637,D,0,1,EC8V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a significant change assessment when the resident's hospice services were discontinued. This was true for 1 of 10 residents reviewed during the survey process. Resident identifier: #6. Facility census: 23. Findings included: a) Resident #6 Review of Resident #6's medical records revealed a quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 06/17/19 indicated he was receiving hospice services. Review of Resident #6's physician's orders [REDACTED]. During an interview on 08/28/19 at 12:32 PM, Registered Nurse (RN) #197 confirmed Resident #6 had been receiving hospice services that were discontinued due to his family's wishes. RN #197 stated she did not know a significant change MDS was required when hospice services were discontinued. On 08/28/19 at 12:40 PM, the administrator was informed of the situation. The administrator had no additional information regarding the matter. No further information was provided through the completion of the survey.",2020-09-01
3571,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2019-08-28,656,D,0,1,EC8V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop and implement the comprehensive care plan for 2 of 10 residents care plans reviewed. Resident #23's care plan was not developed for pressure ulcers and the care plan for anticoagulant monitoring was not implemented and Resident #24's care plan for hospice measures was not implemented. Resident identifiers: #23 and #24. Facility census: 23. Findings included: a) Resident #23 - Pressure Ulcers Review of Resident #23's medical records found the resident was admitted to the facility on [DATE] with no skin breakdown. Nurses note written on 08/11/19 at 10:31 AM by Employee #106, licensed practical nurse (LPN). This note read: Resident has a round blood blister area on the ball of right foot and a round like area on the ball of left foot. Resident stated both feet are sore. Will have (Attending Physician's Name) evaluate tomorrow (08/12/19). No indication the family and/or the physician was notified of the pressure ulcers on both feet. On 08/21/19 at 5:02 PM the physician evaluated the pressure ulcers. Nurses note read: Doctor in to assess resident's right foot blister on bottom and 2nd right toe pressure ulcer. Resident states, it is from my blue shoes and laces, they are new and tight. Area to the bottom of right foot intact, dark purplish in color, dry like and hard. Blister like area on top of the right 2nd toe. Encourage resident to not wear the same blue shoes. No mention of the area on the bottom (ball) of left foot. Observation of Resident #23's feet on 08/28/19 at 10:10 AM, found an area on the bottom (ball) of both feet discolored (dark red/purple) and intact and top of right great toe open. No pressure ulcer prevention and/or development care plan could be located. Interview with the Nursing Home Administer, (NHA), on 08/27/19 at 3:45 PM, confirmed no care plan for pressure ulcers for Resident #23 was initiated. b) Resident #23 - Anticoagulant Monitoring Review of Resident #23's medical records found the resident was admitted to the facility on [DATE] with orders to monitor the blood work for anticoagulant ([MEDICATION NAME]) therapy. Physician orders [REDACTED]. Care plan intervention: Monitor [MEDICATION NAME] time/international ratio (PT/INR) weekly. Review of Resident #23's lab work found a PT/INR was done on 08/07/19. No further lab work was obtained. Interview with the Nursing Home Administer, (NHA), on 08/27/19 at 3:45 PM, confirmed the no care plan Monitor [MEDICATION NAME] time/international ratio (PT/INR) weekly was not implemented b) Resident #24 A review of Resident #24's medical record at 8:52 AM on 08/28/19 found a care plan related to Resident #24's hospice care for the following: --Problems/Strengths: Resident is receiving palliative care with Hospice (name of hospice company) due to Alzheimer. --Goals: Resident will be free of s/s of pain and will remain comfortable through next review. --Interventions: The Resident will no longer receive weekly/monthly weights due to palliative care. Further review of Resident #24's medical record found the resident's weight was measured and recorded in the medical record for 06/27/19, 27/31/19 and 08/27/19. An interview with the administrator at 12:30 p.m. on 08/28/19 confirmed Resident #24's hospice care plan intervention in regards to no longer weighing Resident #24 was not implemented.",2020-09-01
3572,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2019-08-28,657,D,0,1,EC8V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the revision of the comprehensive care plan for 2 of 10 residents reviewed during the survey process. Resident #6's care plan was not updated in the area of [MEDICAL CONDITION] medication. Resident #13's care plan was not updated in the area of pain medication. Resident identifiers: #6 and #13. Facility census: 23. Findings included: a) Resident #6 Review of Resident #6's physician's orders [REDACTED]. --[MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg, twice a day for anxiety --[MEDICATION NAME] ([MEDICATION NAME]) 0.25 mg, twice a day for dementia with behavioral issues --[MEDICATION NAME] ([MEDICATION NAME]) 25 mg, at bedtime for depression Review of Resident #6's comprehensive care plan revealed the problem, Risk for discomfort and side effects r/t (related to) [MEDICAL CONDITION] meds needed for anxiety/depression/dementia with behaviors. The interventions included, Meds per orders - [MEDICATION NAME] 1 mg po (orally) every 6 hours - Trazadone (sic) 50 mg at bedtime - [MEDICATION NAME] 0.25 mg every 8 hours - observe for possible side effects every shift, monitor for non-verbal s/s (signs and symptoms) of adverse side effects, report pertinent lab results to MD (medical doctor) - maintain behavior log every shift. (Typed as written.) During an interview on 08/28/19 at 12:39 PM, Registered Nurse (RN) #197 agreed Resident #6's comprehensive care plan was not updated when his [MEDICATION NAME] was decreased to 0.5 mg twice a day, his [MEDICATION NAME] was decreased to twice a day, and his [MEDICATION NAME] was decreased to 25 mg. On 08/28/19 at 12:40 PM, the administrator was informed of the situation. He had no further information regarding the matter. No additional information was provided through the completion of the survey. b) Resident #13 Review of Resident #13's physician's orders [REDACTED]. Review of Resident #13's comprehensive care plan revealed the problem, Pain related to low back pain, [MEDICAL CONDITIONS], gout, restless leg syndrome, and left shoulder pain as evident by verbal complaints and/or nonverbal signs and symptoms of pain. The interventions included, [MEDICATION NAME] 10 mg/325 mg po (orally) q (every) 12 hrs (hours) prn (as needed). During an interview on 08/28/19 1:43 PM, Registered Nurse (RN) #197 agreed Resident #13's comprehensive care plan was not updated when her [MEDICATION NAME]/[MEDICATION NAME] was changed from as needed to a schedule of for twice a day. No additional information was provided through the completion of the survey.",2020-09-01
3573,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2019-08-28,684,D,0,1,EC8V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to follow physician orders [REDACTED]. This was true for one (1) of five (5) residents reviewed for unnecessary medication. Resident identifier: #23. Facility census: 23. Findings included: a) Resident #23 Review of Resident #23's medical records found the resident was admitted to the facility on [DATE] with orders to monitor the blood work for anticoagulant ([MEDICATION NAME]) therapy. Physician orders [REDACTED]. Care plan intervention: Monitor [MEDICATION NAME] time/international ratio (PT/INR) weekly. Review of Resident #23's lab work found a PT/INR was done on 08/07/19. No further lab work was obtained. Interview with the Nursing Home Administer, (NHA), on 08/27/19 at 3:45 pm, confirmed the order for [MEDICATION NAME] time/international ratio (PT/INR) weekly was not implemented.",2020-09-01
3574,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2019-08-28,880,D,0,1,EC8V11,"Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Infection prevention and control measures were not maintained during indwelling urinary catheter care for one (1) of one (1) residents reviewed for the care area of indwelling catheter. Resident identifier: #11. Facility census: 23. Findings included: a) Resident #11 On 08/27/19 at 10:05 AM, indwelling urinary catheter care for Resident #11 was observed as performed by Health Service Worker (HSW) #105. Licensed Practical Nurse #140 was also in attendance. HSW #105 washed his hands and donned gloves before beginning the procedure. HSW #105 first cleaned Resident #11 of incontinent stool using washcloths. HSW #105 did not perform hand hygiene and change his gloves after completing the fecal incontinence care and before beginning the indwelling urinary catheter care. He cleaned Resident #11's periarea with washcloths and then cleaned the indwelling catheter tubing with an alcohol wipe. HSW #105 was informed he did not perform hand hygiene and change his gloves after completing the fecal incontinence care and before beginning the indwelling urinary catheter care. He was informed the resident's periarea and catheter tubing could have been contaminated with fecal matter that may have been left on his gloves. LPN #140, who was present during the procedure, agreed HSW #105 should have performed hand hygiene and changed his his gloves between performing fecal incontinence care and indwelling urinary catheter care. On 08/27/19 at 10:32 AM, the administrator was informed of this situation. He had no further information regarding the matter. No additional information was provided through the completion of the survey.",2020-09-01
4533,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2016-04-21,159,E,0,1,OVQ111,"Based on record review, family interview, and staff interview, the facility failed to ensure each resident and/or responsible party who had a resident trust account with the facility was provided a financial record (statement) of the account on a quarterly basis and/or upon request. This was true for five (5) of five (5) resident reviewed for the care area of personal funds during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifiers: #7, #20, #1, #17, and #6. Facility Census: 36. Findings Include: a) Resident #7 During a family interview at 12:50 p.m. on 04/18/16, Resident #7's responsible party indicated that he was the resident's representative for financial decisions. When asked if the facility maintained a resident trust account for Resident #7, he said they did have an account for her in case she wanted to get her hair done or should she need anything. He was then asked, Does the facility give you a statement of how much money is in the resident's account? He stated, I don't recall them ever giving me anything like that. In the afternoon on 04/19/16, the facility was asked to provide any statements sent to Resident #7's responsible party and/or to Resident #7. The facility did not provide any statement for Resident #7 as of 04/21/16 at 1:00 p.m. at which time the facility was asked to provide a complete accounting of Resident #7's trust fund. Review of this accounting found the first money deposited into Resident #7's account was deposited on 10/14/15, which was six (6) months prior to this review. During an interview at 12:35 p.m. on 04/21/16, the Chief Financial Officer (CFO) confirmed the facility had sent no statements to Resident #7 or her responsible party. The CFO said they had provided all that they had as far as statements were concerned, and none were found for Resident #7. b) Resident #20 The facility provided a list of all residents who currently had a resident trust fund with the facility. Resident #20 was chosen as a random sample for review. On the afternoon of 04/19/16, the facility was asked to provide the quarterly statements sent to Resident #20 and/or her responsible party regarding Resident #20's personal funds account for the previous 12 months. A review of the statements provided on 04/21/16 at 12:00 p.m., found the resident had only received one (1) quarterly statement in the last 12 months. She received a statement for the quarter of 07/01/15 through 09/30/15. She had not received a statement for 01/01/16 through 03/31/16, 10/01/15 through 12/31/15, or 04/01/15 through 06/30/15. c) Resident #1 Resident #1's name was on the list of residents with funds handled by the facility. The resident was chosen as a random sample for review. On the afternoon of 04/19/16, the facility was asked to provide the quarterly statements sent to Resident #1 and/or her responsible party regarding the resident's personal funds account for the previous 12 months. A review of the statements provided on 04/21/16 at 12:00 p.m. found the resident had only received two (2) quarterly statement in the last 12 months. She received a statement for the quarter of 07/01/15 through 09/30/15 and 04/01/15 through 06/30/15. She had not received a statement for 01/01/16 through 03/31/16, or 10/01/15 through 12/31/15. d) Resident #17 Resident #17 was chosen at random for review of funds from the list the facility provided. On the afternoon of 04/19/16, upon request, the facility provided the quarterly statements sent to Resident #17 and/or her responsible party in the last 12 months. A review of the statements provided on 04/21/16 at 12:00 p.m., found the resident had only received two (2) quarterly statement in the last 12 months. She received a statement for the quarter of 07/01/15 through 09/30/15 and 04/01/15 through 06/30/15. She had not received a statement for 01/01/16 through 03/31/16, or 10/01/15 through 12/31/15. e) Resident #6 Resident #6 was randomly selected for the list provided by the facility. On the afternoon of 04/19/16 the facility provided the quarterly statements sent to Resident #6 and/or her responsible party during previous 12 months. A review of the statements provided on 04/21/16 at 12:00 p.m., found the resident had only received two (2) quarterly statement in the last 12 months. She received a statement for the quarter of 07/01/15 through 09/30/15 and 04/01/15 through 06/30/15. She had not received a statement for 01/01/16 through 03/31/16, or 10/01/15 through 12/31/15. f) An interview with the CFO at 12:35 p.m. on 04/21/16 confirmed the facility had not sent the quarterly statements to these residents as required. He stated they had provided all the statements they were able to locate.",2019-10-01
4534,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2016-04-21,225,D,0,1,OVQ111,"Based on review of the facility's reportable allegations of abuse/neglect, staff interview, and review of the facility's abuse policy, the facility failed to immediately report allegations of abuse/neglect to the appropriate State authorities as required by State law. This was true for one (1) of five (5) investigations of abuse/neglect reported by the facility within the past year. Resident identifier: #10. Facility census: 36. Findings include: a) Resident #10 Review of the facility's reportable allegations of abuse/neglect on 04/20/16 found the following documentation: On 05/02/15, Registered Nurse (RN) #11 completed a resident complaint/grievance form from Resident #10. The nurse documented on the grievance/concern form: Resident #10 said, . staff are making her feel bad when they come to change her after having bowel movements. She was able to describe 2 workers and denies any other problems with other staff. On 05/03/15, a second staff member, the Director of Nursing (DON), spoke with the resident regarding the complaint received on 05/02/15. The DON wrote the following statement on 05/03/15 (typed as written): This nurse to resident's room to speak with her concerning complaint she filed on 5/2/15. (Name of resident) had stated that two staff members 'made her feel bad' when she they come to her room to change her after having she had bowel movements. (typed as written). (Name of resident) stated that it had been happening for about a month or so. I reminded (name of resident) of the conversation I had with her regarding reporting instances such as this to me and she stated she 'hated to say anything.' (name of resident) stated 'When they diaper me, they go on and one about how I've pooped.' (Name of resident) stated 'the colored girl in the morning told me to quit taking my medicines because they make me have diarrhea.' (name of Resident) also stated she 'told the colored girl that I didn't want to take any more of that medicine and she that I didn't have to do anything I didn't want to do.' (Name of resident) stated, 'that colored girl didn't make me feel bad.' (name of resident) stated that the other staff member was a fat lady with blond hair that limps and that lady told her 'I'm not getting anybody up today because there's not enough people here' and 'shoo, you've done it now, you need to stop that' when (name of resident) had a bowel movement. (Name of resident) stated 'I cried all the time.' (Name of resident) stated that 'fat lady' also told her 'they can't fire anyone', that it was 'no use to talk to anyone', and that she was 'going to quit anyway.' The immediate fax reporting to the Nurse Aide Registry, completed by the facility social worker, was not completed until 05/04/15. Two (2) days after the resident's initial allegation. At 12:54 p.m. on 04/20/16, the DON said the incident was not reported when the initial statement was taken because the facility did not have enough information. The resident only said staff made her feel bad and the resident did not elaborate. She said the incident was reported two (2) days later after the facility received more information and identified the employees. At 10:00 a.m. on 04/21/16, RN #11, who took the initial statement on 05/02/15, stated she did not report the incident because she was waiting for the DON. Review of the facility's policy, entitled Abuse Investigation, found: . An initial report is made to OHFLAC (Office of Health Facility Licensure and Certification). While we have 24 hours to notify OHFLAC, the immediate report should occur as quickly as events will allow. Waiting 24 hours to report should not be the norm The facility should have reported the allegation staff became aware of the situation. The initial report should have been made to OHFLAC. When the facility identified the employees, the allegations could have then been reported to the Nurse Aide Registry. The guidance to surveyors defines immediately as, means as soon as possible, but ought not exceed 24 hours after discovery of the incident",2019-10-01
4535,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2016-04-21,272,E,0,1,OVQ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #39's comprehensive Minimum Data Set (MDS) assessment accurately reflected her behavioral status. Resident #43's comprehensive MDS did not accurately reflect her prognosis, and Resident #6's comprehensive MDS did not accurately reflect her pressure ulcers. This was true for three (3) of seventeen1(7) comprehensive MDSs reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifiers: #39, #43, and #6. Facility Census: 36. Findings include: a) Resident #39 A review of Resident #39's Significant Change MDS with an assessment reference date (ARD) of 12/24/15 found the resident assessed as having physical behavioral symptoms directed toward others for one (1) to three (3) days during the seven (7) day look back period. This MDS also indicated Resident #39 had wandered daily during the seven (7) day look back period and that this wandering had placed the resident at significant risk of getting into dangerous places. Further review of the medical record found no supporting documentation of the behaviors identified on the MDS with the ARD of 12/24/15. During an interview with the Social Worker on 04/20/16 at 9:35 a.m., she indicated that prior to completing the behavioral sections of the MDS, she would perform a chart review and staff interviews to determine what behaviors each resident exhibited. She said she did not necessarily only count occurrences of the behaviors which happened within the seven (7) day look back period. She said, If a resident is in the hospital for a few days during the look back period I will look at a few days prior to the beginning of the look back period. She was then asked to provide the basis for the answers she had chosen on the MDS with an ARD of 12/24/15. During and additional interview with the Social Worker at 10:38 a.m. on 04/20/16, she provided a Morning Nursing Assistant Flowsheet dated 12/22/15, which indicated the resident had refused care. She said this was the only documentation she could find in Resident #39's medical record for any behavioral symptoms during the seven (7) day look back period. She stated, she was certain the staff had reported these behaviors to her in interviews, but she had not written a note about the interviews. She stated that there was no documentation in the medical record to support the answers given on the MDS with an ARD of 12/24/15 regarding the presence of behaviors. b) Resident #6Review of Resident #6's medical record on 03/19/16 at 2:00 p.m., found Resident #6 was admitted to the facility on [DATE]. The pressure ulcer assessment/body audit completed by Registered Nurse (RN) #33, indicated the resident had a Stage 2 pressure wound on the left shoulder measuring 1 centimeter (cm) in length and 0.3 cm in width. Additionally, the wound was first observed was 01/10/16 and was in-house acquired. Review of Resident #6's annual MDS assessment with an assessment reference date (ARD) of 01/10/16, found the number of Stage 2 pressure ulcers coded as one (1) and the number of Stage 2 pressure ulcers present on admission coded as zero (0). In Section S, the assessment had zeros (0) for the number of new or recurring pressure ulcers during last quarter and in what setting did the in pressure ulcer develop. The location and status of existing wounds was left blank in Section S.Interview with Registered Nurse (RN) #11, MDS coordinator, on 03/19/16 at 3:15 p.m., confirmed Section S of the annual MDS with ARD of 01/10/16 was inaccurately coded. She confirmed the left shoulder area had developed since the last MDS review and was in-house acquired. She confirmed she had just missed placing the information in Section S.The director of nursing (DON) was informed on 03/19/16 at 4:30 p.m., of the inaccurately coded MDS with an ARD of 01/10/16 under section S. No further information was provided prior to exit at 4:00 p.m. on 04/21/16.",2019-10-01
4536,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2016-04-21,278,D,0,1,OVQ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the individual completing and certifying the accuracy of Resident #6's quarterly minimum data set (MDS) assessments failed to complete the pressure ulcer assessment accurately. This was found for one (1) of fourteen (14) MDSs reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #6. Facility census: 36. Findings include: a) Resident #6Review of the resident's medical record on 03/19/16 at 2:00 p.m., found she was admitted to the facility on [DATE]. The pressure ulcer assessment/body audit completed by Registered Nurse (RN) #33, indicated the resident had a Stage 2 pressure wound on the left shoulder measuring 1 centimeter (cm) in length and 0.3 cm in width. The wound, first observed on 01/10/16, was in-house acquired. Review of the resident's quarterly MDS assessment with an assessment reference date (ARD) of 04/08/16, found Section M identified the resident had one (1) Stage 2 pressure ulcer that was present on admission. Additionally, a zero (0), indicating none, was the response in Section S regarding in what setting did the pressure ulcer develop, and the assessment items for location and status of existing wounds were left blank.Interview with Registered Nurse (RN) #11, MDS Coordinator, on 03/19/16 at 3:15 p.m., confirmed the pressure ulcer assessments of the quarterly MDS with an ARD of 04/08/16 were inaccurately coded. She confirmed the left shoulder area had developed on 01/10/16 and was in-house acquired. She confirmed said she coded section M incorrectly and just missed placing the information in Section S.The director of nursing (DON) was informed on 03/19/16 at 4:30 p.m., of the inaccurately coded MDS with an ARD of 04/08/16 under sections M and S. No further information was provided as of exit at 4:00 p.m. on 04/21/16",2019-10-01
4537,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2016-04-21,279,D,0,1,OVQ111,"Based on record review and staff interview, the facility failed to develop a comprehensive care plan for one (1) of three (3) resident's whose care plans were reviewed for the care area of vision during Stage 2 of the Quality Indicator Survey (QIS). Resident #8's comprehensive assessment indicated the resident would have a care plan developed for the care area of visual functioning. Resident identifier: #8. Facility census: 36. Findings include: a) Resident #8 Review of the most recent comprehensive minimum data set (MDS), an annual, with an assessment reference date (ARD) of 01/13/16, found the assessment identified the resident as having moderately impaired vision - defined as not able to see newspaper headlines, but can identify objects. Review of Section V, the Care Area Assessment (CAA) Summary, noted the resident triggered the care area of visual function and the facility would proceed to the care plan. During an interview with Registered Nurse (RN) #11, Minimum Data Set (MDS)Coordinator, at 9:30 a.m. on 04/19/16, she confirmed the resident's current care plan did not include any problems, goals, or interventions related to the resident's visual deficits. She stated, It was just an oversight on our part.",2019-10-01
4538,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2016-04-21,282,D,0,1,OVQ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident observation, the facility failed to ensure implementation of the care plans for two (2) of seventeen (17) Stage 2 sampled residents. Resident #7's care plan was not implemented in the area of fall interventions. Resident #6's care plan was not implemented in regards to her feeding tube and for devices related to range of motion services. Resident Identifiers: #7 and #6. Facility Census: 36. Findings Include: a) Resident #7 A review of Resident #7's care plan at 2:08 p.m. on 04/19/16, found a care plan problem dated 04/11/16 of, Fall. The goal associated with this problem was, Resident's needs will be identified and met and resident will remain safe through next review. Interventions related to this problem included, Tabs monitor at all times to bed and wheelchair. An observation on 04/19/16 at 4:25 p.m., with the Director of Nursing (DON) and Registered Nurse (RN) #11, found the resident up in her wheelchair sitting in the hallway. An activities worker was painting the resident's fingernails. During the time of this observation, the resident did not have a tabs monitor in place. RN #11 then went to Resident #7's room and found the tabs monitor on the resident's chest of drawers. The DON and RN #11 both confirmed the tabs monitor was not in place at the time of this observation. b) Resident #6 1. A review of Resident #6's medical record at 10:00 a.m. on 04/20/16, found a physician's orders [REDACTED]. Give one half (1/2) can (125 ml) every four (4) hours through gastrostomy feeding tube; follow with 75ml of water. Hold if residual is over 100 ml and notify physician. Review of Resident #6's care plan found it contained a focus statement dated 04/12/09 of (typed as written),Potential for complications due to needing feeding tube. Has vomiting, gagging after tube feedings The goals related to this focus statement with target dates of 01/16/15, were Resident will not exhibit signs/symptoms of complications due to enteral nutrition during next review. Interventions included (typed as written), Verify tube placement prior to administering feedings, flushes, and medications. This intervention was added to the care plan on 08/26/09. Review of Resident #6's medication administration record (MAR) and treatment administration record (TAR), from 04/01/16 through 04/20/16, found no documentation of tube feeding residual. Observation of the tube feeding on 04/20/16 at 3:55 p.m., completed by Licensed Practical Nurse (LPN) #25, noted the nurse failed to check the residual prior to administering the tube feeding. When asked how often the residual was checked, she stated, Oh I didn't do it did I, well it is usually about 100 ml anyway. I guess I messed up. An interview with Director of Nursing (DON), at 4:30 p.m. on 04/20/16, confirmed Resident #6's care plan intervention related to checking feeding tube residual was not implemented by nursing staff. She reviewed Resident #6's MAR and TAR and confirmed the resident's residual amounts could not be found. No further information was provided as of exit at 4:00 p.m. on 04/21/16. 2. Medical record at 2:00 p.m. on 04/20/16, found the resident had been receiving Hospice services since 10/20/14 for a [DIAGNOSES REDACTED]. Further review of the physician's orders [REDACTED]. Review of the current care plan found the problem of Risk for body odor is totally dependent on staff with personal hygiene d/t (due to) dx. (diagnosis) advanced dementia (picks disease) with long and short term memory problems, inability to express wants and needs and is unable to make any decisions. Has b/b (bowel and bladder) incontinence d/t profound cognitive and physical cognitive and physical deficits and is dependent upon staff for bed mobility. Has contractures bilaterally at hands, neck, hip, ankles and knees. Develops dependent [MEDICAL CONDITION] easily, risk for skin breakdown The goal associated with this problem was, Resident will have needs met by staff daily during the next review period Approaches included: -- Rolled washcloths to contracted hands -- Place pillow between lower extremities, ankles and knees to prevent pressure. -- Position arms with pillows to prevent worsening of contractures and dependent [MEDICAL CONDITION] d/t crossing arms across chest-ROM (range of motion) to upper extremities 10 reps (repetitions) BID (two times a day). Observation of the resident on the afternoon of 04/19/16 from 1:30 p.m. to 4:00 p.m., found the hand rolls to both hands and the pillows for positioning of the arms were not in use. At 4:00 p.m. on 04/19/16, Registered Nurse (RN) #11, the minimum data set (MDS) coordinator, observed the resident. RN #11 confirmed the hand rolls were not being used and the pillows for positioning of the resident's arms were not being used. RN #11 also observed the resident's lower extremities for placement of pillows, as directed by the care plan. The nurse confirmed the pillows were not being used.",2019-10-01
4539,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2016-04-21,309,D,0,1,OVQ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure each resident received care and services in accordance with the individual's plan of care. Resident #45 did not have her vital signs take every shift for 72 hours after admission as ordered by the physician. One (1) of twenty-one (21) Stage 2 sample residents were affected. Resident identifier: #45. Facility census: 36. Findings include: a) Resident #45 On 04/20/16 at 10:30 a.m., a review of Resident #45's medical record revealed she was admitted to the facility on [DATE] at 9:40 a.m. Her admission physician's orders [REDACTED]. A review of the electronic progress notes and vital signs record revealed Resident #45's vital signs were not obtained on the following dates: -- 04/14/16 - 7-3 shift and 3-11 shift. -- 04/15/16 - 7-3 shift and 3-11 shift -- 04/16/16 - 11-7 shift, 7-3 shift, and 3-11 shift During an interview on 04/20/16 at 12:08 p.m., the Director of Nursing (DON), confirmed the resident's vital signs were not taken every shift for 72 hours as ordered on admission. The DON further confirmed Resident #45's vital signs should have been obtained through 04/16/16.",2019-10-01
4540,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2016-04-21,318,D,0,1,OVQ111,"**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 three (3) residents who met the criteria to review for contractures, was provided services to increase range of motion and/or to prevent further decrease in range of motion. Observation of the resident found devices for prevention of further contractures were not in place as directed by physician's orders [REDACTED]. Resident identifier: #6. Facility census: 36. Findings include: a) Resident #6 Medical record review at 2:00 p.m. on 04/20/16, found the resident had been receiving Hospice services since 10/20/14 for a [DIAGNOSES REDACTED]. Further review of the physician's orders [REDACTED]. Review of the current care plan found a care plan problem of, Risk for body odor is totally dependent on staff with personal hygiene d/t (due to) dx.(diagnosis) advanced dementia (picks disease) with long and short term memory problems, inability to express wants and needs and is unable to make any decisions. has b/b (bowel and bladder) incontinence d/t profound cognitive and physical cognitive and physical deficits and is dependent upon staff for bed mobility. Has contractures bilaterally at hands, neck, hip, ankles and knees. Develops dependent [MEDICAL CONDITION] easily, risk for skin breakdown The goal associated with this problem was, Resident will have needs met by staff daily during the next review period . Approaches included: -- Rolled washcloths to contracted hands -- Place pillow between lower extremities, ankles and knees to prevent pressure. -- Position arms with pillows to prevent worsening of contractures and dependent [MEDICAL CONDITION] d/t crossing arms across chest-ROM to upper extremities 10 reps BID. Observation of the resident on the afternoon of 04/19/16, from 1:30 p.m. to 4:00 p.m., found the hand rolls to both hands and the pillows for positioning of the arms were not in use. At 4:00 p.m. on 04/19/16, Registered Nurse (RN) #11, minimum data set (MDS) coordinator, observed the resident. RN # 11 confirmed the hand rolls were not in the resident's hands and the pillow for positioning of the arms was not being used. The nurse observed the residents lower extremities for placement of a pillow as directed by the care plan, and found no pillow was in place. Review of the most recent minimum data set (MDS) with an assessment reference date (ARD) of 01/10/16, found Section S identified the resident as having contractures of her neck, hands, hip, ankles and knees. A physical therapist's evaluation, completed on 01/20/16, directed staff to, keep pillows between knees and between arms and chest. Wash cloth rolls in hands. At 9:00 a.m. on 04/20/16, the director of nursing (DON), was informed of the observations made on 04/19/16. No further information was provided.",2019-10-01
4541,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2016-04-21,322,G,0,1,OVQ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .NEED TO ADD ACTUAL HARM AND FINDINGS Based on observation, interview, and record review, the facility did not ensure that one (Resident #6) of one (1) sampled resident who had a gastrostomy tube received the appropriate treatment and services to prevent aspiration pneumonia. Resident #6 was observed receiving tube feeding without first checking the tube placement and residual prior to bolus feeding the resident on 04/20/16. During this observation the resident was observed gagging and coughing repeatedly and face became flushed. This practice resulted in actual harm. Resident identifier: #6. Facility census: 36. Findings include: a) Resident #6 Review of Resident #6's medical record at 10:00 a.m. on 04/20/16, found a physician's orders [REDACTED]. Give one half (1/2) can (125 ml) every four (4) hours through gastrostomy feeding tube; follow with 75 ml of water. Hold if residual is over 100 ml and notify physician. Review of Resident #6's care plan found it contained a focus statement dated 04/12/09 of (typed as written), Potential for complications due to needing feeding tube. Has vomiting, gagging after tube feedings The goal related to this focus statement with a target date of 01/16/15, was Resident will not exhibit signs/symptoms of complications due to enteral nutrition during next review. Interventions included (typed as written), Verify tube placement and check residual prior to administering feedings, flushes, and medications. This intervention was added to the care plan on 08/26/09. Review of Resident #6's Medication Administration Record [REDACTED]. Observation of tube feeding on 04/20/16 at 3:55 p.m., completed by Licensed Practical Nurse (LPN) #25, found the nurse failed to check the placement of the feeding tube and residual prior to administering the tube feeding. During this observation, the nurse allowed the tube feeding and flush to instill rapidly. The resident repeatedly coughed and gagged throughout the feeding. The resident's face also became flushed and the resident looked frightened. The administration of tube feeding without checking the residual, not administering the feeding in a manner to avoid causing the resident to cough and gag and look frightened, resulted in actual harm to the resident. When asked how often the residual was checked, the nurse stated, Oh I didn't do it did I? Well it is usually about 100 milliliters anyway. I guess I messed up. She said the resident always coughed and gagged when given the tube feedings. During an interview on 04/21/16 at 9:30 a.m., when asked if the staff had tried to give the tube feeding slower, or by using a feeding pump or bag, to prevent the resident from gagging, coughing and becoming frightened, the director of nursing (DON) said, No, but I will asked the doctor about this. This resident was observed on 04/19/16 from 1:30 p.m. to 4:00 p.m. for the use of positioning devices. During that time, the resident was not noted to cough or gag, and her face was expressionless.",2019-10-01
4542,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2016-04-21,332,E,0,1,OVQ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. A nurse failed to check Resident #45's blood pressure prior to administering medication. This resulted in a total of two (2) errors out of twenty-six (26) opportunities resulting in an error rate of 7.69%. Facility census: 36. Findings include: a) Resident #45 Observation on 04/20/16 at 8:39 a.m., revealed Licensed Practical Nurse (LPN) #1 failed to obtain Resident #45's blood pressure prior to administering [MEDICATION NAME] 5 milligrams (mg) and Losartan 50 mg (both medications are used to treat high blood pressure) by mouth as directed by the physician orders. Medical record review on 04/21/16 at 8:45 a.m., found physician's orders [REDACTED]. Hold if systolic blood pressure is 110 or below or heart rate below 60. Losartan 50 mg by mouth daily . Hold if systolic blood pressure is 110 or below or heart rate below 60. Interview with LPN #1 on 04/20/16 at 8:43 a.m., revealed she did not obtain the resident's blood pressure prior to the administration of medications. She was unaware of the physician's orders [REDACTED]. Review of the resident's Medication Administration Record [REDACTED]. On 04/20/16 at 11:30 a.m., when informed of the medication errors, the director of nursing (DON) provided no further information",2019-10-01
4543,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2016-04-21,371,E,0,1,OVQ111,"Based on observation and staff interview, the facility failed to ensure all food was stored under safe and sanitary conditions to prevent the outbreak of foodborne illness. Individual cartons on chocolate milk that had passed the Best by date were found in the walk-in cooler. This had the potential to affect more that a limited number of resident who received milk from this central location. Facility Census: 36. Findings Include: a) During the initial tour of the facility's kitchen with Certified Dietary Manager (CDM) #50 at 10:30 a.m. on 04/18/16, a box containing approximately 22 individual cartons of chocolate milk was found in the walk-in cooler. Upon further observation of the chocolate milk the best by date was found to be 04/16/16 two (2) days prior to this observation. The CDM confirmed this milk needed to be discarded and should not have been in the walk-in cooler.",2019-10-01
4544,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2016-04-21,441,D,0,1,OVQ111,"Based on observations and staff interviews, the facility failed to conduct medication pass in a sanitary manner. A nurse gave a resident medication after it dropped on the resident's bed and handled the medication with bare hands. This practice affected one (1) four (4) residents observed during medication pass. Resident identifier: #45. Facility census: 36. Findings include: a) Resident #45 During a random observation of a medication pass on 04/20/16 at 8:39 a.m., Licensed Practical Nurse (LPN) #1 was dropped Resident #45's medications on the resident's bed. The nurse picked the medication up with her bare hands and attempted to place the medication in the resident's mouth. The medication dropped onto the resident's bed again, the nurse picked up medication with bare hands, and placed it in the resident's mouth. In an interview on 04/20/16 at 10:00 a.m., the director of nursing agreed medications were not to be picked up by a nurse using bare fingers to place medication in a resident's mouth or cup during a medication pass.",2019-10-01
4545,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2016-04-21,520,F,0,1,OVQ111,"Based on staff interview and review of the facility's Quality Assessment and Assurance (QAA) Program, the program failed to meet quarterly as required, and failed to have a designated physician present at each meeting. This failure had the potential to affect all residents at the facility. Facility census: 36. Findings include: a) Physician attendance and meetings At 1:30 p.m. on 04/21/16, the Director of nursing (DON) provided evidence of the staff members present at the QAA meetings held during the past year. The facility had only three (3) meetings in the past year- (MONTH) (YEAR) to (MONTH) (YEAR). The DON verified the facility's medical director or a designated physician had not attended any of the quarterly meetings. The attendance roster for the 3 meetings listed the medical director as being absent. In addition, the facility did not hold a meeting for all four (4) quarters of the year. At 1:30 p.m. on 04/21/16, the DON verified three (3) meetings were held for the year. Two (2) meetings did not have a date recorded on the attendance roster and the DON was unsure of the dates. Only one date was present on the third meeting, 05/14/15. At 1:56 p.m. on 04/21/16, the administrator was informed of these findings related to the QAA meetings. At the close of the survey on 04/21/16 at 4:00 p.m., no further information had been provided.",2019-10-01
5493,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2015-04-23,225,D,0,1,H66T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, resident interview, and staff interview, the facility failed to report an allegation of mistreatment/abuse for one (1) of one (1) residents reviewed for abuse allegations in Stage 2. The facility investigated an allegation made by Resident #13, but failed to notify the State agencies of the alleged incident. Resident identifier: #13. Facility census: 40. Findings include: a) Resident #13 During an interview on 04/20/15 at 9:48 a.m., Resident #13 stated one (1) nurse aide pulled her legs apart roughly when she provided care to her. She said she thought the nurse aide might have been mad or having a bad day. She said she reported the incident to the facility and the nurse aide no longer took care of her. During a follow-up interview, on 04/21/15 at 9:00 a.m., Resident #13 stated the staff member in question talked loudly with a rough voice. During this interview, Resident #13 stated she would not say the NA abused her, but she would say the care she provided was done in a rude and disrespectful manner. A review of the facility's abuse policy and procedure, on 04/21/15 at 9:15 a.m., revealed when a resident makes an allegation of abuse The facility will notify the Stage Agency within 24 hours. During an interview on 04/20/15 at 3:30 p.m., Director of Nursing (DON) #29 stated Resident #13 never complained any staff being rude, rough, or disrespectful while providing care. The DON stated the daughter reported an incident on 08/25/14 regarding a staff person being rough with her mother while providing care. The daughter had placed the completed complaint form under the DON's door. The DON received it on 08/26/14. The DON stated she conducted an investigation with regard to the allegation. She moved the staff member named in the grievance to work a different hall, and instructed the nurse aide she would not be providing care to Resident #13. On 04/21/15 at 10:05 a.m., review of the grievance form dated 08/25/14, revealed the daughter documented her mother needed to receive better treatment than she was getting. The daughter documented Nurse Aide (NA) #22 spoke rudely at times to her mother and moved her roughly at times when providing care to her. The investigation revealed DON #29 went to Resident 13's room to speak to her on 08/26/14 at 9:30 a.m., and the resident stated she wanted her daughter to be with her when she spoke to DON. The DON arranged a meeting with the resident and her daughter for 08/28/14 at 1:00 p.m. Review of the investigative notes from a meeting conducted on 08/28/14 between the resident's daughter and DON revealed: -- The daughter come to the facility to visit her mother on 08/25/14 at 5:00 p.m.; -- Her mother stated she was not being treated right by the a staff member; -- The daughter stated her mother told her she called out several times to be put back to bed at 3:00 p.m. on 08/25/14, but no one put her to bed; -- The daughter stated she went to get assistance for her mom at 5:00 p.m. and NA #22 was rude and had an attitude; -- The daughter stated NA #22 put her mom to bed at that time, but she felt the NA #22 had a loud and rude tone to her voice; -- The daughter stated when she changed her mom NA #29 told her mom to open her legs; -- The daughter told NA #22 her mom was not able to due to previous [MEDICAL CONDITION]; and -- The NA forcefully separated her mother's legs apart. The report documented the daughter and the DON went to Resident #13's room at 2:30 p.m. on 08/28/14. The DON interviewed Resident #13. The report indicated the resident stated the same events the daughter revealed about the NA being rude and pulling her legs apart when providing care. Further interview with DON #29 on 04/22/15, confirmed she had not reported to the State Agency. She stated as long as they investigate and determine within 24 hours that it was abuse, then they do not have to report it to the State. According to the regulatory requirement, The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The guidelines include, 'Immediately' means as soon as possible, but ought not exceed 24 hours after discovery of the incident, in the absence of a shorter state timeframe requirement. Conformance with this definition requires that each state has a means to collect reports, even on off-duty hours (e.g., answering machine, voice mail, fax).",2019-01-01
5494,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2015-04-23,226,D,0,1,H66T11,"Based on record review, policy review, resident interview, and staff interview, the facility failed to implement their written Abuse Prohibition Policy and Procedure to ensure an allegation of abuse was reported to the appropriate State agencies. This involved one (1) of one (1) resident reviewed for abuse allegations in Stage 2. Resident identifier: #13. Facility census: 40. Findings include: a) Resident #13 During an interview on 04/20/15 at 9:48 a.m., Resident #13 stated one nurse aide pulled her legs apart roughly when she provided care to her. She said she thought the nurse aide might have been mad or having a bad day. She said she reported the incident to the facility and the nurse aide no longer takes care of her. During a follow-up interview, on 04/21/15 at 9:00 a.m., Resident #13 stated the staff member in question talked loudly with a rough voice. During this interview, Resident #13 stated she would not say the NA abused her, but she would say the care she provided was done in a rude and disrespectful manner. During an interview on 04/20/15 at 3:30 p.m., the Director of Nursing (DON) #29 stated Resident #13's daughter reported an incident on 08/25/14 regarding a staff person being rough with her mother while providing care. The DON stated she conducted an investigation with regard to the allegation. Review of the incident report revealed the daughter and the DON went to Resident #13's room at 2:30 p.m. on 08/28/14. The DON interviewed Resident #13. The report indicated the resident stated the same events the daughter revealed about being rude and pulling her legs apart when providing care. Further interview with DON #29, on 04/22/15, revealed she had not reported to the State Agency. She stated as long as they investigate and determine within 24 hours that it was abuse then they do not have to report it to the State. A review of the facility abuse policy and procedure, on 04/21/15 at 9:15 a.m., revealed when a resident makes an allegation of abuse The facility will notify the Stage Agency within 24 hours. .",2019-01-01
5495,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2015-04-23,272,D,0,1,H66T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure an accurate comprehensive assessment for one (1) of twenty-two (22) residents whose minimum data set (MDS) assessments were reviewed. The resident's comprehensive MDS was not accurate related to contractures. Resident identifier: #18. Facility census: 40 Findings include: a) Resident #18 This resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A review of the comprehensive MDS assessment, with an assessment reference date (ARD) of 03/08/15, was conducted on 04/21/15 at 2:10 p.m. The section titled WV (West Virginia) Supplemental indicated Resident #18 had a contracture of the hand. The MDS assessment erroneously indicated a right hand contracture, when the resident actually had a left hand contracture. Multiple observations were conducted of the resident's right hand during all four (4) days of the survey. The resident was able to fully extend all five (5) fingers on the right hand, but demonstrated contractures of the left hand to include the ring finger, middle finger (third digit), and the thumb. The resident was not verbally interviewable, but could follow both visual and verbal commands. The resident was able to extend her fingers fully on the right hand when requested to do so. Upon request, she was unable to actively extend the thumb, ring finger or middle finger on the left hand. And interview was conducted with Nurse Aide (NA) #14, on 04/23/15 beginning at approximately 9:55 a.m. The NA confirmed the resident had a left hand contracture which included contractures of the middle finger, ring finger, and thumb. Another interview was conducted with NA #17 on 04/23/15, beginning at approximately 9:58 a.m. This NA attempted to passively extend the resident's fingers and thumb on the left hand. This demonstration revealed the ring finger, middle finger, and thumb on the left hand were contracted. An interview with Licensed Practical Nurse (LPN) #3 on 04/23/15, beginning at approximately 10:00 a.m., confirmed Resident #18 had contractures of the left hand to include the middle finger, ring finger, and thumb. The LPN also voiced there was no contracture of the right hand or fingers. An interview was also conducted on 04/23/15, beginning at approximately 1:10 p.m., with the Director of Nursing (DON). The DON conveyed understanding the MDS was not accurate related to the left hand contracture which was coded as a right hand contracture.",2019-01-01
5496,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2015-04-23,274,D,0,1,H66T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to conduct a significant change in status comprehensive assessment within fourteen (14) days after it was determined, or should have been determined, a significant change in the resident's physical condition occurred. Resident #42 had significant declines in her functional abilities that persisted for nearly two (2) months without completion of a significant change comprehensive assessment. This was found for one (1) of twenty-two (22) residents whose care areas were reviewed in Stage 2 of the Quality Indicator Survey. Resident identifier: #42 Findings include: a) Resident #42 1. Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record on 04/21/15 at 10:30 a.m., revealed Resident #42 was discharged to the hospital on [DATE] and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 04/21/15 at 10:30 a.m., review of the most recent Minimum Data Set (MDS) assessment, dated 02/17/15, revealed a Brief Interview for Mental Status score of 6 which indicated Resident #42 had severe cognitive impairment. This MDS documented Resident #42 was independent in bed mobility, transfers, walking in her room, walking in the hall, toilet use, bathing, and was steady at all times for moving from seated to standing, walking, turning around, moving on off toilet seat, and surface to surface transfer. On 04/21/15 10:39 a.m., review of the current care plans dated 08/21/13, revealed Resident #42 was at risk for falls with injury due to impaired safety awareness and visual impairment. Interventions included staff to encourage the use of a walker when the resident was ambulating, provide shoes with non-skid soles, and maintain room and pathways free from clutter. The care plan indicated she experienced frequent falls at home, required the assistance of one staff with her walker, but was known to ambulate unassisted without her walker. She also had a self-care deficit care plan dated 08/24/13, related to her lack of hygiene awareness and cognitive deficits and her need for assistance with personal hygiene. The interventions were for staff to assist her with a shower by setting up her supplies and assist her to the bathroom per her request. The care plan documented the resident was usually independent in this area. 2. The nurses' notes on 03/12/15, documented Resident #42 continued to try to get out of the bed and staff had to provide assistance to take her to toilet. The nurses' notes on 03/14/15 documented Resident #42 attempted to get out of the bed two (2) times stating she needed to go to the bathroom. Staff provided assistance to take her to the bathroom. Review of the nurse's note dated 04/10/15 at 2:43 p.m., revealed Resident #42's activities of daily living had declined over the past several months. Observation of Resident #42 on 04/22/15 at 8:20 a.m., revealed staff assisted her to the bathroom with the use of her walker. She required the assistance of one (1) staff member as she was unsteady when ambulating. Interview with Nurse Aides (NA) #17 and #11 on 04/22/15 at 8:30 a.m., revealed Resident #42 was always trying to ambulate on her own. They stated the resident was in the hospital back in February. They said when she returned, she was very weak and was now unable to walk or dress herself on her own. They also stated she used to be able to notify them when she needed to go to the bathroom, but now she did not do that very often. They stated when they checked on her, she was usually incontinent and they just had to change her. Interview with NA #14 on 04/22/15 at 8:50 a.m., revealed Resident #42 used her walker to go to the bathroom and could not ambulate on her own as she was weak. She stated the resident used to be able to walk on her own a month or so ago, but since she returned from the hospital, she had been falling and they were placing her in a wheelchair for ambulation. She stated Resident #42 used to tell her when she needed to go to the bathroom, but now she just checks on her like the other residents every two (2) hours. The NA said sometimes when she checked the resident, she was already incontinent. She said sometimes the resident called out for assistance if she needed to go to the bathroom, but most often she was incontinent. Interview with NA #15 on 04/22/15 at 9:37 a.m., revealed she took care of Resident #42 most of the time on the 7:00 a.m. to 3:00 p.m. shift. She stated the resident was not able to dress herself or walk independently anymore. She said the resident went out to the hospital a few months ago and after she returned, she had been very weak. The NA stated she had to physically help the resident to get dressed and take her to the bathroom. She said the resident used to use a walker to go to the bathroom with assistance, but now she placed her in a wheelchair. She stated she checked the resident every two (2) hours and she was often wet or soiled before she (the NA) got there. In an interview with the Director of Nursing (DON), on 04/22/15 at 9:40 a.m., she verified Resident #42 was able to independently walk, transfer herself, and was usually continent prior to her hospitalization on [DATE]. She stated when the resident returned on 02/26/15, she was extremely weak and was no longer able to walk or transfer independently and was often incontinent. In an interview on 04/22/15 11:07 a.m., when asked if there was a more recent MDS other than the 02/17/15 MDS for Resident #42, MDS Nurse #30 stated she was not yet due for a quarterly assessment. She said they discussed doing a significant change MDS, but felt the resident was going to get better so they had not yet done one. She verified as of 04/22/15, Resident #42 had not improved, was still very weak, and was unable to walk, dress herself, or safely transfer. She stated the resident was sent to the hospital on [DATE] due to lethargy, and returned on 02/26/15 with a [DIAGNOSES REDACTED]. MDS Nurse #30 indicated after the resident's return from the hospital, they noted a decline in the resident's functional status, but felt with time she would improve, so they were going to evaluate her again in a few weeks to determine if a significant change MDS would be required. She verified the resident's functional status, transfers, ambulation, dressing, and incontinence had not improved (since readmission on 02/26/15), but they had still not completed a significant change MDS. Interview again with DON #29 on 04/22/15 at 1:00 p.m., revealed she was the one that instructed MDS Nurse #30 that she did not have to complete the significant change MDS because she thought the resident was going to to improve. She verified the resident's condition had not improved, and they should have completed a significant change MDS.",2019-01-01
5497,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2015-04-23,278,D,0,1,H66T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, observation, and staff interview, the facility failed to ensure the quarterly minimum data set (MDS) assessments for three (3) of twenty-two (22) residents, whose assessments were reviewed, accurately reflected their status. The MDS for Resident #29 was not accurate related to falls. The dental portion of the MDS was not accurate for Resident #36. Resident #16's quarterly MDS was not accurate related to hydration. Resident identifiers: #29, #36, and #16. Facility census: 40. Findings include: a) Resident #29 This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS quarterly assessment, with an assessment reference date (ARD) of 11/23/14, was reviewed on 04/21/15 at 10:09 a.m. The fall history section, J1800, of the MDS indicated the resident had no falls since the prior assessment, which was the MDS with an ARD of 08/24/14. Review of fall incident reports on 04/21/15 at 12:23 p.m., identified the resident had two (2) falls. One (1) of the falls, on 10/19/14, was not reflected on the 11/23/14 quarterly MDS. Interview with Registered Nurse (RN) #29 on 04/21/15 at 1:20 p.m., verified the MDS quarterly assessment, with an ARD of 11/23/14, was not accurate as it did not reflect the resident's status related to falls. b) Resident #36 Review of the resident's medical record began on 04/21/15 at 8:57 a.m. The review revealed an admitted for Resident #36 of 08/21/11. Further review revealed multiple diagnoses, including unspecified mental [MEDICAL CONDITION] and other [MEDICAL CONDITION]. Review of the MDS quarterly assessment, with an ARD of 02/15/15, revealed the resident was independent with eating. The oral/dental status section indicated the resident had no broken or loosely fitting full or partial denture. The care plan, dated 02/16/15, indicated the resident had dentures. It noted the resident required assistance with denture care and to remove her upper and lower dentures at night. An interview with Nurse Aide (NA) #17 on 04/21/15 at 9:30 a.m., revealed the resident chose not to wear her dentures. An interview with Registered Nurse (RN) #30, on 04/21/15 at 9:31 a.m., revealed she completed the MDS assessments, and had completed the resident's assessment on 02/15/15. She verified when she completed the 02/15/15 MDS, she did not put the dentures in the resident's mouth to check as required in the Resident Assessment Instruction (RAI) manual to assess for loose fitting dentures. She verified she used paperwork to complete the oral and dental status of the MDS assessment. She was not aware until 04/21/15, the resident's dentures were loose fitting. She said she just thought the resident did not wear her dentures as an individual or personal choice, not because they were ill fitting. Observations on 04/21/15 at 9:33 a.m., revealed the resident was not wearing her dentures. A resident interview at that time revealed she did not wear her dentures because the top denture plate was too loose. c) Resident #16 Review of the clinical record for Resident #16, on 04/21/15 8:23 a.m., revealed she was readmitted to facility on 11/07/14, with [DIAGNOSES REDACTED]. On 04/21/15 at 8:35 a.m., the MDS, with an ARD of 01/26/15, was reviewed. It indicated Resident #16 was dehydrated. Review of the current care plan, dated 05/04/14, indicated the resident was at risk for dehydration due to the use of diuretic medication. There was no indication the resident was currently dehydrated. The care plan goal was for Resident #16 to remain well hydrated. The dietary notes, reviewed on 04/21/15 at 8:45 a.m., were silent to any indication Resident #16 was dehydrated. Review of laboratory results also showed no indication of dehydration during the MDS assessment period with an ARD of 01/26/15. Interview on 04/21/15 at 9:30 a.m., with MDS Nurse #30, revealed she was not the MDS nurse who completed Resident #16's 01/26/15 MDS. She reviewed the MDS and the clinical record during this interview. The MDS nurse stated she was unable to determine why the resident's 01/26/15 MDS indicated the resident was dehydrated. Interview with the resident, on 04/21/15 at 10:02 a.m., revealed she got the fluids she wanted. She pointed out seven (7) bottles of diet Pepsi, water, and juice on her over-the-bed table and cabinet. She stated she had a hernia repair surgery last week, but was feeling much better. Resident #16 said she had not been well off and on for the past 6-8 months, but things were getting better. On 04/21/15 at 3:00 p.m., the Director of Nursing (DON) #29 stated the MDS Staff who completed the 01/26/15 MDS for Resident #16 was currently off due to an illness, so she would not be able to verify why she indicated the resident was dehydrated on the MDS. The DON stated, according to the RAI guidance, Resident #16 did not meet the criteria for dehydration. She said they would have to complete a correction MDS. .",2019-01-01
5498,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2015-04-23,282,D,0,1,H66T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement the care plan for one (1) of twenty-two (22) residents whose care plans were reviewed. The intervention for a scheduled toileting program related to falls was not implemented. Resident identifier: #42. Facility census: 40 Findings include: a) Resident #42 Medical record review on 04/21/15 at 10:30 a.m., revealed the most recent Minimum Data Set (MDS), with an assessment reference date (ARD) of 02/17/15, included a Brief Interview for Mental Status score of six (6) which indicated Resident #42 had severe cognitive impairment. This MDS indicated Resident #42 was independent in bed mobility, transfers, walking in her room, walking in the hall, toilet use, bathing, and was steady at all times for moving from seated to standing, walking, turning around, moving on off toilet seat, and surface to surface transfer. This MDS also indicated Resident #42 used a walker and was on a trial scheduled toileting program. Review of current care plans dated 08/21/13, on 04/21/15 at 10:39 a.m., revealed the resident was at risk for falls with injury due to impaired safety awareness and visual impairment. The care plan indicated the resident had experienced frequent falls at home, required the assistance of one (1) staff with her walker, but was known to ambulate unassisted without her walker. The goal was for Resident #42 to remain safe with no injury or falls with injury, and to use her walker constantly. The care plans contained an episodic care plan dated 03/17/15. Resident #42 experienced a fall while going to the bathroom on 03/17/15. She was placed on a scheduled toileting program. Review of the nursing assistant tracking forms, since the resident was placed on a scheduled toileting program, revealed the program was not consistently implemented: -- During the 7:00 a.m. to 3:00 p.m. shift, the scheduled toileting program was not provided from 03/17/15 through the 03/31/15. -- During the 3:00 p.m. - 11:00 p.m. shift, the scheduled toileting program was not provided from 03/17/15 through 03/31/15. -- During the 3:00 p.m. - 11:00 p.m. shift, the scheduled toileting program was not provided from 04/16/15 through 04/21/15. On 04/22/15 at 8:50 a.m., Nurse Aide (NA) #14 was asked if Resident #42 was on any type of toileting program. NA #14 stated, Not really. She stated she just checked on Resident #42 like she checked on the other residents every two (2) hours. She stated sometimes when she checked the resident, she was already incontinent. Interview with NA #15 on 04/22/15 at 9:37 a.m., revealed she took care of Resident #42 most of the time on the 7:00 a.m. - 3:00 p.m. shift. She stated she had to physically help the resident and take her to the bathroom. She stated she checked the resident every two (2) hours to see if she was incontinent, and the resident was often wet or soiled before she got there. NA #15 verified the resident was not on any type of scheduled toileting program. An interview was conducted with Director of Nursing (DON) #29, on 04/22/15 at 1:00 p.m. When informed staff were not providing a scheduled toileting program with Resident #42, which was a planned fall intervention, she stated she did not start the toileting program until after the resident fell on [DATE]. The DON was shown staff's documentation which validated staff were signing off that no toileting program was provided. She verified the dates NA staff signed off as not providing the scheduled toileting program, and stated staff were required to implement all planned interventions listed on the care plan. .",2019-01-01
5499,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2015-04-23,311,D,0,1,H66T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, and record review, the facility failed to provide maintenance and restorative programs to not only maintain, but improve the ability to transfer and ambulate for one (1) resident reviewed in Stage 2 for Activities of Daily Living (ADL). Resident identifier: #42. Facility census: 40. Findings include: a) Resident #42 Review of the clinical record on 04/21/15 at 10:30 a.m., revealed Resident #42 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. According to the medical record and staff interviews, there was a decline in the resident's abilities to ambulate and transfer when she returned to the facility. The facility failed to provide any type of restorative or maintenance programs to enhance Resident #42's ability to ambulate and transfer. Review of the most recent Minimum Data Set (MDS), with an assessment reference date (ARD) of 02/17/15, revealed Resident #42: -- was independent in bed mobility, transfers, walking in her room, walking in the hall, and toilet use -- was steady at all times for moving from seated to standing , walking, and surface to surface transfer. -- was on a trial scheduled toileting program -- used a walker The current care plan, dated 08/21/13, reviewed on 04/21/15 10:39 a.m., revealed Resident #42 was at risk for falls with injury due to impaired safety awareness and visual impairment. Interventions included staff to encourage the use of a walker when the resident was ambulating. The resident also had a care plan intervention for staff to assist her to the bathroom upon her request; however, the care plan indicated the resident was usually independent in this area. Review of the nurses' notes on 04/21/15 at 11:00 a.m. revealed: -- On 03/06/15 at 5:30 p.m., Resident #42 was trying to get out of the bed and slid to the floor. -- Again on 03/06/15 the nursing documentation revealed Resident #42's alarm sounded, staff responded and the resident was found on the floor, -- On 03/11/15 at 2:41 a.m., a nurse's note revealed staff responded to Resident #42's sounding alarm. She was noted standing in her room stating she needed to go to the bathroom. She was taken to the bathroom and assisted back to bed. -- On 03/11/15 at 6:32 a.m., a nurse's note indicated the resident attempted to get up unassisted numerous times throughout the night. -- On 03/12/15, a nurse's notes indicated Resident #42 continued to try to get out of the bed and staff assisted her to the toilet. The note said Resident #42 stated she knew she could walk but nobody would let her. The nurse reassured the resident that as soon as she was steady, she would be able to walk again. The resident stated I sure hope so. -- On 03/14/15, nurses' notes indicated Resident #42 attempted to get out of the bed two (2) times, stating she needed to go to the bathroom. -- On 03/15/15 at 10:30 a.m., nurses' notes indicated Resident #42 attempted to ambulate, her alarm sounded, but she was already in the bathroom before the staff could get there. The nurse advised the resident she needed to call for assistance and use the call light. The resident said I know. -- On 03/16/15 at 4:35 a.m., a nurse's note revealed Resident #42 was attempting unassisted ambulation and telling staff she could do it by herself. -- On 03/17/15 at 3:50 a.m., a nurse's note revealed Resident #42 was again attempting unassisted ambulation and telling staff she could do it by herself. Review of the nurses' notes and an accident report dated 03/17/15, revealed Resident #42 fell while ambulating to the bathroom. -- On 04/01/15 at 6:30 a.m., a nurse's note revealed Resident #42 continued to get up on her own. The note indicated as soon as the alarm sounded, staff responded, but the resident was up before staff could reach her. -- On 04/02/15, a nurse's note indicated Resident #42 was found on the floor in the bathroom on 04/01/15 with the bed alarm sounding. The resident stated I tried to be careful. -- On 04/10/15 at 2:43 p.m., a nurse's note revealed the resident's activities of daily living had declined over the past several months. -- On 04/20/15 at 1:32 p.m., a nurse's note indicated the resident attempted to exit the bed several times during the shift without assistance. The staff responded and the resident stated, I can walk by myself. Observation of Resident #42, on 4/22/15 at 8:10 a.m., revealed she was in bed with bilateral 1/2 rails in the up position. During an interview at that time, Resident #42 stated she was supposed to call for help, but did not always do that because she knew she could walk by herself. She stated, No one will help me walk. Interview with Nurse Aide (NA) #17 and NA #11, on 04/22/15 at 8:30 a.m., revealed Resident #42 was always trying to ambulate on her own. They stated she used an alarm, but all the alarm did was to tell them the resident was up. The NAs said by the time they were able to get there she was already up. When asked if they walked Resident #42 in the hall or to the dining room, they stated, No. The NAs said the facility did not currently have any residents that received any type of walking program or restorative services. They stated the facility did not offer any type of therapy service. The NAs said if residents needed those services they would have to transfer to another facility. The NAs said Resident #42 was so weak she was using the wheelchair lately. They stated the resident was in the hospital in (MONTH) and when she returned, she was very weak and unable to walk on her own. The NAs stated she was unsafe to walk on her own, but she did it anyway. They said at times they saw her get up from her wheelchair and walk without assistance down the hall. Interview with NA #14, on 04/22/15 at 8:50 a.m., revealed Resident #42 used her walker to go to the bathroom, but any other time they put her in her wheelchair for ambulation in the hall and around the facility. She stated the resident was not safe to walk on her own. The NA stated the resident used to be able to walk on her own, but lately, since she had been falling, they had her use the wheelchair. She stated the resident was not on any type of restorative program in which staff actually tried to take her for a walk. Interview with NA #15, on 04/22/15 at 9:37 a.m., revealed she took care of Resident #42 most of the time on the 7:00 a.m. - 3:00 p.m. shift. She stated the resident was no longer able to dress or walk independently. The NA said the resident went out to the hospital a few months ago, and after she returned she had been very weak. She stated she had to physically help the resident get dressed and take her to the bathroom. The NA said the resident used the walker to go to the bathroom, and then she was placed in a wheelchair. She verified she did not walk Resident #42, other than with her walker from her bed to the bathroom and back. In an interview with the resident on 0/22/15 at 9:30 a.m., she stated she knew she was not supposed to get up by herself, but sometimes she did it anyway. She stated, I think I can walk and then I get weak and sometimes fall. The resident said at other times she was able to walk to bathroom and back on her own. An interview with Director of Nursing (DON) #29, on 04/22/15 at 9:40 a.m., confirmed Resident #42 was able to independently walk prior to her hospitalization on [DATE]. The DON confirmed when the resident returned, on 02/26/15, she was extremely weak. She stated the resident may have benefited from some type of restorative walking program to help her re-gain her strength. The DON stated implementing a restorative program was on her list of things that she would like to start at the facility, but she had not yet been able to get it established. She stated they were not a skilled nursing facility, so if a resident wanted or needed any type of skilled service, such as therapy, they would have to transfer to another facility. The DON verified Resident #42 was not currently receiving any type of restorative services to help improve her ability to ambulate or transfer.",2019-01-01
5500,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2015-04-23,315,D,0,1,H66T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review, the facility failed to provide one (1) of three (3) residents, discovered during the review of activities of daily living, treatment and services to achieve or maintain as much normal urinary function as possible. A scheduled toileting program was not implemented as planned for an incontinent resident. Resident identifier: #42. Facility census: 40. Findings include: a) Resident #42 Review of the clinical record on 04/21/15 at 10:30 a.m., revealed Resident #42 was discharged to the hospital on [DATE] and returned to the facility on [DATE]. There was no evidence of a nursing assessment of Resident #42 when she returned to the facility on [DATE]. Review of the resident's most recent Minimum Data Set (MDS) assessment, dated 02/17/15, revealed Resident #42 was independent in bed mobility, transfers, toilet use, and moving on and off the toilet seat. It indicated the resident was occasionally incontinent of urine and never incontinent of stool. This MDS also identified Resident #42 was on a trial scheduled toileting program. On 04/21/15 10:39 a.m., review of the current care plans dated 08/21/13, revealed an intervention for staff to assist the resident to the bathroom upon her request. The care plan indicated the resident was usually independent in this area. Review of the nurses' notes, on 04/21/15 at 11:00 a.m., revealed: -- On 03/11/15 at 2:41 a.m., nurses' notes revealed staff responded to Resident #42's sounding alarm. She was noted standing in her room stating she needed to go to the bathroom. She was taken to the bathroom and assisted back to bed. -- On 03/11/15 at 6:32 a.m., nurses' notes indicated the resident attempted to get up unassisted numerous times throughout the night to go to the bathroom unassisted. -- On 03/12/15, nurses' notes indicated Resident #42 continued to try to get out of the bed and staff assisted her to the toilet. The note said Resident #42 stated she knew she could walk but nobody would let her. -- On 03/14/15 nurses' notes indicated Resident #42 attempted to get out of the bed two (2) times, stating she needed to go to the bathroom. -- On 03/15/15 at 10:30 a.m., nurses' notes indicated Resident #42's alarm sounded but she was already in the bathroom before staff could get there. The nurse advised the resident she needed to call for assistance and use the call light. The resident said, I know. -- On 03/17/15 at 3:50 a.m., nurses' notes revealed Resident #42 was again attempting unassisted ambulation and telling staff she could do it by herself. Review of the nurses' notes and an accident report, dated 03/17/15, revealed Resident #42 fell while ambulating to the bathroom. The note indicated the resident continued to take off her personal alarm to ambulate to the bathroom unassisted. According to the note, the resident was placed on a scheduled toileting plan at that time, for staff to take her to the bathroom every two (2) hours. -- On 04/02/15, nurses' notes indicated Resident #42 was found on the floor in the bathroom on 04/01/15 with the bed alarm sounding. The resident stated, I tried to be careful. -- On 04/10/15 at 2:43 p.m., nurses' notes revealed the resident's activities of daily living had declined over the past several months. -- On 04/15/15, nurses' notes indicated Resident #42 became upset as staff tried to assist her. She stated, I don't like for people to have to wait on me, I can do for myself. -- On 04/17/15 at 2:37 p.m., nurse's notes revealed Resident #42 removed her personal alarm and took herself to the bathroom. In an interview with Resident #42, on 04/22/15 at 8:10 a.m., she stated she was supposed to call for assistance to go to the bathroom, but did not always do that because she knew she could walk by herself. She stated, No one will help me walk. Review of the nursing assistant tracking forms revealed since the resident was placed on a scheduled toileting program on 03/17/15, the program was not consistently implemented. In (MONTH) on the 7:00 a.m. to 3:00 p.m. shift, there was no evidence the scheduled toileting program was provided 03/17/15 through 03/31/15. Review of the 3:00 p.m. to 11:00 p.m. records revealed no evidence the scheduled toileting program was provided from 03/17/15 through 03/31/15, or from 04/16/15 through 04/21/15. Interview with Nurse Aide (NA) #17 and NA #11, on 04/22/15 at 8:30 a.m., revealed they were unaware the resident was on a scheduled toileting plan. When asked if Resident #42 was on a scheduled toileting program, they replied they just checked the resident every two (2) hours. They both indicated she was often already incontinent. On 04/22/15 at 8:50 a.m., upon inquiry, NA #14 stated the resident was not on any type of special toileting program. The NA said she just checked on her every two (2) hours, like all of the other residents. She said sometimes when she checked her, Resident #42 was already incontinent. Interview with NA #15, on 04/22/15 at 9:37 a.m., revealed she took care of Resident #42 most of the time on the 7:00 a.m. to 3:00 p.m. shift. She said she checked on her every two (2) hours to see if she was incontinent. NA #15 said the resident was often wet or soiled before she got there for the check. An interview was conducted with Director of Nursing (DON) #29, on 04/22/15, at 9:40 a.m She stated they did not currently have any type of restorative programs in the facility. The DON said a restorative program was on her list of things she would like to start at the facility, but had not yet been able to get that established. On 04/22/15 at 1:00 p.m., the failure to implement the scheduled toileting program with Resident #42, which was put in place on 03/17/15, was shared with DON #29. She was shown the NA flow records which indicated the toileting program was not provided. In addition, she was informed of the discussions with NAs who were unaware the resident was supposed to be provided a scheduled toileting program. She stated she was not aware staff were not following the toileting program for Resident #42 as planned.",2019-01-01
5501,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2015-04-23,318,D,0,1,H66T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, review of the facility's nursing resource, and resident interview, the facility failed to ensure one (1) of one (1) resident who met the criteria to review for contractures, was provided services to reach and maintain the highest level of range of motion (ROM) and to prevent a decrease in ROM. The facility failed to assess for and implement routine preventative treatment and services to address the contracture of the resident's left hand. Resident identifier: #18. Facility census: 40. Findings include: a) Resident #18 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no evidence in the clinical record to support the resident received any type of range of motion (ROM) services or splinting devices to maintain, improve, or to prevent a decline in ROM. In addition, there was no evidence in the clinical record which indicated the resident was ever offered these specific services. 1. A review of the comprehensive minimum data set (MDS) assessment, with an assessment reference date of 03/08/15 was conducted on 04/21/15 at 2:10 p.m. The section entitled WV (West Virginia) Supplemental revealed Resident #18 had a contracture of her hand. The MDS assessment erroneously indicated the resident had a right hand contracture, when the resident actually had a left hand contracture. The number of days receiving restorative programs was coded as zero. Section G, entitled Functional Status, of the same comprehensive MDS assessment, noted the resident had an impairment on one side, upper extremity, (shoulder, elbow wrist, hand). Section O of the same MDS assessment, entitled Special Treatments, Procedures and Programs, further described as (Restorative Nursing programs) noted the resident did not receive any active or passive range of motion services, nor the application of a splint or brace. The number of days receiving restorative programs was coded as zero. A review of the care area assessment (CAA) related to ADL Function and Rehabilitation Potential was conducted on 04/22/15, beginning at approximately 2:55 p.m. The CAA was dated 03/10/15 at 2:54 p.m. It noted: Indicator: Possible underlying problems that may affect function, some may be reversible. The note section indicated, Family does not wish for resident to be transferred to another facility for rehab (rehabilitation) services. 2. The care plan was reviewed on 04/22/15 beginning at approximately 3:05 p.m. The care plan problem area was dated 12/01/10. It did not address contractures of the hand, but instead noted the resident had slight contractures at the elbow, right wrist, hips, and knees. 3. The nurse's notes section of the clinical record, dated 08/11/13, was reviewed at 04/21/15 at 10:06 a.m. The nurse's note indicated, ROM (range of motion) to upper and lower extremities BID (twice daily) with care. An addendum to a nursing progress note, dated 03/01/15, revealed in part, the resident's left hand was contracted. The note was signed by a previously employed registered nurse who was not identified on the facility's staff roster list. On 04/22/15 at 4:05 p.m., review of the admission nurse's note dated 11/08/10, revealed Resident #18 had, No deficit, under the section entitled contracture. The same admission nursing note also noted in part, that the resident had no contractures, but tended to hyperextend (left fingers). 4. A history and physical, dated 03/01/15, reviewed on 04/22/15 beginning at approximately 4:09 p.m., noted the resident had [MEDICAL CONDITION] the past. The history and physical revealed in part, dystonic disorders (muscles contract involuntarily, causing uncontrollable repetitive or twisting movements of the affected body part) of the head, neck, hands, and leg which were gradually getting worse. The 01/24/14 clinical history by the attending physician, reviewed on 04/22/15 beginning at approximately 4:13 p.m., indicated the resident had [DIAGNOSES REDACTED] disorder of the head and neck, hand, and legs which was gradually worsening. The physician noted there was no treatment in sight at this time. The history also described the resident had been seeing a neurologist for a long time, but was not going there anymore. 5. Review of the medical record, to include the physician's progress notes and physician's orders, on 04/23/15, beginning at approximately 9:35 a.m., revealed no physician's orders for a splint device or any type of hand roll. Many physician's progress notes discussed contractures: -- The physician's progress notes dated 08/08/13 and 09/10/13 each indicated contractures or contractures of the hand. -- A physician progress notes [REDACTED]. marked spastic dystonic movements . hand contracture with dystonic movements -- The physician's progress note, dated 02/24/14 indicated contractures of hand under the section entitled Musculoskeletal. -- Another physician's progress note, dated 03/26/14 indicated the resident had contractures of the hands with dystonic movements. -- A review of the physician's monthly progress note, dated (MONTH) 2014, revealed under review of systems, a section entitled Extremities. It noted in part, . some contractures. -- The most recent physician's progress note, dated 02/27/15, was reviewed on 04/23/15 beginning at approximately 9:40 a.m. The progress note, under the section entitled Extremities, read in part, . some deformity related to [DIAGNOSES REDACTED]. 6. An observation on 04/21/15 beginning at 9:55 a.m., revealed Resident #18 was able to communicate by smiling and shaking her head yes and no. The left hand revealed partial contractures of the ring finger, middle finger, and the thumb. The resident attempted to actively extend the contracted fingers and thumb, but was unable to do so. The resident was able to fully extend all of the fingers and her thumb on the right hand on command. When interviewed at the same time, she was asked if she could extend the fingers or thumb on the left hand. The resident smiled and shook her head No. The resident smiled and shook her head Yes when asked to do the same for the fingers and thumb on the right hand. This observation revealed no splint device or hand rolls in use. A second observation, on 04/21/15 at 3:37 p.m., revealed the left hand had no splint device or hand roll in place. When asked to extend her hands and fingers, the resident was again unable to extend the fingers on her left hand to include the ring finger, middle finger, and thumb. A second surveyor was present for this observation. She confirmed the resident did not have a splint or hand roll present in the left hand. A third observation was conducted on 04/22/14 beginning approximately 12:30 p.m. The resident was observed sitting in the television area of the lobby. Again there was no splint device or hand roll noted in her hand. A fourth observation was conducted on 04/22/15 beginning at 3:55 p.m. The resident was observed sitting in lobby area with no hand roll or splinting devices applied to her left hand. 7. According to Director of Nursing (DON) #29, on 04/23/15 at 11:43 a.m., the facility provided no therapy services or restorative nursing services. The DON said she would like to have one. She stated they would have to send the resident to another nursing home to receive physical therapy services. The DON conveyed there was also no restorative nursing program in place. She said she was working on getting that program in place, but just had not had time to pull it all together. Upon inquiry, the DON stated the facility did not have a policy or procedure for range of motion, hand rolls, or splinting devices. She stated the facility uses 'The Nursing Procedures ' Manual by Lippincott Williams and Wilkins Sixth Edition, For Patient Care of Nursing procedures as a guide or reference. 8. The nursing procedures manual form, dated 3/2005,and revised on 5/2011 and 8/2014, noted in part: The nursing staff will have easy access to the 'Nursing Procedures' manual at all times . The staff will refer to this manual for procedures anytime that there is a question as to how a procedure should be done . The procedure manual will be utilized throughout the facility, to ensure uniformity in nursing care. Page 176 of the nursing procedures manual provided by the DON, noted in part under the section entitled Therapeutic Exercise: 3. Perform passive range-of- motion (ROM) exercise. a. Carried out with assistance from patient b. The purpose is to retain as much joint ROM as possible and to maintain circulation c. Move the joint smoothly through its full ROM, see pages 177-180. Do not push beyond the point of pain. Page 178, of the procedure manual revealed multiple visual images for different types of range of motion specific to the hands, wrist, fingers and thumb. The range of motion images included adduction and abduction of the fingers and thumb, as well as flexion and extension of the fingers and hands as well. 9. An interview was conducted with Registered Nurse (RN) # 30, on 04/22/15 at approximately 1:15 p.m. RN #30 stated the facility did not have a contracture policy or specific contracture assessment form. Regarding ROM services for contractures, RN #30 stated facility staff just used a visual assessment according to the guidance in the MDS and Resident Assessment Instrument (RAI) manual. She stated, We use the MDS guidance to help determine whether or not the residents have a contracture. RN #30 did not specify a particular reference point in the RAI manual that was utilized. Upon inquiry, RN #30 was not familiar with the therapeutic exercise section of the Lippincott manual which the DON said the facility used. 10. Nurse Aide (NA) #14 was interviewed on 04/23/15 beginning at 9:55 a.m. She conveyed, They (facility staff and nursing administration) don't say to put a hand roll in her left hand. We have never had an order for [REDACTED]. The NA stated they should have an order in their treatment record book for NAs to conduct ROM . We learned to do that in nursing school on everybody. The NA reviewed the NA treatment book to see if there was an order. The NA was unable to find an order for [REDACTED].>An interview was conducted with NA #17, on 04/23/15 at approximately 9:58 a.m. The NA conveyed she regularly cared for Resident #18. She voiced she did not provide a hand roll or splinting device in the resident's hand, but stated all residents were supposed to receive ROM. She too was unable to find any directives in the treatment book to provide ROM, or to place a splinting device or hand roll, for Resident #18. The NA stated the resident did not have a contracture. During the interview, NA #17 walked over to the resident and attempted to extend the resident's fingers on the left hand. She was unable to fully extend the ring, middle finger, and thumb on the left hand. An interview was conducted, on 04/23/15 beginning at approximately 10.00 a.m., with direct care Licensed Practical Nurse (LPN) #3, who was very familiar with Resident #18. The LPN stated, She is supposed to have a hand roll. The LPN also stated the NAs were supposed to provide ROM. LPN #3 was unable to find an order for [REDACTED]. The LPN also looked in the discontinued order's section, but still was unable to find any orders for range of motion, hand rolls or splinting devices. She stated, I guess she doesn't have one. The LPN also reviewed the NA flow sheets and treatment sheets, which were used to instruct NAs to provide ROM or place hand rolls. She stated there was nothing on the forms to indicate a hand roll, splint device, or range of motion services were to be implemented for the resident. An interview was conducted with the DON, on 04/20/15 at 1:46 p.m., regarding the resident's contractures and the absence of hand rolls, splints or range of motion services. The DON said, She would remove the splint. The DON stated she would need to research this issue, but did not believe the resident would allow the ROM either. By he end of the survey, the DON provided no evidence to support her theory regarding the resident's refusals for range of motion, splints, or the use hand rolls.",2019-01-01
5502,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2015-04-23,323,D,0,1,H66T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review, the facility failed to provide an environment as free from accident hazards as possible and failed to provided adequate supervision for one (1) of two (2) residents reviewed for accidents during Stage 2 of the survey. The facility failed to evaluate planned interventions for appropriateness for individual needs, failed to implement planned interventions to reduce falls, and failed to evaluate the effectiveness of the planned interventions. Resident identifier: #42. Facility census: 40. Findings include: a) Resident #42 During a Stage 1 staff interview on 04/20/15 at 1:58 p.m., Director of Nursing (DON) #29 stated Resident #42 experienced a fall the past weekend with no injury. She stated the resident also experienced two (2) falls on 03/06/15. 1. Review of the clinical record on 04/21/15 at 10:30 a.m., revealed Resident # 42 was discharged to the hospital on [DATE] and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. There was no evidence of a nursing assessment of Resident #42 when she returned to the facility on [DATE]. Review of the most recent Minimum Data Set (MDS), with an assessment reference date of 02/17/15, on 04/21/15 at 10:30 a.m., revealed a Brief Interview for Mental Status score of 6 which indicated Resident #42 had severe cognitive impairment. This MDS indicated Resident #42 was independent in bed mobility, transfers, walking in her room, walking in the hall, toilet use, bathing, and was steady at all times for moving from seated to standing, walking, turning around, moving on off toilet seat, and surface to surface transfer. This MDS also indicated Resident #42 used a walker, was on a trial scheduled toileting program, and had one (1) fall since her admission with no major injury. As well, the MDS indicated Resident #42 was receiving antianxiety and antidepressant medications. Review of the fall risk assessment, dated 02/27/15, on 04/21/15 at 10:22 a.m. revealed Resident #42 had 1 to 2 falls in the past three (3) months and required assistive devices. This fall risk assessment indicated the resident had intermittent confusion. There were no further fall risk assessments since 02/27/15. The resident was noted to be on aspirin and bruised easily. Review of the bed safety assessment on 04/21/15 at 10:26 a.m., revealed interventions to include adjustable bed height, bed alarms, 1/2 rails upper only, periodic assisted toileting every two (2) hours, and visual and verbal reminders for the resident to use her call light. Review of current care plans, on 04/21/15 at 10:39 a.m., revealed the resident was at risk for falls with injury due to impaired safety awareness and visual impairment. She had experienced frequent falls at home, required the assistance of one (1) staff with her walker, but was known to ambulate unassisted without her walker. The goal was for Resident #42 to remain safe with no injury or falls with injury, and to use her walker consistently. Continued review of the fall care plan found the following interventions: -- Upper side rails x 2 to assist with bed mobility -- Keep the bed at lowest level -- Encourage resident to use her walker when ambulating -- WanderGuard to ankle and check placement and function on 11-7 shift -- Remind Resident #42 to call out for assistance as needed and keep her call light and personal items within reach -- Provide shoes with non skid soles -- Offer diversional activities -- Personalize her room On 03/17/15, a scheduled toileting program was added to the fall care plan. Review of the nursing assistant tracking forms revealed the program was not consistently implemented since the resident was placed on a scheduled toileting program on 03/17/15. In (MONTH) (YEAR) on the 7:00 a.m. to 3:00 p.m. shift, there was no evidence the scheduled toileting program was provided 03/17/15 through 03/31/15. Review of the 3:00 p.m. to 11:00 p.m. records revealed no evidence the scheduled toileting program was provided from 03/17/15 through 03/31/15, or from 04/16/15 through 04/21/15. The current physician orders, dated 02/26/15, contained orders for the use of a bed and chair alarm, although those were not listed on the current fall care plan. 2. Review of the nurses' notes, on 04/21/15 at 11:00 a.m., revealed on 03/06/15 at 5:30 p.m., Resident #42 was trying to get out of the bed and slid to the floor. No injury was noted. The interventions added at that time on the episodic care plan, were to remind the resident to use her call light and to continue with the bed alarm that was currently in place. Review of the nurses' note and accident report dated 03/06/15, indicated Resident #42's alarm sounded, staff responded, and the resident was found on the floor. The note also indicated the resident had been confused. Despite this noted confusion, the new intervention added after this fall was to place a visual reminder on the wall in the resident's room to remind her to use the call light to ask for assistance. The nurses' notes on 03/11/15 at 2:41 a.m., indicated staff responded to Resident #42's sounding alarm. The noted identified the resident was standing in her room stating she needed to go to the bathroom. She was taken to the bathroom and assisted back to bed. The nurse's note on this date, at 6:32 a.m., indicated the resident attempted to get up unassisted numerous times throughout the night. The nurses' notes on 03/12/15 indicated Resident #42 continued to try to get out of the bed, and staff assisted her to the toilet. Resident #42 stated she knew she could walk but nobody would let her. The nurse reassured the resident that as soon as she had a steady gait, she would be able to walk again. The resident stated, I sure hope so. The nurses' notes on 03/14/15 indicated Resident #42 attempted to get out of the bed twice, stating she needed to go to the bathroom. Once she was taken to the bathroom the nurses' note described the resident rested quietly in bed. The nurse's note on 03/15/15 at 10:30 a.m., indicated Resident #42 attempted to ambulate and her alarm sounded; however, she was already in the bathroom before staff could get there. The nurse advised the resident she needed to call for assistance and use the call light. The resident said, I know. The nurse asked Resident #42 if she would like to move to a room closer to the nurses' station. The resident said she liked the room she was in, so they did not change her room at that time. The nurses' notes on 03/16/15 at 4:35 a.m. and 03/17/15 at 3:50 a.m., each revealed Resident #42 was attempting unassisted ambulation and telling staff she could do it by herself. Review of the nurses' note and accident report, dated 03/17/15, revealed Resident #42 fell while ambulating to the bathroom. They also indicated the resident continued to take off her personal alarm to ambulate to the bathroom unassisted. The note indicated the resident had a skin tear to her left shin and elbow. New Interventions at that time were to place the resident on a toileting program, and staff asked the resident if she would like to move closer to the nurses' station. The cognitively impaired resident refused to be moved at that time. Review of the nurse's note dated 04/01/15 at 6:30 a.m., revealed Resident #42 continued to get up on her own. It indicated staff responded as soon as the alarm sounded, but she was up before staff could reach her. The nurse's note dated 04/02/15 indicated Resident #42 was found on the floor in the bathroom on 04/01/15 with the bed alarm sounding. The resident denied pain and no injury was noted. The resident stated, I tried to be careful. The intervention after this fall was to move the resident closer to the nurses' station. A nurse's note dated 04/10/15 at 2:43 p.m., revealed the resident's activities of daily living had declined over the past several months. The nurses' notes documented on 04/15/15, revealed Resident #42 had increased confusion and was crying at night. A urinalysis and culture was ordered to rule out a urinary tract infection. The resident was later placed on an antibiotic for treatment. The nurse's note at 6:17 a.m. revealed the resident became upset as staff were trying to assist her. She stated, I don't like for people to have to wait on me, I can do for myself. Review of the nurse's note dated 04/17/15 at 2:37 p.m., revealed Resident #42 removed her personal alarm and took herself to the bathroom. The nurse's note dated 04/19/15, revealed at 1:52 p.m., Resident #42 was found by the respiratory therapy staff sitting on the floor in her room. The resident stated she just lost her balance and fell . She had a skin tear to her right hand and shoulder and a Band-Aid was applied. There were no new interventions noted after this fall. A nurse's note dated 04/20/15 at 1:32 p.m., indicated the resident attempted to exit the bed without assistance several times during the shift. When staff responded to the bed alarm, the resident stated, I can walk by myself. 3. Observation of Resident #42 on 04/21/15 at 2:18 p.m., revealed she was seated in the dining room playing cards with another resident. Her personal alarm, a pressure alarm, was in place on her wheelchair, and was turned on. Observation of Resident #42, on 4/22/15 at 8:10 a.m., revealed she was in bed with bilateral 1/2 rails in the up position. Her call button was in reach. Upon request, she demonstrated how to use the alarm. During an interview at this time, she stated she was supposed to call for help, but did not always do that because she knew she could walk by herself. There was a sign posted on the wall at the foot of her bed that reminded her to call for assistance when she wanted to get up. When asked if she knew what the sign said, she stated she could not read it. There was a pressure alarm noted on her bed. The box to operate the alarm was located under the bed, out of the resident's reach. The bed alarm was in the on position. 4. Interview with Nurse Aide (NA) #17 and NA #11 on 04/22/15 at 8:30 a.m., revealed Resident #42 was always trying to ambulate on her own. They stated she used an alarm, but all the alarm did was tell them the resident was up. They said by the time they got there, she was already standing up. They stated she was really quick. NA #17 said sometimes by the time they got to her, she was on the floor. They said Resident #42 could walk with a walker, but she had been using the wheelchair lately. The NAs said the resident was in the hospital in February, and when she returned, she was very weak and was unable to walk on her own. They stated now she was unsafe to walk on her own, but she did it anyway. The NAs said at times they looked down the hall, and the resident would have gotten up from her wheelchair and be walking down the hall without assistance. When asked if Resident #42 was on a scheduled toileting program, they replied they just checked the resident every two (2) hours. Interview with NA #14 on 04/22/15 at 8:50 a.m., revealed Resident #42 used her walker to go to the bathroom. The NA said any other time they put her in her wheelchair for ambulation in the hall and around the facility. She stated she was not safe to walk on her own. The NA said she used to be able to walk on her own, but lately since she was falling, they had her use the wheelchair. When asked if Resident #42 was on any type of toileting program, NA #14 stated, Not really. She said she just checked on her every two (2) hours, like all of the other residents. She said sometimes the resident called out for assistance if she needed to go to the bathroom, but often she just tried to take herself, even though she was not supposed to do that. Interview with NA #15 on 04/22/15 at 9:37 a.m., revealed she took care of Resident #42 most of the time on the 7:00 a.m. to 3:00 p.m. shift. She stated the resident was not able to walk independently anymore. NA #15 stated she had to physically help take her to the bathroom. She said the resident used the walker to go to the bathroom, and then was placed in a wheelchair. NA #15 stated she checked the resident for incontinence every two (2) hours, and the resident was often wet or soiled. She said she did not walk with the resident with her walker other than from her bed to the bathroom 5. An interview was conducted with the resident on 04/22/15 at 9:30 a.m. When asked if she had fallen recently, she stated she had fallen a few times. She said if she fell , she tried to get up before staff found her. She said she fell a couple of nights ago and hit her left shoulder and right hand. Observation revealed her right hand was bruised and had a Band-Aid on it. She said they kept an alarm on her, but that did not stop her from getting up when she wanted to get up. She stated she knew she was not supposed to get up by herself, but sometimes she did it anyway. She stated, I think I can walk and then I get weak and sometimes fall, but sometimes I am able to walk to the bathroom and back and they don't even know I did it. 6. An interview was conducted with Director of Nursing (DON) #29 on 04/22/15 at 9:40 a.m. Upon inquiry, she verified interventions such as reminding cognitively impaired Resident #42 to use the call light and placing a sign at the foot of her bed to visually remind her to call for assistance were not appropriate interventions to prevent further falls. She also verified that often, when the intervention of the personal alarm sounded, the resident was already up and in the bathroom, and sometimes already on the floor. She verified Resident #42 was able to independently walk prior to her hospitalization on [DATE], but when she returned on 02/26/15, she was extremely weak. She stated the resident may have benefited from some type of restorative walking program to help her re-gain her strength to walk and not experience falls. She stated implementing a restorative program was on her list of things she would like to start at the facility, but she had not yet been able to get that established. On 04/22/15 at 1:00 p.m., the failure to implement the scheduled toileting program with Resident #42, which was an intervention related to falls established on 03/17/15 after the resident fell was discussed with the DON. She was shown the NA flow records which indicated the toileting program was not provided. In addition, she was informed of the discussions with NAs who were unaware the resident was supposed to be provided a scheduled toileting program. She stated she was not aware staff were not following the toileting program for Resident #42 as planned. When asked if there were any new interventions put into place after Resident #42 fell on [DATE], the DON stated she did not establish any new interventions because she just could not think of anything else to do.",2019-01-01
5503,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2015-04-23,329,E,0,1,H66T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observations, the facility failed to ensure four (4) of five (5) residents reviewed for unnecessary medications were free from unnecessary medications. The residents received medications without adequate monitoring, without adequate indication for use, and without attempts at gradual dose reductions (GDRs). Resident identifiers: #29, #30, #8, and #18. Facility census: 40. Findings include: a) Resident #29 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment, with an assessment reference date of 02/21/15, was reviewed on 04/21/15 at 10:09 a.m. It indicated the resident used anti-anxiety and anti-depressant medications. The MDS did not indicate the resident displayed any indicators of [MEDICAL CONDITION] or any behavioral symptoms. The resident's care plan, dated 05/23/14, was reviewed on 04/21/15 at 10:22 a.m. The care plan indicated the resident was at risk for altered mental status related to anxiety, newly diagnosed depression as evidenced by episodes of crying (which has improved with medication), and a history of possible sexual abuse over two (2) years ago. Interventions included: -- Administer [MEDICATION NAME] 0.5 milligrams (mg) twice a day and monitor for side effects -- Allow resident time to voice needs and speak to resident in calm soothing voice -- Administer [MEDICATION NAME] 25 mg at bedtime for depression, monitor for signs and symptoms of trauma such as flashbacks, crying, tearfulness, talking about incident, provide emotional support and reassurance of safety and behavior monitoring every shift. The resident's medical record was reviewed on 04/21/15 at 10:27 a.m. The physician's (MONTH) (YEAR) orders indicated the resident received [MEDICATION NAME] 25 mg at bedtime and [MEDICATION NAME] 0.5 mg twice a day for anxiety. The Behavioral Monitoring Forms for Anxiety and Depression were reviewed for the past six (6) months. The monitoring forms indicated staff would monitor for anxiety, with a target behavior of agitation. They were also to monitor for depression, with target behaviors of crying or sadness. The monitoring forms were signed by the nurses on the day, evening, and night shifts. The forms were all documented with zeros, which indicated there were no episodes of these behaviors. The resident's Medication Regimen Reviews were reviewed on 04/21/15 at 10:50 a.m. On 11/13/14, the consultant pharmacist documented for the physician to please evaluate for a dosage reduction for [MEDICATION NAME] 0.5 mg twice a day and [MEDICATION NAME] 25 mg every day. The pharmacist indicated the resident had been taking the medications since admission on 05/15/14. A handwritten nurse's note, dated 11/14/14, indicated Director of Nursing (DON) #29 reviewed the pharmacy recommendations for gradual dose reductions (GDRs) related to [MEDICATION NAME] and [MEDICATION NAME]. There there were no changes in the medication regimen at that time. The note indicated the resident was still tearful at times and had an appointment to follow up with the psychiatrist on 12/08/14. The nurse's note was signed by the DON and the physician. The physician provided no rational for not attempting a GDR. Interview with Nursing Assistant (NA #12), on 04/21/15 at 10:43 a.m. revealed the resident cried at times. The NA said she provided reassurance and talked to the resident. She stated sometimes the resident did not want to talk, and they re-approached her later. She stated the resident had no other behaviors other than crying occasionally. Interview with Licensed Practical Nurse (LPN) #2 on 04/21/15 at 10:59 a.m., revealed at times the resident cried, but that had improved over time. She stated when the resident cried, she reassured the resident and she was easily redirected. The LPN stated there were no real concerns with the resident, and no problems with agitation related to anxiety. On 04/21/15 at 3:15 p.m., the resident was observed sitting in the dining room crying softly. The DON walked by the resident and stopped to ask the resident why she was crying. The resident told the DON she wanted a soda. The DON instructed a NA to get the resident a a can of soda. Observation revealed the resident stopped crying. On 04/22/15 at 9:37 a.m., the DON was interviewed and the Medication Regimen Review dated 11/13/14, was reviewed with the DON. The DON verified the behavioral flow records did not indicate any agitation or signs of anxiety for use of the [MEDICATION NAME]. b) Resident #30 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. On 04/21/15 at 12:43 p.m., the resident's medical record was reviewed. The most recent annual MDS Assessment, with an assessment reference date of 02/24/15, indicated the resident received anti-psychotic and anti-anxiety medications. It indicated since the prior MDS assessment, the resident's behavior status had improved. The (MONTH) (YEAR) physician's orders [REDACTED]. The Behavioral Monitoring Forms for the past six (6) months indicated the resident had no behaviors, except on three (3) occasions, 04/06/15, 04/19/15, and 04/20/15. The flow records indicated the targeted behaviors were yelling, paranoia and restlessness. The care plan dated (MONTH) (YEAR), was reviewed on 04/21/15 at 12:43 p.m. The care plan indicated the resident had a history of [REDACTED]. Interventions included: -- assess resident's understanding of situation, coping skills -- set goals for appropriate behavior -- give positive reinforcement -- social services to visit weekly -- follow up with psychiatrist -- pharmacy review monthly to assess medications -- instruct resident to call for assist if wandering resident enters room and staff to respond immediately. Interview with NA #17, on 04/21/15 at 1:45 p.m., revealed the resident yelled out at times, mostly because he wanted things immediately. She stated she offered reassurance, gave him what he wanted, and he usually calmed down. Interview with LPN #3, on 04/21/15 at 1:48 p.m., revealed the resident mostly yelled because staff did not do things fast enough. The LPN said when offered reassurance, food, or drinks, it helped calm down the resident. The Medication Regimen Review, dated 09/15/14, indicated the Consultant Pharmacist requested an evaluation for an annual GDR for the use of [MEDICATION NAME] 1 mg at bedtime. The pharmacist documented the resident had been taking the medication since 09/13/13. A handwritten note by the DON on 09/16/14, indicated she reviewed the pharmacy recommendation with the physician for the GDR of the [MEDICATION NAME] and there were no changes to the medication. There was no evidence of a previous dose reduction or why a dose reduction was clinically contraindicated. A Medication Regimen Review, dated 03/19/15, indicated the Consultant Pharmacist requested an evaluation for a possible dose reduction for [MEDICATION NAME] to 50 mg at bedtime. The Pharmacist documented the resident had been taking the medication since 03/11/13. A handwritten note by the DON dated 03/20/15, indicated she spoke with the physician regarding the pharmacy recommendation to decrease the [MEDICATION NAME]. There was no evidence of a previous dose reduction or why the GDR was clinically contraindicated. On 04/22/15 at 9:37 a.m., the resident's Medication Regimen Reviews, dated (MONTH) 2014 and (MONTH) (YEAR) were reviewed with the DON. The DON stated she was not aware of any documentation from the physician regarding contraindications for a dose reduction or any notes by the physician which explained why the GDR for [MEDICATION NAME] was not attempted. She verified the behavioral flow records did not indicate paranoia or restlessness, and there were only three (3) occasions of yelling. All the other entries for behavioral monitoring were recorded as no behaviors noted. c) On 04/23/15 at 9:31 a.m., Consultant Pharmacist #40 was interviewed. The Pharmacist stated he identified problems with a lack of documentation on the Behavioral Monitoring Forms last summer (2014). He said in the past two (2)months he talked with the DON about the importance of using Behavioral Monitoring Forms to document behaviors for monitoring and continued use of medications. He verified staff were not completing the forms as they should. He verified there was no attempted dose reductions and the documentation did not support why a dose reduction was not attempted and/or why a GDR was clinically contraindicated. At 10:43 a.m. on 04/23/15 the DON was interviewed. She stated in (MONTH) the Pharmacist talked to her about using a new behavioral monitoring form. The DON said the form had to be ordered, and in March, the pharmacist educated her about the form. She stated in April, staff started using them for all residents. The DON stated nursing staff were not educated on the use of the forms. She verified she had seen discrepancies in the nurses' notes and in the documentation on the flow records regarding residents' behaviors. d) Resident #8 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (a significant change MDS), with an assessment reference date of 04/11/15, was reviewed on 04/21/15 at 12:57 p.m. It indicated the resident had delusions and rejected care on 1 to 3 days during the assessment reference look back time. This MDS also indicated Resident #8 was receiving antipsychotic, antianxiety, and antidepressant medications. Review of the current care plans, on 04/21/15 at 1:08 p.m., revealed the care plan, dated 03/11/11, indicated the resident had short term memory loss with periods of disorientation related to [MEDICAL CONDITION] and required the use of antipsychotic and antidepressant medications. The care plan revealed the resident had episodes of verbal and physical abuse toward staff, name calling, cursing, and making untrue statements about staff. The care plan also indicated the resident liked to fight with certain staff members, and then joke with them later. The 03/11/11 care plan included these interventions: -- to allow Resident #8 to make day to day decisions such as clothing, beverage and choose her bath and bedtime. -- to administer [MEDICATION NAME] (antianxiety Medication) at bedtime for anxiety and monitor the effectiveness and side effects. Additional care plan interventions were added on 03/16/11: -- to explore the source of resident's dissatisfaction and agitation -- give positive feedback -- assist her to verbalize her source of agitation -- set goals for more pleasant behavior. The care plan interventions also indicated when the resident became agitated, staff were to intervene before the resident's agitation escalated, guide away from the source of distress, offer to talk with her, and if she became aggressive, walk away and come back later. Review of the current physician orders, on 04/11/15 at 12:50 p.m., revealed an order, which originated on 07/2/12, for [MEDICATION NAME] 0.125 mg to be given at bedtime for dementia, mixed type, with behavior problems. There was also an order [REDACTED]. Review of the behavior monitoring forms for February, March, and (MONTH) of (YEAR), on 04/21/15 at 1:45 p.m., revealed the forms were silent to any resident behaviors. On 4/21/25 at 1:22 p.m., a Pharmacy Medication Regimen Review dated 06/17/14 was reviewed. The record indicated identified the need for a GDR of [MEDICATION NAME] 0.125 mg and [MEDICATION NAME] 15 mg. This report indicated Resident #8 had been on these same medications since 06/12/13. A request was made to evaluate the resident for a potential annual GDR. There was a nursing progress note addressing this request. The nursing progress note indicated the DON spoke with the resident's physician on 06/18/14 at 3:00 p.m., and advised the physician of the request for the dose reduction of the medications. The note indicated Resident #8 still exhibited some verbal and physical outbursts. The DON documented, on this progress note there were no changes made to the [MEDICATION NAME] or the [MEDICATION NAME]. The physician provided no rationale for not attempting a GDR and/or why a GDR was clinically contraindicated. Continued review of the resident's Pharmacy Medication Regimen Reviews revealed on 02/11/14, 01/21/15, 02/12/15, and 03/19/15 there were no pharmacist recommendations for medication changes or dose reductions. On 04/16/15, the pharmacist recommended a dose reduction of [MEDICATION NAME] 0.5 mg, indicating the resident had been on the medication since 04/15/14 with no attempted dose reductions. There was no evidence this recommendation for a dose reduction was considered and acted upon. Interview with NA #12 on 04/21/15 at 2:23 p.m., revealed Resident #8 yelled at staff and called them names at times, but later she would be apologetic. The NA stated, I guess if you're [AGE] years old you can be like that. A telephone interview was conducted with Consultant Pharmacist #40 on 04/23/15 at 9:38 a.m. A discussion was held regarding the lack of physician justification when a recommendation was made for dose reduction and the physician elected to not attempt the recommended GDR. The pharmacist stated the attending physician did not act upon these recommendations directly, nor did the physician write a note to respond to pharmacy recommendations. The pharmacist stated, instead, he made recommendations through speaking with the DON. The pharmacist stated he accepted the notes from the DON, on behalf of the physician as a response to dose reduction recommendations. The pharmacist verified the DON's notes did not reference the dose reduction was contraindicated and/or how the risk of a reduction outweighed the benefits. Upon inquiry related to behavior monitoring, the pharmacist verified staff often failed to document behaviors on the behavior monitoring tool. He stated staff often documented the resident did not exhibit any behaviors, when they actually had behaviors. He stated he introduced a new behavior monitoring tool in (MONTH) (YEAR), so he was hopeful the documentation concern would get better. Interview with the DON at 10:23 a.m. on 04/23/15, confirmed she conducted the follow-up with the physician after the pharmacy consultant made a recommendation. The DON stated she and the physician discussed the recommendations. She said she hand wrote narratives regarding the resident's medications and the doctor signed it. The DON verified there were no actual physician progress notes [REDACTED].#8. The DON stated they had identified concerns with the lack of appropriate behavior documentation to support the use of antipsychotic and antianxiety medications. She stated in (MONTH) 2014, the pharmacy consultant identified a concern that resident behaviors were not being accurately monitored and documented by nursing staff. She said the pharmacist recommended a new monitoring form to monitor behaviors, interventions, and the effectiveness of the medications. The DON stated she was educated on the new form in (MONTH) 2014, but none of the other nurses or nursing assistants were in-serviced on the forms as of the date of the interview, on 04/23/15. She stating the new forms were currently being used, and they were working toward an action plan to correct this identified concern. She confirmed they did not have an actual action plan in place. The DON verified although she was educated on the new form, nursing personnel who actually were using the new form had not been educated on its use. e) Resident #18 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent annual comprehensive MDS, with an assessment reference date of 03/08/15, was conducted on 04/21/15 at 2:10 PM. Section E of the MDS assessments, entitled Behavior, indicated the resident had no potential indicators of [MEDICAL CONDITION]. Under the same section, the resident was noted with behavioral symptoms not directed at others 4 to 6 days per week, but not on a daily basis. The care area assessments (CAAs), dated 03/10/15, were reviewed on 04/22/15 at 2:25 p.m. The [MEDICAL CONDITION] Drug Use CAA revealed the following entry: Resident #18 required use of antipsychotic, antianxiety, and antidepressant medications D/T (due to) to long history of [MEDICAL CONDITION], anxiety and depression. Behavior monitoring Q (every) shift. Follow up visits to physician as needed. Will have episodes of continuous yelling even after staff attempts to resolve. Difficult to redirect. Staff to provide calm environment and provide reassurance. The Behavioral Symptoms CAA contained exactly the same documentation as the [MEDICAL CONDITION] Drug Use CAA. A review of the current care plan was conducted on 04/22/15 at 3:20 p.m. The care plan was dated (MONTH) (YEAR). The care plan identified use of [MEDICAL CONDITION], antidepressant, and anti-anxiety medications for [DIAGNOSES REDACTED]. The care plan problem area listed the date of origin as 11/26/11. The care plan goal indicated the resident would be free from any discomfort or adverse side effects due to [MEDICAL CONDITION] medications. The care plan interventions included in part, -- Monitor effectiveness and adverse reactions of drowsiness, hallucinations, delusions, coma and stroke. -- Other interventions included the need to monitor for side effects of muscle rigidity, [DIAGNOSES REDACTED], and tardive dyskinesia. In addition, there were also interventions listed specifically for the use of antipsychotic medications. They were: -- Give [MEDICATION NAME] per order -- Monitor for SE (side effects) -- Pharmacist to review meds Q month -- Monitor and record behaviors Q shift The care plan also addressed the following problem, goal and interventions as they related to anxiety and anti-anxiety medications: [REDACTED] Problem: Anxiety, [MEDICAL CONDITION] related to cognitive deficit. Needs antianxiety medication in PM (evening) D/T (due to) anxiety Goal: Resident will have no adverse SE (side effects) or discomfort from [MEDICATION NAME] and will sleep at least 6-8 hours during the next review. Interventions: Give [MEDICATION NAME] 0.25 mg BID (twice a day) Monitor for adverse SE. Pharmacist to review Q (every) month for possible dose reduction. Follow up with physician. Monitor behavior Q shift. The care plan interventions indicated the licensed nurse was to monitor and record behaviors Q shift and the pharmacists was to review meds (medications) Q month. The behavior monitoring sheets for the months of September, October, November, and (MONTH) 2014 were reviewed on 04/23/15, at approximately 8:50 a.m. The targeted behaviors to monitor were crying, sad facial expressions, agitation, and aggressiveness. The behavior monitoring sheets indicated the resident had not had any of these behaviors during the same four (4) month period. This was evidenced by a zero entered in the columns which indicated the number of behavioral episodes each day. The resident was being monitored for the use of anti-psychotics ([MEDICATION NAME]), anti-depressant ([MEDICATION NAME] and [MEDICATION NAME]), and for anti-anxiety medication ([MEDICATION NAME]/[MEDICATION NAME]). The behavior monitoring sheets for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) were also reviewed at the same time. They too indicated no behaviors were present, as evidenced by zeros entered into the columns indicating the number of behavioral episodes each day. The resident was to be monitored for the same behaviors of crying, sad facial expressions, agitation, and aggressiveness. A review of the current behavior monitoring sheets for the month of (MONTH) (YEAR) also failed to show any documented episodes where the resident was exhibiting any types of behaviors. The behavior monitoring sheet revealed no behaviors were documented for the entire month of (MONTH) from the 1st through the current date of 04/22/15. All three shifts, 7-3, 3-11, and the 11-7 shifts indicated there were no behaviors, as evidenced by a zero in the columns next to number of behavior episodes. The behavior monitoring sheets also failed to indicate Resident #18 was monitored for hallucinations or delusions as indicated in the care plan. A review of the nurses' notes, dated 07/28/14 at 2:00 p.m., was conducted on 04/22/15 at 4:15 p.m. The notes related to GDRs revealed the following entry: This nurse, (#29) reviewed pharmacy recommendation for reduction of [MEDICATION NAME] and [MEDICATION NAME] for GDR. Resident still gets anxious at times. Stays up and yells most of the time at night. Resident is admitted under Hospice services and family does not want GDRs. Resident has appointment with Dr. (named physician) scheduled for 9/09/2014. Residents previous appointment with Dr. (named physician) was on 6/30/2014 with no medication order changes. A review of the pharmacist's monthly medication regimen review, dated 07/24/14, was conducted on 04/23/15 at 10:57 a.m. The pharmacist's recommendation was for a GDR of [MEDICATION NAME], an antipsychotic medication, as evidenced by the following note: (Resident #8) has been taking [MEDICATION NAME] 20 mg QAM (every morning) and 40 mg QPM (every evening) since 7/31/2013. Please evaluate for any potential dosage reduction at this time, the annual GDR. The same pharmacist's monthly medication regimen review, dated 07/24/14, also revealed the pharmacist recommended a GDR for [MEDICATION NAME], an anti-anxiety medication, as evidenced by the following entry: (Resident #18) has been taking [MEDICATION NAME] 0.25 mg BID since 7/30/2013. Please evaluate for a possible dosage reduction, the annual GDR. A review of the pharmacist medication regimen review related to behavior monitoring and [MEDICATION NAME], was conducted on 04/23/15, at approximately 10:57 a.m. The review indicated concerns with monitoring. It noted Resident #180 was taking [MEDICATION NAME] and the medication was stopped and [MEDICATION NAME] was started. The nurses are still monitoring behaviors and side effects for [MEDICATION NAME]. Please stop monitoring [MEDICATION NAME] and begin monitoring the side effects of [MEDICATION NAME], i.e., falls, confusion, drowsiness, and urinary incontinence. A telephone interview was conducted with Consultant Pharmacist #40, on 04/23/15 beginning at 9:10 a.m. regarding the absence of behavior monitoring for [MEDICAL CONDITION] medications. The pharmacist indicated awareness that nurses were not documenting behaviors on the behavior monitoring sheets. He conveyed he had recently made the DON aware of this concern and that they were trying to address this issue. The pharmacists also conveyed that he himself conducted in-service education for the nursing staff, and a new behavior monitoring sheet had been utilized within the past few months. An interview was conducted on 04/23/15 at 10:43 a.m. with the DON, regarding behavior monitoring and to validate the continued need for [MEDICATION NAME], and [MEDICATION NAME]. The DON indicated she was the only nursing staff member whom the pharmacist educated on behavioral monitoring and the new behavioral monitoring sheets. She said it was her responsibility to educate the other staff nurses. The DON conveyed she had not yet educated the other nurses on the behavior monitoring documentation issues which the pharmacist identified, nor had she educated them on the use of the new behavior monitoring forms which were currently in use. The DON conveyed that she was working on some things to make this better.",2019-01-01
5504,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2015-04-23,371,E,0,1,H66T11,"Based on observation, record review, and staff interview, the facility failed to implement procedures to prevent foodborne illnesses to the extent possible. Thawing foods were not labeled and dated. In addition a pan of prepared food, stored in the freezer, was not used or discarded by the use by date. This practice had the potential to affect all residents who received food from the dietary department. Facility census: 40. Findings include: a) The initial tour of the kitchen was conducted on Monday 04/20/15, beginning at 7:15 a.m. Dietary Manager (DM) #39 was present for the entire initial tour. Observation in the cooler revealed two (2) separate meat items thawing in two (2) separate large metal pans. Neither product was labeled or dated. The DM identified the items as beef patties and chicken. She conveyed both meat items should have been labeled and dated when they were first placed into the cooler. The DM conveyed these items were placed in the cooler to be thawed for the week. The large bag of hamburger patties appeared completely thawed, as the meat was brown in color. The blood from the meat was completely separated, or pooled away, from the meat. The DM immediately called for Kitchen Supervisor (KS) #41 to help her identify when the beef patties and chicken were first placed into the cooler for thawing. KS #41 stated the meats for the following week were usually removed from the freezer to the refrigerator on the prior Friday. She said that task was delegated to Cook #43 on Friday 04/17/15. An interview with Cook #43 was conducted on 04/21/15 at 11:00 a.m. The cook stated she actually placed both the beef patties and chicken in the cooler to thaw on Sunday 04/19/15, the day before the observation on 04/20/15. Cook #43 said it slipped my mind. She said she forgot to label and date the meats. The cook also stated, We make a list of foods to be pulled for thawing for the week. She was asked how would staff know when to discard the pulled meat items, if they were not labeled or dated? The cook conveyed, We just know. If it is not all used up by Saturday, then it gets tossed. When asked if the meats were allowed to remain in the cooler for a full week, the cook replied, Yes. She also stated sometimes the meat did not completely thaw, at which point it was thawed under running water. b) Also during the initial tour on 04/20/15, a large pan of prepared turkey and dressing was found in the freezer. It was covered with foil, but was partially opened. The date noted on the foil was, 3/03-3/10. The DM stated the turkey and dressing should have been thrown away, as it had been in the freezer beyond its use by date. c) The DM was interviewed at approximately 11:10 a.m. on 04/21/15. The DM was present for the entire interview with Cook #43 on 04/21/15. Upon inquiry, the DM conveyed there was no policy or procedure on thawing time frames or how long foods can be thawed and stored in the cooler before the food items were no longer safe to use. d) A review of the facility's policy and procedure entitled, Dating and Labeling Food was conducted on 04/21/15, at approximately 11:15 a.m. The policy and procedure form was dated 03/26/12. It and read in part: Purpose: To ensure that all food that is opened has correct dates and labels. Procedure: A. All food will be dated when it is opened with the appropriate expiration date. B. All food will have a (7) day expiration date. C. Labels or bold dark marker will be used to identify date. e) A review of the facility's thawing policy was conducted on 04/21/15, at approximately 11:15 a.m. The policy was entitled, Thawing Meats and was dated 10/27/10. The procedure indicated meats were to be thawed under refrigeration or under cold running water of 70 degrees or less. The policy provided did not identify a time frame for thawing, nor did it address how long the food was allowed to defrost before serving. The DM stated she did not have a policy that addressed time frames for thawing meats. f) The DM also provided a policy and procedure statement form entitled Freezing Prepared Food. A review of the policy was conducted on 04/21/15, at approximately 11:20 a.m. It revealed the following: Purpose: To ensure that prepared food is not frozen for longer than (1) month. Policy: All prepared food that is cooked and frozen will be dated and pulled from the freezer within a time frame of (1) month. Procedure: A. All prepared food that is frozen will be dated for a time period of 1 month. B. Freezer will be checked daily for frozen items that can be pulled out and used in preparing meals for that day or next day's use. C. If frozen prepared food is not used within one month it is to be discarded immediately.",2019-01-01
5505,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2015-04-23,428,E,0,1,H66T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure the pharmacist's recommendations for four (4) of five (5) residents whose medication regimens were reviewed were acted upon. The consultant pharmacist recommended gradual dose reductions (GDR) for each of the residents. The facility failed to act upon the recommendations. Resident identifiers: #29, #30, #8, and #18. Facility census: 40. Findings include: a) Resident #29 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment, with an assessment reference date (ARD) of 02/21/15, was reviewed on 04/21/15 at 10:09 a.m. It indicated the resident used anti-anxiety and anti-depressant medications. The MDS did not indicate the resident displayed any indicators of psychosis or any behavioral symptoms. The resident's medical record was reviewed on 04/21/15 at 10:27 a.m. The physician's (MONTH) (YEAR) orders indicated the resident received Zoloft 25 milligrams (mg) at bedtime and Ativan 0.5 mg twice a day for anxiety. The Behavioral Monitoring Forms for Anxiety and Depression were reviewed for the past six (6) months. The monitoring forms indicated staff would monitor for anxiety, with a target behavior of agitation. They were also to monitor for depression, with target behaviors of crying or sadness. The monitoring forms were signed by the nurses on the day, evening, and night shifts. The forms were all documented with zeros, which indicated there were no episodes of these behaviors. The resident's Medication Regimen Reviews were reviewed on 04/21/15 at 10:50 a.m. On 11/13/14, the consultant pharmacist documented for the physician to please evaluate for a dosage reduction for Ativan 0.5 mg twice a day and Zoloft 25 mg every day. The pharmacist indicated the resident had been taking the medications since admission on 05/15/14. A handwritten nurse's note, dated 11/14/14, indicated Director of Nursing (DON) #29 reviewed the pharmacy recommendations for gradual dose reductions (GDRs) related to Ativan and Zoloft. There were no changes in the medication regimen at that time. The note indicated the resident was still tearful at times and had an appointment to follow up with the psychiatrist on 12/08/14. The nurse's note was signed by the DON and the physician. On 04/22/15 at 9:37 a.m., the DON was interviewed and the Medication Regimen Review, dated 11/13/14, was reviewed with her. Upon inquiry related to the process of addressing the pharmacist's recommendations, the DON stated she and the physician went over the recommendations, she wrote a narrative note regarding the resident's medications, and the doctor signed it. She was not aware of any documentation from the physician regarding why the recommended dose reductions were contraindicated and/or any notes the physician had written explaining why the GDR was not attempted. The DON verified the behavioral flow records did not indicate any agitation or signs of anxiety for use of the Ativan. b) Resident #30 The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. On 04/21/15 at 12:43 p.m., the resident's medical record was reviewed. The most recent annual MDS Assessment, with an assessment reference date of 02/24/15, indicated the resident received antipsychotic and antianxiety medications. It indicated since the prior MDS assessment, the resident's behavior status had improved. The (MONTH) (YEAR) physician's orders [REDACTED]. The Behavioral Monitoring Forms for the past six (6) months indicated the resident had no behaviors, except on three (3) occasions, 04/06/15, 04/19/15, and 04/20/15. The flow records indicated the targeted behaviors were yelling, paranoia and restlessness. The Medication Regimen Review, dated 09/15/14, indicated the Consultant Pharmacist requested an evaluation for an annual GDR for the use of Ativan 1 mg at bedtime. The pharmacist documented the resident had been taking the medication since 09/13/13. A handwritten note by the DON, on 09/16/14, indicated she reviewed the pharmacy recommendation with the physician for the GDR of the Ativan and there were no changes to the medication. There was no documentation of a previous dose reduction or why a dose reduction was clinically contraindicated. A Medication Regimen Review, dated 03/19/15, indicated the Consultant Pharmacist requested an evaluation for a possible dose reduction for Seroquel to 50 mg at bedtime. The Pharmacist documented the resident had been taking the medication since 03/11/13. A handwritten note by the DON, dated 03/20/15, indicated she spoke with the physician regarding the pharmacy recommendation to decrease the Seroquel. There was no documentation of a previous dose reduction or if the dose reduction was clinically contraindicated. On 04/22/15 at 9:37 a.m., the resident's Medication Regimen Reviews, dated (MONTH) 2014 and (MONTH) (YEAR) were reviewed with the DON. The DON stated she was not aware of any documentation from the physician regarding contraindications for a dose reduction or any notes by the physician which explained why the GDR for Seroquel was not attempted. She verified the behavioral flow records did not indicate paranoia or restlessness, and there were only three (3) occasions of yelling. All the other entries for behavioral monitoring were recorded as no behaviors noted. On 04/23/15 at 9:31 a.m., consultant Pharmacist #40 was interviewed. The Pharmacist stated he identified problems with a lack of documentation on the Behavioral Monitoring Forms last summer (2014). He said in the past two (2)months, he talked with the DON about the importance of using Behavioral Monitoring Forms to document behaviors for monitoring and continued use of medications. He verified staff were not completing the forms as they should. He verified there was no attempted dose reduction and the documentation did not support why a dose reduction was not attempted and/or why it was clinically contraindicated. At 10:43 a.m. on 04/23/15, the DON was interviewed. She stated in December, the Pharmacist talked to her about using a new behavioral monitoring form. The DON said the form had to be ordered, and in March, the pharmacist educated her about the form. She stated in April, staff started using them for all residents. The DON stated nursing staff were not educated on the use of the forms. She verified she had seen discrepancies in the nurses' notes and in the documentation on the flow records regarding residents' behaviors. c) Resident #8 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (a significant change MDS), with an assessment reference date of 04/11/15, was reviewed on 04/21/15 at 12:57 p.m. It indicated the resident had delusions and rejected care on 1 to 3 days during the assessment reference look back time. This MDS also indicated Resident #8 was receiving antipsychotic, antianxiety, and antidepressant medications. Review of the current physician orders, on 04/11/15 at 12:50 p.m., revealed an order, which originated on 07/2/12, for Risperdal 0.125 mg to be given at bedtime for dementia, mixed type, with behavior problems. There was also an order [REDACTED]. Review of the behavior monitoring forms for February, (MONTH) and (MONTH) of (YEAR), on 04/21/15 at 1:45 p.m., revealed the forms were silent to any resident behaviors. On 04/21/25 at 1:22 p.m., a Pharmacy Medication Regimen Review, dated 06/17/14 was reviewed. The record identified the need for a GDR of Risperdal 0.125 mg and Remeron 15 mg. This report indicated Resident #8 had been on these same medications since 06/12/13. A request was made to evaluate the resident for a potential annual GDR. There was a nursing progress note addressing this request. The nursing progress note indicated the DON spoke with the resident's physician on 06/18/14 at 3:00 p.m., and advised the physician of the request for the dose reduction of the medications. The note indicated Resident #8 still exhibited some verbal and physical outbursts. The DON documented in this progress note that there were no changes made to the Remeron or the Risperdal. There was no evidence of a physician's progress note regarding the requests. Continued review of the resident's Pharmacy Medication Regimen Reviews revealed on 02/11/14, 01/21/15, 02/12/15, and 03/19/15, there were no pharmacist recommendations for medication changes or dose reductions. On 04/16/15, the pharmacist recommended a dose reduction of Xanax 0.5 mg, indicating the resident had been on the medication since 04/15/14 with no attempted dose reductions. There was no evidence this recommendation for a dose reduction was acted upon. A telephone interview was conducted with Consultant Pharmacist #40, on 04/23/15 at 9:38 a.m. A discussion was held regarding the lack of physician justification when a recommendation was made for dose reduction and the physician elected to not attempt the recommended GDR. The pharmacist stated the attending physician did not act upon these recommendations directly, nor did the physician write a note to respond to pharmacy recommendations. The pharmacist stated, instead, he made recommendations through speaking with the DON. The pharmacist stated he accepted the notes from the DON on behalf of the physician, as a response to dose reduction recommendations. The pharmacist verified the DON's notes did not reference the dose reduction was contraindicated and/or how the risk of a reduction outweighed the benefits. Upon inquiry related to behavior monitoring, the pharmacist verified staff often failed to document behaviors on the behavior monitoring tool. He stated staff often documented the resident did not exhibit any behaviors, when the resident actually had behaviors. He stated he introduced a new behavior monitoring tool in (MONTH) (YEAR), so he was hopeful the documentation concern would get better. Interview with the DON at 10:23 a.m. on 04/23/15, confirmed she conducted the follow-up with the physician after the pharmacy consultant made a recommendation. The DON stated she and the physician discussed the recommendations. She said she hand wrote narratives regarding the resident's medications and the doctor signed it. The DON verified there were no actual physician progress notes [REDACTED].#8. The DON stated they had identified concerns with the lack of appropriate behavior documentation to support the use of antipsychotic and antianxiety medications. She stated in (MONTH) 2014, the pharmacy consultant identified a concern that resident behaviors were not being accurately monitored and documented by nursing staff. She said the pharmacist recommended a new monitoring form to monitor behaviors, interventions, and the effectiveness of the medications. The DON stated she was educated on the new form in (MONTH) 2014, but none of the other nurses or nursing assistants were in-serviced on the forms as of the date of the interview, on 04/23/15. She stated the new forms were currently being used, and they were working toward an action plan to correct this identified concern. She confirmed they did not have an actual action plan in place. The DON verified although she was educated on the new form, nursing personnel who actually were using the new form had not been educated on its use. d) Resident #18 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent annual comprehensive MDS, with an assessment reference date of 03/08/15, was conducted on 04/21/15 at 2:10 PM. Section E of the MDS assessments, entitled Behavior, indicated the resident had no potential indicators of psychosis. Under the same section, the resident was noted with behavioral symptoms not directed at others 4 to 6 days per week, but not on a daily basis. The care area assessments (CAAs), dated 03/10/15, were reviewed on 04/22/15 at 2:25 p.m. The Psychotropic Drug Use CAA revealed the following entry: Resident #18 required use of antipsychotic, antianxiety, and antidepressant medications D/T (due to) long history of psychosis, anxiety and depression. Behavior monitoring Q (every) shift. Follow up visits to physician as needed. Will have episodes of continuous yelling even after staff attempts to resolve. Difficult to redirect. Staff to provide calm environment and provide reassurance. The Behavioral Symptoms CAA contained exactly the same documentation as the Psychotropic Drug Use CAA The behavior monitoring sheets for the months of September, October, November, and (MONTH) of 2014 were reviewed on 04/23/15, at approximately 8:50 a.m. The targeted behaviors to monitor were crying, sad facial expressions, agitation, and aggressiveness. The behavior monitoring sheets indicated the resident had not had any of these behaviors during the same four (4) month period. This was evidenced by a zero entered in the columns which indicated the number of behavioral episodes each day. The resident was being monitored for the use of antipsychotics (Geodon), antidepressants (Elavil and Prozac), and for anti-anxiety medications (Alprazolam/Xanax). The behavior monitoring sheets for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) were also reviewed at the same time. They too indicated no behaviors were present, as evidenced by zeros entered into the columns indicating the number of behavioral episodes each day. The resident was to be monitored for the same behaviors of crying, sad facial expressions, agitation, and aggressiveness. A review of the current behavior monitoring sheets for the month of (MONTH) (YEAR) also failed to show any documented episodes where the resident was exhibiting any types of behaviors. The behavior monitoring sheet revealed no behaviors were documented for the entire month of (MONTH) from the 1st through the current date of 04/22/15. All three shifts, 7-3, 3-11 and the 11-7 shifts indicated there were no behaviors, as evidenced by a zero in the columns next to number of behavior episodes. The behavior monitoring sheets also failed to indicate Resident #18 was monitored for hallucinations or delusions as indicated in the care plan. A review of the pharmacist's monthly medication regimen review, dated 07/24/14 was conducted on 04/23/15 at 10:57 a.m. The pharmacist's recommendation was for a GDR of Geodon, an antipsychotic medication, as evidenced by the following note: (Resident #8) has been taking Geodon 20 mg QAM (every morning) and 40 mg QPM (every evening) since 7/31/2013. Please evaluate for any potential dosage reduction at this time, the annual GDR. The same pharmacist's monthly medication regimen review, dated 07/24/14, revealed the pharmacist recommended a GDR for Xanax, an antianxiety medication, as evidenced by the following entry: (Resident #18) has been taking Xanax 0.25 mg BID (twice a day) since 7/30/2013. Please evaluate for a possible dosage reduction, the annual GDR. During the survey, the facility provided no evidence which indicated the physician acted upon or responded to the pharmacist's recommendations GDRs for Geodon or Xanax. A review of the pharmacist medication regimen review, related to behavior monitoring and Elavil, was conducted on 04/23/15, at approximately 10:57 a.m. The review indicated concerns with monitoring. It noted (Resident #180 was taking Elavil and the medication was stopped and Doxepin was started. The nurses are still monitoring behaviors and side effects for Elavil. Please stop monitoring Elavil and begin monitoring the side effects of Doxepin, i.e., falls, confusion, drowsiness, and urinary incontinence. e) The DON was also interviewed regarding the facility's policy and procedure related to GDRs. She conveyed the facility did not have a policy or procedure relevant to GDRs. She stated they used the MDS and RAI (Resident Assessment Instrument) guidance as a reference tool for GDRs. A review of the document provided, dated (MONTH) 2012, was conducted at the same time as the interview. The document was entitled CMS's RAI Version 3.0 Manual Section, N0410. It read in part: Definition: Gradual Dose Reduction (GDR) - step wise tapering of a dose to determine whether or not symptoms conditions or risks can be managed by a lower dose or whether or not the dose or medication can be discontinued. The document also indicated the . nursing home should attempt to taper the medication or perform gradual dose reduction as long as it is not clinically contraindicated.",2019-01-01
5506,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2015-04-23,520,E,0,1,H66T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility's quality assurance and assessment (QA&A) committee failed to develop and implement a plan of action to address quality deficiencies of which it was aware or should have been aware. The facility was not monitoring behaviors for the use of antipsychotic medications. In addition, the facility failed to act upon the pharmacist's recommendations for gradual dose reductions (GDRs). Four (4) of five (5) residents who were reviewed for unnecessary medications were affected were affected; however, the practices had the potential to affect any resident who received medications. Resident identifiers: #29, #30, #8, and #18. Facility census: 40 Findings include: a) Residents #29, #30, #8, and #18 Each of these residents received antipsychotic medications without attempts at GDRs and in the absence of behavioral monitoring. During an interview with Consultant Pharmacist #40, on 4/23/15 at 9:40 a.m., he said he had identified problems with a lack of documentation on the Behavioral Monitoring Forms last summer (2014). He said over the past few months, he had discussed the importance of using the Behavioral Monitoring Forms, to document behaviors for monitoring and continued use of medications, with the Director Of Nursing (DON). He verified staff were not completing the forms as they should. The pharmacist also verified these residents had no attempted dose reductions He confirmed there was no documentation by the physician which supported why a GDR was not attempted and/or if a GDR was clinically contraindicated for any of the residents. An interview was conducted with the DON on 04/23/15 at 11:15 a.m. She was identified as the lead for the QA&A program. During the interview she verified the committee had concerns with unnecessary medication use, dose reductions, and the lack of appropriate behavior documentation to support the use of those medications. She stated in (MONTH) 2014, the pharmacy consultant also identified a concern with resident behaviors not being accurately monitored and documented by nursing and nurse aide staff. She said he recommended a new monitoring form and to monitor behaviors, interventions, and the effectiveness of the medications. The DON stated she was educated on the new form in (MONTH) 2014, but none of the other nurses or nursing assistants had been in-serviced on the forms as of 04/23/15. She stated the new forms were currently being used. The DON said and they were working toward an action plan to correct this identified concern but they did not not have an actual action plan in place. She verified she was responsible for educating nursing personnel on the forms,but had not yet done so. The DON was also interviewed regarding concerns identified with the lack of GDRs for residents receiving antipsychotic and anti-anxiety medications. She verified she followed up with the physician when she received a pharmacy recommendation, documented with a handwritten note, then the physician signed it. The DON verified there were no physician progress notes [REDACTED]. The DON verified she had not identified this as a concern in any of the QA&A meetings. .",2019-01-01
7139,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2013-10-10,225,E,0,1,LV1R11,"Based on personnel file review and staff interview, the facility failed to ensure a thorough criminal background check was completed for one (1) of five (5) employees reviewed. Employee #64 had listed prior work experience in a state other than West Virginia. The facility had not checked for a criminal history in that state. This practice had the potential to affect more than an isolated number of residents. Employee identifier: #64. Facility census: 39. Findings include: a) Employee #64 On 10/10/13 at 9:30 a.m., the personnel file review for five (5) newly hired employees revealed one (1) employee had listed prior work experience in another state. Employee #64 began working at the facility as a nurse aide on 08/16/13. The personnel record review revealed the facility had completed a criminal background check in the state of West Virginia. However, it did not complete a criminal background check in the state where the individual had worked previously. On 10/10/13 at 9:45 a.m., Employee #81, in human resources, said she did not know if the facility had completed a criminal background check in the other state. At 2:50 p.m. on 10/10/13, the administrator (Employee #78) did not have any further evidence to show the facility had completed a criminal background check in the state where Employee #65 had previously been employed.",2017-08-01
7140,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2013-10-10,226,E,0,1,LV1R11,"Based on policy review, personnel file review, and staff interview, the facility failed to operationalize its policies and procedures for screening employees for abuse for one (1) of five (5) employees reviewed. One (1) employee listed work in a state other than West Virginia. The facility had not completed a criminal background check on the employee in that state. This practice had the potential to affect more than an isolated number of residents. Employee identifier: #64. Facility census: 39. Findings include: a) Employee #64 On 10/10/13 at 9:30 a.m.,the personnel file review for five (5) newly hired employees revealed one (1) employee had listed prior work experience in another state. The facility had completed a criminal background check in the state of West Virginia; however, a criminal background check was not completed in the state where the individual had previously been employed. At 9:45 a.m. on 10/10/13 at 9:45 a.m., Employee #81, in human resources, said she did not know if the facility had completed a criminal background check in the other state. The administrator (Employee #78) had no further evidence to show the facility completed a criminal background check in the state where the individual had previously been employed. On 10/10/13 at 2:50 p.m., the administrator provided a copy of the facility's pre-employment reference and inquiries rule. It stated, . the Director may obtain and review the applicant's state and or federal criminal history . The facility had not obtained a criminal history for Employee #64 in the state where the individual had previously been employed. .",2017-08-01
7141,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2013-10-10,241,D,0,1,LV1R11,"Based on observations, staff interview, and review of documentation on tray cards, the facility failed to promote dignity in dining for two (2) residents identified during random opportunities for observation. Residents #26 and #42 were provided plastic eating utensils at their meals. In addition, Resident #26 was not served the noon meal at the same time as his/her tablemates. Resident identifiers: #42 and #26. Facility census: 39. Findings include: a) Resident #42 During observations of the assistive dining room, at 11:07 a.m. on 10/08/13, the tray card for this resident indicated she was to receive plastic utensils at meals. Observation revealed she had regular silverware on her meal tray. At that time, this was brought to the attention of the director of nursing, DON, Employee #5. The DON stated the resident needed plastic utensils previously, but not at this time. She said she changed the request back to regular utensils a few days ago. Observation, on 10/09/13 at 11:12 a.m., revealed the resident's tray card no longer stated the need for plastic utensils; however, plastic utensils were on the resident's tray. The incorrect type of utensils had been provided again for this resident. b) Resident #26 During dining observations in the fine dining room at 11:30 a.m. on 10/08/13, Resident #26 was observed eating with plastic utensils. No other residents were observed with plastic utensils. Review of the resident's diet ticket on the table revealed no directives for the resident to be given plastic utensils. Employee #37, the Activities Director, was observing the residents during this meal. She was asked why Resident #26 was eating with plastic utensils. Employee #37 stated she did not know why he did not have regular silverware. A registered nurse (RN), Employee #31, entered the dining room and reviewed the diet ticket for Resident #26. She stated, There's no order for that, that's a mistake. c) Resident #26 During dining observations in the fine dining room, at 11:15 a.m. on 10/08/13, it was noted not all residents at the same table were served at the same time. At one table, all residents at that table were served their trays with the exception of Resident #26. Before serving a tray to Resident #26, staff began serving residents at another table. Employee #37, the Activities Director, who was assisting in serving trays, was asked why Resident #26 had not received his meal tray. Employee #37 did not answer the question, but said, We're getting it right now. .",2017-08-01
7142,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2013-10-10,242,D,0,1,LV1R11,"Based on observation, staff interview, and review of the resident's meal tray card, the facility failed to ensure Resident #18's preference to not receive mild with his meals was accommodated. This was found for one (1) resident identified through a random opportunity for discovery. Resident #18's tray card clearly indicated the resident was not to be provided milk; however, observation revealed the resident was served milk. Resident identifier: #18. Facility census: 39 Findings include: a) Resident #18 Observation of lunch on 10/09/13, in the assistive dining room, revealed this resident was served a carton of milk. Review of the resident's meal tray card revealed the resident was not to receive milk. On 10/09/13 at 11:20 a.m., an inquiry was made of Employee #76, the registered dietitian (RD), regarding the resident receiving milk. She was unable to give a rationale why dietary sent milk when they tray card indicated no milk. A discussion was held with the dietary supervisor, Employee #38, the morning of 10/10/13. He stated documentation in the resident's medical record indicated the resident preferred to not receive milk.",2017-08-01
7143,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2013-10-10,257,D,0,1,LV1R11,"Based on observation, resident interview, and staff interview, the facility failed to ensure the maintenance of comfortable room temperatures for one (1) of seven (7) residents interviewed in Stage 1. Resident #44 stated her room was too cold. Measurement of the ambient temperature in her room revealed it was less than 71 degrees Fahrenheit. Resident identifier: #44. Facility census: 39. Findings include: a) Resident #44 On 10/08/13 at 10:22 a.m., Resident #44 said her room was cold and she only got warm if she stayed underneath covers. The room felt cold. Employee #9 (housekeeper) and Employee #65 (housekeeper) tried to turn on the resident's heating unit. It did not work. Employee #69 (licensed practical nurse) said she would get maintenance to come look at the unit. On 10/08/13 at 10:45 a.m., Employee #47 (office assistant III) said they had contacted maintenance and the maintenance director (Employee #80). Employee #47 stated Employee #80 said the facility had not turned on the boilers, and that was why the heating unit did not work. At 11:00 a.m. on 10/08/13, Employee #79 (electrician/maintenance) attempted to turn on the heating unit. The unit did not work. Employee #80 went into Resident #44's room and agreed it felt cold. The resident told Employee #80 she felt cold. The temperature in the room registered 68 degrees Fahrenheit on the surveyor's thermometer. Employee #79 used the facility's heat gun to gage the temperature in the resident's room. It also measured the temperature at 68 degrees Fahrenheit. The temperature in the hallway of the unit measured 69 degrees on the surveyor's thermometer and 70 degrees on Employee #79's device. Employee #80 then said he would turn on the boilers and change out Resident #44's heating/air conditioning unit. On 10/08/13 at 12:30 p.m., Employee #79 changed out the resident's heating unit. On 10/08/13 at 1:30 p.m., observation in Resident #44's room revealed the room still felt cold and the unit did not put out warm air. Employee #79 continued to work on the unit. At 1:00 p.m. on 10/10/13 at 1:00 p.m., an observation of the resident's room revealed the heating unit was still producing cool air. Employee #80 said he had to replace a three-way valve in the unit. He said he had to replace a coil in another unit. Employee #80 said the thermostats on the wall in the resident's room did not work. The director of nursing (Employee #5) and Employee #69 both stated they thought the thermostat worked. Employee #69 attempted to turn on the heat in the resident's room by adjusting this thermostat. Employee #80 said some of the thermostats worked and some did not. He did not know exactly which ones worked and which ones did not work. At the time Resident #44 complained of cold temperatures in her room, the room temperature measured 68 degrees Fahrenheit. The facility uses steam heat from a boiler system. On 10/08/13 at 11:00 a.m., the maintenance director described the facility was heated by steam from a boiler. He stated he had not turned on the boiler system, which would provide heat to the resident rooms. The maintenance director said if he turned it on too early it would get too hot. He turned on the boiler system on 10/08/13 at approximately 11:30 a.m.; however, the resident's room still did not have heat. The heating unit did not work in the resident's room. The maintenance director had to order parts for this unit. Further interview with the maintenance director revealed the facility did not do a test on the heating units prior to the arrival of cooler weather. He said they test them when the weather got cold and they turned on the boilers.",2017-08-01
7144,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2013-10-10,275,D,0,1,LV1R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure an annual comprehensive assessment was completed for one (1) of seventeen (17) residents reviewed in Stage 2 of the Quality Indicator Survey (QIS) within 366 days from the most recent annual comprehensive resident assessment. Resident identifier: #39. Facility census: 39. Findings include: a) Resident #39 Review of this resident's medical records was conducted on 10/09/13 at 2:00 p.m. The resident was admitted to the facility on [DATE]. The annual minimum data (MDS) assessment was initiated with an assessment reference reference date (ARD) of 08/22/13. As of 10/09/13, the MDS had not been completed. During an interview with Employee #31, MDS coordinator, on 10/09/13 at 3:15 p.m., she verified the they had not completed the annual MDS assessment as required. She proceeded to immediately completed the MDS.",2017-08-01
7145,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2013-10-10,278,D,0,1,LV1R11,"Based on medical record review and staff interview, the facility failed to ensure each individual who completed a portion of the assessment certified the accuracy of that section with their signature. This was found for one (1) of seventeen (17) residents reviewed in Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #39. Facility census: 39. Findings include: a) Resident #39 Review of this resident's medical record was conducted on 10/09/13 at 2:00 p.m. The record contained a Minimum Data Set (MDS) assessment which was initiated with an assessment reference date (ARD) of 08/22/13. The individuals who completed each section had not signed their sections verifying the accuracy of the sections they completed. On 10/09/13 at 3:15 p.m., Employee #31, MDS coordinator, confirmed some of the sections were completed but were not signed by the individuals who completed the sections. She confirmed the MDS was not completed as required.",2017-08-01
7146,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2013-10-10,280,D,0,1,LV1R11,"**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 seventeen (17) Stage 2 residents reviewed during the Quality Indicator Survey (QIS). The resident had a medication change for [MEDICATION NAME] (prevention) of urinary tract infections (UTIs). The care plan was not revised to reflect this change. Resident Identifier: #31. Facility Census: 39. Findings include: a) Resident #31 Review of the active orders for medications for Resident #31 was conducted at 2:03 p.m. on 10/09/13. This review revealed the resident was ordered, and was receiving, [MEDICATION NAME] 100 milligrams (mg) everyday for [MEDICATION NAME] of UTIs. On 10/09/13 at 3:21 p.m., the resident's care plan was reviewed. The care plan stated the resident took [MEDICATION NAME] 100 mg everyday for UTI [MEDICATION NAME]. The care plan was not revised to reflect the change from [MEDICATION NAME] to [MEDICATION NAME] for UTI [MEDICATION NAME]. At 3:42 p.m. on 10/09/13, this was discussed with the director of nursing (DON). The DON confirmed the care plan was not revised to reflect the use of [MEDICATION NAME] instead of [MEDICATION NAME]. ,",2017-08-01
7147,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2013-10-10,329,D,0,1,LV1R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure the medication regimens for three (3) of seven (7) residents reviewed for unnecessary medications were managed to promote or maintain each resident's highest practicable physical well-being. The facility failed to ensure vital sign monitoring was completed as ordered. The results of this monitoring were the determining factors regarding whether medications should be given or withheld. Resident identifiers: #11, #24, and #33. Facility census: 39. Findings include: a) Resident #11 Review of the resident's physician orders, on 10/09/13 at 08:00 a.m., revealed the resident had an order for [REDACTED]. The resident's blood pressure and pulse were to be obtained prior to giving [MEDICATION NAME]. The [MEDICATION NAME] was to be held (not given) if the resident's systolic blood pressure was less than ninety (90) and/or the pulse was less than sixty (60). The medication administration record (MAR) and nurses' notes were reviewed on 10/09/13 at 10:15 a.m. This review found between 10/01/13 through 10/07/13, the resident's blood pressure and pulse were not consistently monitored prior to the administration of [MEDICATION NAME]. A pulse of 72 was documented on the MAR on 10/01/13, but there was no blood pressure documented. From 10/03/13 through 10/07/13, no blood pressures or pulses were documented. An interview was conducted on 10/09/13 at 2:00 p.m. with Employee #69, a licensed practical nurse (LPN). She was asked where nurses documented blood pressures and pulses for residents taking blood pressure medication. Employee #69 stated some nurses documented the blood pressure and pulse in the nurses' notes, and other nurses document this information in the comment section of the MAR. She stated if the blood pressure and pulse were adequate, they did not have to document them. During an interview on 10/09/13 at 2:05 p.m., with another LPN, Employee #73, she was asked the same question regarding documentation of blood pressure and pulse prior to administering a blood pressure medication. Employee #73 stated when she was in training, she was taught to document the blood pressure and pulse in the comment section on the MAR. She said that was where she documented blood pressures and pulses she obtained. On 10/10/13 at 2:15 p.m., an interview was conducted with Employee #5, the director of nursing (DON). She was asked where staff were supposed to document a resident's blood pressure and pulse when a resident had a physician's orders [REDACTED]. She stated she was aware staff did not consistently document this information in the same place. The DON stated staff had been documenting the blood pressure and pulse on the twenty-four (24) hour report. Upon inquiry, she stated she knew this report was not part of this resident's medical record. The DON said staff also documented this information in the nurses' notes, the vital cumulative, and the comment section on the MAR. She acknowledged the facility did not have an efficient protocol for monitoring blood pressures and pulses. During this interview, the DON confirmed nursing staff had not been consistently monitoring Resident #11's blood pressure and pulse in the morning prior to providing the resident's blood pressure medication. Review of the facility's policy, on 10/10/13 at 2:17 p.m., revealed appropriate comments were to be entered on the MAR under the comment section. b) Resident #24 This resident's medical record was reviewed on 10/09/13 at 9:20 a.m. The physician's orders [REDACTED]. If the resident's pulse was below 60, the [MEDICATION NAME] was not to be given. Review of the MAR for the dates of 09/09/13 through 10/09/13 revealed no evidence the pulse was taken prior to giving the medication on sixteen (16) occasions: 09/09/13, 09/11/13, 09/12/13, 09/15/13, 09/16/13, 09/23/13, 09/24/13, 09/25/13, 09/27/13, 09/30/13, 10/01/13, 10/02/13, 10/03/13, 10/04/13, 10/05/13, and 10/06/13. An interview was conducted with the DON on 10/10/13 at 10:15 a.m. regarding staff taking the pulse for Resident #24 prior to giving her [MEDICATION NAME]. The DON stated she knew that the staff were not consistently recording the pulses in the same place and that the nurses recorded the pulses on the 24 hour report. When asked if the 24 hour report was available to all staff, she stated it was only available to nurses. When asked if the doctor or the pharmacist could see these vital signs, the DON stated they would only see what was documented in the computer. c) Resident #33 Review of the resident's physician's orders [REDACTED].#33 had an order for [REDACTED]. The orders instructed the medication be held if the pulse was lower than sixty (60). The MAR was reviewed on 10/09/13 at 10:00 a.m., revealing between 10/01/13 to 10/09/13, the resident's pulse was not consistently monitored prior to the administration of [MEDICATION NAME]. The only pulse noted on the MAR was on 10/09/13. There was no evidence the pulse was taken from 10/01/13 through 10/08/13. An interview was conducted with Employee #75, a licensed practical nurse (LPN), during a medication observation on 10/09/13 at 8:25 am. The LPN was asked where staff documented the pulse if a resident was taking a medication which required taking a pulse prior to administration. Employee #75 stated the pulse was documented in the comment section of the medication requiring the pulse on the MAR. During an interview conducted during medication administration on 10/09/13 at 9:01 a.m., Employee #68, an LPN, was asked where staff documented the pulse if a resident was taking a medication which required taking a pulse prior to administration. Employee #86 stated when she was in training, they taught them to document the blood pressure/pulse in the comment section on the MAR. She said that was where she documented pulses. On 10/10/13 at 2:15 p.m., an interview was conducted with the DON. At that time, she confirmed her staff had not consistently monitored Resident #33's pulse prior to administering her blood pressure medication.",2017-08-01
7148,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2013-10-10,365,D,0,1,LV1R11,"Based on observation and staff interview, the facility failed to ensure a resident was provided food in a form the resident could eat. The resident had a sore lip which prevented her from being able to eat a pork chop as it was served. Resident Identifier: Resident #37. Facility Census: 39. Findings include: a) Resident #37: During dining observations in the fine dining area, at 11:40 a.m. on 10/08/13, Resident #37 was observed trying to eat a pork chop from her plate. It appeared the resident was unable to bite the pork chop. The resident was approached, and was observed with a swollen, red lower lip. When asked if she was able to eat the pork chop, Resident #37 stated, No. My mouth hurts. Employee #37, the Activities Director, who was observing resident dining, was asked about the resident's lip. Employee #37's only reply was, It's recent. It was not until after Employee #37 was advised the resident could not eat the pork chop due to the pain in her lip, the resident was offered a substitute. She was given a ham salad sandwich, which she was able to eat.",2017-08-01
7149,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2013-10-10,367,D,0,1,LV1R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the resident's meal tray card, one (1) resident, identified through a random opportunity for discovery, was not provided a therapeutic diet as ordered by the physician. Resident #42 had an order for [REDACTED]. Resident identifier: #42. Facility census: 39. Findings include: a) Resident #42 At lunch time on 10/08/13, in the assistive dining room, this resident received chopped pork with sauce. The tray card, developed from the physician's orders [REDACTED]. Employee #76, the registered dietitian (RD), who was present at 11:20 a.m. on 10/09/13, was asked why the resident was not provided finger foods. The RD replied dietary staff had a problem with providing this resident finger foods since the finger foods were ordered. Observation, on 10/09/13 at 11:30 a.m., revealed a list of finger foods was posted in the dietary department; however, this resident received foods which were not foods the resident could pick up to eat with her fingers.",2017-08-01
7150,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2013-10-10,371,F,0,1,LV1R11,"Based on observation, staff interview, and policy review, the facility failed to follow sanitation and food handling practices to prevent food contamination and/or to ensure foods were safe for consumption. Dishware was dried with a towel, equipment and cookware were soiled with debris, and food items in the nutrition pantry were not dated upon opening. These practices had the potential to affect all residents who consumed food by oral means. Facility census: 39 Findings include: a) During the initial tour of the dietary department, on 10/08/13 prior to lunch, the following sanitation issues were noted: 1) A dietary staff member was observed drying covers for food trays with a cloth, instead of allowing them to air dry according to acceptable sanitation techniques. 2) The tops of ovens were sticky and tacky with grease, food debris, and dust. 3) Sheet pans and steam table pans had blackened crusty debris along the edges, creating a potential for food contamination should the debris flake off into food in the pans. The dietary supervisor, Employee #38, was present during the tour. She confirmed these issues were not acceptable sanitation practices. b) During an observation of the facility's pantry with Employee #75, a licensed practical nurse (LPN), on 10/08/13 at 09:20 a.m., opened and undated packages of hot dogs and bologna were observed in plastic containers. The containers were labeled with Resident #12' s name. Observation at the same time revealed snow cones, with the flavors of birthday cake, strawberry, and blueberry, were open and undated in a cabinet. Employee #75 stated the policy was to date food items upon opening, so staff would know to discard the item in seven (7) days. She agreed the items noted were opened and undated. A review of the facility's policy and procedure, on 10/09/13 at 2:00 p.m., revealed directives to date foods, when they were opened, with the appropriate expiration date. The policy noted all food had a seven (7) day expiration date. .",2017-08-01
7151,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2013-10-10,428,E,0,1,LV1R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the consultant pharmacist failed to identify the facility was not obtaining vital signs (blood pressures and pulses) as ordered prior to the administration of medications for Residents #11, #24 and #33. For Resident #33, the consultant pharmacist also failed to conduct a medication regimen review in August 2013. Three (3) of seven (7) residents reviewed for unnecessary medications were affected. Resident identifiers: #11, #24, and #33. Facility census: 39.Findings include: a) Resident #11 Review of the resident's physician orders, on 10/09/13 at 08:00 a.m., revealed the resident had an order for [REDACTED]. The resident's blood pressure and pulse were to be obtained prior to giving Atenolol. The Atenolol was to be held (not given) if the resident's systolic blood pressure was less than ninety (90) and/or the pulse was less than sixty (60). The medication administration record (MAR) and nurses' notes were reviewed on 10/09/13 at 10:15 a.m. This review found between 10/01/13 through 10/07/13, the resident's blood pressure and pulse were not consistently monitored prior to the administration of Atenolol. A pulse of 72 was documented on the MAR on 10/01/13, but there was no blood pressure documented. From 10/03/13 through 10/07/13 no blood pressures or pulses were documented. A review of the monthly medication regimen review, on 10/09/13 at 10:20 a.m., found the consultant pharmacist failed to recognize the facility was not documenting blood pressure and pulses as ordered by the physician. On 10/10/13 at 2:15 p.m., an interview was conducted with Employee #5, director of nursing (DON). She was asked if the consultant pharmacist notified the facility there was no evidence blood pressures and pulses were being taken prior to administration of Atenolol. The DON confirmed the consultant pharmacist had not identified and notified the facility about this irregularity. b) Resident #24 This resident's medical record was reviewed on 10/09/13 at 9:20 a.m. The physician's orders [REDACTED]. If the resident's pulse was below 60, the Lopressor was not to be given. Review of the MAR for the dates of 09/09/13 through 10/09/13 revealed no evidence the pulse was taken prior to giving the medication on sixteen (16) occasions: 09/09/13, 09/11/13, 09/12/13, 09/15/13, 09/16/13, 09/23/13, 09/24/13, 09/25/13, 09/27/13, 09/30/13, 10/01/13, 10/02/13, 10/03/13, 10/04/13, 10/05/13, and 10/06/13. An interview was conducted with the DON on 10/10/13 at 10:15 a.m. regarding staff taking the pulse for Resident #24 prior to giving her Lopressor. The DON stated staff were not consistently recording the pulses in the same place and that the nurses recorded the pulses on the 24 hour report. When asked if the 24 hour report was available to all staff, she stated it was only available to nurses. When asked if the doctor or the pharmacist could see these vital signs, the DON stated they would only see what was documented in the computer. The resident's medications were reviewed by the pharmacist monthly since her admission. The consultant pharmacist failed to identify and report there was no evidence of monitoring the resident's pulse prior to the administration of Lopressor. c) Resident #33 1) Review of the resident's physician's orders [REDACTED].#33 had an order for [REDACTED]. The orders instructed the medication be held if the pulse was lower than sixty (60). The MAR was reviewed on 10/09/13 at 10:00 a.m., revealing between 10/01/13 to 10/09/13, the resident's pulse was not consistently monitored prior to the administration of Metoprolol. The only pulse noted on the MAR was on 10/09/13. There was no evidence the pulse was taken from 10/01/13 through 10/08/13. Review of the consultant pharmacist medication regimen reviews, on 10/09/13 at 10:20 a.m., found the consultant pharmacist failed to recognize the facility was not documenting the pulses prior to the administration of Metoprolol as ordered by the physician. On 10/10/13 at 2:15 p.m., an interview was conducted with the DON. She was asked if the consultant pharmacist notified the facility there was no evidence this resident's pulses were not consistently taken prior to administration of Metoprolol. The DON confirmed the consultant pharmacist had not identified and notified the facility of this irregularity. 2) Review of the consultant pharmacist's monthly medication regimen reviews, on 10/09/13 at 3:00 p.m., found the consultant pharmacist failed to conduct a monthly review of Resident #33's medication regimen in the month of August 2013. On 10/10/13 at 2:15 p.m., the DON verified the consultant pharmacist failed to review Resident #33's medication regimen in August of 2013.",2017-08-01
7152,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2013-10-10,469,D,0,1,LV1R11,"Based on observation and staff interview, the facility failed to ensure an effective pest control program. Small black flying insects were observed in three (3) of thirty (30) resident rooms. The insects were also observed around the nurses' station and in other common areas of the unit. This affected three (3) residents and had the potential to affect more than an isolated number of residents. Resident identifiers: #2, #20, and #44. Facility census: 39. Findings include: a) Resident #44 During the Stage I resident interview/observation on 10/08/13 at 10:30 a.m., small black insects (the size and appearance of a gnat) were flying around in Resident #44's room. They were also flying near the resident's face. The resident was swatting at the insects, saying they were annoying. b) Resident #20 On 10/08/13 at 3:03 p.m., observations revealed small black insects flying in Resident #20's room. c) Resident #2 At 4:30 p.m. on 10/08/13, observations revealed small black flying insects in this resident's room. d) Throughout the survey, observations revealed small black insects flying around the nurses' station and in other areas of the unit. e) On 10/10/13 at 9:00 a.m., the administrator (Employee #78) indicated he had a contract with a pest control company. The pest report showed the facility received a service on 09/09/13; however, the small black flying insects were present in the facility during the survey from 10/08/13 to 10/10/13. The administrators said gnats were bad this year in the community. He also commented maintenance staff had poured bleach in the drains to try to control the gnats.",2017-08-01
7153,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2013-10-10,514,D,0,1,LV1R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the medical records for three (3) of seventeen (17) Stage 2 sample residents were complete and/or accurate. The medical record for Resident #19 contained conflicting [DIAGNOSES REDACTED].#24 did not have a physician's orders [REDACTED]. The dates on invitations for care plan conferences for Resident #27 did not correlate with the year the conferences were held. Resident identifiers: #19, #24, and #27. Facility census: 39. Findings include: a) Resident #19 Review of the resident's medical records, on 10/10/13 at 10:00 a.m., revealed the physician orders [REDACTED]. The psychiatrist consultation reports indicated the resident received the medication [MEDICATION NAME] for the treatment of [REDACTED]. According to the physician orders, Resident # 19 received [MEDICATION NAME] for the treatment of [REDACTED]. Interview with Employee #5, the director of nursing (DON), was conducted on 10/10/13 at 11:00 a.m. She confirmed the [DIAGNOSES REDACTED]. The DON stated the [DIAGNOSES REDACTED]. b) Resident #24 During a medical record review for Resident #24 on 10/09/13 at 2:30 p.m., her minimum data set (MDS) assessment, with an assessment reference date (ARD) of 08/12/13, revealed she was on a toileting program. The bladder incontinence evaluation, dated 08/14/13, also revealed the resident was on a toileting program. The current physician's orders [REDACTED]. An interview was conducted with the DON, on 10/09/13 at 2:30 p.m. She stated the resident was on a toileting program. She reviewed the physician's orders [REDACTED]. . c) Resident #27. On 10/09/13 at 2:06 p.m., an invitation to the resident's power of attorney (POA) to attend a care plan conference in February 2013 was reviewed. The invitation was dated as written on 01/31/12. Further review revealed an invitation to the POA to attend a care plan conference on 05/16/13. This invitation was dated as written on 05/01/12. Another care plan invitation, for a care plan conference to be held on 08/15/13 was reviewed. This invitation was dated as written on 05/01/12. An interview was conducted, on 10/09/13 at 2:07 p.m., with Employee #46, the social worker. When asked why the dates of the invitations did not correlate with the care plan meeting dates, she stated she had not changed the dates on the care plan invitations.",2017-08-01
8370,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2012-11-29,156,C,0,1,X70T11,"Based on observation of posted information and staff interview, it was discovered the facility did not have the current address for the (state agency) Office of Health Facility Licensure and Certification (OHFLAC) posted as required. This practice had the potential to affect all residents and the public, who are to have access to this information. Facility census: 48. Findings include: a) While observing posted information on 11/28/12, at mid morning, it was discovered the address posted for OHFLAC was incorrect. The address listed was not the address for this agency, and had not been for more than a year. This was discussed and confirmed with the director of nursing, Employee #127, and the social worker, Employee #292, at the time of the review.",2016-07-01
8371,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2012-11-29,159,E,0,1,X70T11,"Based on record review, resident interview, and staff interview, the facility failed to ensure residents received quarterly statements notifying them of the balance in their resident trust (personal) account. Five (5) of five (5) residents reviewed were not provided quarterly statements. Resident identifiers: #23, #54, #6, #11, and #4. Facility census: 48. Findings include: a) Resident #23 and #54 On 11/27/12 at 9:28 a.m., during Stage 1 of the survey, Resident #23 indicated he had a personal funds account with the facility, but did not know how much money he had in the account. He said he thought the facility would tell him if he asked them. On 11/27/12 at approximately 1:00 p.m., Resident #54 indicated the facility also kept personal money for her, but she did not know how much money she had. b) Residents #6, #11, #4, #23, and #54 At 2:30 p.m. on 11/27/12, the account technician III (Employee #296) provided a list of residents who had requested the facility maintain a personal account for them. Five (5) residents were selected for review. Resident #6, #11, #4, #23, and #54 had personal accounts with the facility. Employee #296 indicated the five (5) residents did not have capacity. She said the residents' responsible parties received the quarterly fund balance report. She said the facility did not give quarterly statement balance reports to residents who were incapacitated. On 11/28/12, at approximately 2:00 p.m., the administrator (Employee #4) indicated the facility would evaluate incapacitated residents to determine their interest in receiving quarterly statements. He agreed the resident's incapacity status did not automatically make them unable to understand their quarterly trust account statements.",2016-07-01
8372,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2012-11-29,241,D,0,1,X70T11,"Based on observation, staff interview, and policy review, the facility failed to promote dignity for one (1) of one (1) sample residents who had a urinary catheter. The urinary catheter drainage bag for was not covered. Resident Identifier: #16. Facility Census: 48. Findings include: a) Resident #16 Observation of Resident #16 was conducted at 12:30 p.m. on 11/26/12. The resident was in bed. A urinary catheter drainage bag was attached to the lower frame of the bed. The urinary catheter drainage bag was not covered. Interview with Employee #127, the director of nursing (DON), was conducted at 2:31 p.m. on 11/27/12. The DON stated the facility had plastic like covers for the urinary catheter bags. The DON further explained the staff normally only covered urinary catheter drainage bags when those residents with urinary catheters were in a public area. Review of facility's policy on 'Quality of Life - Dignity' was conducted at 2:45 p.m. on 11/27/12. The policy stated the following: Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: a. Helping the resident to keep urinary catheter bags covered The policy did not specify residents' urinary catheter bags were to be covered only when residents with Foley catheter drainage bags were in a public area.",2016-07-01
8373,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2012-11-29,248,D,0,1,X70T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family interview, and staff interview, the facility failed to ensure the development of a personalized structured activity program for one (1) of four (4) cognitively impaired residents. The facility did not utilize information gathered during the comprehensive activity assessment for Resident #37. Resident identifier: #37. Facility census: 48. Findings include: a) Resident #37 The medical record review for Resident #37, conducted on 11/28/12, at approximately 8:30 a.m., revealed this resident had a [DIAGNOSES REDACTED]. The record also revealed he depended upon staff for completion of activities of daily living and was unable to participate in most group related activities. On 11/28/12 at 8:45 a.m., a review of the resident's activity questionnaire, dated 07/26/12, revealed the resident had a past interest in country music, hunting, fishing, camping, four wheeling, and drawing. On 11/26/12, at approximately 3:00 p.m., Resident #37's wife said she had thought about bringing some country music recordings to the facility for the resident. She said he liked to listen to that genre of music when he was at home. At approximately 8:45 a.m., on 11/28/12, Employee #149 (recreation director) said she completed one-on-one activities with this resident due to his inability to participate in most group events, and his inability to self-initiate activities in his room. She indicated some of these one-on-one activities included reading mail, smelling different lotion scents, and reading a daily devotional. She did not indicate the inclusion of any of the resident's past interests in the one-on- one activities she provided. On 11/28/12, at approximately 1:00 p.m., the recreation director said she had talked to the resident about hunting and fishing, and he had responded to this activity.",2016-07-01
8374,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2012-11-29,253,E,0,1,X70T11,"Based on observation and staff interview, it was determined the facility failed to ensure the environment was safe and sanitary. Furniture was found with the finish worn off and with liquid stains. Walls had scratches and scuff marks. Closet doors did not function properly. These environmental conditions were found in five (5) of twenty-seven (27) rooms observed during Stage I of the Quality Indicator Survey (QIS). Room numbers include: #102, 104, 113, 118, and 129. Facility Census: 48. Findings include: a) During Stage I observations of the facility, the following environmental conditions were observed: 1) Room #102 had a chair with wooden handles that were worn and scuffed. 2) Room #104 had an over-the-bed table with stains from liquid spills on the top. 3) Room #113 had molding missing from around the sink in the bathroom area. 4) Room #118 had a closet door that would not close properly. 5) Room #129 had scrapes and scuffs along the wall at the entrance of the room. These environmental issues were discussed and confirmed with Employee #176, the person who took care of environmental concerns for the unit, on 11/28/12 at 1:55 p.m.",2016-07-01
8375,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2012-11-29,272,D,0,1,X70T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to complete a bladder incontinence trial, as described in the comprehensive assessment, for one (1) of one (1) sampled residents requiring this service. Resident Identifier: #38. Facility Census: 48. Findings include: a) Resident #38 Review of Resident #38's Bladder Incontinence Evaluations was conducted at 10:00 a.m. on 11/29/12. The initial incontinence evaluation was conducted on 04/25/11. At that time, the resident was marked on the evaluation sheet, as having diminished perception of the need to void. At the time, the resident wore incontinence briefs, was assisted to the bathroom, and was incontinent when checked throughout the day. The minimum data set (MDS), dated [DATE], was reviewed at 10:25 a.m. on 11/29/12. Question H0200-A from the MDS asks Has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility. Question H0200-A was coded (answered) Yes. Question H0200-B from the MDS asks, Response - What was the resident's response to the trial program? Question H0200-B was coded (answered) No improvement. An interview with Employee #127, the director of nursing (DON), was conducted at 10:40 a.m. on 11/29/12. A copy of the voiding trial was requested. The facility was unable to provide evidence that a voiding trial was ever conducted for this resident.",2016-07-01
8376,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2012-11-29,278,D,0,1,X70T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on minimum data set (MDS) assessment review, medical record review, and staff interview, the facility failed to ensure one (1) of thirty-two (32) Stage II sample resident's had an accurate MDS assessment. Resident #37 had the [DIAGNOSES REDACTED]. The facility did not have information to support the coding of this diagnosis. Resident identifier: #37. Facility census: 48. Findings include: a) Resident #37 On 11/28/12, at approximately 11:00 a.m., the medical record review for Resident #37 revealed a quarterly MDS assessment with an assessment reference date of 10/18/12. This date referred to the day in which the observation period had ended. The facility had marked the resident had the condition of dehydration in Section J (Health Conditions). On 11/28/12, at approximately 1:00 p.m., Employee #143 (registered nurse) reviewed the MDS. She said she did not know why she had marked the resident had dehydration. She could not locate any supporting information to show why she had marked the resident had this condition.",2016-07-01
8377,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2012-11-29,279,D,0,1,X70T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family interview, care plan review, and staff interview, the facility failed to ensure two (2) of thirty-two (32) Stage 2 sample residents had a care plan which addressed their individual quality of care and/or quality of life needs. Resident #37's care plan did not include an activity plan with interventions related to his past activities of interest. Resident #45's care plan did not address the resident's range of motion needs associated with contractures. Resident identifiers: #37 and #45. Facility census: 48. Findings include: a) Resident #37 The medical record review for Resident #37, conducted on 11/28/12 at approximately 8:30 a.m., revealed this resident had a [DIAGNOSES REDACTED]. The record also revealed he depended upon staff for completion of activities of daily living and was unable to participate in most group related activities. On 11/28/12 at 8:45 a.m., a review of the resident's activity questionnaire, dated 07/26/12, revealed the resident had a past interest in country music, hunting, fishing, camping, four wheeling, and drawing. On 11/26/12, at approximately 3:00 p.m., Resident #37's wife said she had thought about bringing some country music recordings to the facility for the resident. She said he liked to listen to that genre of music when he was at home. At approximately 8:45 a.m., on 11/28/12, Employee #149 (recreation director) said she completed one-on-one activities with this resident due to his inability to participate in most group events, and his inability to self-initiate activities in his room. She indicated some of these one-on-one activities included reading mail, smelling different lotion scents, and reading a daily devotional. She did not indicate the inclusion of any of the resident's past interests in the one-on-one activities she provided. On 11/28/12, at approximately 1:00 p.m., the recreation director said she had talked to the resident about hunting and fishing, and he had responded to this activity. Review of the resident's care plan revealed no individualized plan for activities. b) Resident #45 Observation of this resident, at 9:45 a.m. on 11/27/12, revealed the resident had a contracture to the right hand/fingers. There was no splint or other type of device in the resident's hand to prevent further contractures. Review of the resident's October 2012 care plan, at 10:00 a.m. on 11/27/12, revealed an intervention for range of motion to the upper extremities during daily care, but there were no specific interventions for the contracture to the right hand/fingers. The resident's activities of daily living (ADL) flow sheet was reviewed at 10:12 a.m. on 11/27/12. It included an order for [REDACTED]. Interview with Employee #127, the director of nursing (DON), was conducted at 10:30 a.m. on 11/27/12. She was informed there was no care plan specifically addressing the resident's contracture. After this information was brought to the attention of the DON, the contracture to the right hand/fingers, as well as an intervention for a rolled washcloth to the right hand was added to the care plan.",2016-07-01
8378,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2012-11-29,371,D,0,1,X70T11,"Based on observation and staff interview, the facility failed to ensure each resident received food/drinks under sanitary conditions. One (1) of three (3) sample residents was observed with a soiled plastic drinking cup. Resident identifier: #37. Facility census: 48. Findings include: a) Resident #37 On 11/29/12 at approximately 10:00 a.m., Resident #37 was observed in his room. He had a plastic drinking cup with a lid. The lid on the cup had a dried pink substance around the top. The resident was dependent upon staff to assist him with drinking, as he was unable to perform this activity himself. Employee #149 (recreation specialist) was in the hallway outside the resident's room. She was shown the cup and agreed it needed cleaned/sanitized. Employee #149 said she would take the cup to the kitchen and have it washed.",2016-07-01
8379,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2012-11-29,441,D,0,1,X70T11,"Based on record review, staff interview, and review of the facility's infection control policy, the facility failed to ensure all employees attended an annual infection control training, as required by facility policy. This practice had the potential to affect more than an isolated number of residents. Employee identifier: #150. Facility census: 48 Findings include: a) Employee #150 Record review and staff interview, on 11/28/12 at 2 p.m., with Employee #203, a licensed practical nurse (LPN), revealed Employee #150, a health service worker (HSW), did not receive the facility required annual infection control training for the year 2012. Employee #203 stated this employee only received infection control training upon hire, which was 03/16/11. An interview was conducted, on 11/28/12 at 2:30 p.m., with Employee #127, the director of nursing (DON). The DON was asked how often employees were required to have infection control training. The DON stated employees received training on infection control upon hire, then they were required to have annual infection control training. Employee #127 stated the facility offered infection control training in January and February of every year. When asked why Employee #150 did not receive annual infection control training in 2012, the DON stated she would have to see if she could find evidence the employee had the training for 2012. On 11/29/12 at 08:10 a.m., the DON reported she had looked everywhere and could not find evidence Employee #150 received the annual infection control training for the year of 2012. On 11/28/12 at 3:00 p.m., review of the facility's infection control policies confirmed all resident care staff members were required to attend an infection control in-service at least annually.",2016-07-01
8380,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2012-11-29,463,E,0,1,X70T11,"Based on observation and staff interview, it was determined the call light cords for one (1) of twenty-seven (27) resident rooms and one (1) of two (2) showers rooms were not of sufficient length for the residents to reach them, should they fall to the floor. The call light in the common bathroom would not stay on, and it had no indicator light which was visible from the hallway. An additional resident room had a call light which was not functional. These practices had the potential to affect more than a limited number of residents. Facility census: 58. Findings include: a) While checking call cords in the facility, at 1:55 p.m. on 11/25/12, with Employee #176, the electrician, observation revealed only a short chain was available in the shower room across from room 121. Additionally, room 124 also had only a short chain. These chains were too short for residents to activate to summons help should they fall to the floor. b) The call light in room 121 was tested , and did not function at all. c) Observation of a common resident bathroom, across from room 122, revealed the call light would not stay on. Additionally, it had no indicator light which was visible from the hallway. These issues were confirmed with Employee #176 during the observations.",2016-07-01
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
10245,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-08-18,456,F,0,1,5XSR12,". Based on observation and staff interview, the facility failed to assure all equipment within the residents' environment was maintained according to the manufacturer's recommendations, thereby creating a potential fire hazard to all residents on this unit. The facility failed to assure the residents' personal clothing dryer was in safe operating condition, when it failed to assure the equipment was maintained and monitored according to manufacturer's specifications. This practice had the potential to all units residents on the unit. Facility census: 41. Findings include: a) On 08/17/10 at 9:00 a.m., observation revealed a member of the maintenance staff (Employee #104) removing a very large amount of lint from the dryer used for residents' personal clothing. This amount was enough to more than fill a gallon container. The facility's laundry aide (LA), who was also present, stated a new ""screen"" was being installed on the machine. The item referred to as a ""screen"" was later determined to be the dryer's lint filter. Further discussion with Employee #104 revealed this ""screen"" prevented the lint from entering the back of the dryer and/or the exhaust system. Upon inquiry, the LA stated this was lint from seven (7) loads of laundry she had done that morning. The LA, when asked how often she removed the lint from the dryer, stated she removed it every evening. The LA and Employee #104 further described how a makeshift lint screen was used until the facility could obtain the type of filter this particular dryer required. Neither was able to state how long the makeshift filter had been in place, and neither knew how long the old filter had a hole in it. Next, Employee #104 stated he was removing all the lint he could while he was putting on the new screen. Further inquiry of Employee #104 revealed another laundry aide (Employee #11) had reported to him that the other screen had a hole in it. When asked when he received this report, Employee #104 stated, ""About a week and a half ago."" Employee #25, the director of nursing (DON) was present, and was asked about speaking with this person. The DON stated Employee #11 retired on 07/31/10. This meant it was at least seventeen (17) days since the problem was brought to the attention of Employee #104. Employee #104 was asked to provide the work request for this problem. He stated there was no work request. At 9:15 a.m. on 08/17/10, the dryer lint was shown to the facility's administrator. The surveyor stated the very large amount of lint appeared to present a fire hazard. The administrator agreed. The administrator was asked to provide the manufacturer's instructions for the dryer and evidence the dryer received preventive maintenance. At 2:00 p.m. on 08/17/10, the administrator reported the facility did not have an instruction or user manual for the dryer. The administrator also reported there was no preventive maintenance program for this piece of equipment. Due to this, there was no evidence of a systematic approach to reduce a potential fire hazard through assuring the dryer was used and maintained according to manufacturer's specifications. The administrator provided a copy of an e-mail from another member of the maintenance staff (Employee #105), which contained the following information, ""Usually we check this about every a months or less as in: Checking for lint build up, damaged parts, loose connections, drive belt for wear or tension, etc. Or, if a problem is brought to our attention during intervals, we address it at that point. When we check it we also look for any grease from bearings, lint build up behind dryer and any other potential problem."" Upon inquiry, the administrator was unable to provide evidence for the last time the dryer was checked, or any time the dryer received a preventive maintenance inspection. Since the facility had no instructions for the dryer, the administrator went online and found the instructions. These were reviewed, and at 1:40 p.m. on 08/17/10, the following information from the manual was shown to the administrator: Page 5 of the instructions, entitled ""Important Safety Instructions,"" contained a warning, ""To reduce the risk of fire... when using your tumbler, follow these basic precautions:"" - Precaution #12 described removal of lint before every load. - Precaution #13 described the importance of keeping the exhaust opening and adjacent area free from accumulation of lint, dust and dirt. - Precaution #14 described that the interior of the tumbler and the exhaust duct should be cleaned periodically by qualified service personnel. The administrator was unable to provide evidence that these precautions were being implemented to avoid environmental fire hazards and to minimize the likelihood of an accident. On 08/18/10 at 9:00 a.m., an observation was made to determine how much lint was accumulating inside the lint removal area, now that the filter was replaced. The LA stated she had dried four (4) loads. When asked to remove the lint, she produced an amount the size of a baseball. During the morning of 08/18/10, the administrator provided an e-mail from the manager of technical services and service training for the dryer's manufacturer. The e-mail, dated 08/18/10 at 10:05 a.m., indicated the filter did not need cleaning after every load, except at the time of installation and initial use. This person stated, ""If a minimal amount of lint is observed during these initial checks, it is permissible to change the lint removal frequency to once per day as indicated on PDF page 67, document page 65."" The facility had no way of knowing this information prior to the survey. More importantly, the facility failed to assure the safe functioning of the dryer, when the filter was not promptly replaced after a hole was discovered in the filter. On 08/18/10, the administrator was asked to provide a work order, a purchase order, and/or any other evidence the facility acted promptly once the hole in the original lint filter was reported. During exit at 6:15 p.m. on 08/18/10, the administrator confirmed this information did not exist. The potential of a fire from lint buildup in a dryer's exhaust or the back of the dryer, due to a faulty filter, had not been identified through routine preventive maintenance or by other means. .",2015-06-01
11305,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2011-02-11,223,G,1,0,3UQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the facility's self-reported allegations of resident abuse / neglect and staff interview, the facility failed to ensure one (1) of three (3) residents were free from abuse. One (1) resident suffered mental anguish after staff members intentionally deprived him of free access to his bed. The facility staff did not allow this resident (who was physically able to get into his bed on his own) to access his bed freely. Staff kept the bed elevated with side rails up so as to prevent him from accessing his bed without staff assistance, and then failed to assist him to bed for a period of approximately five (5) during which time he begged staff members to put him in his bed. Resident identifier: #8. Facility census: 43. Findings include: a) Resident #8 1. On 02/11/11 at approximately 11:00 a.m., review of the facility's self-reported allegations of resident abuse / neglect revealed a report dated 01/05/11, which was submitted to the Office of Health Facility Licensure and Certification (OHFLAC) Nurse Aide Registry. The report identified Employee #33 (a nurse aide) as the alleged perpetrator and Resident #8 as the alleged victim. The allegation was: ""(Employee #33) states she elevated the resident's bed so that he would not get into the bed. She states this was done in an attempt to prevent the resident from choking on tobacco, as he refuses to remove the tobacco from his mouth prior to getting in bed. This information was obtained during a counseling session with (Employee #33) on 01/04/11."" -- 2. The five (5) day follow-up report dated 01/12/11 (an extension was granted by OHFLAC due to an employee being on sick leave) stated: ""(Employee #33) states she elevated the resident's bed so he could not get into bed by himself. Done to prevent resident from getting into bed with tobacco in his mouth and possibly choking (sic). DON (director of nursing - Employee #141) stated it was okay to raise the bed for safety purposes. However, there was no order to raise the bed and this was not a part of the resident's care plan."" The facility substantiated the allegation against Employees #33 and #141; however, the facility identified the issue as neglect as opposed to abuse. -- 3. The facility's internal investigation into this incident (titled ""Long Term Care Investigation"") was completed by the facility ' s administrator (Employee #139). The allegation was stated as follows: ""Resident (name of Resident #8)'s bed was elevated so that he could not get into bed by himself. This was allegedly done so that the resident would not get into bed with tobacco in his mouth, putting him at risk for choking and/or aspiration."" The investigative report included summaries of interviews conducted by the administrator with various staff members by the administrator on 01/06/11, 01/10/11, and 01/11/11, including the following: - Employee #68 (housekeeping), interviewed on 01/06/11 - ""(Employee #68) states that one evening while he was working the resident asked for a 'chew.' He states it was probably around five or six o'clock. (Employee #68) states the resident spit the tobacco out and said he would like to go to bed. He states this went on for approximately four hours. ""(Employee #68) states he went in at 21:30 (9:30 p.m.) to pull the trash and the resident was still asking to go to bed. He states that at 22:30 (10:30 p.m.), 'the (sic) man still wanted to go to bed.' (Employee #68) states the resident begged to go to bed. He states the resident's bed was 'in the air' the whole time. (Employee #68) states the resident asked him to put his bed down, but (Employee#68) told the resident he could not put the bed down. (Employee #68) states he reported the incident to (Employee #99), CNO (chief nursing officer)."" - Employee #10 (licensed practical nurse - LPN), interviewed on 01/10/11 - ""(Employee #10) states she was doing a medication pass on December 14, 2010 at approximately 17:30 (5:30 p.m.). She states she was returning to the medication room when (Resident #8) asked her for 'a chew and a pop.' (Employee #10) states that at 19:30 (7:30 p.m.) the resident was at the gate at the nurse's station saying, 'Honey, put me in the bed. My bed is raised up.' (Employee #10) states she informed the resident that 'they' didn't want him to get in bed with a chew. (Employee #10) states (Resident #8) gave her his tobacco. She states she told the resident's nurse, (Employee #30) (LPN) that he wanted to go to bed. ""(Employee #10) states she personally did not see the resident's bed up because she was 'not allowed' to go on that side of the unit. She states (Employee #68) told her it was true, that the resident's bed was up. (Employee #10) states she told the resident to follow (Employee #33 - a nurse aide) and that she would put him to bed. ""(Employee #10) states that at 21:50 (9:50 p.m.) the resident was following her during a medication pass and said he wanted to go to bed. (Employee #10) states that she told (Employee #30 - an LPN), 'If someone doesn't put him in bed, I'm giving him another chew.' (Employee #10) states that (Employee #140 - a registered nurse) came on the unit and she asked (Employee #140) to look and see if the resident's bed was up. (Employee #10) states that (Employee #140) told her the bed was up. (Employee #10) told (Employee #140) not to say anything. ""(Employee #10) states she called (Employee #141), DON, the next morning. (Employee #10) states (Employee #141) asked her, 'What are you doing on that side?' (Employee #10) states she told (Employee #141) that somebody was putting the resident's bed up. She states (Employee #141) replied, 'Day shift does it.' (Employee #10) states she told (Employee #141) that (Employee #68) told her the resident's bed was up. (Employee #10) states that (Employee #141) replied, '(Employee #68) comes behind the desk, too, and he's not supposed to.' (Employee #10) further states that (Employee #39), LPN, told her that (Employee #141) had asked her to write an order to put the bed up, but (Employee #39) said she was not comfortable doing this. ..."" - Employee #17 (a nurse aide), interviewed on 01/06/11 - ""(Employee #17) states that (Employee #33) told her she needed to lock the resident's bed and that (Employee #141) had told her she could put the bed up and lock it. (Employee #17) states that the bed has been put up several times by (Employee #33) and that this has been going on for about a month to a month and a half."" - Employee #142 (physician), interviewed on 01/06/11 - ""(Employee #139) asked (Employee #142) if he had given (Employee #39), LPN, a verbal order to elevate the bed. (Employee #142) states that is not exactly the way it happened. He states that (Employee #141) discussed with him the resident's fall risk, stating that if the resident gets into bed by himself the bed alarm will not be turned on. (Employee #142) states he told (Employee #141) that if it was within the law to raise the bed it was fine. He states he didn't know if that would be like a restraint and also that he did not know if that would keep the resident from falling. He states he does not think that he gave an order for [REDACTED]. -- 4. Included with the facility's investigative report was a typed statement from Employee #141 dated 01/11/11, explaining her why she allowed staff to raise Resident #8's bed up to a point where he could not access it independently. A portion of the letter stated (quoted verbatim), ""... in (Resident #8)'s care plan he is to have at least a one person assist to enter and exit his bed, as he is unable to bear weight on his feet, in his care plan he is to have a bed alarm on at all times, to assure that he does not attempt to exit bed unassisted. (Resident #8) chews tobacco, (Employee #33) C.N.A. came to me expressing her concern that she was unable to comply with (Resident #8's) care plan, nor protect him from aspiration, due to his non compliance. She stated that he would ask the nurses for chewing tobacco, wheel himself back to his room, at which time he would stand on one foot and throw himself into the bed without assistance, the staff unaware of him getting back in bed, his bed alarm would not be on, he would lie in bed with his mouth full of tobacco, falling asleep, the staff would find him asleep, tobacco amber running out of his mouth, his pillow case and bedding covered with tobacco stains, which would be enough fluid that could cause aspiration if the right circumstance presented itself. She told me that she had been raising his bed to the highest level and raising all side rails, so that (Resident #8) would have to ask for assistance to get into bed, which the care plan states that he is to be assisted, at this time she could not assure that he was not going to bed with tobacco in his mouth, this would prevent the chance of aspirating on tobacco, and the bed alarm could be set, to comply with the residents plan of care. At no time was any of the residents' rights denied him, he was never placed in any danger, because with the bed in the highest position and all rails up he could not attempt to enter the bed without assistance. ..."" -- 5. An interview with the administrator and review of the documentation from the facility's internal investigation revealed Resident #8 had the physical ability to get into bed, even though the facility did not want him to do so without staff assistance for safety purposes. Staff had placed a bed alarm on the resident's bed to alert them when he got out of bed, because he was at risk for falls. The investigation by the facility concluded that Employee #141 had given Employee #33 permission to raise the resident's bed up in the air to prevent him from getting into his bed at will. The investigation also showed the resident had gone to his room and saw his bed raised to the point he could not get into it by himself. He had begged Employee #68 to place him in the bed, because he could not do so himself. On 12/14/10, from approximately 5:30 p.m. until at least 10:30 p.m., Resident #8 asked various staff members to put him to bed, because he could not access his bed independently. Staff deprived Resident #8 of the ability to get into his bed on his own. This action caused him to wait several hours, as well as to beg staff members for assistance, before he was assisted into his bed. .",2014-07-01
11306,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2011-02-11,225,D,1,0,3UQL11,". Based on a review of the facility's self-reported alleged violations of resident abuse / neglect and staff interview, the facility failed to ensure all allegations of abuse / neglect made against employees were reported to the appropriate State officials as required by law. Facility documentation revealed Employee #33 (a nurse aide) elevated Resident #8's bed to prevent him from accessing his bed at will. The facility reported Employee #33 to State officials as required; however, the facility's internal investigation revealed Employee #141 ( a registered nurse) was also involved in the incident, and there was no evidence that this employee was reported as required. Resident identifier: #8. Facility census: 43. Findings include: a) Resident #8 On 01/05/11, the facility self-reported Employee #33 to the State nurse aide registry. The allegation stated, ""(Employee #33) states she elevated the resident's bed so that he could not get into the bed. She states this was done in an attempt to prevent the resident from choking on tobacco, as he refuses to remove the tobacco from his mouth prior to getting in bed."" This information was obtained during a counseling session with Employee #33 on 01/04/11. The facility identified the incident as having occurred on or about 11/26/10. The facility's five (5) day follow-up report stated, ""Neglect substantiated on the part of (Employee #33) (nurse aide) and (Employee #141) RN/LTC (long term care director) director of nurses."" However a review of the information submitted to State officials revealed Employee #141 had not been identified as an alleged perpetrator and, consequently, had not been reported to any State agency as required.",2014-07-01
11307,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2009-04-10,323,D,0,1,4JJY11,"Based on observations, medical record review, and staff interviews, the facility failed to ensure the residents' environment was as free of accident hazards as possible. One (1) of the three (3) styles of beds in use in the facility exhibited gaps between the side rail and the mattress sufficient to pose a risk of entrapment to a resident's arm or leg. Six (6) of nine (9) residents on the sample were affected. Additionally, a housekeeper was observed mopping the floor in the hall. She mopped across the entire hall and did not leave a dry lane for residents who were traveling through the hall. One (1) resident was observed removing the bar from a Merrywalker-type chair so she could sit on her bed. She had difficulty lifting her foot over the strap of the chair, which passed between her legs, in order to exit the chair. This created a falls hazard. Resident identifiers: #5, #9, #22, #34, #35, #47, and #12, and any residents ambulating through the hall. Facility census: 47. Findings include: a) Residents #5, #9, #22, #34, #35, and #47 These residents had been observed periodically throughout the survey to have their side rails elevated when they were in bed. On the morning of 04/10/09, nine (9) of the twelve (12) residents on the sample were still in bed. The space between the side rails and the mattresses were evaluated. It was found that one could easily pass one's arm (to a height above the elbow) through the space between the mattress and below the the end of the side rails on these residents' beds. The thin arms and legs of the residents could easily become entrapped between the rails and the mattress. Resident #47's bed rails were covered with fitted pads, but the pads did not prevent passage of one's arm between the rails and the mattress. Three (3) styles of beds and side rails were assessed. Two (2) styles did not pose a problem. However, the third type of bed had side rails that were offset from the frame, resulting in a gap between the side rail and mattress. b) Housekeeping On 04/09/09 at 10:40 a.m., a housekeeper was observed mopping the hallway. She would mop a section of the hall from one (1) side to the other, then move to the next part of the hall and again mop clear across the hall. This resulted in residents and staff having to walk on wet, or partially wet, tiles increasing the potential for falls. c) Resident #12 On the morning of 04/10/09, while assessing this resident's ability to release herself from a Merrywalker-type chair, the resident was observed to enter her room and remove the bar from the front of the chair. She was wanting to sit on her bed. She tried to stand and lift her right foot over the strap that went from the front of the device, between her legs, and to the seat of the chair. She was unable to lift her foot high enough to clear the strap. She then sat on the seat of the chair and began to try to lift her foot over the strap. After several attempts, she was able to clear the strap, get out of the chair, and sit on the side of her bed. The director of nursing was present during this observation. The possibility of the resident becoming entangled in the strap was discussed. She later related the strap had been removed from the chair. .",2014-07-01
11308,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2009-07-03,225,E,1,0,HMYP11,"Based on record review and staff interview, the facility failed to immediately report and thoroughly investigate an allegation of neglect by Employee #33, a nursing assistant (NA), involving Resident #3, and failed to investigate the reasons six (6) additional current residents and five (5) discharged residents refused to be cared for by Employee #33. Resident identifiers: #3, #13, #16, #22, #32, #41, #45, #49, #50, #51, #52, and #53. Facility census: 47. Findings include: a) Resident #3 Review of facility records revealed an incident, occurring on 05/21/09, in which a NA (Employee #33) was observed, by the respiratory therapist (RT), pushing Resident #3 in a shower chair, with the resident's feet dragging under the shower chair twice. The RT stated the NA continued pushing the resident, even though the resident yelled, ""My foot, my foot! You're hurting my foot!"" The NA did not stop pushing the shower chair until the RT intervened. Additionally, the RT reported to the facility that Employee #33 ""threw"" briefs onto each resident's bed and that Employee #33 ""had a bad attitude."" After the RT reported the incident to the facility, but the facility did not report it to State agencies as neglect, nor did the facility thoroughly investigate the incident. The resident's roommate, whom the facility identified as ""interviewable"", was present, yet the facility did not interview this resident regarding the incident. In addition, there was no statement (written or dictated) from the alleged perpetrator (Employee #33). Facility staff interviewed another NA (Employee #36), who witnessed the briefs thrown on the beds and confirmed that Employee #33 ""did throw the briefs onto each of the beds and that she (Employee #33) did have a bad attitude."" According to the facility's grievance form, the social worker (SW) and director of nursing (DON) interviewed Employee #33, who denied the incident, said the resident's foot was caught only once, and that she ""laid the diapers on the bed."" Review of the grievance form, completed by the SW, revealed no evidence that the incident was ever considered an incident of neglect and/or abuse. b) Residents #13, #16, #22, #32, #41, #45, #49, #50, #51, #52, and #53 During the survey, it was discovered these residents refused to allow Employee #33 to provide care for them. None of these refusals were addressed as allegations of abuse or neglect. The facility had compiled the names of these residents on a list and were working the schedule so that they were not assigned to Employee #33. The facility had not ascertained and/or investigated the reasons these residents did not want Employee #33 to care for them. These processes were necessary to rule out abuse and/or neglect. .",2014-07-01
11309,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2009-07-03,226,E,1,0,HMYP11,"Based on record review, staff interview, and policy review, the facility failed to operationalize their policies and procedures regarding identification, investigation, and reporting of suspected neglect or abuse. Resident identifiers: #3, #13, #16, #22, #32, #41, #45, #49, #50, #51, #52, and #53. Facility census: 47. Findings include: a) Resident #3 Review of facility records revealed an incident, occurring on 05/21/09, in which a nursing assistant (NA - Employee #33) was observed, by the respiratory therapist (RT), pushing Resident #3 in a shower chair and dragging this resident's foot under a shower chair twice. According to the director of nursing (DON) at 12:00 p.m. on 07/03/04, the RT did not report the incident to anyone. The DON stated, ""We heard rumors and sought her out."" Review of the facility's abuse / neglect policy revealed, ""All personnel must promptly report any incident or suspected incident of resident neglect, abuse..."" This information is in the section of the policy entitled ""Reporting"". The RT was a hospital employee, not an employee of the nursing home; however, all personnel who work with residents in the nursing facility are required to know and operationalize facility abuse policies. In addition, the facility failed to operationalize its procedures to notify the appropriate State regulatory agencies, and failed to operationalize its procedures to investigate an allegation of neglect regarding this incident. b) Residents #13, #16, #22, #32, #41, #45, #49, #50, #51, #52, and #53 During the survey, it was discovered these residents refused to allow Employee #33 to provide care for them. The facility had not investigated the reasons why these residents were refusing care from Employee #33. At 12:15 p.m. on 07/03/09, the social worker (SW) was asked how the facility became aware that these residents did not want Employee #33 to provide their care. The SW stated the nurses informed them. When asked if the residents had been asked why they were refusing care by Employee #33, the SW stated they had not. The facility failed to operationalize procedures to rule out possible abuse or neglect. It was also confirmed, at that time, that none of the situations had been immediately reported or thoroughly investigated as required by law. The facility had not operationalized its procedure which stated, ""When a resident or other person makes an allegation (or complaint) to an employee, the employee is responsible for promptly assisting the resident in bringing the matter to the attention of the Long-term Care Coordinator, the Charge Nurse, or the Social Worker, by immediately completing a Resident Complaint Form..."" This form was not completed for any of these residents. Since there were reasons why the residents refused care by Employee #33, the facility had an obligation to ascertain why. This was necessary to rule out possible abuse and/or neglect. c) Since twelve (12) incidents of possible neglect or abuse were not reported or investigated, it was determined the facility had not operationalized the training necessary to assure all employees were aware of what constitutes neglect and/or abuse and how staff should report allegations of neglect and/or abuse. Additionally, the facility also failed to operationalize their procedures for reporting and investigating suspected incidents of abuse. .",2014-07-01
11310,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2009-07-03,323,D,1,0,HMYP11,"Based on observation and staff interview, the facility failed to identify and mitigate an accident hazard for one (1) of seven (7) sampled residents. Resident identifier: #36. Facility census: 47. Findings include: a) Resident #36 On 07/01/09 at 10:10 a.m., this resident was observed attempting to get out of bed. According to nursing staff present at that time, the resident was able to get out of bed unassisted and did so at will. The resident had full length gap guards on her bed. They ran from the top of the bed to the bottom of the bed. The resident was observed extending her legs over the guard at the foot of her bed, to get out of the bed. Due to the guard, the resident was unable to simply position herself on the side of the bed, allow her feet to touch the floor, then rise normally. Additionally, since the guards were not permanently attached to the bed, if one (1) of the guards happened to slide away from the side of the bed the resident was exiting, the resident could become entangled, causing a fall. .",2014-07-01
2690,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2020-01-09,641,D,0,1,I2XH11,"Based on record review and staff interview the facility failed to ensure Resident #92's Minimum Data Set (MDS) was accurate. This was true for one (1) out two (2) resident's reviewed for the care area of hospitalization . Resident identifier: #92. Facility census 90. Findings included: a) Resident #92 Medical record review revealed Resident #92 was discharged to her home with her husband on 12/02/19. The long term care survey process (LTCSP) pre-selected the resident for review in the care area of hospitalization (which comes from the Minimum data set (MDS). On 01/09/20 at 10:37 AM, Registered Nurse Assessment coordinator (RNAC) #116 verified the information on MDS section A was inaccurate for Resident #92. The resident was discharged to her home and not to the hospital as coded by the facility on the MDS.",2020-09-01
2691,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2020-01-09,656,D,0,1,I2XH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #86 had a person-centered care plan developed and / or implemented to meet his / her medical, physical, mental, and psychosocial needs. This was true for one (1) of twenty (20) residents reviewed. Resident identifier: 86. Facility census 90. Findings include: a) Resident #86 During a review of Resident #86's record, the following order was entered on 12/11/19: No blood pressures or lab draws in left arm due to AV (arteriovenous) graft. every day and night shift. An arteriovenous graft is used for [MEDICAL TREATMENT]. A review of Resident #86's care plan noted the following: Review of Resident #86's care plan found a focus problem: [MEDICAL TREATMENT] End Stage [MEDICAL CONDITION]. The goal associated with this problem: Will have immediate intervention should any s/sx (signs and symptoms) of complications from [MEDICAL TREATMENT] occur through the review date. Interventions included: Do not draw blood or take B/P (blood pressure) in (left) arm. The following blood pressures were documented in Resident #86's medical record: -- 12/29/2019 2:04 PM - 112 / 77 mmHg Sitting l (left) /arm -- 12/28/2019 3:36 PM 132 / 78 mmHg Sitting l/arm -- 12/20/2019 3:01 PM 111 / 53 mmHg Lying l/arm -- 12/18/2019 11:19 AM 142 / 59 mmHg Sitting l/arm During an interview with Employee #116, Registered Nurse Assessment Coordinator (RNAC) on 01/09/20 at 11:53 AM, RN #116 stated Resident #86 is care planned to not have vital signs taken in the left arm and Resident #86 should not have had blood pressures taken in that arm. On 01/09/20 at 12:03 PM the findings were discussed with the Administrator. No further information was provided by the end of the survey on 01/09/20 at 1:00 PM.",2020-09-01
2692,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2020-01-09,657,D,0,1,I2XH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the comprehensive care plan for two (2) of twenty (20) residents reviewed during the long-term care survey process. Resident identifiers: #31, #54. Facility census: 90. Findings included: a) Resident #31 Resident #31's comprehensive care plan contained the focus, (Resident's name) receives anti-anxiety medications ([MEDICATION NAME]) r/t (related to) Anxiety disorder. Review of Resident #31's current medication orders revealed he was not currently prescribed the medication [MEDICATION NAME] ([MEDICATION NAME]). Review of Resident #31's past medication orders revealed he had been prescribed [MEDICATION NAME] ([MEDICATION NAME]) on 10/01/19, one (1) mg by mouth every six (6) hours as needed for agitation, to be continued for seven (7) Days. During an interview on 01/09/20 at 10:33 AM, Registered Nurse Assessment Coordinator (RNAC) #115 agreed Resident #31's comprehensive care plan was not revised to reflect he was no longer prescribed the medication [MEDICATION NAME] ([MEDICATION NAME]) for anxiety. She stated she would revise Resident #31's comprehensive care plan. No further information was provided through the completion of the survey. b) Resident #54 A review of Resident #54's medical record noted the following order dated 06/23/18: Head of bed elevated at nurses discretion. Review of Resident #54's care plan found a focus problem: (Name of Resident) requires tube feeding r/t (related to) resisting eating. The goal associated with this problem: Patient will remain free of side effects or complications related to tube feeding through review date. Interventions included: ASPIRATION PRECAUTIONS: Ensure the HOB (head of bed) is elevated during and at least thirty minutes after tube feeding. During an interview with Employee #116, Registered Nurse Assessment Coordinator (RNAC) on 01/09/20 at 12:16 PM, RN #116 stated Resident #54's care plan does not match the current physician's orders [REDACTED]. RN #116 stated she believed the order was related to the angle of the head of the bed and not whether the head of the bed is elevated during and at least thirty minutes after tube feeding. RN #116 confirmed that the care plan did not match the physician's orders [REDACTED].>On 01/09/20 at 12:20 PM the findings were discussed with the Administrator. No further information was provided by the end of the survey on 01/09/20 at 1:00 PM.",2020-09-01
2693,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2020-01-09,687,D,0,1,I2XH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure Resident #46 received proper treatment and care to maintain mobility and good foot health, in accordance with professional standards of practice. This was a random opportunity for discovery during the long term care survey process. Resident identifier: 46. Facility census: 90. Findings include: a) Resident #46 An observation with Employee #63, Registered Nurse (RN) of Resident #46 at 11:12 AM on 01/09/20, found the resident had long, thick and discolored toenails with thick, dry crusty skin at the base of toes and extending to the end of toes. The toenails were discolored (dark purple/black in color) on multiple toes. A review of Resident #46's medical record, found the resident has a history of severe [MEDICAL CONDITION] and has had multiple vascular ulcers on both lower extremities and feet. The resident currently has a vascular ulcer on the left lower extremity. Further review of medical records found a consultation report from the treating vascular physician dated 11/13/19: Left lower vascular ulcers continue. Right lower extremity vascular wound healed. Continue daily treatments to left lower leg until completely healed. Recommend compression to both lower extremities to prevent new ulcers. Return to the clinic as needed if wounds do not heal completely. An interview with the Director of Nursing (DON) on 01/09/20 at 11:30 AM, confirmed the facility knew the residents toe nails were long and discolored with very dry, flaky skin noted from base of toes extending to the ends of toes. She also verified a follow-up appointment with the vascular physician was needed due to the resident's long standing vascular disease.",2020-09-01
2694,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2020-01-09,689,D,0,1,I2XH11,"Based on observation and staff interview, the facility failed to ensure the residents environment remains as free of accident hazards as is possible. This was a random opportunity for discovery. This failed practice had the potential to affect a limited number of residents residing at the facility. Resident identifiers: # 87 and # 50. Facility census: 90. Findings included: a) Resident # 87 On 01/06/20 at 12:19 PM, observation revealed a canister of Micro Kill (wipes used to clean and disinfect medical equipment) setting on the resident's night stand. Resident #87 stated the the wipes have been in the room for a long time. On 01/06/20 at 12:19 PM, Licensed Practical Nurse (LPN) # 102 verified the canister of Micro Kill wipes setting on the night stand. LPN #102 removed the wipes and stated she did not know why the wipes were in the room or how long they had been there. On 01/06/19 at 2:00 PM, the Administrator said, they have only one wondering resident on the first floor. This was Resident #50. Below is the information about the risk and hazards of Micro Kill wipes: -SERIOUS EYE DAMAGE /EYE IRRITATION Eye Contact: Immediately flush eyes with plenty of water for at least 15 minutes. Remove contact lenses, if present and easy to do. Continue rinsing. If eye irritation persists: Get medical advice/attention. -Inhalation: Move to fresh air. Call a physician if symptoms develop or persist. Skin Contact: Wash off with soap and water. Get medical attention if irritation develops and persists. -Ingestion: Rinse mouth. Get medical attention if symptoms occur. Most important symptoms and effects, both acute and delayed: Exposed individuals may experience eye tearing, redness, and discomfort. -General Information: Ensure that medical personnel are aware of the material(s) involved, and take precautions to protect themselves.",2020-09-01
2695,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2020-01-09,698,E,0,1,I2XH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure one (1) of one (1) resident reviewed for the care area of [MEDICAL TREATMENT] received care and services consistent with professional standards of practice. Resident identifier: 86. Facility census 90. Findings include: a) Resident #86 Resident #86 was admitted to the facility on [DATE]. During a review of Resident #86's record, the following order was entered on 12/11/19: No blood pressures or lab draws in left arm due to AV (arteriovenous) graft. every day and night shift. An arteriovenous graft is used for [MEDICAL TREATMENT]. The following blood pressures were documented in Resident #86's medical record: -- 12/29/2019 2:04 PM - 112 / 77 mmHg Sitting l (left) /arm -- 12/28/2019 3:36 PM 132 / 78 mmHg Sitting l/arm -- 12/20/2019 3:01 PM 111 / 53 mmHg Lying l/arm -- 12/18/2019 11:19 AM 142 / 59 mmHg Sitting l/arm During an interview with Employee #116, Registered Nurse Assessment Coordinator (RNAC) on 01/09/20 at 11:53 AM, RN #116 stated Resident #86 has an order to not have vital signs, including blood pressure, taken in the left arm. RN #116 states Resident #86 should not have had blood pressures taken in that arm. On 01/09/20 at 12:03 PM the findings were discussed with the Administrator. No further information was provided by the end of the survey on 01/09/20 at 1:00 PM.",2020-09-01
2696,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2020-01-09,812,E,0,1,I2XH11,"Based on observation and staff interview, the facility failed to store and prepare food in a sanitary manner. This failed practice had the potential to affect more than a limited number of residents. Facility census: 90. a) Kitchen On 01/06/20 at 11:45 AM, a tour of the kitchen was conducted with the Dietary Services Supervisor. In the walk-in freezer an opened box of pizza was noted on one of the shelves. The opened box was in a plastic bag, but the bag was not sealed. The plastic bag was gaping open. A piece of pizza was visible in the box and was lying on a piece of cardboard. The rest of the pizza pieces were beneath this piece of cardboard. Additionally, this box of pizza was not dated to indicate when the box had been opened. The Dietary Services Supervisor confirmed the bag containing the box of pizza was not sealed and was not dated to indicate when the box had been opened. b) First Floor Nutrition Pantry. On 01/06/20 at 12:00 PM, a tour of the first-floor nutrition pantry was conducted with the Dietary Services Supervisor. The microwave in the pantry was noted to have a greasy-appearing substance covering the glass turntable. Bits of food were noted on the bottom of the microwave. The bottom of the freezer was noted to have a beige-colored substance that was sticky to the touch. Two of the refrigerator shelves were noted to have white and beige-colored substances that were sticky to the touch. The Dietary Services Supervisor stated he would clean the microwave, refrigerator, and freezer. c) Second Floor Nutrition Pantry. On 01/06/20 at 12:10 PM, a tour of the second-floor nutrition pantry was conducted with the Dietary Services Supervisor. The refrigerator was noted to have a yellow substance spilled in the bottom of the left bottom drawer and the bottom of the refrigerator. The Dietary Manager stated he would clean the refrigerator.",2020-09-01
2697,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2020-01-09,880,D,0,1,I2XH11,"Based on observation and staff interview the facility failed establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifiers: #71 and #84. Facility census 90. Findings included: a) Resident #71 Observation of the resident on 01/06/20 at 12:45 PM, found the resident was in a wheelchair. The residents Foley catheter bag was underneath the chair. The Foley tubing was coming out of the bottom of the residents' pant leg and was laying on the floor under the resident. Approximately three (3) to four (4) inches of the Foley tubing was on the floor. On 01/06/20 at 12:45 PM, Nurse Aide (NA) #25 confirmed the catheter tubing was on the floor. NA #25 used a blue clip on the tubing to keep the Foley tubing from touching the floor. b) Resident #84 On 01/06/2020 at 12:35 AM, observation found the Resident's Nebulizer (a device that turns liquid medicine into a mist for inhalation) mouthpiece and tubing laying on the Residents nightstand. The mouthpiece was exposed and not properly stored in order to prevent the spread of infection. Licensed Practical Nurse (LPN) #80 entered the room and verified the Nebulizer mouthpiece should be stored in a storage bag. LPN #80 stated, I will get a new set up and storage bag right now, it (Nebulizer mouthpiece) was in the bag this morning. No storage bag was found to be present within the Resident's room for the Nebulizer mouthpiece. Record review revealed an active order for the use of [REDACTED]. During an interview on 01/09/2020 at 11:00 AM, the Administrator stated, They (the Residents) take those bags and use them to put things in. Procedure policy provided by the Administrator titled, Medication Administration via Nebulizer states in Step #9 to: Clean the mask or mouthpiece and store in a clean container, such as a plastic bag.",2020-09-01
2698,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2018-01-10,641,D,0,1,VCZ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete an accurate assessment for Resident #33. The MDS did address the [DIAGNOSES REDACTED]. This failed practice had the potential to affect a limited number of residents. Resident identifier: #33. Facility census: 98. Findings include: a) Resident #33 Review of the medical record on 01/10/18 at 10:38 AM revealed an MDS with ARD date of 08/16/17. This MDS had a Section I coded with no [DIAGNOSES REDACTED]. Review of the care plan [MEDICAL CONDITION] a [DIAGNOSES REDACTED]. Review of the current physcian's order indicated Resident #33 received [MEDICATION NAME] 300 mg at night for GERD. This medication had a start date of 06/27/17. Interview with MDS Coordinator on 01/10/18 at 10:45 AM verified the MDS with ARD of 08/16/17 did not include the [DIAGNOSES REDACTED].",2020-09-01
2699,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2018-01-10,656,D,0,1,VCZ811,"Based on observation, medical record review and staff interview, the facility failed to develop a comprehensive care plan in the area of self-injurious behavior of scratching herself for one (1) of twenty (20) sampled residents. Resident identifier: #23. Facility census: 98. Findings include: a) Resident #23 On 01/08/18 at 11:31 AM, Resident #23 was observed scratching her left arm. She stated her arm was hurting. Resident #23 had several scabbed areas on her left forearm. One area was bleeding. She also had a small scabbed area on her the right side of her nose. A Resident Summary note written on12/24/17 stated, Patient has scratched and scabbed areas on bilateral arms and reddened areas on bilateral lower legs, scratched and scabbed areas on abdomen due to patient scratching self. A Resident Summary note written on 01/07/18 stated, Patient has bilateral scabbed and scratched areas to bilateral arms and legs from patient scratching skin. A review of the comprehensive care plan revealed the intervention of Geri sleeves to alarms (sic) bilaterally as resident will allow. This intervention was for the focus area of Activities of Daily Living. The comprehensive care plan did not have a focus area relating to resident's self-injurious behavior of scratching herself. During an interview on 01/10/18 at 10:10 AM, Certified Nursing Assistant (CNA #17) stated Resident scratched herself on her left arm and her face. When asked how the scratches were treated, CNA #17 stated lotion had been applied during the bed bath that had just been completed. She also stated she was going to get new geri-sleeves to apply. CNA #17 stated Resident #23 didn't always leave her geri-sleeves on. During an interview on 01/10/18 at 10:41 AM, Registered Nurse Assessment Coordinator (RNAC) #94 confirmed Resident #23's comprehensive care plan did not contain a focus area for resident's self-injurious behavior of scratching herself. RNAC #94 stated she would add a focus for this behavior to the comprehensive care plan.",2020-09-01
2700,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2018-01-10,689,D,0,1,VCZ811,"Based on observation, record review, and staff interview, the facility failed to ensure the environment was as free from accident hazards as possible for one (1) of twenty (20) sampled residents. Resident identifier: #47. Facility Census: 98. Findings include: a) Resident #47 Review of Resident #47's comprehensive care plan revealed a focus area of high risk for falls. An intervention for this focus area was Fall mats to right and left sides of bed while in bed to help prevent injury. During an observation on 01/09/18 at 7:55 AM, Resident #47 was noted to be resting in bed with a fall mat on the left side of her bed. The right side of her bed (near the window) did not have a fall mat. During an interview on 01/09/18 at 7:58 AM, Unit Charge Nurse (UNC) #33 confirmed Resident was care planned for bilateral fall mats, but only had one in use at that time. On 01/10/18 at 2:20 p.m., the administrator was notified of the finding of only one fall mat in use for Resident #47, although the comprehensive care plan indicated the use of bilateral fall mats. On 01/09/18 at 3:55 PM, the Director of Nursing (DoN) reported Resident #47's second fall mat had been inadvertently placed next to her roommate's bed. Resident #47's roommate did not have an indication for fall mats. The DoN stated this had been corrected, and Resident #47 now had two (2) fall mats in use.",2020-09-01
2701,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2018-01-10,842,D,0,1,VCZ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain a complete and accurate medical record for Resident #94. This failed practice had the potential to affect a limited number of residents. Resident identifier: #94. Facility census: 98. Findings include: a) Resident #94 Review of the medical record for Resident # 94 revealed an admission date of [DATE]. Further review of the medical record revealed Resident #94 was ordered the following medications for the following conditions: --[MEDICATION NAME] .25 mg by mouth three times a day for Generalized Anxiety Disorder with a start date of 12/05/17 --[MEDICATION NAME] 10 mg by mouth one time a day for Generalized Anxiety Disorder with a start date of 12/05/17 --[MEDICATION NAME] 2.5 mg by mouth twice a day for [MEDICAL CONDITION] with a start date of 11/20/17 The most recent Minimum Data Set (MDS) was the 30-Day with an Assessment Reference Date (ARD) of 12/18/17 under Section I for Active [DIAGNOSES REDACTED]. Anxiety and [MEDICAL CONDITION] were checked as no. The 14-Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/17 under Section I for Active [DIAGNOSES REDACTED]. Anxiety and [MEDICAL CONDITION] were checked as no. The electronic health record listed the following psychiatric and mood disorders: Major [MEDICAL CONDITION], Recurrent, Unspecified with a creation date of 11/22/17. Review of the Care Plan with an initiation date of 11/21/17 had the following: --Focus area: (Resident name) receives antipsychotic/hypnotic/ mood stabilizer medications ([MEDICATION NAME]) related to hallucinations. --Focus area: (Resident name) receives anti-anxiety medications ([MEDICATION NAME]) related to Anxiety disorder. --Focus area: (Resident name) receives antidepressant medication ([MEDICATION NAME]) related to Depression. On 01/10/18 08:04 AM asked the administrator for information concerning discrepancy. On 01/10/18 at 9:26 a.m., the DON #103 confirmed the physician did not provide a [DIAGNOSES REDACTED]. She stated the resident entered the facility with a [DIAGNOSES REDACTED].",2020-09-01
2702,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2018-11-28,759,D,0,1,DZOV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a medication error rate below 5%. The facility's medication error rate was 8%, which was the result of two errors in 25 opportunities. This affected two (Residents #5 and #16) of six residents for whom medication administration was observed. Finding include: 1. On 11/26/18 at 11:21 AM, licensed practical nurse (LPN) #68 was observed as she administered a puff of [MEDICATION NAME] HFA inhaler to Resident #16. Following the administration of the first puff, the LPN waited approximately 3 seconds and administered the second puff. She did not wait one minute between puffs per the manufacturer's instructions and the facility's policy and procedure. The package insert for a [MEDICATION NAME] HFA inhaler documented: .If your healthcare provider has told you to use more sprays, wait 1 minute and shake the inhaler again (prior to administration of second inhalation) . The facility's Oral Inhalation Administration policy and procedure documented: .If another puff of the same or different medication is required, wait at least 1 minutes between (puffs) . On 11/26/18 at 3:30 PM, the physician's orders [REDACTED]. A physician's orders [REDACTED]. The order documented the resident was to inhale two puffs every six hours related to her [DIAGNOSES REDACTED]. At 3:38 PM, LPN #68 was shown the package insert for the [MEDICATION NAME] HFA inhaler and the instructions for the period of time to wait to administer a second puff. The above observation was reviewed with the LPN. She stated she had not waited one minute to administer the second puff of the [MEDICATION NAME] inhaler per the manufacturer's instructions. 2. On 11/26/18 at 10:15 AM, LPN #68 was observed as she prepared Resident #5's medication for administration. She measured [MEDICATION NAME] 17 grams and poured it into eight ounces of water and administered the medication to Resident #5. On 11/26/18 at 01:05 PM, the physician's orders [REDACTED]. A physician's orders [REDACTED]. At 01:14 PM, LPN #68 was asked to review the order for [MEDICATION NAME] on the resident's medication administration record. She noted the order documented the medication was to be administered in 12 ounces of fluid. She stated she had administered the medication in eight ounces of water and acknowledged it was a medication error.",2020-09-01
2703,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2018-11-28,801,C,0,1,DZOV11,"Based on staff interviews, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, the facility failed to employ a Dietary Services Supervisor hired after 11/28/17 that was a Certified Dietary Manager (CDM). This affected one of one kitchen in the facility. The resident census at the time of the survey was 93. Findings include: The Dietary Services Supervisor (DSS) was interviewed on 11/27/18 at 9:04 AM. He said he was currently enrolled in the CDM class. He started the class in the summer; approximately (MONTH) or July. He was enrolled once before but said he never took the test. He said they do not have a full-time dietician. They have a dietician in their corporate office and they have a consultant dietician that comes every two weeks. The DSS was interviewed on 11/28/18 at 12:57 PM. He said he did not have a degree in food service management. He only had experience as a food service manager. He said he started with the company as a DSS in 07/2017 and started at this facility in 01/2018. He again confirmed that he was enrolled in his CDM classes. He was hoping to finish and test for his CDM in the summer of 2019. He thought he had one year to complete the CDM once he was hired. He did not know that he needed to be a CDM prior to starting the position. The Nursing Home Administrator (NHA) was interviewed on 11/28/18 at 2:10 PM. She thought that the DSS had a year after hire to complete the CDM course and take the test. She did not realize that the DSS had to be a CDM by 11/28/17.",2020-09-01
3957,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2016-09-15,253,E,0,1,MJ2111,"Based on observation and staff interview, the facility failed to provide effective housekeeping and maintenance services for five (5) of twenty-nine (29) resident rooms observed during Stage 1 of the Quality Indicator Survey (QIS). These cosmetic imperfections included a bathroom with broken floor tiles and commodes needed caulking replaced, cove base missing or pulled away from walls, a scuffed wall, a facet needed to be replaced, and a heating/cooling unit had pulled away from the wall. This failed practice had the potential to affect more than an isolated number of residents. Room identifiers: A15, B3, B6, C9 and C13. Facility census: 99. Findings include: a) Cosmetic imperfections -- Observation of Room A15 on 09/13/16 at 9:28 a.m., to have cracked floor tile in the bathroom and the caulking around the commode needed to be replaced. -- Observation of Room B3 on 09/12/16 at 1:52 p.m., had cove base pulled away from the wall and the caulking around the commode needed to be replaced. -- Observation of Room B6 on 09/12/16 at 2:03 p.m., had missing cove base and a stained ceiling tile above the window. -- Observation of Room C9 on 09/13/16 at 9:28 a.m., to have scuff marks on the wall and the chrome finish on the sink facet was missing. -- Observation of Room C13 on 09/12/16 at 2:26 p.m., a heating/cooling unit had pulled away from the wall. -- Observation of Hallways A and B on 09/13/16 at 9:15 a.m., had cove base pulled away from the walls. b) Observation and interview with the Maintenance Supervisor During an observation with the Maintenance Supervisor on 09/15/16 at 9:25 a.m., he verified the the cracked floor tiles, caulking around commodes, cove base missing or pulled away from the walls, scuff marks on the wall and the heating/cooling unit needed to be repaired or replaced.",2020-04-01
3958,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2016-09-15,280,D,0,1,MJ2111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise a care plan for a resident who declined in the area of urinary incontinence, and who sustained a urinary tract infection. This affected one (1) of three (3) residents reviewed for urinary incontinence, out of twenty-one (21) Stage II sampled residents. Resident identifier: #18. Facility census: 99. Findings include: a) Resident #18 On 08/14/16 at 4:00 p.m., Resident #18's medical record was reviewed. According to the resident's minimum minimum data set (MDS), with the assessment reference date (ARD) of 04/04/16, the facility assessed her as frequently incontinent of urine at the time of admission to the facility. Review of the quarterly MDS, with ARD of 06/29/16, found the facility assessed her as always incontinent of urine. This amounted to a decline in urinary continence over a span of three (3) month period. Review of the resident's care plan found no revision of new interventions to treat this decline. Review of the medical record found the following nurse progress notes which spoke of voiding discomfort: -- A progress note on 07/01/16 noted burning with urination. -- A progress note on 07/12/16 noted complaint of suprapubic area pain. -- A progress note of 07/26/16 noted an oral antibiotic treatment for [REDACTED]. -- A progress note on 08/26/16 address a new physician's orders [REDACTED]. -- A progress note on 08/27/16 addressed the facility sent her to the emergency room (ER) with flank pain. She received an injectable antibiotic in the ER, followed by a ten (10) day course of oral antibiotic therapy. Review of the care plan found no revision to note the urinary symptoms, or the urinary tract infection with the change in mental acuity that necessitated a trip to the hospital. Review of the medical record found changes in her diuretic medication therapy. On 05/03/16, the physician increased her daily [MEDICATION NAME] to forty (40) milligrams (mg) each morning, and twenty (20) mg each evening. On 06/06/16, the physician stopped the [MEDICATION NAME]. In its place, the physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. An interview was conducted with the MDS registered nurse Employee #116 on 09/15/16 at 7:45 a.m She reviewed the medical record and the seven (7) day look back periods prior to the two (2) assessment dates, and verified the accuracy of the two (2) comparative MDS's. She said when the resident first came to the facility, she was incontinent of urine about half of the time. She said at the time of the 06/29/16 MDS, the resident was incontinent of urine all of the time during the seven (7) day look back period. She spoke awareness of the resident's diuretic medication order changes, and of the resident's urinary tract infection. On 09/15/16 at 8:00 a.m., an interview was conducted with the director of nursing (DON), and with physical therapy assistant Employee #127. The DON said they completed a three (3) day voiding diary with the resident once from 03/29/16 through 03/31/16, shortly after she first came to the facility. She said they decided this resident had functional incontinence caused by the resident's decreased ability to transfer between surfaces. To help remedy this mobility deficit, the physician ordered physical therapy and occupational therapy five (5) days per week beginning 03/28/16, and ending on 06/29/16. Upon inquiry as to what interventions the facility implemented after the 06/29/16 MDS showed the resident's urinary continence declined from frequently incontinent to always incontinent of urine, the DON said they resumed the physical therapy on 07/19/16 for five (5) days per week. Employee #127 said physical therapy continued through 08/30/16. She said they enrolled the resident in occupational therapy (OT) the second time on 08/25/16 for five (5) days per week, and OT continues. Employee #127 said the resident also sustained an acute urinary tract infection on 08/27/16. Review of the care plan found no revision to reflect the 08/27/16 urinary tract infection which necessitated an emergency room visit and a treatment with antibiotics. The DON acknowledged that a care plan intervention directed the facility to keep a three (3) day voiding diary. She explained that they typically do this only once after admission, in order to assess the type of urinary incontinence a resident demonstrates. Upon inquiry, she said the facility did not repeat another three (3) day voiding diary after they assessed her with a decline in urinary continence on 06/29/16. She said the facility did not revise the care plan with new interventions to address the decline in urinary continence, and did not revise the care plan to include the documented urinary tract infection. Review of the original care plan found an intervention to treat the resident's bladder incontinence and to develop/implement a toileting plan to avoid incontinence episodes. Upon inquiry, the DON said this resident was not, and is not currently, on a specific toileting program. Rather, the staff offer to toilet all residents every two (2) hours, and dry them if found incontinent. Upon inquiry as to whether offering toileting times on the even hours coincided with the times the resident most likely needed to urinate, the DON provided no answer. She said the one (1) three (3) day voiding diary obtained between 03/29/16 and 03/31/16 was the only voiding diary this resident has had since admission to the facility. Upon inquiry as to how staff could, without the benefit of a voiding diary assessment, ascertain the times of day the Demedex created increased urine output which would subsequently increase the resident's need to evacuate the bladder, the DON provided no answer.",2020-04-01
3959,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2016-09-15,315,D,0,1,MJ2111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the resident's comprehensive assessment, medical record review and staff interview, the facility failed to ensure that a resident who entered the facility with urinary incontinence received appropriate treatment and services to restore as much normal bladder function as possible. This was evident for one (1) three (3) Stage II sampled residents reviewed for urinary incontinence. Resident identifier: #18. Facility census: 99. Findings include: a) Resident #18. On 08/14/16 at 4:00 p.m., Resident #18's medical record was reviewed. According to the resident's minimum minimum data set (MDS), with the assessment reference date (ARD) of 04/04/16, the facility assessed her as frequently incontinent of urine at the time of admission to the facility. Review of the quarterly MDS, with ARD of 06/29/16, found the facility assessed her as always incontinent of urine. This amounted to a decline in urinary continence over a span of three (3) months' time. During interview with nursing assistant #57 on 09/14/16 at 1:55 p.m., she said they check the resident every two (2) hours on the even hours, and change her incontinence product if found wet. Upon inquiry, she agreed that the resident was on a check and change program. She said the resident does not call to use the bedpan or toilet. She said this resident initially resided on the A Hall downstairs, then transferred to the C Hall upstairs, and recently returned downstairs to the B Hall. An interview was conducted with the MDS registered nurse Employee #116 on 09/15/16 at 7:45 a.m She reviewed the medical record and the seven (7) day look back periods prior to the two (2) assessment dates, and verified the accuracy of the two (2) comparative MDS's. She said when the resident first came to the facility, she was incontinent of urine about half of the time. She said at the time of the 06/29/16 MDS, the resident was incontinent of urine all of the time during the seven (7) day look back period. She spoke awareness of a new medication order for Demedex (a diuretic) in June, and thought the medication could affect her urinary incontinence in a negative way. Prior to the Demedex she took [MEDICATION NAME] once daily, that later changed to twice daily. Medical record review found a physician's orders [REDACTED]. On 06/06/16 the physician ordered to stop the [MEDICATION NAME], and in its place give Demedex twenty (20) mg twice daily. Review of the Medication Administration Record [REDACTED]. at 9:00 a.m and 9:00 p.m. daily. On 09/15/16 at 8:00 a.m., an interview was conducted with the director of nursing (DON), and with physical therapy assistant Employee #127. The DON said they completed a three (3) day voiding diary with the resident from 03/29/16 through 03/31/16, shortly after she first came to the facility. She said they decided this resident had functional incontinence caused by the resident's decreased ability to transfer between surfaces. To help remedy this mobility deficit, the physician ordered physical therapy and occupational therapy five (5) days per week beginning 03/28/16, and ending on 06/29/16. Upon inquiry as to what interventions the facility implemented when the 06/29/16 MDS showed the resident's urinary continence declined from frequently incontinent to always incontinent of urine, the DON said they resumed the physical therapy on 07/19/16 for five (5) days per week. Employee #127 said physical therapy continued through 08/30/16. She said they enrolled the resident in occupational therapy (OT) the second time on 08/25/16 for five (5) days per week, and OT continues. Employee #127 said the resident sustained [REDACTED]. The DON acknowledged that a care plan intervention directed the facility to keep a three (3) day voiding diary. She explained that they typically do this only once after admission, in order to assess the type of incontinence a resident demonstrates. Upon inquiry, she said the facility did not repeat another three (3) day voiding diary after they assessed her with a decline in urinary continence on 06/29/16. The DON said this resident was not, and is not currently, on a specific toileting program. Rather, the staff offer to toilet all residents every two (2) hours, and dry them if found incontinent. Upon inquiry as to whether offering toileting times on the even hours coincided with the times the resident most likely needed to urinate, the DON provided no answer. She said the one (1) three (3) day voiding diary obtained between 03/29/16 and 03/31/16 was the only voiding diary this resident has had since admission to the facility. Upon inquiry as to how staff could, without the benefit of a voiding diary assessment, ascertain the times of day the Demedex created increased urine output which would subsequently increase the resident's need to evacuate the bladder, the DON provided no answer. Upon inquiry, the DON said the resident would be able to use a bedpan if needed.",2020-04-01
3960,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2016-09-15,425,E,0,1,MJ2111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of manufacturer's guideline's, the facility failed, in collaboration with the pharmacist, to ensure the safe and effective use of medications. In one (1) of two (2) medication room refrigerators, a multi-dose vial of Purified Protein Derivative (PPD) was open for use for greater than the number of days directed by the manufacturer. This had the potential to negatively affect the safety and/or potency of the medication. Facility census: 99. Findings include: a) Second floor medication storage refrigerator Observation of the second floor medication storage room on 09/13/16 at 1:30 p.m., found a ten (10) test vial of Purified Protein Derivative (PPD) that was open for greater than thirty (30) days. PPD is a medication injected beneath the skin to aid in the detection of exposure to [DIAGNOSES REDACTED]. This vial of PPD was approximately half full, meaning that approximately five (5) test doses remained in the vial. The open date on the vial was 08/07/16. Licensed nurse Employee #83 said staff should have discarded this vial after having been opened for greater than thirty (30) days, and she will dispose of it now. Review of manufacturer's instructions revealed that multi-dose vials of PPD in use for more than thirty (30) days should be discarded. During an interview with the director of nursing on 09/15/16 at 8:45 a.m., she agreed that the multi-dose PPD vials should be discarded thirty (30) days after opening, and this vial was not discarded timely.",2020-04-01
5193,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2016-03-31,225,D,1,0,22Y611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interviews, and review of the facility's policy, the facility failed to report injuries of unknown origin to the appropriate State agencies for one (1) of three (3) residents reviewed for abuse and neglect. Resident identifier: #61. Facility census: 97. Findings include: a) Resident #61 A review of the progress notes for this resident on 03/30/16 at 9:30 a.m., found that Resident # 61 was transferred to an acute-care hospital on [DATE]. On 12/05/15 at 2:15 p.m., clinical care coordinator-wound nurse (CCS-WN) was called to the shower room by a nurse aide (NA) on duty. The NA was present in the shower room with fell ow NA and a unit charge nurse (UCN). The UCN asked her to assess the resident's left lower extremity. The CCS-WN's observations identified Resident #61's left lower extremity was drawn up and flexed outwardly and swollen. The nurse wrote, Yelling out and moaning observed from resident when left hip and upper extremity touched gentle. The CCS-WN informed UCN-LPN (Licensed Practical Nurse) #25 at that time, they should call emergency medical services (EMS) for transport. The record revealed the resident required incontinence care, and the staff applied a brief in which they used the log rolling technique to put the brief on the resident. The staff also placed a gown on the resident. Once the EMS arrived, the resident was transferred from the shower gurney to the EMS transportation bed. CCS-WN noted that the left lower extremity was no longer flexed outward, and was rotated back to the same alignment as the right lower extremity, but she observed shortening of the left lower extremity compared to the right lower extremity. The family nurse practitioner (FNP) was aware at that time what had happened to the resident. The resident's guardian was notified of the resident's condition. No incident or accident report was found relating the resident had a fall or injury. Resident #61's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 11/19/15 was reviewed on 03/30/16 at 10:00 a.m. The MDS found under section G of the MDS, the resident was totally dependent for bed mobility, transfer, dressing, eating, toileting use, and personal hygiene. The MDS revealed the resident did not walk in her room or in the corridor (hallway) unit. Under Section C, Cognitive Patterns, the MDS indicated the resident could not be interviewed for a Brief Interview for Mental Status (BIMS). The resident was not coded as having a fracture or a fall. The review Resident #61's discharge MDS with the ARD of 12/05/15, on 03/30/16 at 10:10 a.m., found Resident's #61 continued to be totally dependent on staff for her activities of daily living. The resident was unable to walk in her room or in the corridor. The resident was still unable to be interviewed to determine her cognitive status. The resident did not have any falls or fracture upon discharge from the facility. A review of the resident's care plan on 03/30/16 at 10:15 a.m., found a care plan with an initial date of 07/20/10. The plan identified the resident was disoriented, had impaired speech, was not ambulatory, had a non-weight bearing status, had contractures of her hand, impaired hearing in both ears, left and right side paralysis, and was incontinent of bladder and bowel. The resident required a full body mechanical lift with the assists of two (2). A review of the shower record on 03/30/16 at 10:19 a.m., found Resident #61 was showered at 1:43 p.m. on 12/05/15. A review of the history and physical from an acute-care hospital revealed the resident was seen on 12/06/15. The report said the chief complaint was the resident was sent from the facility for evaluation of left leg pain. The x-ray report indicated Resident #61 had a comminuted (which means broken or crushed into small pieces) left femur fracture. The discharge summary, written on 12/14/15, noted the resident had a closed (meaning skin intact) non displaced comminuted [MEDICAL CONDITION] of the left femur (the femoral shaft runs from below the hip to where the bones begin to widen at the knee). In an interview on 03/30/16 at 3:14 p.m., when asked how Resident #61's left lower extremity became swollen, with her leg drawn up, and flexed outwardly on 12/05/15, Unit Charge Nurse-Licensed Practical Nurse (UCN-LPN) #25 stated, I do not know what happened to (resident's name) left leg. When asked whether the injury was observed, the nurse stated, No. She was then asked whether the resident could tell how she injured her leg. UCN-LPN stated, (resident's name), could not tell us what had happened to her leg. The nurse was asked whether she reported this as an allegation to the appropriate State agencies as an injury of unknown origin due to no one had witnessed the injury, the resident could not explain what had happened to her leg, and the extent and location of the injury. The UCN-LPN stated, No. Clinical care supervisor-wound nurse (CCS-WN) #87 overheard the discussion with UCN-LPN #25 about Resident #61 having to go to the acute-care hospital on [DATE]. The CCS-WN said that she was present that day. She revealed that she was called to the shower room to evaluate the resident's injury. The CCS-WN said she informed the staff to call 911 because the resident's left lower extremity was drawn up and flexed outwardly. There was swelling present and the resident was yelling out and moaning when the left hip and the upper extremity were touched gently. This nurse said they were unable to identify what caused the injury to the resident's left leg. The CCS-WN was asked since no staff witnessed any injury, the resident was incapable of telling staff what had occurred to her left leg, and due to the extent and location of the injury, did you report this injury of unknown of origin to the appropriate State agencies? The CCS-WN stated, I reported this to the family nurse practitioner and to the director of nursing. I did not report this. During an interview on 03/30/16 at 5:00 p.m., Social Services Supervisor (SSS) #95 was asked whether she had reported the resident's injury to the appropriate State agencies as an injury of unknown origin when the staff observed Resident #61's left lower extremities was swollen, drawn up, and flexed outwardly on 12/05/15. The social worker stated no one informed her that she needed to report this to the appropriate State agencies as an injury of unknown origin. She verbalized that she was aware of the situation that had occurred. The administrator on 03/31/16 at 11:10 a.m., stated they talked about what had happened to the resident, but they did not identify this as being an injury of unknown origin, so therefore they did not report this to the appropriate State agencies. @ A review of the facility's policy for abuse, neglect and misappropriation of resident property: protection of residents/reporting and investigation policy on 03/31/16 at 11:35 a.m., found the policy included that the facility would report allegation(s) to the appropriate State agencies for injuries of unknown origin if the source of the injury was not observed by any person, could not be explained by the resident, and the injury was suspicious because of the extent or location of the injury; or the number of injuries observed at one particular point in time; or the incident of injuries over time. The facility's policy stated the facility will report immediate as soon as possible after the event.",2019-03-01
5194,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2016-03-31,441,D,1,0,22Y611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to ensure staff provided wound care in a manner to prevent the development and transmission of disease and infection for one (1) of two (2) residents observed during wound care treatment. The wound nurse failed to maintain clean technique during a non-pressure ulcer wound treatment. Resident identifier: #45. Facility census: 97. Findings include: a) Resident #45 A review of the physician's orders [REDACTED]. The resident had an order for [REDACTED]. The wound vac was to be changed every three (3) days. Clinical Care Supervisor-Wound Nurse (CCS-WN) #87 was observed performing wound care to Resident #45's left lower leg anterior and posterior wounds on 03/29/16 at 9:55 a.m. The nurse went into the room with Resident #45's wound care supplies and placed them on the over-bed table without first cleaning the table or establishing a barrier. She put on an isolation gown, and then she washed her hands. Next the wound nurse reached in and pulled out a bunch of gloves from the isolation box on the resident's door. The CCS-WN donned a pair of the gloves and afterwards placed the other non-sterile gloves directly on the resident's over-bed table. The resident's coffee cup, water pitcher, and crossword puzzles and books were also on the over-bed table. The wound nurse proceeded to touch Resident #45's coffee cup, water pitcher, and crossword puzzle book and subsequently handling the gloves that were lying on the over-bed table several times, and then lay the gloves back down onto the over-bed table. The nurse picked up the items that were on the over-bed table and placed them on his bedside dresser so she could have more room to put her wound care supplies. The over-bed table was not cleaned, nor was a barrier used prior to placing the supplies on the table. The gloves that were directly on the table were no longer considered clean as they were contaminated by any microorganisms that were on the table and/or the resident's personal items. The wound nurse removed her gloves, washed her hands, and donned another pair of gloves from the isolation box hanging from the resident's door. The nurse removed the wound vac dressing and the left lower anterior leg wound dressing. Using the same gloves, the wound nurse sprayed gauze with Skin Integrity wound cleanser (this is the normal saline based wound cleanser) and cleansed the left lower posterior wound. She then donned a pair of the contaminated gloves that were on the over-bed table and applied [MEDICATION NAME] ointment to the gloves. She applied the ointment that was on the gloves to the left lower posterior wound. She removed the gloves and donned another pair of the contaminated gloves from the table and handled the black foam for the wound vac as she cut it with her scissors. The CCS-WN then applied the black foam to the left posterior wound and secured the black foam in place with a transparent drape material. The CCS-WN cut an opening into the black foam touching the black foam with her gloved fingers; she placed the Sensa Trac pad (a pad which has tubing attached to connect to a canister in which the drainage will drain from the wound into the canister) to the black foam. After the wound Vac pressure reached 50 mmhg the CCS-WN removed her gloves and washed her hands. The nurse donned a pair of gloves from the isolation box hanging on the resident's door. She dipped a sterile gauze into the Dakin's solution, cleansed the left lower anterior leg wound, removed her gloves, and donned a pair of the contaminated gloves on the over-bed table. The nurse applied [MEDICATION NAME] ointment to the gloves and rubbed the [MEDICATION NAME] ointment onto the wound bed, and then she used a sterile Q-tip to spread the ointment over the entire wound. The wound nurse then measured the wound with a measuring indicator that was on the outside of the gauze packet that was lying on the over-bed table face down. The measuring device came into direct contact with the resident's wound. The wound nurse then removed her gloves and applied a dry dressing and wrapped the left anterior and posterior wound with Kerlix dressing and secured the dressing in place. In an interview with the wound care nurse on 03/29/16 at 10:30 a.m., she wanted to know how well she did during the wound treatment. The wound care nurse was informed about the gloves that were taken from the isolation box on the back of Resident #45's door and placing them on the resident's over-bed table had rendered the gloves contaminated. After she handled the resident's crossword puzzles, books, coffee cup, and water picture, and then handled the gloves several times, allowed for more contamination of the gloves. The table was not cleaned, nor was a barrier used to maintain a clean field for the gloves and other wound care supplies. The contaminated gloves were used during Resident #45's wound care, which created the potential for transfer of organisms to the wound beds. Also, removing the old dressings and not changing gloves created a potential to transfer organisms from the outer surfaces of the dressings, which had been in contact with the environment, to the wound beds. The wound nurse verbalized that she did touch the gloves after she had handled the resident's crossword puzzles, books, coffee cup and water pitcher several times. She also stated that she did not clean the table, and she did use the same gloves to perform wound care.",2019-03-01
5408,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-07-23,157,D,0,1,5V2S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the physician of a change of condition in a timely manner for one (1) of five (5) residents reviewed for the care area of nutrition. The resident had a significant weight loss. There was no evidence the physician was informed of this in a timely manner. Resident identifier: #133. Facility census: 99.Findings include: a) Resident #133On 07/22/15 at 11:00 a.m., review of the resident's medical record found this [AGE] year-old resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident was determined unable to make informed medical decisions by the attending physician on 01/29/15. Resident #133's weights, which were documented in the electronic weight and vital sign summary, were reviewed. The records indicated each weight was obtained using a full body lift. Weight records revealed the following weights and weight losses: -- 01/30/15 at 1:13 a.m. - 123.2 pounds (lbs.) -- 01/30/15 at 2:11 a.m. - 123.2 lbs. -- 02/01/15 at 1:56 p.m. - 123.5 lbs. -- 02/01/15 at 1:57 p.m. - 123.5 lbs. -- 02/08/15 at 1:43 p.m. - 119.9 lbs. -- 02/15/15 at 1:59 p.m. - 120.1 lbs. -- 02/15/15 at 2:00 p.m. - 120.1 lbs. -- 02/22/15 at 2:39 p.m. - 94.6 lbs. - (Loss of 23.2% between [DATE] and [DATE] -- 02/22/15 at 2:40 p.m. - 94.6 lbs. -- 02/23/14 at 2:27 p.m. - 90.7 lbs. - (An additional loss of 4.1%) -- 02/26/15 at 3:09 p.m. - 87.8 lbs. - (An additional loss of 3.19%) -- 02/26/15 at 3:10 p.m. - 87.8 lbs. Further review of Resident #133 medical records found no evidence the physician and/or nurse practitioner were notified of the severe weight loss of 23.2%, which occurred between 01/30/15 and 02/22/15, until 02/26/15. By the time the physician was notified of the weight losses, the resident had lost another 7.2% of her total body weight. On 0723/15 at 1:40 p.m., during an interview with the director of nursing (DON) and the administrator, they reviewed Resident #133's electronic medical records and confirmed there was no evidence the physician and/or nurse practitioner were notified of the resident's weight losses in a timely manner.",2019-01-01
5409,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-07-23,241,D,0,1,5V2S11,"Based on a random opportunity for observation and staff interview, the facility failed to ensure a dignified dining experience during dining for a resident who was eating in her room. The resident was not served her meal at the same time as her roommate. Resident identifier: #117. Facility Census: 99. Findings include: a) Resident #117Observation of the noon meal, at 11:45 a.m. on 07/20/15, found Resident #117 and Resident #58 having the noon meal in their room. The residents did not receive their meals at the same time. Resident #58 received her meal at 11:45 a.m. Resident #117 did not receive her meal until 12:05 p.m., 20 minutes after Resident #58 received her meal. At 12:07 p.m. on 07/20/15, this observation was discussed and verified with Licensed Practical Nurse #98.On 07/21/15 at 10:45 a.m., a discussion was held with the administrator and the director of nursing regarding the observations of the facility's failure to promote dignity for Residents #117 on 07/20/15. No additional information was provided.",2019-01-01
5410,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-07-23,246,D,0,1,5V2S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure reasonable accommodations of individual needs for one (1) of thirty (30) residents observed for positioning during Stage I of the Quality Indicator Survey (QIS). Resident #149's bed did not accommodate the physical needs of the resident. Resident identifier: #149. Facility census: 99. Findings include: a) Resident #149 Observation of the resident, at 2:28 p.m. on 07/20/15, found he was in his room lying in bed on his back. The bottoms of both of his feet were firmly pressed against the foot board of the bed. Employee #33, a nursing assistant (NA), was asked about the positioning of the resident. She stated the resident continually slid down in the bed and could not be kept up in the bed. She explained the head of the bed had to be elevated because the resident was receiving a tube feeding. At that time, NA #33 and NA #35 repositioned the resident in bed with a draw sheet which was under the resident. Record review, at 2:00 on 07/21/15, confirmed the resident received nourishment through a gastric tube. Section (G0110), entitled, Functional status/bed mobility, on the last minimum data set (MDS), a 30 day Medicare assessment, with an assessment reference date (ARD) of 06/24/15, indicated the resident required extensive assistance of one (1) staff member for bed mobility. According to the medical record, the resident had a past history of pressure ulcers. He was admitted to the facility on [DATE] with four (4) pressure areas that had healed since his admission to the facility. At 10:46 a.m. on 07/22/15, NA, #33 and Employee #110, a registered nurse clinical care supervisor, stated facility staff extended the resident's bed with an extender to keep his feet off the foot board.",2019-01-01
5411,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-07-23,272,E,0,1,5V2S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the Centers for Medicare and Medicaid (CMS)Guidance to Surveyors, and staff interview, the facility failed to ensure comprehensive minimum data set (MDS) assessments were accurate for four (4) of twenty-three (23) Stage 2 residents whose MDSs were reviewed. The MDSs for Resident #6 and #85 were not accurate in the area of nutrition. The MDSs for Residents #33 and #3 were not accurate related to hospice. Resident identifiers: #6, #33, #3 and # 85. Facility census: 99. Findings include: a) Resident #6 A review of the medical record, on 07/22/15 at 1:30 p.m., revealed Resident #6's annual MDS, with an assessment reference date (ARD) of 07/01/15, was not accurate related to weight loss. The quarterly MDS, with an ARD of 01/06/15, was not accurate related to the resident's weight. When the weight loss for the annual MDS, with an ARD of 07/01/15, was calculated, the inaccurate weight was used. The quarterly MDS, with an ARD of 01/06/15 showed the resident weighed 138 pounds (lbs); however, weight records, dated 01/05/15, noted a weight of 141 lbs. The annual MDS, with an ARD of 07/01/15, showed the resident weighed 124 lbs. Based on the inaccurate weight of 138 lbs on the 01/06/15 MDS, and an incorrect calculation, the dietitian calculated the weight loss as 9%, which did not represent a significant change. A significant weight loss in six (6) months is 10% or more. An interview with Registered Dietitian (RD) #114, on 07/23/15 at approximately 9:30 a.m., confirmed the regular dietitian used an incorrect weight to calculate the weight loss. RD #114 also agreed, according to the percentage of weight loss calculation recommended by CMS, the weight loss percentage would have been more than 10%, which was a significant weight loss. Calculation of the weight loss percentage between 01/05/15 and 07/01/15, using the correct weight of 141 lbs and the CMS surveyor guidance method for calculation of the percentage of body weight loss, (usual weight - actual weight) / (usual weight) x 100) revealed the resident had a significant weight loss of 12%. b) Resident #3 Review of the facility's information, provided on the entrance conference worksheet (form #CMS- ) during Stage I of the Quality Indicator Survey (QIS), found the facility listed Resident #3 received certified Medicare Hospice services; therefore, Resident #3 was chosen for review of Hospice services in Stage 2 of the QIS. Record review, at 1:00 p.m. on 07/22/15, found the resident's physician completed a certification of terminal illness on 03/30/15. The physician certified to the best of his knowledge given the data available, the resident had a life expectancy of six (6) months or less, if the terminal illness ran its normal course. The physician documented the focus of care was on comfort and palliation, rather than cure. The significant change MDS, with an ARD of 04/03/15, found item J1400, in Section J, entitled Health Conditions, indicated the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. At 2:11 p.m. on 07/22/15, Registered Nurse/Clinical Care Supervisor #110, verified section J1400 of the MDS was not accurate because the resident was receiving Hospice services. She stated the facility would do a correction of the MDS. c) Resident #85 On 07/22/15 at 4:00 p.m., review of the annual MDS, with an ARD of 07/01/15, revealed Resident #85 was coded as zero (0) (no) or unknown to have a weight loss of five (5) percent or more in the last month or loss of ten (10) percent or more in last six (6) months in item K0300. A review of Resident #85's weights, on 07/22/15 at 4:15 p.m., revealed the resident weighed 135 pounds (lbs) on 07/01/15, and the resident weighed 152.2 lbs on 01/04/15. This represented an 11.3% weight loss in six (6) months. In an interview with Registered Dietitian #114, on 07/22/15 at 4:20 p.m., she confirmed the resident had a weight loss of more than 10% in six (6) months. She verified the MDS was inaccurate and should have reflected Resident #85's weight loss. d) Resident #33 A review of Resident #33's medical record, at 9:12 a.m. on 07/23/15, found an annual MDS with an ARD of 04/23/15. Review of this MDS found item K0300, Weight Loss Loss of 5% in the last month or loss of 10 % in the last 6 months was coded, Yes. This indicated the resident was on a prescribed weight loss regimen. Review of the Resident Assessment Instrument (RAI), Version 3.0 Manual, found the following coding instructions for K0300: Mathematically round weights as described in Section K0200B before completing the weight loss calculation. Code 0, no or unknown: if the resident has not experienced weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days or if information about prior weight is not available. Code 1, yes on physician-prescribed weight loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was planned and pursuant to a physician's orders [REDACTED].>Code 2, yes, not on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was not planned and prescribed by a physician. Further review of the medical record found no indication Resident #33 was on a physician prescribed weight loss regimen. In fact, a note by the nurse practitioner (NP), dated 03/16/15, indicated the chief complaint for the visit was weight loss. The NP indicated she was referring the resident to the registered dietitian (RD) because of the weight loss. The NP also ordered a pre-[MEDICATION NAME] level for the next day. In an interview with RD #114, at 10:47 a.m. on 07/23/2015, she stated Resident #33 had never been on a physician prescribed weight loss regimen. The RD also indicated the NP would not have seen the resident for weight loss if it was a prescribed weight loss regimen. She confirmed the MDS with an ARD of 04/23/15 was inaccurate.",2019-01-01
5412,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-07-23,278,D,0,1,5V2S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the accuracy of the five (5) - day minimum data set (MDS) assessment for one (1) of twenty-three (23) Stage 2 sample residents whose MDSs were reviewed. The MDS did not reflect the resident received [MEDICAL TREATMENT]. Resident Identifier: #112. Facility Census: 99. Findings Include: a) Resident #112 A review of Resident #112's medical record, at 3:12 p.m. on 07/21/15, found the five (5) day minimum data set (MDS), with an assessment reference date (ARD) of 06/26/15, did not indicate the resident received [MEDICAL TREATMENT] while a resident of the facility. Further review of the medical record found [MEDICAL TREATMENT] communication sheets dated 06/16/15, 06/18/15, and 06/20/15. Additionally, there were corresponding progress notes for 06/16/15, 06/18/15, 06/20/15, all of which indicated Resident #112 had [MEDICAL TREATMENT] treatments on these dates. Review of the Resident Assessment Instrument (RAI), Version 3.0 Manual, found the coding instructions for Column 2 of Section O were, Check all treatments, procedures and programs received or performed by the resident after admission/entry or reentry to the facility and within the 14-day look-back period. The RAI instructions for the area of O0100J - [MEDICAL TREATMENT], Code peritoneal or [MEDICAL TREATMENT] that occurs at the nursing home or at another facility in this item. Record treatments of hemofiltration, slow continuous ultrafiltration (SCUF), continuous arteriovenous hemofiltration (CAHV) and continuous ambulatory peritoneal [MEDICAL TREATMENT] (CAPD) in this item. Employee #113, Registered Nurse Assessment Coordinator (RNAC), was interviewed at 9:14 a.m. on 07/22/15. The RNAC reviewed the MDS assessment, and confirmed Item O0100J was not accurate, as it did not indicate the resident had [MEDICAL TREATMENT] treatments while a resident of the facility. She verified the MDS was not completed as directed by the RAI manual.",2019-01-01
5413,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-07-23,280,D,0,1,5V2S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the care plan for one (1) of twenty-three (23) residents whose care plans were reviewed was revised to accurately reflect the resident's needs. The care plan was not revised after [MEDICATION NAME] and [MEDICATION NAME] were discontinued. Resident Identifier #85. Facility Census 99. Findings Include: a) Resident #85 A review of Resident #85's care plan, on 07/23/15 at 11:15 a.m., revealed it noted the resident received antidepressant medications, [MEDICATION NAME] and [MEDICATION NAME], related to depression and poor appetite. The revision date of the care plan was 06/26/15. A review of the physician's orders [REDACTED]. An interview and review of the resident's care plan, with Clinical Care Supervisor (CCS) #110, on 07/23/15 at 11:22 p.m., confirmed the care plan was not revised after [MEDICATION NAME] and [MEDICATION NAME] were discontinued.",2019-01-01
5414,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-07-23,282,E,0,1,5V2S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, staff interview, resident interview, and observation, the facility failed to provide care and services in accordance with the care plans for six (6) of of twenty-three (23) residents whose care plans were reviewed. Residents #133's care plan interventions for decreased appetite and weight loss were not implemented. The care plan interventions for Residents #48 and #149 related to the prevention and/or treatment of [REDACTED]. Resident #112's care plan related to restricted fluids was not implemented. Resident identifiers: #133, #48, #7, #63, #149, and #112. Facility census: 99. Findings include: a) Resident #133 On 07/22/15 at 11:00 a.m., review of the resident's medical record found this [AGE] year-old resident was admitted to the facility on [DATE]. This resident was determined unable to make informed medical decisions by the attending physician on 01/29/15. Her care plan for nutrition included, (typed as written) Patient has a potential nutritional problem related to disease process. Date Initiated: 02/13/2015. The goal for this problem was, Resident will maintain adequate nutritional status as evidenced by maintaining weight within 5% of baseline, no signs/symptoms of malnutrition, and consuming at least 50% of at least three (3) meals daily through review date. The interventions included, Monitor/record/report to physician as necessary (prn) sign/symptoms of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: greater than 5% in 1 month, greater than 7.5% in 3 months, greater than 10% in 6 months.Review of the resident's medical record found the resident suffered a significant weight loss of 23.2 % (28.6 pounds) within twenty-four (24) days after admission. There was no evidence the physician was kept informed of the resident's nutritional status as required by the care plan.During an interview, on 07/22/15 at 1:10 p.m., the Administrator and Director of Nursing acknowledged the nutrition intervention to monitor/record/report to physician as necessary (prn) sign/symptoms of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: greater than 5% in 1 month, greater than 7.5% in 3 months, greater than 10% in 6 months was not implemented. b) Resident #48 On 07/22/15 at 9:00 a.m., review of the resident's medical record found this [AGE] year-old resident was readmitted to the facility on [DATE]. Resident #48's readmission nursing assessment and initial pressure ulcer assessments indicated the resident had two (2) Stage II pressure ulcers on her right buttocks and left outer ankle, four (4) unstageable pressure ulcers on the right outer ankle, right heel, left heel and the bottom of the left great toe, and three (3) suspected deep tissue injuries (SDTI) on top of the left great toe, on top of the right great toe and on the bottom of the right great toe. Her care plan for pressure ulcers included, (typed as written) (Resident's name) has a pressure ulcer to her right heel, right outer ankle, bottom of right great toe, left great toe bottom and top, left outer ankle, left heel, and potential for pressure ulcer development related to disease process and impaired mobility. Date initiated 06/01/15 and revision on 06/25/15. The goal for this problem was, Patient's pressure ulcer will show signs of healing and remain free from infection by review date and Patient will have intact skin, free of redness, blisters or discoloration by review date.The interventions included, Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible .Review of the resident's medical record revealed, as of 07/22/15, the resident had wound re-assessments only on 06/24/15, 07/01/15, 07/07/15, and 07/15/15, not weekly as care planned. No additional wound assessments were available. records. c) Resident #7 On 07/23/15 at 9:00 a.m., review of the Resident #7's medical record found the resident had a newly acquired pressure ulcer documented on 06/29/15. The pressure ulcer was located on the left trochanter (hip) and was a suspected deep tissue injury (SDTI). The resident's care plan for pressure ulcers included (typed as written): (Resident's name) has a pressure ulcer to her left hip and has potential for pressure ulcer development related to disease process, history of pressure ulcers, immobility, bowel incontinence, and refusal to be repositioned Date initiated on 06/29/15. The goal for this problem was, Patient's pressure ulcer will show signs of healing and remain free from infection by review date and Patient will have intact skin, free of redness, blisters or discoloration by review date.The interventions included, Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible .Review of the resident's medical record found evidence the resident had wound was re-assessed on 07/07/15 and 07/14/15. No further wound assessments were in the medical records.During an interview, on 07/23/15 at 1:10 p.m., the Administrator and Director of Nursing (DON) reviewed the resident's medical records and confirmed the wound assessments were not consistently completed on a weekly basis as directed by the care plan. d) Resident # 63 On 07/23/15 at 10:00 a.m., review of the resident's medical record found the resident was readmitted to the facility on [DATE]. She had a Stage III pressure ulcer on the coccyx. The resident's care plan for pressure ulcers included (typed as written): (Resident's name) has a pressure ulcer to her coccyx and has potential for pressure ulcer development related to disease process, history of pressure ulcers, immobility, bowel incontinence. Date revised was 05/23/15. The goal for this problem was, Patient's pressure ulcer will show signs of healing and remain free from infection by review date and Patient will have intact skin, free of redness, blisters or discoloration by review date.The interventions included, Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible .Review of the resident's medical record found no evidence the resident's wounds were re-assessed on 05/26/15, 06/01/15, 06/10/15, 06/18/15, 06/23/15, 06/30/15, 07/07/15 and 07/14/15. No further wound assessments were in the medical records.During an interview, on 07/23/15 at 1:10 p.m., the Administrator and Director of Nursing (DON) reviewed the medical records. They confirmed the wound assessments were not consistently completed on a weekly basis as directed by the care plan. c) Resident #7 On 07/23/15 at 9:00 a.m., review of the Resident #7's medical record, found the resident had a newly acquired pressure ulcer documented on 06/29/15. The pressure ulcer was located on the left trochanter (hip) and was a suspected deep tissue injury (SDTI). Her care plan for pressure ulcers included, (typed as written) (Resident's name) has a pressure ulcer to her left hip and has potential for pressure ulcer development related to disease process, history of pressure ulcers, immobility, bowel incontinence, and refusal to be repositioned Date initiated on 06/29/15. The goal for this problem was, Patient's pressure ulcer will show signs of healing and remain free from infection by review date and Patient will have intact skin, free of redness, blisters or discoloration by review date.The interventions included, Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible .Review of the resident's medical record found no evidence the resident had wound reassessments on 07/7/15 and 07/14/15. No further wound assessments could be located in the medical records.During an interview on 07/23/15 at 1:10 p.m., the Administrator and Director of Nursing (DON) reviewed the medical records and it was determined the wound assessments were not consistently completed on a weekly basis as directed by the care plan. d) Resident # 63 On 07/23/15 at 10:00 a.m., review of the Resident #63's medical record, found the resident was readmitted to the facility on [DATE]. She had a Stage III pressure ulcer on coccyx. Her care plan for pressure ulcers included, (typed as written) (Resident's name) has a pressure ulcer to her coccyx and has potential for pressure ulcer development related to disease process, history of pressure ulcers, immobility, bowel incontinence. Date revised was 05/23/15. The goal for this problem was, Patient's pressure ulcer will show signs of healing and remain free from infection by review date and Patient will have intact skin, free of redness, blisters or discoloration by review date.The interventions included, Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible .Review of the resident's medical record found evidence the resident had no wound re-assessments on 05/26/15, 06/01/15, 06/10/15, 06/18/15, 06/23/15, 06/30/15, 07/07/15 and 07/14/15. No further wound assessments were located in the medical records.During an interview, on 07/23/15 at 1:10 p.m., the Administrator and Director of Nursing (DON) reviewed the medical records. They confirmed the wound assessments were not consistently completed on a weekly basis as directed by the care plan. On 07/22/15 at 1:10 p.m., during an interview and record review with the Administrator and Director of Nursing, they confirmed the wound assessments were not consistently completed on a weekly basis as directed by the care plan. c) Resident #149 Observation of the resident in bed, during Stage I of the survey, at 2:28 p.m. on 07/20/15, with Nursing Assistant (NA) #33 and NA #35 found the resident's heels were resting on the mattress and his feet were against the foot board of the bed. NAs #33 and #35 repositioned the resident, but his heels were left resting on the mattress. Record review on 07/21/14 at 2:00 p.m., found Resident #149 was admitted to the facility on [DATE] with a Stage II pressure ulcer on the cleft of his buttocks, the right ear, and the sacrum. He also had a Stage I pressure ulcer on the left ear. At the time of the survey, each of these areas were resolved. This was verified by Employee #110, a registered nurse (RN), clinical care supervisor, at 3:55 p.m. on 07/21/15. The current care plan, revised on 05/16/15, found a problem: Resident has a potential for pressure ulcer development r/t (related to) impaired mobility. The goal associated with this problem was: Patient will have intact skin free of redness, blisters or discoloration by/through review date. Interventions included: Float both heels while in bed, document every shift. At 4:18 p.m. on 07/21/15, the resident was again observed in his bed with his heels resting on the mattress. Employee #110, the registered nurse, clinical care supervisor, confirmed the resident's heels were not being floated as directed in the care plan for pressure ulcer prevention. d) Resident #112 A review of Resident #112's medical record, at 3:12 p.m. on 07/21/15, found the resident received [MEDICAL TREATMENT] and had a physician's orders [REDACTED]. Review of Resident #112's care plan found the following focus statement: Resident has a potential nutritional problem r/t (related to) [MEDICAL TREATMENT], [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]) which causes fluctuations in weight and surgical wound. The goal associated with this focus statement was, Patient will maintain adequate nutritional status as evidenced by no s/sx (signs or symptoms) of malnutrition, and consuming at 50% (percent) of at least 3 (three) meals daily through review date. The interventions were, Fluid restriction 1000 in 24 hrs (hours): Dietary - 240 ml at breakfast, lunch, and dinner. Nursing - days 180 ml, nights 100 ml. No water pitcher at bedside. Both interventions had an initiation date of 05/15/15. At 10:45 a.m. on 07/22/15 an observation of Resident #112 found a water pitcher containing water on her over-the-bed table. The resident was observed resting in bed with the water pitcher within her reach. An interview with Licensed Practical Nurse (LPN) #52, at 10:54 a.m. on 07/22/15, confirmed Resident #112 was on a fluid restriction. When asked if the resident should have a water pitcher at her bedside, she stated, No, she should not have one. LPN #52 was then asked to observe Resident #112's over-the-bed table. She confirmed Resident #112 had a water pitcher containing water on her bed side table, even though her care plan indicated she should not.",2019-01-01
5415,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-07-23,309,E,0,1,5V2S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident observation, resident interview, and staff interview, the facility failed to provide the necessary care and services to attain and/or maintain the highest practicable physical, mental, and psychosocial well - being for seven (7) of twenty-three (23) Stage 2 sampled residents. Staff failed to follow physician's orders [REDACTED].#33 and Resident #93. Resident #112's fluid restriction was not implemented, and the resident was not informed of the risks of not complying with her fluid restriction. Residents #48, #7, #133, and #63 had pressure ulcers which were not assessed and/or monitored on a consistent (weekly) basis. Resident Identifiers: #112, #33, #93, #48, #7, #63 and #133. Facility Census: 99. Findings include: a) Resident #112 A review of Resident #112's medical record at 3:12 p.m. on [DATE] found, Resident #112 was admitted to the facility on [DATE]. Resident #112's medical record contained a physician's orders [REDACTED]. There was also an order [REDACTED].>Review of Resident #112's fluid intakes, for the period of [DATE] until [DATE], found fluid intake daily averages which exceeded the 1,000 ml ordered daily: 1. From [DATE] through [DATE], the average daily fluid intake was 2,177 ml 2. From [DATE] through [DATE], the average daily fluid intake was 2,292 ml 3. From [DATE] through [DATE] there was no average. The resident was in and out to the hospital during this time frame, and her total amount of fluids consumed was not documented for these days. 4. From [DATE] through [DATE] the average daily fluid intake was 2,086 ml Further review of Resident #112's medical record found a care plan with the focus statement, Resident has a potential nutritional problem r/t (related to) [MEDICAL TREATMENT], [MEDICAL CONDITION] (End Stage [MEDICAL CONDITION]) which causes fluctuations in weight and, surgical wound. The goal associated with this practice statement was, Patient will maintain adequate nutritional status as evidenced by no s/sx (signs or symptoms) of malnutrition, and consuming at 50% (percent) of at least 3 (three) meals daily through review date. The interventions contained, Fluid restriction 1000 in 24 hrs (hours): Dietary - 240 ml at breakfast, lunch, and dinner. Nursing - days 180 ml, nights 100 ml. No water pitcher at bedside. The interventions had an initiation date of [DATE]. Observation of Resident #112, at 10:43 a.m. on [DATE], revealed the resident was in her bed. There was a water pitcher, which contained water, on her bedside table. An interview with Nurse Aide (NA) #94, at 10:54 a.m. on [DATE], revealed she usually worked with Resident #112. When asked if the resident had any special precautions, she stated, She is on a fluid restriction, but we give whatever she wants because she can ask for it. She indicated they tried to encourage her to follow the restriction, but if she asked for water , they got it for her. She stated, Her husband brings her in soda and she drinks it a lot. An interview with Licensed Practical Nurse (LPN) #52, at 10:54 a.m. on [DATE], confirmed Resident #112 was on a fluid restriction. When asked if the resident should have a water pitcher at her bedside, LPN #52 stated, No she should not have one. LPN #52 was then asked to observe Resident #112's over-the-bed table. She confirmed Resident #112 had a water pitcher, containing water, on her bed side table, even though her care plan and physician's orders [REDACTED]. Resident #112 was interviewed during this observation. When asked about the water pitcher, the resident stated, I brought that in from home, but the staff fill it up for me. When asked if she was familiar with her fluid restrictions she stated, I know, I mostly eat the ice they put in the pitcher. I always drink less than what they give me. When asked if she understood the associated risks of not following her fluid restriction, she did not answer. The clinical care supervisor (CCS) Registered Nurse (RN) #110 was interviewed at 11:18 a.m. on [DATE]. She was asked about Resident #112's fluid restriction. RN #110 indicated Resident #112 was not very compliant with her fluid restriction. She stated that with most residents, who do not follow the recommended course of treatment, they explain the risks and benefits and have them sign an Against Medical Advice (AMA) form. RN #110 was asked if Resident #112 had signed an AMA form. She was unable to provide an AMA form signed by Resident #112. RN #110 stated she knew she had talked to Resident #112 on more than one occasion, but must have forgotten to get the form signed. At 9:02 a.m. on [DATE], the Director of Nursing (DON) confirmed the facility had no evidence they discussed. with Resident #112, the risks regarding her non-compliance with her physician ordered fluid restriction. She indicated after the interview with RN #110 on [DATE], they discussed the risks with Resident #112, and had her sign an AMA form. The DON also stated the resident's care plan was revised to reflect her wishes to be non-compliant with her fluid restriction. b) Resident #33 A review of Resident #33's medical record, at 9:12 a.m. on [DATE], found a physician's orders [REDACTED]. The order directed the insulin be held if Resident #33 ate less than 50% of her meal. The resident's meal percentage documentation, in correlation with the medication administration records (MARs), were reviewed for the period of [DATE] through [DATE]. The [MEDICATION NAME]was not held on the following occasions the resident consumed less than 50% of her meal: 1) Breakfast February 2, 6, 7, 9, 13, 14, 15, and 27. [DATE], 6, 11, 13, 15, 16, 18, 21, 23, 24, 29, and 31. [DATE], 6, 8, 13, 15,16, 18, 24, 26, and 29. [DATE], 6, 9, 13, 14, 16, 19, 21, 23, 27, 29, and 31. [DATE], 8, 10, 11, 14, 16, 22, 24, 25, 28, and 30. [DATE], 9, 11, 14, 18, and 21. 2) Lunch February 07 and 19. [DATE], 13, 17, 28, and 31. [DATE], 26, 30. [DATE], 6, 9, 18, 19, and 30. [DATE], 20, 23, and 30. [DATE], 8, 11, 12, and 20. 3) Dinner February 26. [DATE], 21, 22, and 25. [DATE], 20, 22, and 27. [DATE], 8, 11, and 14. [DATE], and 26. [DATE] and 13. An interview at, 11:14 a.m. on [DATE], with the Director of Nursing (DON), confirmed Resident #33's [MEDICATION NAME]should have been held after each meal for which she consumed less than 50%. The DON said on some of the dates, when 26% percent was documented, the resident may have eaten up to 50% of the meal. She stated the percentage ranges the facility used were 0 - 25%, 26 - 50%, 51 - 75% and 75 - 100%. The DON said she was unable to say on which days, if any, Resident #33 consumed 50% as opposed to 26 - 49%. She confirmed the facility needed to evaluate their meal consumption documentation method to ensure the insulin was given as directed by Resident #33's attending physician. c) Resident #93 Review of Resident #93's medical records, on [DATE] at 9:00 a.m., found a physician's orders [REDACTED]. The order was written on [DATE]. It read, [MEDICATION NAME] solution (Insulin [MEDICATION NAME]) inject 12 (twelve) units subcutaneously two times a day related to diabetes mellitus. Hold if less than 50% of meal at breakfast and supper eaten. Review of the Kiosk (computer) documentation completed by the nursing assistants (NAs) for percentage of meals consumed, found the following scale for meal consumption was used: 0 = ,[DATE]% of meal consumed 26 = ,[DATE]% of meal consumed 51 = ,[DATE]% of meal consumed 76 = ,[DATE]% of meal consumed In the month of (MONTH) (YEAR), the NAs documented the resident's breakfast consumption was 0% or 26% on 13 occasions. 0% : (MONTH) 3, 4, 5, 18, 19, and 22. 26%: (MONTH) 6, 9, 11, 14, 15, 16, and 17. Review of Resident #93's MARs for the month of (MONTH) (YEAR) found the [MEDICATION NAME] was administered on each of the days when NAs documented the resident's breakfast meal consumption was less than 50%. During an interview with the DON, on [DATE] at 2:30 p.m., the NA Kiosk documentation for (MONTH) (YEAR) was reviewed. She confirmed Resident #93 should not have received [MEDICATION NAME] on the days her meal consumption at breakfast was less than 50%. The DON verified Resident #93 received 13 doses of [MEDICATION NAME] when the medication should have been held, because her meal consumption was below the parameters set by the physician. d) Resident #48 On [DATE] at 9:00 a.m., review of the resident's medical record found this [AGE] year-old resident was readmitted to the facility on [DATE]. Resident #48's readmission nursing assessment and initial pressure ulcer assessments indicated the resident had two (2) Stage II pressure ulcers on her right buttocks and left outer ankle, four (4) unstageable pressure ulcers on the right outer ankle, right heel, left heel and the bottom of the left great toe, and three (3) suspected deep tissue injuries (SDTI) on top of the left great toe, on top of the right great toe and on the bottom of the right great toe. Her care plan for pressure ulcers included, (typed as written) (Resident's name) has a pressure ulcer to her right heel, right outer ankle, bottom of right great toe, left great toe bottom and top, left outer ankle, left heel, and potential for pressure ulcer development related to disease process and impaired mobility. Date initiated [DATE] and revision on [DATE]. The goal for this problem was, Patient's pressure ulcer will show signs of healing and remain free from infection by review date and Patient will have intact skin, free of redness, blisters or discoloration by review date.The interventions included, Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible .Review of the resident's medical record revealed, as of [DATE], the resident had wound re-assessments only on [DATE], [DATE], [DATE], and [DATE], not weekly as care planned. No additional wound assessments were available. records. e) Resident #7 On [DATE] at 9:00 a.m., review of the Resident #7's medical record found the resident had a newly acquired pressure ulcer documented on [DATE]. The pressure ulcer was located on the left trochanter (hip) and was a suspected deep tissue injury (SDTI). The resident's care plan for pressure ulcers included (typed as written): (Resident's name) has a pressure ulcer to her left hip and has potential for pressure ulcer development related to disease process, history of pressure ulcers, immobility, bowel incontinence, and refusal to be repositioned Date initiated on [DATE]. The goal for this problem was, Patient's pressure ulcer will show signs of healing and remain free from infection by review date and Patient will have intact skin, free of redness, blisters or discoloration by review date.The interventions included, Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible .Review of the resident's medical record found evidence the resident had wound was re-assessed on [DATE] and [DATE]. No further wound assessments were in the medical records.During an interview, on [DATE] at 1:10 p.m., the Administrator and Director of Nursing (DON) reviewed the resident's medical records and confirmed the wound assessments were not consistently completed on a weekly basis as directed by the care plan. f) Resident # 63 On [DATE] at 10:00 a.m., review of the resident's medical record found the resident was readmitted to the facility on [DATE]. She had a Stage III pressure ulcer on the coccyx. The resident's care plan for pressure ulcers included (typed as written): (Resident's name) has a pressure ulcer to her coccyx and has potential for pressure ulcer development related to disease process, history of pressure ulcers, immobility, bowel incontinence. Date revised was [DATE]. The goal for this problem was, Patient's pressure ulcer will show signs of healing and remain free from infection by review date and Patient will have intact skin, free of redness, blisters or discoloration by review date.The interventions included, Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible .Review of the resident's medical record found no evidence the resident's wounds were re-assessed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. No further wound assessments were in the medical records.During an interview, on [DATE] at 1:10 p.m., the Administrator and Director of Nursing (DON) reviewed the medical records. They confirmed the wound assessments were not consistently completed on a weekly basis as directed by the care plan. g) Resident #133 On [DATE] at 9:00 a.m., review of Resident #133's medical record found the resident was admitted to the facility on [DATE]. She was admitted with a Stage II pressure ulcer on the right buttock. Resident #133 expired at the facility on [DATE]. Review of the resident's medical record found no pressure ulcer re-assessments since her admission on [DATE]. During an interview, on [DATE] at 1:10 p.m., the Administrator and Director of Nursing (DON) reviewed the medical records. No further wound assessments were provided.",2019-01-01
5416,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-07-23,314,D,0,1,5V2S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical reord review, observation, and staff interview, the facility failed to provide care and services to promote the prevention of pressure ulcer development for one (1) of and five (5) residents reviewed for pressure ulcers. The resident was admitted to the facility with pressure ulcers, and was assessed at risk for the development of additional pressure ulcers. Resident identifier: #149. Facility census: 99 Findings include: a) Resident #149 Record review, on 07/21/14 at 2:00 p.m., found Resident #149 was admitted to the facility on [DATE]. The resident was admitted with a Stage II pressure ulcer on the cleft of his buttocks, the right ear, and the sacrum. He also had a Stage I pressure ulcer on the left ear. At the time of the survey, each of these areas were resolved. This was verified by Employee #110, a registered nurse (RN), clinical care supervisor, at 3:55 p.m. on 07/21/15. Registered Nurse (RN) #110, was asked about the areas to the left and right ears at 3:55 p.m. on 07/21/15. She stated they could have occurred from the oxygen tubing, but she was not sure. RN #110 verified the wound assessment sheets did not specify exactly where the pressure areas were located on the left and right ears. A wound assessment, dated 06/25/15, noted the resident had a pressure area to the cleft of the buttocks and a Stage II pressure to the right shoulder. At 3:55 p.m. on 07/21/15, RN #110 stated the right shoulder was a documentation error, as the resident never had a pressure area to the right shoulder. The current care plan, revised on 05/16/15, found a problem: Resident has a potential for pressure ulcer development r/t (related to) impaired mobility. The goal associated with this problem was: Patient will have intact skin free of redness, blisters or discoloration by/through review date. Interventions included: Float both heels while in bed, document every shift. Observe skin for changes, redness, blisters or open areas during routine care. Report observations to unit charge nurse. Observation of the resident in bed, during Stage I of the survey, at 2:28 p.m. on 07/20/15, with Nursing Assistant (NA) #33 and NA #35 found his heels were not floated. They were resting on the mattress and his feet were against the foot board of the bed. NAs #33 and #35 repositioned the resident, but did not float his heels. The resident's heels were left lying on the mattress. At 4:18 p.m. on 07/21/15, the resident was again observed in his bed with his heels resting on the mattress. Employee #110, the registered nurse, clinical care supervisor, confirmed the resident's heels were not being floated as directed in the care plan for pressure ulcer prevention. During the observation at 4:18 a.m. on 07/21/15, the oxygen tubing was observed resting in the crease at the top of the ears between the ears and the head. Observation of the right and left ears found reddened areas under the tubing at the tops of the ears. RN #110 examined the areas and stated both areas were blanchable. She stated, We will get some padding for the oxygen tubing. She stated the areas had not been reported to the unit charge nurse.",2019-01-01
5417,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-07-23,325,D,0,1,5V2S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure one (1) of six (6) residents reviewed for the care area of nutrition was provided services to maintain acceptable parameters of nutritional status to the extent possible. The facility did not recognize, evaluate, or address the resident's severe weight loss, a continuing weight loss, and another severe weight loss in an eleven (11) day period. Resident identifier: #133. Facility census: 99. Findings include: a) Resident #133On 07/22/15 at 11:00 a.m., review of the resident's medical record found this [AGE] year-old resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident was determined unable to make informed medical decisions by the attending physician on 01/29/15. Resident #133's weight records and progress notes were reviewed on 07/22/15 at 3:15 p.m. The records indicated each weight was obtained using a full body lift. Weight records revealed the following weights and weight losses: -- 01/30/15 at 1:13 a.m. - 123.2 pounds (lbs.) -- 01/30/15 at 2:11 a.m. - 123.2 lbs. -- 02/01/15 at 1:56 p.m. - 123.5 lbs. -- 02/01/15 at 1:57 p.m. - 123.5 lbs. -- 02/08/15 at 1:43 p.m. - 119.9 lbs. -- 02/15/15 at 1:59 p.m. - 120.1 lbs. -- 02/15/15 at 2:00 p.m. - 120.1 lbs. -- 02/22/15 at 2:39 p.m. - 94.6 lbs. The 25.5 lb weight loss between 02/15/15 and 02/22/15 (seven (7) days) represented a severe weight loss of 21.23% of the resident's total body weight. -- 02/22/15 at 2:40 p.m. - 94.6 lbs. -- 02/23/14 at 2:27 p.m. - 90.7 lbs - (An additional loss of 4.1%) -- 02/26/15 at 3:09 p.m. - 87.8 lbs. - (An additional loss of 3.19%) -- 02/26/15 at 3:10 p.m. - 87.8 lbs. The weight loss between 02/22/15 and 02/26/15 (four (4) days) represented another severe weight loss of 7.18% of the resident's total body weight. Between 01/30/15 and 02/26/15, the resident lost a total of 28.6 lbs, representing 23.21% of her total body weight. Review of Resident #133 medical records found no evidence the facility identified or addressed the 25.5 lb weight loss between 02/15/15 and 02/22/15 (seven (7) days) which represented a severe weight loss of 21.23%. In addition, there was no evidence the facility identified the resident had another severe weight loss of 7.18%, between 02/22/15 and 02/26/15 (four (4) days). The physician and/or nurse practitioner were not notified of the resident's severe weight loss and continued weight losses until 02/26/15. By that time, the resident had an unaddressed weight loss of 28.6 lbs, a loss of 23.21% of her total body weight. Medical record review revealed the dietitian saw the resident only on 02/02/15. There was no evidence the dietitian was notified of the weight losses, so she could assess the resident and offer suggestions for weight loss interventions. Review of the facility's policy on weight assessment and interventions, on 07/22/15 at 3:00 p.m., revealed any weight change of 5 lbs. or more since the last weight assessment was to be retaken and reported to the nurse. The policy indicated if the weight was verified, nursing was to notify the physician. This policy was not implemented for Resident #133 when the resident had a severe weight loss of 21.73% in seven (7) days, between 02/15/15 and 02/22/13. During an interview with the administrator and the director of nursing (DON), on 07/23/15 at 1:00 p.m., they were asked if staff identified the resident's weight loss. The DON said staff recognized the weight change when they weighed her, but staff felt it was from [MEDICAL CONDITION]. Upon inquiry, they were unable to provide any evidence in the medical record related to the presence of and/or the amount of [MEDICAL CONDITION] present. No further information regarding [MEDICAL CONDITION] was provided. On 07/23/15 at 1:40 p.m., review of Resident #133's electronic medical records with the DON and the administrator found no evidence licensed nursing staff notified the physician, the nurse practitioner, and/or the dietitian of the weight loss in a timely manner. In addition, the medical record contained no discussion of the weight loss as it occurred.",2019-01-01
5418,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-07-23,329,E,0,1,5V2S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure two (2) of six (6) residents reviewed for the care area of unnecessary medications were free of unnecessary medications. The residents each had orders for insulin with physician established parameters regarding when the insulin should be held. The facility did not hold the insulin as ordered for either resident, resulting in excessive doses of insulin. Resident identifiers: #33 and #93. Facility census: 99. a) Resident #33 A review of Resident #33's medical record, at 9:12 a.m. on 07/23/15, found a physician's orders [REDACTED]. The order directed the insulin be held if Resident #33 ate less than 50% of her meal. The resident's meal percentage documentation, in correlation with the medication administration records (MARs), were reviewed for the period of 02/01/15 through 07/22/15. The [MEDICATION NAME]was not held on the following occasions the resident consumed less than 50% of her meal. This resulted in excessive doses of insulin on multiple occasions between 02/01/15 through 07/2215. 1) Breakfast February 2, 6, 7, 9, 13, 14, 15, and 27. March 3, 4, 6, 11, 13, 15, 16, 18, 21, 23, 24, 29, and 31. April 1, 2, 6, 8, 13, 15,16, 18, 24, 26, and 29. May 1, 4, 6, 9, 13, 14, 16, 19, 21, 23, 27, 29, and 31. June 1, 4, 8, 10, 11, 14, 16, 22, 24, 25, 28, and 30. July 7, 8, 9, 11, 14, 18, and 21. 2) Lunch February 07 and 19. March 2, 9, 13, 17, 28, and 31. April 03, 15, 26, 30. May 1, 3, 6, 9, 18, 19, and 30. June 7, 12, 20, 23, and 30. July 1, 5, 8, 11, 12, and 20. 3) Dinner February 26. March 6, 10, 21, 22, and 25. April 15, 17, 20, 22, and 27. May 2, 3, 8, 11, and 14. June 10, 20, and 26. July 9 and 13. An interview at, 11:14 a.m. on 07/23/15, with the Director of Nursing (DON), confirmed Resident #33's [MEDICATION NAME]should have been held after each meal for which she consumed less than 50%. The DON said on some of the dates, when 26% percent was documented, the resident may have eaten up to 50% of the meal. She stated the percentage ranges the facility used were 0 - 25%, 26 - 50%, 51 - 75% and 75 - 100%. The DON said she was unable to say on which days, if any, Resident #33 consumed 50% as opposed to 26 - 49%. She confirmed the facility needed to evaluate their meal consumption documentation method to ensure the insulin was given as directed by Resident #33's attending physician. b) Resident #93 Review of Resident #93's medical records, on 07/22/15 at 9:00 a.m., found a physician's orders [REDACTED]. The order was written on 06/05/15. It read, [MEDICATION NAME] solution (Insulin [MEDICATION NAME]) inject 12 (twelve) units subcutaneously two times a day related to diabetes mellitus. Hold if less than 50% of meal at breakfast and supper eaten. Review of the Kiosk (computer) documentation completed by the nursing assistants (NAs) for percentage of meals consumed, found the following scale for meal consumption was used: 0 = 0-25% of meal consumed 26 = 26-50% of meal consumed 51 = 51-75% of meal consumed 76 = 76-100% of meal consumed In the month of (MONTH) (YEAR), the NAs documented the resident's breakfast consumption was 0% or 26% on 13 occasions. 0% : (MONTH) 3, 4, 5, 18, 19, and 22. 26%: (MONTH) 6, 9, 11, 14, 15, 16, and 17. Review of Resident #93's MARs for the month of (MONTH) (YEAR) found the [MEDICATION NAME] was administered on each of the days when NAs documented the resident's breakfast meal consumption was less than 50%. This resulted in excessive doses of insulin on multiple occasions in (MONTH) (YEAR). During an interview with the DON, on 07/22/15 at 2:30 p.m., the NA Kiosk documentation for (MONTH) (YEAR) was reviewed. She confirmed Resident #93 should not have received [MEDICATION NAME] on the days her meal consumption at breakfast was less than 50%. The DON verified Resident #93 received 13 doses of [MEDICATION NAME] when the medication should have been held, because her meal consumption was below the parameters set by the physician.",2019-01-01
5419,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-07-23,502,D,0,1,5V2S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain laboratory (lab) services as ordered by the attending physician for one (1) of one (1) resident who was reviewed for [MEDICAL TREATMENT] services during Stage 2 of the Quality Indicator Survey. The resident had physician's orders [REDACTED]. This lab was not obtained on two (2) separate occasions. Resident Identifier: #112. Facility census: 99. Findings include: a) Resident #112 A review of Resident #112's medical record, at 3:12 p.m. on 07/21/15, found the following physician's orders [REDACTED].>1) 06/10/15, to obtain 24 hour urine every Sunday starting at 6:00 a.m. and end on Monday at 6:00 a.m. send to (name of local hospital) send results to [MEDICAL TREATMENT] every Tuesday. 2) 06/21/15, to obtain 24 hour urine every Sunday starting at 6:00 a.m. and end on Monday at 6:00 a.m. send to (name of local hospital) send results to [MEDICAL TREATMENT] every Tuesday. This order was still an active order on the date of this review on 07/21/15. Based on these orders, Resident #112 was to have a 24 hour urine lab test on 06/14/15, 06/21/15, 07/05/15, 07/12/15, and 07/09/15. Review of the medical record revealed no lab results for theses 24 hour urine tests. At 9:14 a.m. on 07/22/15, the results for the 06/14/15, 06/21/15, 07/05/15, 07/12/15, and 07/09/15 were requested from the Director of Nursing (DON). Results for 06/14/15 and 07/12/15 were not provided. An interview with the DON, at 10:21 a.m. on 07/23/15, revealed the 24 hour urine results for 06/14/15 and 07/12/15 were not available because the the lab work was not obtained as ordered by the physician.",2019-01-01
5420,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-07-23,514,D,0,1,5V2S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain an accurate and complete electronic medical record for three (3) of twenty-three (23) Stage 2 sampled residents. Residents #150, #16, and #133 did not have a complete medical record. Resident Identifiers: #150, #16, and #133. Facility Census: 99. Findings Include: a) Resident #150 A review of Resident #150's medical record, at 1:58 p.m. on 07/21/15, found a nursing progress note dated 06/01/15, which indicated the attending physician for the resident was in the facility and saw Resident #150. Further review of the record found no physician progress notes [REDACTED]. At 2:29 p.m. on 07/21/15, the physician progress notes [REDACTED]. The NHA was advised the note was not in the electronic medical record. She stated it might not have been scanned into the record. Later in the afternoon on 07/21/15, the physician progress notes [REDACTED]. This indicated the progress note was printed from the physician's note system on 07/21/15. The Director of Nursing (DON) was interviewed at 3:00 p.m. on 07/22/15. The DON confirmed the physician progress notes [REDACTED]. When asked why the note was not already printed and scanned into Resident #150's medical record she stated, We have had one medical records clerk off and the other one has been filling a different role and they are pretty backed up. She was then asked why the note was not even printed to be scanned into the system. She stated, It was just easier to print it than to go through the stacks and stacks of papers in medical records to find it. b) Resident #16 Medical record review, on 07/23/15 at 1:00 p.m., found the physician ordered a CBC (complete blood count) with differential/platelet on 05/07/15. Further review of the medical record found the consulting pharmacist conducted medication reviews on 05/24/15 and 06/22/15, and had notified the attending physician of irregularities with the medication regime. The electronic medical record did not contain the results of the laboratory values and the exact nature of the pharmacist report to the physician. Registered Nurse #110, clinical care supervisor, provided paper copies of the laboratory report and pharmacy consultant reports at 3:30 p.m. on 07/23/15. She verified they had not been scanned into the resident's electronic medical record. c) Resident #133 Review of Resident #133's electronic medical record, on 07/22/15 at 2:15 p.m., revealed the history and physical (H&P) completed on 01/29/15 by the physician was not available in the electronic medical record. Interview with the director of nursing, on 07/22/15 at 3:00 p.m., confirmed the H&P completed on 01/29/15 was not available in the electronic medical records. She stated medical records staff were behind on the scanning of medical records because one was off work and the other was deployed to cover shifts of licensed nurses on the floor.",2019-01-01
5421,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-07-23,520,E,0,1,5V2S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility's quality assessment and assurance (QA&A) committee failed to identify and act upon quality deficiencies during the daily operation of the facility, in which it had, or should have had knowledge. Systematic problems were identified related to pressure ulcers and nutrition for five (5) of twenty-three (23) sample residents. -- In the area of pressure ulcers the QA&A committee failed to ensure residents with pressure ulcers and/or at risk for pressure ulcers were assessed as required. In addition, the QA&A committee failed to ensure residents received services to promote healing of existing pressure ulcers and to prevent the development of pressure ulcers. Residents #48, #7, #133 and #63 and #149. -- In the area of nutrition, the QA&A committee failed to ensure the facility identified, assessed, and implemented measures to ensure the provision of services to maintain acceptable parameters of nutritional status to the extent possible. Resident #133. Resident Identifiers: #48, #7, #133, #63, and #149. Facility Census: 99. Findings Include: a) Pressure ulcers Residents with pressure ulcers and/or at risk for pressure ulcers were not assessed as required. 1. Resident #48 On [DATE] at 9:00 a.m., review of the resident's medical record found this [AGE] year-old resident was readmitted to the facility on [DATE]. Resident #48's readmission nursing assessment and initial pressure ulcer assessments indicated the resident had two (2) Stage II pressure ulcers on her right buttocks and left outer ankle, four (4) unstageable pressure ulcers on the right outer ankle, right heel, left heel and the bottom of the left great toe, and three (3) suspected deep tissue injuries (SDTI) on top of the left great toe, on top of the right great toe and on the bottom of the right great toe. Her care plan for pressure ulcers included, (typed as written) (Resident's name) has a pressure ulcer to her right heel, right outer ankle, bottom of right great toe, left great toe bottom and top, left outer ankle, left heel, and potential for pressure ulcer development related to disease process and impaired mobility. Date initiated [DATE] and revision on [DATE]. The goal for this problem was, Patient's pressure ulcer will show signs of healing and remain free from infection by review date and Patient will have intact skin, free of redness, blisters or discoloration by review date.The interventions included, Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible .Review of the resident's medical record revealed, as of [DATE], the resident had wound re-assessments only on [DATE], [DATE], [DATE], and [DATE], not weekly as care planned. No additional wound assessments were available. records. 2. Resident #7 On [DATE] at 9:00 a.m., review of the Resident #7's medical record found the resident had a newly acquired pressure ulcer documented on [DATE]. The pressure ulcer was located on the left trochanter (hip) and was a suspected deep tissue injury (SDTI). The resident's care plan for pressure ulcers included (typed as written): (Resident's name) has a pressure ulcer to her left hip and has potential for pressure ulcer development related to disease process, history of pressure ulcers, immobility, bowel incontinence, and refusal to be repositioned Date initiated on [DATE]. The goal for this problem was, Patient's pressure ulcer will show signs of healing and remain free from infection by review date and Patient will have intact skin, free of redness, blisters or discoloration by review date.The interventions included, Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible .Review of the resident's medical record found evidence the resident had wound was re-assessed on [DATE] and [DATE]. No further wound assessments were in the medical records.During an interview, on [DATE] at 1:10 p.m., the Administrator and Director of Nursing (DON) reviewed the resident's medical records and confirmed the wound assessments were not consistently completed on a weekly basis as directed by the care plan. 3. Resident # 63 On [DATE] at 10:00 a.m., review of the resident's medical record found the resident was readmitted to the facility on [DATE]. She had a Stage III pressure ulcer on the coccyx. The resident's care plan for pressure ulcers included (typed as written): (Resident's name) has a pressure ulcer to her coccyx and has potential for pressure ulcer development related to disease process, history of pressure ulcers, immobility, bowel incontinence. Date revised was [DATE]. The goal for this problem was, Patient's pressure ulcer will show signs of healing and remain free from infection by review date and Patient will have intact skin, free of redness, blisters or discoloration by review date.The interventions included, Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible .Review of the resident's medical record found no evidence the resident's wounds were re-assessed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. No further wound assessments were in the medical records.During an interview, on [DATE] at 1:10 p.m., the Administrator and Director of Nursing (DON) reviewed the medical records. They confirmed the wound assessments were not consistently completed on a weekly basis as directed by the care plan. 4. Resident #133 On [DATE] at 9:00 a.m., review of Resident #133's medical record found the resident was admitted to the facility on [DATE]. She was admitted with a Stage II pressure ulcer on the right buttock. Resident #133 expired at the facility on [DATE]. Review of the resident's medical record found no pressure ulcer re-assessments since her admission on [DATE]. During an interview, on [DATE] at 1:10 p.m., the Administrator and Director of Nursing (DON) reviewed the medical records. No further wound assessments were provided. b) A resident with a pressure ulcer was not provided care and services to promote the prevention of pressure ulcer development. 1. Resident #149 Record review, on [DATE] at 2:00 p.m., found Resident #149 was admitted to the facility on [DATE]. The resident was admitted with a Stage II pressure ulcer on the cleft of his buttocks, the right ear, and the sacrum. He also had a Stage I pressure ulcer on the left ear. At the time of the survey, each of these areas were resolved. This was verified by Employee #110, a registered nurse (RN), clinical care supervisor, at 3:55 p.m. on [DATE]. Registered Nurse (RN) #110, was asked about the areas to the left and right ears at 3:55 p.m. on [DATE]. She stated they could have occurred from the oxygen tubing, but she was not sure. RN #110 verified the wound assessment sheets did not specify exactly where the pressure areas were located on the left and right ears. A wound assessment, dated [DATE], noted the resident had a pressure area to the cleft of the buttocks and a Stage II pressure to the right shoulder. At 3:55 p.m. on [DATE], RN #110 stated the right shoulder was a documentation error, as the resident never had a pressure area to the right shoulder. The current care plan, revised on [DATE], found a problem: Resident has a potential for pressure ulcer development r/t (related to) impaired mobility. The goal associated with this problem was: Patient will have intact skin free of redness, blisters or discoloration by/through review date. Interventions included: Float both heels while in bed, document every shift. Observe skin for changes, redness, blisters or open areas during routine care. Report observations to unit charge nurse. Observation of the resident in bed, during Stage I of the survey, at 2:28 p.m. on [DATE], with Nursing Assistant (NA) #33 and NA #35 found his heels were not floated. They were resting on the mattress and his feet were against the foot board of the bed. NAs #33 and #35 repositioned the resident, but did not float his heels. The resident's heels were left lying on the mattress. At 4:18 p.m. on [DATE], the resident was again observed in his bed with his heels resting on the mattress. Employee #110, the registered nurse, clinical care supervisor, confirmed the resident's heels were not being floated as directed in the care plan for pressure ulcer prevention. During the observation at 4:18 a.m. on [DATE], the oxygen tubing was observed resting in the crease at the top of the ears between the ears and the head. Observation of the right and left ears found reddened areas under the tubing at the tops of the ears. RN #110 examined the areas and stated both areas were blanchable. She stated, We will get some padding for the oxygen tubing. She stated the areas had not been reported to the unit charge nurse. c) A resident was not provided services to maintain acceptable parameters of nutritional status to the extent possible. The facility did not recognize, evaluate, or address the resident's severe weight loss, a continuing weight loss, and another severe weight loss in an eleven (11) day period. 1. Resident #133 On [DATE] at 11:00 a.m., review of the resident's medical record found this [AGE] year-old resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident was determined unable to make informed medical decisions by the attending physician on [DATE]. Resident #133's weight records and progress notes were reviewed on [DATE] at 3:15 p.m. The records indicated each weight was obtained using a full body lift. On [DATE] at 1:13 a.m., the resident weighed 123.2 pounds (lbs.) When weighed on [DATE] at 2:39 p.m., the resident weighed 94.6 lbs. This loss of 25.5 lbs between [DATE] and [DATE] (seven (7) days) represented a severe weight loss of 21.23% of the resident's total body weight. On [DATE] at 2:27 p.m., the resident weighed 90.7 lbs, an additional loss of 4.1%. When she was weighed on [DATE] at 3:09 p.m., she weighed 87.8 lbs, an additional loss of 3.19%. The weight loss between [DATE] and [DATE] (four (4) days) represented another severe weight loss of 7.18% of the resident's total body weight. Between [DATE] and [DATE], the resident lost a total of 28.6 lbs, representing 23.21% of her total body weight. Review of Resident #133 medical records found no evidence the facility identified or addressed the 25.5 lb weight loss between [DATE] and [DATE] (seven (7) days) which represented a severe weight loss of 21.23%. In addition, there was no evidence the facility identified the resident had another severe weight loss of 7.18%, between [DATE] and [DATE] (four (4) days). The physician and/or nurse practitioner were not notified of the resident's severe weight loss and continued weight losses until [DATE]. By that time, the resident had an unaddressed weight loss of 28.6 lbs, a loss of 23.21% of her total body weight. Medical record review revealed the dietitian saw the resident only on [DATE]. There was no evidence the dietitian was notified of the weight losses, so she could assess the resident and offer suggestions for weight loss interventions. Review of the facility's policy on weight assessment and interventions, on [DATE] at 3:00 p.m., revealed any weight change of 5 lbs. or more since the last weight assessment was to be retaken and reported to the nurse. The policy indicated if the weight was verified, nursing was to notify the physician. This policy was not implemented for Resident #133 when the resident had a severe weight loss of 21.73% in seven (7) days, between [DATE] and [DATE]. During an interview with the administrator and the director of nursing (DON), on [DATE] at 1:00 p.m., they were asked if staff identified the resident's weight loss. The DON said staff recognized the weight change when they weighed her, but staff felt it was from [MEDICAL CONDITION]. Upon inquiry, they were unable to provide any evidence in the medical record related to the presence of and/or the amount of [MEDICAL CONDITION] present. No further information regarding [MEDICAL CONDITION] was provided. On [DATE] at 1:40 p.m., review of Resident #133's electronic medical records with the DON and the administrator found no evidence licensed nursing staff notified the physician, the nurse practitioner, and/or the dietitian of the weight loss in a timely manner. In addition, the medical record contained no discussion of the weight loss as it occurred. d) A discussion was held with the Nursing Home Administrator (NHA) and the Director or Nursing (DON) at 2:37 p.m. on [DATE], related to the facility's QA&A program. When asked what things they discussed as part of the QA&A process, they indicated the topics discussed included pressure ulcers and nutritional status. They were asked why the QA&A committee had not identified the concerns discovered during the Quality Indicator Survey (QIS) related to pressure ulcers and nutrition. Related to pressure ulcer assessments, the NHA stated they were not looking at it from an every seven (7) day aspect, but from a once a week stand point. When asked to explain further, the NHA stated, If the assessment is done on Monday this week then as long as it was done on Monday through Friday of the next week we thought it was okay. The NHA and DON were asked why the QA&A committee had not identified the concerns related to nutrition. They said when they has a weight loss that was significant or severe, they determined interventions to put in place, and to made sure the physician was notified. They indicated they must have just missed this one (Resident #133) as far as notifications and interventions were concerned.",2019-01-01
5526,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-11-19,155,D,1,0,TPT811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to afford Resident #99 the right to formulate an advanced directive. This was found for one (1) of five (5) sampled residents. Resident #99 was deemed to have capacity to make medical decisions; however, the facility allowed someone other than the resident to make decisions in regards to his advanced directives and/or refusals of treatment. Resident identifier: #99. Facility census: 98. Findings include: a) Resident #99 A review of Resident #99's medical record, at 1:10 p.m. on [DATE], found a Physician's Determination of Capacity completed by Resident #99's attending physician on [DATE]. This form indicated Resident #99 maintained capacity to make his own healthcare decisions. Further review of the record found a West Virginia Physician order [REDACTED].#99's attending physician on [DATE]. This form indicated Resident #99 was to receive cardiopulmonary resuscitation (CPR) in the event he would need it. This form was signed by another person, not the resident. There was no indication the resident was consulted about this decision or had asked for another person to sign on his behalf. The person who signed the POST form also signed a Psychoactive Medication Informed Consent form and an Informed Refusal of Treatment consent form on behalf of Resident #99. These forms were signed on [DATE], again with no evidence of input by the resident. An interview with Social Service Director (SSD) #21 and Social Worker (SW) #55, at 3:13 p.m. on [DATE], confirmed Resident #99 was deemed to have capacity to make healthcare decisions on [DATE] by his attending physician. SSD #21 and SW #55 indicated that until the attending physician saw the resident and made a determination of incapacity, the capacity of a resident who was alert and orientated should be assumed. They stated even though Resident #99 was somewhat confused on admission, his capacity should have been assumed. SSD #21 confirmed another person should not have signed the referenced forms because the resident's capacity was presumed and he had the right to make the decisions in regards to CPR, psychoactive medication use, and any refusals of treatment he chose.",2018-11-01
5527,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-11-19,157,E,1,0,TPT811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of on-line resources, and staff interview, the facility failed to promptly notify the attending physician/nurse practitioner of changes in condition of three (3) of five (5) sampled residents. Resident #99 experienced multiple days with low blood pressure ([MEDICAL CONDITION]) while being administered medication for high blood pressure (hypertension), had a decline in meal consumption, and experienced a weight loss. There was no evidence staff notified his physician and/or nurse practitioner about these issues. The physician and/or nurse practitioner were not notified when Resident #100, who had an indwelling Foley catheter, experienced signs and/or symptoms of a urinary tract infection. Resident #47's physician and/or nurse practitioner were not notified when he experienced a weight loss. Resident Identifiers: #99, #100, and #47. Facility Census: 98. a) Resident #99 1. [MEDICAL CONDITION] A review of Resident #99's medical record, at 1:10 p.m. on 11/17/15, found this [AGE] year-old male was hospitalized from [DATE] through 08/05/15. He entered the facility on 08/05/14 and returned home on 08/25/15 at 2:37 p.m. A review of Resident #99's physician orders, beginning on the day of admission, found Resident #99 was receiving 12.5 milligrams (mg) of [MEDICATION NAME] HCT 160 (an antihypertensive/diuretic combination drug) one time a day,12, and 12.5 mg of [MEDICATION NAME] (an antihypertensive medication) two (2) times a day. Resident #99 received both medications as ordered daily beginning on 08/06/15 through 08/24/15. (Antihypertensive medications are given to treat high blood pressure.) According to definitions provided by the Mayo Clinic, WebMd, the National Institutes of Health, and others, [MEDICAL CONDITION] is a blood pressure below 90 systolic or below 60 diastolic. A review of the resident's records found the following blood pressures which were considered in the [MEDICAL CONDITION] range, recorded for Resident #99: -- 08/14/15 at 12:18 a.m. - 89/87 -- 08/16/15 at 10:59 a.m. - 105/49 -- 08/17/15 at 12:24 a.m. - 82/58 -- 08/18/15 at 12:33 a.m. - 76/59 -- 08/21/15 at 2:12 p.m. - 88/50 -- 08/22/15 at 2:58 a.m. - 110/56 -- 08/22/15 at 12:13 p.m. - 98/56 -- 08/23/15 at 11:07 a.m. - 90/50 There was no evidence the physician or nurse practitioner (NP) were notified of Resident #99's low blood pressure readings which occurred between 08/14/15 and 08/23/15. An interview with the Director of Nursing (DON), at 9:30 a.m. on 11/19/15, confirmed the facility had not notified the physician and/or nurse practitioner about Resident #99's low blood pressure. The DON stated this was because, He only wants notified if something is going on with the resident. She indicated, Resident #99's baseline blood pressure was in the [MEDICAL CONDITION] range so they did not notify the physician or nurse practitioner. In an interview with the attending physician, at 3:00 p.m. on 11/19/15, when asked if he wanted to be notified if the resident was experiencing [MEDICAL CONDITION], he stated he would expect to be notified if the resident's systolic number was consistently (more than 2 or 3 days) below 90 or 95. He stated he would definitely want to be notified if the systolic number went below 80 just one time. The attending physician reviewed Resident #99's medical record during the telephone interview and stated, On the 18th is was below 80, so I should have been notified. The medical record contained no evidence the physician or nurse practitioner were notified of Resident #99's blood pressure on 08/18/15 when it was recorded as 76/59. 2) Weight Loss/Decreased Meal Intake A review of Resident #99's medical record, at 1:10 p.m. on 11/17/15, found the following recorded weights: -- 08/06/15 - 153.8 lb (pounds) -- 08/07/15 - 153.8 lb -- 08/09/15 - 154.8 lb -- 08/16/15 - 143.8 lb -- 08/17/15 - 146.2 lb -- 08/23/15 - 139 lb -- 08/25/15 - 141.1 lb and 141 lb From 08/06/15 to 08/16/15, the resident lost 10 pounds or 4.94 percent (%) of his body weight. From 08/06/15 to 08/23/15 the resident lost 14.8 pounds or 9.62% of his body weight. From 08/06/15 to 08/25/15, the resident lost 12.7 pounds or 8.3% of his body weight. (All percentages calculated using the formula: % of body weight loss = (usual weight - actual weight) / (usual weight) x 100) A review of Resident #99's meal intakes found that from 08/06/15 through 08/12/15, the resident's average meal consumption was 82.14%. His meal consumption percentage drastically declined from 08/13/15 through 08/24/15 to an average percentage of 25.44%. Review of Resident #99's progress notes found the following notations related to Resident #99's nutritional status: -- 08/12/15 at 11:31 a.m. - for a weight and nutrition meeting held on 08/11/15: Current status: 154.8 Weight history. status: 153.8 His IBW (ideal body weight) is 149 - 180 and BMI (body mass index) is 25 Average weekly intake of foods/fluids: He is currently receiving a NCS (no concentrated sweets) with ground meats no salt packets. His fluids intake is 1492 and meal intakes are 82%. Residents weight has been stable since admission. Will continue with the current interventions as the resident's weight is stable and he is within his ideal body weight -- 08/14/15 at 12:06 p.m. - Consumed less than 50% of meals will enc (encourage) intake at meal time. -- 08/15/15 at 2:37 p.m. - Consumed less than 50% of meals will enc intake at meal time. -- 08/16/15 at 12:04 p.m. - Consumed less than 50% of meal will enc intake at meal time. -- 08/17/15 at 11:43 a.m. - Consumed less than 50% of meals will encourage intake at meals. -- 08/19/15 at 4:04 p.m. - an Appointment/Outing Return note, following his return from a Modified [MEDICATION NAME] Study - . Recommendations: . Diet level Liquids Regular Dietary Supplement if pts (patients) oral intake continues to be poor recommend he be given a dietary supplement at least once a day,) -- 08/21/15 at 9:59 a.m. - a Multidisciplinary Care Conference note - .Response to treatment including dietary interventions: Patients weights are stable. He receives regular, ground meat diet, no added salt packet on tray, super cereal every day and pudding bid (twice a day) By this time, the resident had lost over 7 pounds in 11 days. There was no indication the physician and/or nurse practitioner were made aware of the resident's decreased intake and weight loss. There was no evidence of any discussion about whether he consumed the meals, super cereal and pudding at this conference. -- 08/25/15 at 2:18 p.m. - Late entry (name of nurse practitioner (NP) in facility yesterday 08/24/15 informed of weight loss, no new orders regarding weight status. The staff noted on 08/14/15 through 08/17/15 the resident consumed less than 50% of his meal, but failed to notify the physician and/or nurse practitioner and failed to put into place any interventions in an attempt to increase Resident #99's intake and prevent weight loss. On 08/16/15, the facility obtained Resident #99's weight, which represented a 10 pound weight loss or a loss 4.94% since admission and failed to notify the physician, the nurse practitioner, or the Registered Dietitian of the resident's declined intake status and weight loss at that time. It was not until 08/24/15, the day before Resident #99's scheduled discharged , that the facility notified the nurse practitioner, who provided no new orders in regards to the resident's weight loss. At 2:30 p.m. on 11/18/15, the Director of Nursing was asked to provide any information pertaining to the notification of Resident #99's attending physician and/or nurse practitioner in regards to the resident's weight loss or decreased meal intake. At the time of exit on 11/19/15 at 6:15 p.m., she had provided no further information. b) Resident #100 Review of Resident #100's medical record found this [AGE] year-old female, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Further review of Resident #100's medical record found she was admitted to the facility with an indwelling Foley catheter. A review of her care plan found the following goal related to Resident #100's indwelling catheter: Patient will show no s/sx (signs/symptoms) of urinary tract infection [MEDICAL CONDITION] through review date. This goal had a target date of 01/04/16. Interventions pertaining to this goal included, Document/report to physician s/sx UTI: burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased temp. (temperature), urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. The nursing progress notes from 08/28/15 (the day of resident's readmission) through 09/09/15 (the day of resident's next discharge to an acute care hospital) found the following progress notes: -- 08/31/15 at 10:35 p.m. - Reason: odor to urine . action taken: patient continues with catheter, patent and draining amber colored urine. -- 09/06/15 at 11:11 p.m. - Reason: uncharacteristic odor of urine . Actions taken: patient urine with strong odor, yellow urine draining into bedside drainage bag There was no indication the facility notified the attending physician or the nurse practitioner when Resident #100's urine had an odor change and color change on 08/31/15, or when the urine had a change in odor on 09/06/15, as directed by her care plan as signs and symptoms of a UTI. Interviews with Clinical Care Supervisor (CCS) Registered Nurse (RN) #89 at 3:22 p.m., 4:05 p.m., and 5:30 p.m. on 11/19/15, confirmed the physician and/or nurse practitioner were not notified of the changes in the color and odor of the resident's urine on 08/31/15 and 09/06/15, as possible indicators of a urinary tract infection and as directed by the resident's care plan. . c) Resident #47 Review of the resident's medical records on 11/17/15 at 1:00 p.m., revealed this [AGE] year-old male, admitted to the facility on [DATE], had admission [DIAGNOSES REDACTED]. The review of medical records found a Physician's Determination of Capacity completed on 11/02/15. This form indicated Resident #47 demonstrated the capacity to make decisions. A review of Resident #47's weights in the electronic medical record found the following weights recorded: -- 10/23/15 at 6:18 p.m. - 254.1 lb (pounds) -- 10/25/15 at 11:03 a.m. - 254.2 lb -- 11/01/15 at 10:50 a.m. - 250.0 lb -- 11/01/15 at 10:51 a.m. - 254.0 lb -- 11/08/15 at 2:18 p.m. - 221.6 lb -- 11/10/15 at 1:18 p.m. - 215.9 lb -- 11/10/15 at 2:18 p.m. - 216.0 lb -- 11/15/15 at 1:25 p.m. - 213.6 lb From 11/01/15 to 11/08/15, the resident lost 32.4 pounds or 12.76 percent (%) of his body weight in 7 days. From 11/08/15 to 11/10/15 the resident lost 5.6 pounds or 2.5% of his body weight in 2 days. From 11/10/15 to 11/15/15 the resident lost 2.4 pounds or 1.11% of his body weight in 5 days. From 10/23/15 to 11/15/15 the resident lost 40.5 pounds or 15.94% in 23 days. Further review of Resident #47's medical records found no evidence the physician and/or nurse practitioner were notified of the severe weight loss of 12.76%, which occurred between 10/23/15 and 11/08/15, until 11/15/15. By the time the physician or nurse practitioner was notified of the resident's weight loss, the resident had lost another 3.61% of his total body weight.",2018-11-01
5528,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-11-19,279,D,1,0,TPT811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the Resident Assessment Instrument Manual, and staff interview, the facility failed to develop a comprehensive care plan for Resident #99 related to his risk of dehydration. Resident #99 was admitted on a diuretic medication with a [DIAGNOSES REDACTED]. The facility failed to incorporate his risk of dehydration into his comprehensive care plan. This was true for one (1) of five (5) sampled residents. Resident Identifier: #99. Facility Census: 98. Findings include: a) Resident #99 A review of Resident #99's medical record, at 1:10 p.m. on 11/17/15, found this [AGE] year-old male was admitted to the facility on [DATE] and discharged to home on 08/25/15 at 2:37 p.m. Resident #99 was admitted from an area hospital where he was a patient from 07/31/15 through 08/05/15. The history and physical from the hospital indicated Resident #99's [DIAGNOSES REDACTED]. Further review of the record found up on admission, Resident #99 received 12.5 milligrams (mg) of [MEDICATION NAME] HCT 160 tablet, one (1) time a day for hypertension (high blood pressure). The Nursing (YEAR) Drug Handbook published by Wolters Kluwer, the drug book utilized by the facility indicated [MEDICATION NAME] - HCT is a combination drug made up of [MEDICATION NAME] (generic name for [MEDICATION NAME]) and [MEDICATION NAME] (HCTZ). Each component of the drug was individually discussed in the the Drug handbook. The drug handbook indicated, HCTZ a component of [MEDICATION NAME] - HCT was a diuretic. The drug book contained a list of adverse reactions which included volume depletion and dehydration. Nursing considerations for HCTZ included monitor fluid intake and output, weight, BP (blood pressure), and electrolyte levels, and monitor elderly patients, who are especially susceptible to excessive diuresis. Diuresis is an increased or excessive production of urine. Resident #99's Medication Administration Record [REDACTED]. Review of the resident's admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 08/12/15, found Item N0510G did not identify the resident was receiving a diuretic. According to the Resident Assessment Instrument (RAI) Manual, Chapter 3, page N-6, found the instructions for completing Section N - Medications, included, Combination medications should be coded in all categories/pharmacologic classes that constitute the combination. For example, if the resident receives a single tablet that combines an antipsychotic and an antidepressant, then both antipsychotic and antidepressant categories should be coded. Had this item been coded, it would have triggered the Care Area Assessment for Dehydration/Fluid Maintenance for additional assessment. A review of Resident #99's care plan found no mention of his risk for dehydration, nor did it contain any goals or interventions to alert staff to monitor for signs and/or symptoms of dehydration for Resident #99. An interview with the Director of Nursing (DON) at 9:30 a.m. on 11/19/15, confirmed Resident #99 did not have a care plan for risk of dehydration. When asked why this was not addressed on Resident #99's care plan, the DON stated, because they felt he was not at risk for dehydration. This was despite his use of a diuretic medication and previous [DIAGNOSES REDACTED].",2018-11-01
5529,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-11-19,282,D,1,0,TPT811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to implement Resident #100's care plan in regards to reporting signs and symptoms of a urinary tract infection [MEDICAL CONDITION] to the attending physician and/or nurse practitioner. This was true for one (1) of five (5) sampled residents. Resident Identifier: #100. Facility Census: 98. Findings include: a) Resident #100 Review of Resident #100's medical record found this [AGE] year-old female was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Further review of the Resident #100's medical record found she was admitted to the facility with an indwelling Foley catheter. A review of her care plan found the following goal related to Resident #100's indwelling catheter: Patient will show no s/sx (signs/symptoms) of urinary tract infection [MEDICAL CONDITION] through review date. This goal had a target date of 01/04/16. Interventions pertaining to this goal included: Document/report to physician s/sx (signs/symptoms) UTI: burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased temp. (temperature), urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. The nursing progress notes from 08/28/15 (the day of resident's readmission) through 09/09/15 (the day of the resident's next admission to the acute care hospital) found the following progress notes: -- 08/31/15 at 10:35 p.m. - Reason: odor to urine . action taken: patient continues with catheter, patent and draining amber colored urine. -- 09/06/15 at 11:11 p.m. - Reason: uncharacteristic odor of urine . Actions taken: patient urine with strong odor, yellow urine draining into bedside drainage bag . There was no indication the facility notified the attending physician or the nurse practitioner when Resident #100's urine had an odor change and color change on 08/31/15 and had a change in odor on 09/06/15, as directed by her care plan as signs and symptoms of a UTI. Interviews with with the Clinical Care Supervisor (CCS) Registered Nurse (RN) #89 at 3:22 p.m., 4:05 p.m. and 5:30 p.m. on 11/19/15, confirmed the physician and/or nurse practitioner were not notified of the the changes in the color and odor of Resident #100's urine on 08/31/15 and 09/06/15 as directed by the resident's care plan.",2018-11-01
5530,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-11-19,309,G,1,0,TPT811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > . Based on resident interview, staff interview, observation, and record review, the facility failed to adequately assess and manage pain for one (1) of five (5) residents (Resident #47) reviewed for pain. This resulted in the resident experiencing pain which was avoidable, and failed to ensure the resident was able to participate optimally in rehabilitative therapy sessions, and therefore was actual harm. The facility also failed to monitor vital signs before administering [MEDICATION NAME] in accordance with physician's orders [REDACTED].#100) reviewed. Resident identifiers: #47 and #100. Facility census: 98. Findings include: a) Resident #47 Resident #47's medical records, reviewed on 11/17/15 at 1:00 p.m., revealed this [AGE] year-old male, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. A comminuted fracture is a fracture in which the bone involved in the fracture is broken into several pieces. At least three separate peices of the bone must be present for a fracture to be considered comminuted. Review of medical records found a Physician's Determination of Capacity completed on 11/02/15. This form indicated Resident #47 demonstrated the capacity to make decisions. Review of the most recent Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/06/15, revealed Resident #47 was moderately cognitively impaired, able to make himself understood and able to understand others. Resident #47 was assessed as requiring the extensive assistance of two (2) staff for bed mobility and transfers. He was incontinent of bowel functions and had an indwelling Foley catheter. His pain assessment on this MDS revealed he was on a PRN (as or when needed) pain medication regimen. The MDS indicated the resident experienced occasional pain over the last five (5) days (the assessment reference period). The pain had made it hard to sleep at night and had limited the resident's day-to-day activities due to pain. The resident indicated his worst pain as an 8 (on a zero (0) to ten (10) scale with zero being no pain and ten as the worst pain you can imagine). Interview with Resident #47 on 11/17/15 at 12:45 p.m., found the resident lying in bed. When asked about his pain, he said, I hurt a lot of the time. I broke my right hip and had to have surgery on it. The scar goes from my stomach down my leg and I broke my left shoulder/arm and my right arm is banged up from the fall. Sometimes the pain is real bad. Resident #47's physician's orders [REDACTED]. -- Review of Resident #47's comprehensive care plan, initiated on 11/08/15 revealed: -- Focus: (Resident's name) has pain related to fractures. -- Goal: Patient will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through next review date.(01/14/16) -- Interventions included: 1. Administer scheduled pain management as per orders. Provide treatments and therapies at least 30 minutes after medication administered. 2. Anticipate patient's need for pain relief and respond immediately to any complaint of pain. 3. Identify, record and treat patient's existing conditions which may increase pain and/or discomfort from fractures. 4. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. 5. Monitor/record/report to nurse loss of appetite, refusal to eat and weight loss. 6. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. 7. Observe and report to physician changes in usual routine, sleep patterns, decrease in functional abilities, and decrease range of motion (ROM), withdrawal or resistance to care. According to the Medication Administration Record [REDACTED] -- 10/24/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 9:00 a.m., for resident complaining of pain rated at 10, after the medication administered documented, E (effective). -- 10/24/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 7:06 p.m., for resident complaining of leg pain rated at 7, after the medication administered documented, E. -- 10/24/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 11:43 p.m., for resident complaining of body pain rated at 7, after the medication administered documented, E. -- 10/25/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 4:45 a.m., for resident complaining of pain rated at 10, after the medication administered documented, E. -- 10/25/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 9:32 a.m., for resident complaining of pain rated at 8, after the medication administered documented, E. -- 10/26/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 2:34 a.m., for resident complaining of pain rated at 10, after the medication administered documented, E. -- 10/26/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 8:37 a.m., for resident complaining of pain rated at 8, after the medication administered documented, E. -- 10/26/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 12:45 p.m., for resident complaining of pain rated at 7, after the medication administered documented, E. -- 10/27/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 2:00 a.m., for resident complaining of pain rated at 7, after the medication administered documented, Effective. -- 10/27/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 6:09 a.m., for resident complaining of pain rated at 8, after the medication administered documented, I (Ineffective). -- 10/27/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 10:15 a.m., for resident complaining of pain rated at 8, after the medication administered documented, E. -- 10/27/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 3:00 p.m., for resident complaining of pain rated at 9, after the medication administered documented, E. -- 10/27/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 8:28 p.m., for resident complaining of pain rated at 9, after the medication administered documented, E. -- 10/28/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 2:13 a.m., for resident complaining of pain rated at 8, after the medication administered documented, E. -- 10/28/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 6:15 a.m., for resident complaining of pain rated at 7, after the medication administered documented, I. -- 10/28/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 11:08 a.m., for resident complaining of pain rated at 8, after the medication administered documented, E. -- 10/29/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 9:09 p.m., for resident complaining of pain rated at 9, after the medication administered documented, E. -- 10/30/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 9:17 p.m., for resident complaining of pain rated at 6, after the medication administered documented, E. -- 10/31/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 2:00 a.m., for resident complaining of pain rated at 8, after the medication administered documented, E. -- 10/31/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 8:28 a.m., for resident complaining of pain rated at 8, after the medication administered documented, I. -- 10/31/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 1:15 p.m., for resident complaining of pain rated at 7, after the medication administered documented, E. -- 11/01/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 9:14 p.m., for resident complaining of pain rated at 8, after the medication administered documented, E. -- 11/02/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 6:51 a.m., for resident complaining of pain rated at 8, after the medication administered documented, U (Unable to determine-out to doctor's appointment). -- 11/02/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 2:22 p.m., for resident complaining of generalized pain rated at 8, after the medication administered documented, E. -- 11/03/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 1:11 a.m., for resident complaining of body pain rated at 8, after the medication administered documented, E. -- 11/03/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 5:17 a.m., for resident complaining of shoulder and back pain rated at 9, after the medication administered documented, E. -- 11/03/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 9:40 a.m., for resident complaining of generalized pain rated at 8, after the medication administered documented, E. -- 11/04/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 6:46 a.m., for resident complaining of body pain rated at 0, after the medication administered documented, E. -- 11/06/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 9:39 a.m., for resident complaining of generalized pain rated at 7, after the medication administered documented, E. -- 11/07/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 1:41 a.m., for resident complaining of body pain rated at 7, after the medication administered documented, E. -- 11/07/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 6:30 a.m., for resident complaining of body pain rated at 7, after the medication administered documented, E. -- 11/08/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 5:09 a.m., for resident complaining of pain all over body rated at 8, after the medication administered documented, E. -- 11/08/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 10:09 p.m., for resident complaining of pain in legs rated at 5, after the medication administered documented, E. -- 11/09/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 11:00 a.m., for resident complaining of generalized pain rated at 7, after the medication administered documented, E. -- 11/12/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 5:04 a.m., for resident complaining of body pain rated at 7, after the medication administered documented, E. -- 11/13/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 12:55 a.m., for resident complaining of body pain rated at 7, after the medication administered documented, E. -- 11/13/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 9:02 a.m., for resident complaining of generalized pain rated at 7, after the medication administered documented, E. -- 11/14/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 1:06 a.m., for resident complaining of pain rated at 8, after the medication administered documented, E. -- 11/15/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 6:43 a.m., for resident complaining of pain rated at 7, after the medication administered documented, E. -- 11/15/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 9:37 p.m., for resident complaining of back pain rated at 7, after the medication administered documented, E. -- 11/16/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 3:38 a.m., for resident complaining of pain rated at 8, after the medication administered documented, E. -- 11/16/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 5:18 am., for resident complaining of pain rated at 7, after the medication administered documented, E. -- 11/17/15-[MEDICATION NAME]/Tylenol 10/325 mg 1 tablet was given at 1:45 a.m., for resident complaining of back and left arm pain rated at 8, after the medication administered documented, E. There was no evidence of other pain medication administered from (MONTH) 23, (YEAR) through (MONTH) 17, (YEAR). Review of the Occupational Therapy (OT) Evaluation completed on 10/26/15 revealed: -- Pain at Rest: Intensity: = 6/10; Frequency = constant; Location: right side/hip and left shoulder; Description/Type: aching, sharp, shooting and stabbing. -- Pain on Movement: Intensity= 10/10; Frequency = constant; Location: right side/hip and left shoulder; Description/Type/ Passive Range of Motion (PROM): stabbing and excruciating. -- Patient verbalized the pain level and he expressed the pain limits his functional activities. -- Discussed with the interdisciplinary team (IDT) of the intensity and the limitations caused by the pain. Intervention: Patient receives pain medication on scheduled program. Further review found daily OT progress notes with concerns on the following days: -- 11/11/15: .Patient was very lethargic and reports increased tiredness . Participated at very low levels today. -- 11/12/15: . The patient will not initiate pendulum exercises to left upper extremity however will let therapist perform passive range of motion (PROM) exercises in pendulum patterns. -- 11/16/15: . Patient again refuses pendulum exercises and refused PROM in place for pendulum. He states that that the pain is too bad. Therapist advised (Physician's name) of continued refusal of pendulum exercises. -- 11/17/15: . The patient again refuses pendulum exercises to left shoulder with complaints of pain During an interview with the Director of Nursing (DON) on 11/17/15 at 2:00 p.m., it was verified the resident should be assessed for the need for pain medication prior to performing a resident's treatments and/or prior to the therapy sessions. During a telephone interview on 11/19/15 at 3:00 p.m., the physician indicated the resident had a history of [REDACTED]. He further indicated it was his understanding the resident received the medication prior to therapy sessions. He confirmed he was aware of the resident's refusal to do the pendulum exercises to left shoulder; however was not aware it was due to pain. During the interview, the physician accessed the electronic medical records of Resident #47. He further confirmed the therapy staff and nursing staff did not appear to be communicating concerning Resident #47's pain management during therapy sessions. b) Resident #100 Review of Resident #100's medical record found this [AGE] year-old female, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Further review of the record found a physician's orders [REDACTED]. Hold for pulse Review of Resident #100's Medication Administration Record [REDACTED]. The other days from 08/28/15 through present Resident #100 had been in the hospital, therefore this medication was not administered by the facility. Further review of the medical record found no indication nursing obtained Resident #100's pulse prior to administering her [MEDICATION NAME]. The failure to obtain the resident's pulse meant the nurse would not know whether the medication should be given or held could not hold the medication if her pulse was below 60 bpm as directed by the physician's orders [REDACTED].>An interview the Director of Nursing at 4:45 p.m. on 11/19/15, confirmed nursing had not been obtaining Resident #100's pulse prior to the administration of her [MEDICATION NAME] as directed by the physician's orders [REDACTED].>",2018-11-01
5531,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-11-19,325,G,1,0,TPT811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, resident interview, record review, and observation, the facility failed to ensure two (2) of five (5) residents reviewed for nutrition maintained, to the extent possible, acceptable parameters of nutritional status. Resident #47's weight was not accurately assessed. The resident had severe weight losses which were not identified and addressed in a timely manner. In addition, the weight loss interventions suggested by the dietitian, and/or those interventions outlined in the resident's care plan, were not implemented. For Resident #99, the facility failed to identify the resident's decreased meal intake and weight loss. While at the facility, the resident continued to lose weight with no new interventions and/or treatments implemented to prevent continued weight loss. The failure to provide necessary care and services resulted in actual harm to these residents. Resident identifiers: #47 and #99. Facility census: 98. Findings include: a) Resident #47 Resident #47's medical records, reviewed on 11/17/15 at 1:00 p.m., revealed this [AGE] year-old male, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Review of the admission nursing assessment, completed on 10/23/15 at 6:54 p.m., revealed Resident #47 had an [MEDICAL CONDITION] scrotum and three (3) plus (+) [MEDICAL CONDITION] of bilateral feet. Further review of Resident #47's record found a Registered Dietitian Nutritional assessment dated [DATE], with an effective time of 2:34 p.m. This assessment, completed by Registered Dietitian (RD) #119, identified the resident's intake was poor with a 34% meal intake average. The RD noted the resident did have [MEDICAL CONDITION], and had no pressure ulcers. She recommended Resident #47 have Ensure one (1) can twice daily and record the percentage (%) taken, Multivitamin one (1) tablet by mouth daily, and [MEDICATION NAME] (a [MEDICATION NAME] used for bowel problems) one by mouth daily for thirty (30) days. Further review of the clinical record found a history and physical (H&P) completed by the attending physician on 11/02/15. This H&P indicated, There is no [MEDICAL CONDITION] of the lower extremities. Interview with Resident #47 on 11/17/15 at 12:45 p.m., found the resident lying in bed. When asked if he had ate lunch, he said, I don't know. He spoke in a very low voice. He further indicated he was uncomfortable. When asked about his ability to feed himself he said, I broke my left shoulder/arm and my right arm is banged up from the fall and it is difficult to eat at times, but not very hungry anyways. A review of Resident #47's weights in the electronic medical record found the following weights recorded: - 10/23/15 at 6:18 p.m. - 254.1 lb (pounds) - 10/25/15 at 11:03 a.m. - 254.2 lb - 11/01/15 at 10:50 a.m. - 250.0 lb - 11/01/15 at 10:51 a.m. - 254.0 lb - 11/08/15 at 2:18 p.m. - 221.6 lb - 11/10/15 at 1:18 p.m. - 215.9 lb - 11/10/15 at 2:18 p.m. - 216.0 lb - 11/15/15 at 1:25 p.m. - 213.6 lb From 11/01/15 to 11/08/15 the resident lost 32.4 pounds or 12.76 percent (%) of his body weight in 7 days. From 11/08/15 to 11/10/15 the resident lost 5.6 pounds or 2.5% of his body weight in 2 days. From 11/10/15 to 11/15/15 the resident lost 2.4 pounds or 1.11% of his body weight in 5 days. From 10/23/15 to 11/15/15 the resident lost 40.5 pounds or 15.94% in 23 days. (All percentages calculated using the following formula % of body weight loss = (usual weight - actual weight) / (usual weight) x 100.) Guidance to Surveyors related to suggested parameters for evaluating significance and unplanned and undesired weight loss, found in Appendix PP of the CMS State Operations Manual contained the following: -- Interval of 1 month, 5% is a significant weight loss, and greater than 5% is a severe weight loss. -- Interval of 3 months, 7.5% is a significant weight loss, and greater than 7.5% is a severe weight loss. -- Interval of 6 months, 10% is a significant weight loss, and greater than 10% is a severe weight loss. Review of Resident #47's progress notes found the following notations related to Resident #47's nutritional status: -- 10/27/15 at 12:29 p.m., Weight and Nutrition Meeting, Weight on 10/23/15 254.1 lbs. Resident is a new admission to the facility, Ideal Body Weight (IBW) 187-226 lbs. Intake in last week meals 38%, fluids 1230 cubic centimeters (cc) and snacks 83%. Resident receives a regular diet. -- 11/03/15 at 3:59 p.m., Weight and Nutrition Meeting, Weight on 11/01/15 254 lbs. No significant changes in weight. Resident had RD consult, with recommendations for Ensure twice daily, multivitamin daily and [MEDICATION NAME] daily for 30 days, approved by physician. Weekly weights. -- 11/04/15 at 8:01 a.m., Patient consumed less than 50% of meal. Will continue to encourage meal intake. -- 11/04/15 at 3:42 p.m., Multidisciplinary Care Conference, . Patient's weight are stable. He receives regular diet, no salt packet on tray; ensure twice daily (bid) and ProMod one ounce bid -- 11/09/15 at 11:21 a.m., Patient consumed less than 50% of meal. Will continue to encourage meal intake. -- 11/10/15 at 2:03 p.m., Weight and Nutrition Meeting, Weight on 11/08/15 221.6 lbs. Weight today 216.0 lbs. with wheel chair weight scale, weight today with full body lift 215.9 lbs . Meal intake 9% fluids 983 cc in last week . Resident currently receives ensure one can twice a day, with poor acceptance, talked with resident who stated does not like Ensure early in the morning, time changed to afternoon and at 8pm (8:00 p.m.) in the evening, phone RD for recommendations due to weight loss, no answer on telephone, left message for return call to facility --11/10/15 at 3:38 p.m., RD returned call to facility with recommendations for magic cup twice daily, approved by physician --11/11/15 at 10:16 a.m., Multidisciplinary Care Conference, . Patients weights are stable. He receives regular diet, ensure one can bid, magic cup bid and Promod one ounce bid --11/12/15 at 11:30 a.m., Patient consumed less than 50% of meal. Will continue to encourage meal intake. --11/14/15 at 4:35 p.m., Patient consumed less than 50% of meal. Will continue to encourage meal intake. --11/17/15 at 5:53 p.m., Current weight 213.6 lbs. Nurse practitioner (NP) notified at this time. No new orders will evaluate in the facility on 11/18/15. --11/18/15 at 5:46 p.m., Weight and Nutrition Meeting, Weight on 11/15/15 213.6 lbs. Loss of 5% change in weight compared to weight on 10/23/15. IBW- 187-226 lbs. Resident had decreased meal intake now beginning to improve from last week 9% to 19% meal consumption this week . Phoned RD for consult, recommendations for a super doughnut daily Seven (7) days after the weight loss should have been identified the multidisciplinary team noted the resident's weights were stable and he was not in need of any new interventions. They failed to identify the 38 pound weight loss and/or the resident drastic decrease in meal consumption and missed another opportunity to implement interventions to prevent further weight loss. Failed to address the RD recommendations from 11/11/15. On 11/11/15 at 5:42 p.m., RD #119, completed a review note. This note revealed, RD note due to weight loss and pressure ulcers: Current body weight (CBW) 216 (11/10/15) -14.9% since 10/23/15 admission. Body Mass Index (BMI) =27.7 (overweight). Doctor orders- Regular diet with no salt packet on tray (3%, refused x 7) average meal, ensure one (1) can (42% consumed), Promod bid, and 1193 milliliters (ml) fluids average for 11/8/15 through 11/10/15. Started magic cup 11/11/15 to supplement other interventions in place. Swift decrease in weight. However, patient noted to have [MEDICAL CONDITION] at admission so weight decrease anticipated as swelling subsides. Medication changes: [MEDICATION NAME] (11/03/15), receiving [MEDICATION NAME] due to elevated ammonia level 11/10/15. Unable to locate other lab results . At nutritional risk due to weight loss, inadequate meal intake, pressure ulcers, depleted protein stores and therapeutic diet. Currently on weekly weights . New recommendations: record % consumed of Promod, Vitamin C 500 milligrams (mg) bid for 30 days, Zinc 220mg daily for 14 days, and appetite stimulant for a trail period if an appropriate candidate. There was no evidence the facility implemented these recommendations. As well, the clinical record revealed no orders or considerations for an appetite stimulant. Review of Resident 47's comprehensive care plan, found a care plan initiated on 11/11/15: -- Focus: (Resident's name) has experienced an unplanned/unexpected weight loss related to acute illness. -- Goal: Patient will consume at least 50% two (2) of three (3) meals/day through the review date of 01/14/2016. -- Interventions: 1. Alert attending physician if intake averages less than 25% of offered foods for more than 48 hours. Consult RD as directed by physician. 2. Give supplements as ordered (Ensure one can bid). Alert Unit Charge Nurse if patient not consuming supplements on a routine basis. 3. Give supplements as ordered (Magic cup bid). Alert Unit Charge Nurse if patient not consuming supplements on a routine basis. 4. Give supplements as ordered (Promod liquid one ounce bid). Alert Unit Charge Nurse if patient not consuming supplements on a routine basis. 5. Provide and serve regular diet, no salt packet on tray with thin liquids as ordered. Monitor and document % consumed each meal. Resident preference for grilled cheese sandwich for lunch. Review of Resident #47's meal intake, as documented on the Activities of Daily Living revealed, from 10/24/15 through 10/31/15: -- Breakfast - the resident refused all except on 10/28/15 he consumed 25%. -- Lunch meal- consumed - 0% - 65%. -- Dinner meal consumption was from 0% - 65%. Review of meal consumption from 11/01/15 through 11/17/15: -- Breakfast - Refused 13 out of 17 breakfasts and consumed 20% on 11/12/15, 35% on 11/13/15, 20% on 11/15/15, and 45% on 11/16/15. -- Lunch- Refused 9 lunch meals and averaged 25-80% the other 8 days. -- Dinner- Refused 11 of 17 dinners and averaged 25-50% the other 6 days. Review of Physician order [REDACTED]. --10/30/15 - Ensure one can by mouth bid. --11/10/15 - Magic cup twice a day at lunch and dinner. --11/18/15 - Super donut daily at breakfast. --10/29/15 - Promod one ounce po bid for hypo [MEDICATION NAME]. Review of Medication Administration Record [REDACTED] --10/31/15 through 11/05/15- No documentation found for Ensure supplement. --10/29/15 through 11/17/15- No documentation on the % of Promod found. --11/10/15 through 11/17/15 -No documentation found for Magic cup consumed. --11/05/15 through 11/10/15- 9:00 a.m. dose refused --11/05/15 through 11/07/15- 9:00 p.m. dose refused --11/08/15 through 11/9/15 - 9:00 p.m. dose consumed 100% --11/11/15 - 1:00 p.m. - 75% consumed and 8:00 p.m. - 100% consumed --11/12/15 through 11/14/15- 1:00 p.m. and 8:00 p.m. doses refused --11/15/15- 1:00 p.m. - 25% consumed and 8:00 p.m. dose refused --11/16/15- 1:00 p.m. - 50% consumed and 8:00 p.m. dose 50% consumed --11/17/15- 1:00 p.m. - 100% consumed and 8:00 p.m. dose 70% consumed. An interview at 9:30 a.m. on 11/19/15 with the DON, confirmed Resident #47 had a decrease in his weight. She indicated that the admitting hospital had overloaded him with excess fluid and the weight loss was a result of the loss of fluid due to [MEDICAL CONDITION]. The DON was asked to provide information that demonstrated the resident had [MEDICAL CONDITION] upon admission and that the [MEDICAL CONDITION] was assessed and had diminished throughout the resident's stay at the facility. She was unable to provide the requested information. She stated, I don't have what you are looking for. The DON was also asked to provide information as to any interventions and or notifications of the physician/nurse practitioner and/or dietitian in regards to Resident #47's weight loss and poor meal intake. At the time of exit on 11/19/15 at 6:15 p.m., she had not provided any additional information. b) Resident #99 A review of Resident #99's medical record at 1:10 p.m. on 11/17/15, found this [AGE] year-old male was admitted to the facility on [DATE] and discharged to home on 08/25/15 at 2:37 p.m. Resident #99 was admitted from an area hospital where he was a patient from 07/31/15 through 08/05/15. The history and physical from the hospital indicated Resident #99's [DIAGNOSES REDACTED]. Review of Resident #99's record found a Registered Dietician Nutritional assessment dated [DATE] with an effective time of 2:58 p.m. This assessment, completed by Registered Dietitian (RD) #119, indicated the resident's intake was good with an 84% meal intake average. The RD noted the resident did not have any [MEDICAL CONDITION] or pressure ulcers. She made recommendations for Resident #99 to have super cereal six (6) ounces and pudding twice daily. Further review of the record found a physician's orders [REDACTED]. A review of Resident #99's meals intakes found that from 08/06/15 through 08/12/15, the resident's average meal consumption was 82.14 %. His meal consumption percentage drastically declined from 08/13/15 through 08/24/15 to an average percentage of 25.44%. Review of the Medication Administration Record [REDACTED]. A review of Resident #99's vital signs in the electronic medical record found the following weights recorded: -- 08/06/15 - 153.8 lb (pounds) -- 08/07/15 - 153.8 lb -- 08/09/15 - 154.8 lb -- 08/16/15 - 143.8 lb -- 08/17/15 - 146.2 lb -- 08/23/15 - 139 lb -- 08/25/15 - 141.1 lb and 141 lb From 08/06/15 to 08/16/15 the resident lost 10 pounds or 4.94 percent (%) of his body weight. From 08/06/15 to 08/23/15 the resident lost 14.8 pounds or 9.62% of his body weight. From 08/06/15 to 08/25/15 the resident lost 12.7 pounds or 8.3% of his body weight. (All percentages calculated using the following formula % of body weight loss = (usual weight - actual weight) / (usual weight) x 100.) Guidance to Surveyors related to suggested parameters for evaluating significance and unplanned and undesired weight loss, found in Appendix PP of the CMS (Centers for Medicare and Medicaid Services) State Operations Manual contained the following: -- Interval of 1 month, 5% is a significant weight loss, and greater than 5% is a severe weight loss. -- Interval of 3 months, 7.5% is a significant weight loss, and greater than 7.5% is a severe weight loss. -- Interval of 6 months, 10% is a significant weight loss, and greater than 10% is a severe weight loss. Review of Resident #99's progress notes found the following notations related to Resident #99's nutritional status: -- 08/12/15 at 11:31 a.m. - for a weight and nutrition meeting held on 08/11/15, read: Current status: 154.8 Weight history. status: 153.8 His IBW (ideal body weight) is 149 - 180 and BMI (body mass index) is 25 Average weekly intake of foods/fluids: He is currently receiving a NCS (no concentrated sweets) with ground meats no salt packets. His fluids intake is 1492 and meal intakes are 82%. Residents weight has been stable since admission. Will continue with the current interventions as the resident's weight is stable and he is within his ideal body weight -- 08/14/15 at 12:06 p.m. read, Consumed less than 50% of meals will enc (encourage) intake at meal time. -- 08/15/15 at 2:37 p.m. read, Consumed less than 50% of meals will enc intake at meal time. -- 08/16/15 at 12:04 p.m. read, Consumed less than 50% of meal will enc (encourage) intake at meal time. -- 08/17/15 at 11:43 a.m. read, Consumed less than 50% of meals will encourage intake at meals. -- 08/19/15 at 4:04 p.m., an Appointment/Outing Return note, this note was following his return from a Modified [MEDICATION NAME] Study, it read: . Recommendations: . Diet level Liquids Regular Dietary Supplement (if pts (patients) oral intake continues to be poor recommend he be given a dietary supplement at least once a day,) -- 08/21/15 at 9:59 a.m. a Multidisciplinary Care Conference note, . Response to treatment including dietary interventions: Patients weights are stable. He receives regular, ground meat diet, no added salt packet on tray, super cereal every day and pudding bid (twice a day) -- 08/25/15 at 2:18 p.m. read, Late entry (name of nurse practitioner (NP)) in facility yesterday 08/24/15 informed of weight loss, no new orders regarding weight status. The facility failed to identify the resident's decreased meal intake and weight loss. The resident while at the facility continued to lose weight with no new interventions and/or treatments implemented to prevent the weight loss. The staff noted on 08/14/15 through 08/17/15, the resident consumed less than 50% of his meal, but failed to notify the physician and/or nurse practitioner and failed to put into place any interventions in attempts to increase Resident #99's intakes and prevent weight loss. On 08/16/15 the facility obtained Resident #99's weight which represented a 10 pound weight loss (or a loss 4.94%) since admission and still failed to notify the physician, the nurse practitioner, or the Registered Dietitian. Five (5) days after the weight loss should have been identified, the multidisciplinary team noted the resident's weights were stable and he was not in need of any new interventions. They failed to identify the 10 pound weight loss and/or the resident's drastic decrease in meal consumption and missed another opportunity to implement interventions to prevent further weight loss. It was not until 08/24/15, the day before Resident #99 was scheduled to be discharged , that they notified the nurse practitioner who provided no new orders in regards to the resident's weight loss. By the time of discharge on 08/25/15, Resident #99 had lost 12.7 pounds or 8.3% of his body weight in 20 days. This represented a severe weight loss. An interview at 9:30 a.m. on 11/19/15 with the DON, confirmed Resident #99 had a decrease in his weight. She indicated, that the admitting hospital had overloaded him with excess fluid and the weight loss was a result of the loss of fluid. She stated, Resident #99 was receiving [MEDICATION NAME] - HCT which had a diuretic component and that in combination with the excess fluid caused the weight loss when the excess fluid resolved. The DON was asked to provide information that demonstrated the resident had [MEDICAL CONDITION] upon admission and that the [MEDICAL CONDITION] was assessed and diminished throughout the residents stay at the facility. She was unable to provide the requested information. She stated, I don't have what you are looking for. The DON was also asked to provide information as to any interventions and or notifications of the physician and/or nurse practitioner and/or dietitian in regards to Resident #99's weight loss and poor meal intake. At the time of exit on 11/19/15 at 6:15 p.m., she had not provided any additional information.",2018-11-01
5532,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-11-19,327,G,1,0,TPT811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based record review, staff interview, resident interview and observation, the facility failed, for two (2) of five (5) residents, to recognize a decline in fluid intake and implement measures to ensure adequate fluid intake and avoid dehydration. This resulted in actual harm to Resident #47, whom developed a urinary tract infection and a significant weight loss, whom required appetite stimulant after surveyor's intervention and Resident #99 whom required a hospitalization for treatment of [REDACTED].#47 and #99. Facility census: 98. Findings include: a) Resident #47 Resident #47's medical records reviewed on 11/17/15 at 1:00 p.m. revealed a [AGE] year old male was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #47's record found a Registered Dietician Nutritional assessment dated [DATE] with an effective time of 2:34 p.m. This assessment was completed by Registered Dietician (RD) #119. This assessment indicated Resident #47's estimated fluid needs were 3466 milliliters (ml) per day. The facility had the following total fluid intakes listed for Resident #47 none of which totaled his estimated fluid needs of 3466 ml: -- 11/01/15 - 1840 cubic centimeters (cc) (it should be noted a cc equals a ml) resulting in a fluid deficit of 1626 cc -- 11/02/15 - 680 cc resulting in a fluid deficit of 2786 cc -- 11/03/15 - 960 cc resulting in a fluid deficit of 2506 cc -- 11/04/15 - 1440 cc resulting in a fluid deficit of 2026 cc -- 11/05/15 - 100 cc resulting in a fluid deficit of 3366 cc -- 11/06/15 - 1330 cc resulting in a fluid deficit of 2136 cc -- 11/07/15 - 1300 cc resulting in a fluid deficit of 2166 cc -- 11/08/15 - 960 cc resulting in a fluid deficit of 2506 cc -- 11/09/15 - 1440 cc resulting in a fluid deficit of 2026 cc -- 11/10/15 - 1260 cc resulting in a fluid deficit of 2206 cc Review of Resident #47's record found a Registered Dietician Review Note dated 11/11/15 with an effective time of 5:24 p.m. This assessment was completed by Registered Dietician (RD) #119. This assessment indicated Resident #47's estimated fluid needs were 2945-3240 milliliters (ml) per day. -- 11/11/15 - 400 cc resulting in a fluid deficit of 2840 cc -- 11/12/15 - 1400 cc resulting in a fluid deficit of 1840 cc -- 11/13/15 - 1,640 cc resulting in a fluid deficit of 1600 cc -- 11/14/15 - 715 cc resulting in a fluid deficit of 2525 cc -- 11/15/15 - 1640 cc resulting in a fluid deficit of 1600 cc -- 11/16/15 - 1800 cc resulting in a fluid deficit of 1440 cc -- 11/17/15 - 940 cc resulting in a fluid deficit of 2300 cc The facility had the following total fluid outputs listed for Resident #47. *= Days the output was greater than intake -- 11/01/15- 1700 cc output 140 cc less than intake -- *11/02/15- 1100 cc output 420 cc more than intake -- *11/03/15- 1425 cc output 465 cc more than intake -- 11/04/15- 1150 cc output 290 cc less than intake -- 11/05/15- 100 cc output is same as intake -- *11/06/15- 1800 cc output is 470 cc more than intake -- 11/07/15- 950 cc output is 350 cc less than intake -- *11/08/15- 1800 cc output is 840 cc more than intake -- 11/09/15- 1400 cc output is 40 cc less than intake -- *11/10/15- 1750 cc output is 490 cc more than intake -- *11/11/15- 1350 cc output is 950 cc more than intake. -- *11/12/15- 1650 cc output is 250 cc more than intake -- *11/13/15- 1800 cc output is 160cc more than intake -- *11/14/15- 1350 cc output is 635 cc more than intake -- 11/15/15- 1500 cc output is 140 cc less than intake -- 11/16/15- 1150 cc output is 650 cc less than intake -- *11/17/15- 1220 cc output is 280 cc more than intake Resident #47's output exceeds his intake 10 out of 17 days. Dehydration is a condition that occurs when the loss of body fluids, mostly water, exceeds the amount that is taken in. With dehydration more water is moving out of our cells and bodies than what we take in through drinking. When we lose too much water, our bodies may become out of balance or dehydrated. A review of Resident #47's meals intakes found that from 10/23/15 through 10/29/15 resident's average meal consumption was 34%. His meal consumption percentage drastically declined from 10/29/15 through 11/1/15 to an average percentage of 3%. A review of the results of a comprehensive metabolic panel obtained for Resident #47 on 10/27/15 found the following pertinent lab values: -- Creatinine was below reference interval at 0.61 (Reference interval is .76 to 1.27); -- BUN (blood urea nitrogen) was within the reference interval at 10 (Reference Interval 8 - 27); -- Sodium was within the reference interval at 139 (Reference Interval 134 - 144); -- Potassium was within reference interval at 4.4 (reference interval 3.5 - 5.2); -- Chloride was within the reference interval at 100 (reference interval is 97 - 108); and --carbon [MEDICATION NAME] (CO2) was within the reference interval at 22 (reference interval is 18 - 29). No further lab results could be found in the medical records; however a blood specimen was obtained on 11/10/15 at 3:54 a.m. A review of Resident #47's weights in the electronic medical record found the following weights recorded: -- 10/23/15 at 6:18 p.m. - 254.1 lb (pounds) -- 10/25/15 at 11:03 a.m. - 254.2 lb -- 11/01/15 at 10:50 a.m. - 250.0 lb -- 11/01/15 at 10:51 a.m. - 254.0 lb -- 11/08/15 at 2:18 p.m. - 221.6 lb -- 11/10/15 at 1:18 p.m. - 215.9 lb -- 11/10/15 at 2:18 p.m. - 216.0 lb -- 11/15/15 at 1:25 p.m. - 213.6 lb An interview with the Director of Nursing (DON) and Clinical Care Supervisor (CCS) Registered Nurse (RN) # 74 at 2:30 p.m. on 11/18/15, found the facility determines residents fluid needs based on the residents ideal body weight, their current weight and any fluid restrictions they may have. When asked if the registered dietician assists with the determination of how much fluid a resident would need they indicated, the dietician will look at new admissions and will help them with those decisions. The DON and CCS #74 was then asked how the track and determine if a residents intake is sufficient or not, The DON replied, the CCS's look at the fluid intake total for the day before for all residents every morning. She stated, if a resident has consumed less than 1500 ccs of fluid they will encourage the resident to consume more fluid the following day. Resident #99's low fluid intakes, weight loss, and decreased meal intakes were reviewed with the DON and CCS #74. They were asked to provide any information pertaining to notifications of the physician and/or nurse practitioner, any interventions put into place to prevent dehydration, and any information they had pertaining to their monitoring of Resident #47 for signs and/or symptoms of dehydration. At 9:30 a.m. on 11/19/15, the DON provided the following information pertaining to Resident #47. She indicated, while at the hospital prior to admission to the facility the resident was given intravenous fluids and was plumped up on fluids prior to his admission to the facility. She indicated the resident had excessive [MEDICAL CONDITION] in abdomen and extremities. She determined these factors caused the resident to lose weight. The DON was asked to provide any information related to his excess fluid such as their monitoring of his [MEDICAL CONDITION] and/or lung sounds. She was unable to provide any evidence to support the resident was overloaded with excess fluid and/or excessive [MEDICAL CONDITION] upon his admission to the facility. In regards to his fluid deficit on a daily basis during his stay at the facility, the DON indicated the Registered Dietician's just made a recommendation that the resident receive 3466 cc per day and the resident did not require that much fluid to stay hydrated. She indicated, they encourage resident #47 to drink fluids when his intake was less than 1500 cc and the days following his decreased intake it bounced back proving they had encouraged him to drink fluids the following days. Review of the nursing progress notes showed Resident #47 was encouraged to drink more fluids on the following dates: -- Note dated 11/04/15 at 7:54 a.m. indicated Resident #47 drank on 920 cc of fluid on 11/03/15 and they would continue to encourage fluids. -- Note dated 11/07/15 at 1:47 p.m. indicated Resident #47's fluid intake was 1230 cc on 11/06/15 and they would continue to encourage fluid. -- Note dated 11/08/15 at 11:56 a.m. indicated Resident #47's fluid intake was 1300 cc on 11/07/15 and they continued to encourage fluid intake and report any changes to the nurse practitioner. -- Note dated 11/09/15 at 11:14 a.m. indicated Resident #47's fluid intake was 1140 cc on 11/08/15 will continue to encourage fluid. This note also indicates to notify nurse practitioner of any changes. -- Note dated 11/12/15 at 11:22 a.m. indicated Resident #47's fluid intake was 660 cc on 11/11/15 will continue to encourage fluid. This note also indicates to notify nurse practitioner of any changes. -- Note dated 11/13/15 at 10:33 a.m. indicated Resident #47's fluid intake was 1300 cc on 11/12/15 will continue to encourage fluid. This note also indicates to notify nurse practitioner of any changes. Resident #47's fluid intake was also below 1500 cc on 11/03/15 with 960 cc, 11/09/15 with 1440 cc, 11/10/15 with 1260 cc, 11/14/15 with 715 cc and 11/17/15 with 940 cc. These dates were not noted or acknowledged by nursing nor were fluids encouraged. The interview with the DON continued and she stated, He was capacitated we could not make him drink. She stated we give him fluids with meals and between meals and he had a water pitcher. She indicated all we can do is encourage fluids. Review of Resident #47's comprehensive care plan related to hydration: -- Focus: Urinary tract infection initiated 11/17/15. -- Goal: The urinary tract infection will resolve without complications. -- Intervention: Encourage adequate fluid intake 1500- 2000 cc/day. The DON provided a photocopied page which she stated was part of the Lippincott manual which is what they base their standards of practice from. She referenced the page and stated of the signs and symptoms of fluid and electrolyte imbalances and the only one Resident #47 demonstrated was weight loss greater than five (5) percent. The excerpt was reviewed and contained the following signs and symptoms of fluid and electrolyte imbalances in regards to fluid, Acute weight loss (>5%), drop in body temperature, dry skin and mucous membrane, postural [MEDICAL CONDITION], longitudinal wrinkles or furrows of tongue, oliguria or anuria. The DON was unable to provide any evidence the facility had assessed Resident #47 for any of the aforementioned signs or symptoms with the exception of body temperature due to the regular recording of the Resident #47's body temperature. Blood pressures obtained were not taken upon the resident rising from a seated position which is what postural [MEDICAL CONDITION] identification would require. She stated again , we only document to the exception so if it is not documented then he must not have had the any symptoms presenting. c) Resident #99 A review of Resident #99's medical record at 1:10 p.m. on 11/17/15, found this [AGE] year old male was admitted to the facility on [DATE] and discharged to home on 08/25/15 at 2:37 p.m. Resident #99 was admitted from an area hospital where he was a patient from 07/31/15 through 08/05/15. The history and physical from the hospital indicated Resident #99's [DIAGNOSES REDACTED]. Further review of the record found Resident #99 was receiving upon admission to the facility, 12.5 millgrams (mg) of [MEDICATION NAME] HCT tablet 160, one time a day for hypertension. The Nursing (YEAR) Drug Handbook, published by Wolters Kluwer, the drug book utilized by the facility, indicated [MEDICATION NAME] - HCT is a combination drug made up of [MEDICATION NAME] (generic name for [MEDICATION NAME]) and [MEDICATION NAME] (HCTZ). Each component of the drug was individually discussed in the drug handbook. The handbook indentified HCTZ, a component of [MEDICATION NAME] - HCT, as a diuretic. The book contained a list adverse reactions which included volume depletion and dehydration. Nursing considerations for HCTZ included monitor fluid intake and output, weight, BP (blood pressure), and electrolyte levels, and monitor elderly patients, who are especially susceptible to excessive diuresis. The drug book also indicated HCTZ may decrease potassium, and sodium levels. Resident #99's Medication Administration Record [REDACTED]. Further review of Resident #99's record found a Registered Dietitian Nutritional assessment dated [DATE], with an effective time of 2:58 p.m. This assessment, completed by Registered Dietitian (RD) #119, indicated Resident #99's estimated fluid needs were 2,111 milliliters (ml) per day. The RD's assessment also noted [MEDICATION NAME] - HCT as a medication which could have potential nutritional side effects. The facility had the following total fluid intakes listed for Resident #99 none of which totaled his estimated fluid needs of 2,111 ml: -- 08/06/15 - 1880 cubic centimeters (cc) (a cc equals a ml) resulting in a fluid deficit of 231 ccs. -- 08/07/15 - 1150 cc resulting in a fluid deficit of 961 cc -- 08/08/15 - 2060 cc resulting in a fluid deficit of 51 cc -- 08/09/15 - 1740 cc resulting in a fluid deficit of 371 cc -- 08/10/15 - 1640 cc resulting in a fluid deficit of 471 cc -- 08/11/15 - 1500 cc resulting in a fluid deficit of 611 cc -- 08/12/15 - 1860 cc resulting in a fluid deficit of 251 cc -- 08/13/15 - 1960 cc resulting in a fluid deficit of 151 cc -- 08/14/15 - 1260 cc resulting in a fluid deficit of 851 cc -- 08/15/15 - 1640 cc resulting in a fluid deficit of 471 cc -- 08/16/15 - 1390 cc resulting in a fluid deficit of 721 cc -- 08/17/15 - 900 cc resulting in a fluid deficit of 1211 cc -- 08/18/15 - 1740 cc resulting in a fluid deficit of 371 cc -- 08/19/15 - 620 cc resulting in a fluid deficit of 1491 cc -- 08/20/15 - 1560 cc resulting in a fluid deficit of 551 cc -- 08/21/15 - 780 cc resulting in a fluid deficit of 1331 cc -- 08/22/15 - 1200 cc resulting in a fluid deficit of 911 cc -- 08/23/15 - 1500 cc resulting in a fluid deficit of 600 cc -- 08/24/15 - 1260 cc resulting in a fluid deficit of 840 cc The facility was unable to track Resident #99's output due to bladder incontinence and he wore a disposable brief. In fact a review of the resident's bladder observation records completed by the nurse aides found Resident #99 only had urine output two (2) times on 08/14/15, three (3) times on 08/06/15 through 08/12/15, and 08/15/15 through 08/24/15, and four (4) times on 08/13/15. A review of Resident #99's meals intakes found that from 08/06/15 through 08/12/15, the resident's average meal consumption was 82.14%. His meal consumption percentage drastically declined from 08/13/15 through 08/24/15 to an average percentage of 25.44 %. This reduced his fluid intake further. (Food is nearly as an important source of water as food, with the exception of some processed foods, has a high water content. Metabolic water is water produced during the oxidation of food. Carbohydrates are completely metabolized to carbon [MEDICATION NAME] and water. Metabolic water is about 350 to 400 ml/day (ie 5 mls/kg). This offsets some of the obligatory water losses (sweat, breathing, bowel movements, etc.).) A review of the results of a comprehensive metabolic panel obtained for Resident #99 on 08/08/15 found the following pertinent lab values: -- Creatinine was within the reference interval at 1.22 (Reference interval 0.76 to 1.27), -- BUN (blood urea nitrogen) was 27 (Reference Interval 8 - 27), -- Sodium was 40 (Reference Interval 134 - 144), -- Potassium was 4.4 (reference interval 3.5 - 5.2), -- Chloride was 102 (reference interval 97 - 108), and -- carbon [MEDICATION NAME] (CO2) was 23 (reference interval 18 - 29). A review of Resident #99's vital signs in the electronic medical record found the following weights recorded: -- 08/06/15 - 153.8 lb (pounds) -- 08/07/15 - 153.8 lb -- 08/09/15 - 154.8 lb -- 08/16/15 - 143.8 lb -- 08/17/15 - 146.2 lb -- 08/23/15 - 139 lb -- 08/25/15 - 141.1 lb and 141 lb Additional review of the record found the following blood pressures which were considered in the [MEDICAL CONDITION] range (below 90 systolic or below 60 diastolic): -- 08/23/15 at 11:07 a.m. - 90/50 -- 08/22/15 at 12:13 p.m. - 98/56 -- 08/22/15 at 2:58 a.m. - 110/56 -- 08/21/15 at 2:12 p.m. - 88/50 -- 08/18/15 at 12:33 a.m. - 76/59 -- 08/17/15 at 12:24 a.m. - 82/58 -- 08/16/15 at 10:59 a.m. - 105/49 -- 08/14/15 at 12:18 a.m. - 89/87 A review of records from a local hospital, obtained at 12:04 p.m. on 11/18/15, found, Resident #99 was seen in the emergency room at the local hospital at 2:40 p.m. on 08/26/15, which was 24 hours after his discharge from the facility. The hospital records indicated the clinical impression of Resident #99, when seen in the emergency roiagnom on [DATE], was dehydration and [MEDICAL CONDITION]. Lab results obtained at the local hospital on [DATE] at 2:43 p.m. contained the following pertinent values: -- Creatinine was high at 2.90 (Reference range is .80 to 1.30), -- BUN (blood urea nitrogen) was high 97 (Reference Range 7 - 18), -- Sodium was low at 132 (Reference Range 135 - 145), -- Potassium was within normal range at 3.9 (Reference Range 3.5 - 5.1), -- Chloride was low at 97 (Normal Range is 98 - 107), and -- CO2 was within normal limits at 24.4 (Reference Range 21 - 32). An interview with the Director of Nursing (DON) and Clinical Care Supervisor (CCS) Registered Nurse (RN) #74, at 2:30 p.m. on 11/18/15, found the facility determined as resident's fluid needs based on the resident ' s ideal body weight, their current weight, and any fluid restrictions the resident might have. When asked if the registered dietitian assisted with the determination of how much fluid a resident would need, they said the dietitian would look at new admissions and would help them with those decisions. The DON and CCS #74 were then asked how they tracked and determined whether a resident's intake was sufficient. The DON replied, the CCS's look at the fluid intake total for the day before, for all residents every morning. She stated if a resident had consumed less than 1500 cc of fluid, they would encourage the resident to consume more fluid the following day. Resident #99's low fluid intakes, weight loss, decreased meal intakes, and [MEDICAL CONDITION] episodes were reviewed with the DON and CCS #74. They were asked to provide any information pertaining to notifications of the physician and/or nurse practitioner, any interventions put into place to prevent dehydration, and any information they had pertaining to their monitoring of Resident #99 for signs and/or symptoms of dehydration. At 9:30 a.m. on 11/19/15, the DON provided the following information pertaining to Resident #99. She said while at the hospital, prior to admission to the facility, the resident was given intravenous fluids, and was plumped up on fluids prior to his admission to the facility. She indicated this, in combination with his use of [MEDICATION NAME] - HCT caused the resident to lose weight. The DON was asked to provide any information related to his excess fluid such as their monitoring of his [MEDICAL CONDITION] and/or lung sounds. She was unable to provide any evidence to support the resident was overloaded with fluid upon his admission to the facility. In regards to his fluid deficit on a daily basis during his stay at the facility, the DON indicated the Registered Dietitian just made a recommendation that the resident receive 2111 cc per day and the resident did not require that much fluid to stay hydrated. She stated they encouraged Resident #99 to drink fluids when his intake was less than 1500 cc and the days following his decreased intake it bounced back proving they had encouraged him to drink fluids the following days. She indicated they would not call the physician and consider dehydration unless the resident consumed less than 1000 cc of fluid for three (3) consecutive days. Review of the nursing progress notes showed Resident #99 was encouraged to drink more fluids on the following dates: -- Note dated 08/08/15 at 2:17 p.m. indicated Resident #99's fluid intake was 1410 cc on 08/07/15 and they would encourage fluids. The residents intake was 1740 cc on 08/09/15 according to the facility's intake records. -- Note dated 08/22/15 at 2:32 indicated Resident #99's fluid intake was 1160 cc on 08/21/15. (It should be noted that the facility intake logs for 08/21/15 indicated the resident only consumed 780 cc on 08/21/15 not 1160 cc as noted.) Resident only consumed 1200 cc on 08/22/15 according to the facility's intake records. This amount is still below the facility's practice of 1500 cc per day. -- Note dated 08/15/15 at 12:12 a.m. indicated Resident #99's fluid intake was 860 cc on 08/14/15 will continue to encourage fluid. This note also indicates the nurse practitioner was notified. This is the only indication the physician and/or nurse practitioner was ever notified of the residents decreased fluid intake. On 08/16/15 the residents fluid intake was 1390 cc according to the facility's intake records. This amount is still below the facility's practice of 1500 cc per day. -- Note dated 08/23/15 at 10:47 a.m. indicated Resident #99's fluid intake was 1160 cc on 08/22/15 and they would continue to encourage fluid. Resident only consumed 1500 cc the following day on 08/23/15 according to the facility's intake records. -- Note dated 08/25/15 at 11:32 a.m. indicated Resident #99 drank 1380 cc of fluid on 08/24/15 and they would continue to encourage fluids. The resident was discharged on [DATE] at 2:37 p.m. Resident #99's fluid intake was also below 1500 cc on 08/16/15 with 1390 cc, 08/17/15 with 900 cc, and 08/19/15 with 620 cc. There was no evidence on these dates that nursing identified the resident's lack of fluid intake, nor was there any indication fluids were encouraged. The interview with the DON continued. She stated, He was capacitated we could not make him drink. She stated we gave him fluids with meals and between meals and he had a water pitcher. She said all we could do was encourage fluids. When asked if the facility had assessed Resident #99 for signs and symptoms of dehydration, she indicated they documented by exception and if there was nothing documented then he must not have had any sign or symptoms. The DON stated, Resident #99 did not have a care plan for risk of dehydration because they felt he was not at risk despite his use of a diuretic medication and previous [DIAGNOSES REDACTED]. The DON provided a photocopied page which she stated was part of the Lippincott manual which was what they based their standards of practice on. She referenced the page and stated of the signs and symptoms of fluid and electrolyte imbalances and the only one Resident #99 demonstrated was weight loss greater than five (5) percent. The excerpt was reviewed and contained the following signs and symptoms of fluid and electrolyte imbalances in regards to fluid, Acute weight loss (>5%), drop in body temperature, dry skin and mucous membrane, postural [MEDICAL CONDITION], longitudinal wrinkles or furrows of tongue, oligura (small amounts of urine) or anuria (no urine). The DON was unable to provide any evidence the facility had assessed Resident #99 for any of these signs or symptoms during his stay at the facility, with the exception of body temperature, due to the regular recording of the Resident #99's body temperature. Blood pressures obtained were not taken upon the resident rising from a seated position which is what postural [MEDICAL CONDITION] identification would require. She stated again, We only document to the exception, so if it is not documented, then he must not have had the any symptoms presenting. The DON stated that she had spoken with the resident's attending physician and he felt the resident was not dehydrated when he presented to theER on [DATE]. (The resident's attending physician did not examine Resident #99 at the ER.) She stated the attending physician stated the resident's lab's indicated volume depletion and that he had some kidney problems not dehydration. She stated they had not notified the physician and/or nurse practitioner about Resident #99's fluid deficits or episodes of [MEDICAL CONDITION] because, He (the physician) only wants notified if something is going on with the resident. An interview with the attending physician at 3:00 p.m. on 11/19/15, confirmed he was of the opinion the resident was suffering from volume depletion not dehydration when he presented to theER on [DATE] 24 hours after his discharge from the facility. He stated, Hospitals are too quick to give the [DIAGNOSES REDACTED]. He stated the resident's sodium level would have been higher than 132 if he was dehydrated and that is why he felt it was just a case of volume depletion (Volume depletion can be defined as a reduction in extracellular fluid volume that occurs when salt and fluid losses exceed intake on a sustained basis). He stated the resident also had some kidney issues which was also a factor. The attending physician was also asked if he wanted to be notified if the resident was suffering from [MEDICAL CONDITION]. He stated he would expect to be notified if the resident's systolic number was consistently (more than two (2) or three (3) days) below 90 or 95. He stated he would definitely want to be notified if the systolic number went below 80 just one time. The attending physician was reviewing Resident #99's medical record while participating on the telephone interview via the electronic medical record and stated, on the 18th is was below 80 so I should have been notified. The medical record contained no indication he was notified of the resident's blood pressure on 08/18/15 when Resident #99's blood pressure was 76/59.",2018-11-01
5533,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-11-19,329,E,1,0,TPT811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facility failed to ensure Resident #99's drug regimen was as free from unnecessary medications as possible. Resident #99 received an antihypertensive medication which had an identified effect of [MEDICAL CONDITION] (slow heart rate) without the proper monitoring of his pulse. This was true for one (1) of five (5) sampled residents. Resident Identifiers: #99. Facility Census: 98 Findings Include: a) Resident #99 A review of Resident #99's medical record at 1:10 p.m. on 11/17/15, found this [AGE] year old male was admitted to the facility on [DATE] and discharged to home on 08/25/15 at 2:37 p.m. Further review of the record found Resident #99 was receiving upon admission to the facility [MEDICATION NAME] Tablet 12.5 milligrams (mg) by mouth two (2) times a day at 9:00 a.m. and 9:00 p.m. for a [DIAGNOSES REDACTED]. The Nursing (YEAR) Drug Handbook published by Wolters Kluwer, utilized by the facility indicated the following in regards to [MEDICATION NAME]: .Therapeutic Class: Antihypertensive's . Adverse reactions . [MEDICAL CONDITIONS] (slow heart rate) . Nursing Considerations: Always check patient's apical pulse rate before giving drug. If it's slower than 60 beats/(per)minute, withhold drug and call prescriber immediately . Review of Resident #99's Medication Administration Record [REDACTED]. Review of Resident #99's nursing progress notes found the following dates and time when Resident #99's pulse was obtained: -- 08/07/15 at 1:00 p.m. Pulse 60 beats per minute (bpm) -- 08/08/15 at 12:36 a.m. Pulse 59 bpm -- 08/09/15 at 11:20 a.m. Pulse 90 bpm -- 08/10/15 at 10:58 a.m. Pulse 61 bpm -- 08/12/15 at 4:18 p.m. Pulse 62 bpm -- 08/14/15 at 12:18 a.m. Pulse 60 bpm -- 08/14/15 at 2:58 p.m. Pulse 55 bpm -- 08/15/15 at 12:46 p.m. Pulse 51 bpm -- 08/16/15 at 10:59 a.m. Pulse 65 bpm -- 08/18/15 at 12:35 a.m. Pulse 66 bpm -- 08/18/15 at 4:17 p.m. Pulse 62 bpm -- 08/21/15 at 1:44 a.m. Pulse 64 bpm -- 08/21/15 at 2:12 p.m. Pulse 50 bpm -- 08/22/15 at 2:58 a.m. Pulse 62 bpm -- 08/22/15 at 12:13 p.m. Pulse 72 bpm -- 08/23/15 at 12:06 a.m. Pulse 66 bpm -- 08/23/15 at 1:46 p.m. Pulse 65 bpm -- 08/24/15 at 4:05 p.m. Pulse 64 bpm Of the pulses obtained none were within the time frame required for the administration of Resident #99's [MEDICATION NAME]. There was also four (4) occasions in which Resident #99's pulse was below 60 bpm. There was no indication in the record Resident #99's attending physician/nurse practitioner was notified of these pulses below 60 bpm. An interview with the Director of Nursing (DON) at 9:30 a.m. 11/19/15, confirmed the facility was not obtaining Resident #99's pulse prior to the administration of his [MEDICATION NAME]. She stated she had spoken with the residents attending physician and that was just a recommendation and it was up to the physician to establish parameters for this medication. An interview with Resident #99's attending physician at 3:00 p.m. on 11/19/15 confirmed for a Resident taking [MEDICATION NAME] it is the best practice to hold the medication if the pulse is less than 60 bpm and to notify the prescriber. He stated that for most everyone he will establish those parameters unless the resident is stable on the medication and has been on it for a long time.",2018-11-01
5534,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-11-19,505,D,1,0,TPT811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to ensure the laboratory test results for one (1) of five (5) residents was given to the resident's physician promptly for review. Resident #47 had an order for [REDACTED].#47. Facility census: 98. Findings include: a) Resident #47 On 11/17/15, at 11:00 a.m., medical record review for Resident #47 revealed a physician's orders [REDACTED]. Resident #47's medical record did not contain the ammonia level test results for 11/13/15. Director of Nursing (DON) provided the ammonia level results on 11/18/15 at 1:30 p.m. The results were 73 (HIGH) micromole/liter (umol/L). Normal ammonia level range 11-32 umol/L. The form contained a signature but no date and/or orders noted. Interview with the attending physician, on 11/19/15 at 3:00 p.m., revealed the staff had contacted the nurse practitioner after this surveyor intervention and new orders were obtained, [MEDICATION NAME] 45 milliliters (ml) by mouth two times a day for four (4) days for treatment of [REDACTED]. Repeat ammonia level on 11/23/15. The attending physician did not recall signing the lab form.",2018-11-01
6484,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2014-03-27,159,D,0,1,TPO611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide one resident (#16) with a quarterly statement of his personal funds account out of four residents with concerns regarding personal funds. Findings include: Resident #16 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the clinical record for resident #16 revealed that he was assessed to be cognitively intact with a Brief Interview of Mental Status score of 12 on a quarterly MDS (Minimum Data Set) assessment dated [DATE]. Further review of the clinical record revealed that resident #16 did not have capacity to make his own decisions. During an interview with resident #16 on 3/25/14 at 9:01 AM, the resident stated that he is not given a quarterly statement of his personal funds account, though occasionally the facility does tell him how much money he has in his account. He further stated that he would like to receive a copy of his quarterly statement. During an interview conducted with Business Office Assistant staff #13 on 3/26/14 at 3:01 PM, staff produced the most recent quarterly statement of the resident's personal funds account. The statement had been signed by the facility's administrator. There was no evidence that the resident had also been provided a copy of his personal funds account statement. During an interview conducted with Nursing Home Administrator staff #94 on 3/26/14 at 3:18 PM, staff stated that as the facility is the Representative Payee for the resident's finances, the administrator signs the quarterly statement on behalf of the resident. Staff stated that they would in the future provide a copy to residents for whom the facility is Representative Payee, but that they do not currently do so.",2018-03-01
6485,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2014-03-27,253,D,0,1,TPO611,"Based on observations and staff interviews, the facility failed to maintain a sanitary and orderly environment with regards to resident privacy curtains and resident room sinks. Findings Include: On 3/27/2014 at 9:10 AM an observation was completed with Environmental Supervisor #7 (ES #7) in room C6. The privacy curtain was noted to have multiple brown stains during observation on 3/24/2014 that had remained. ES #7 said that housekeeping staff would normally look at privacy curtains and clean them as necessary. Observations of sinks in resident rooms D7 and D11 were noted to be loose and easily movable. ES #7 said that he would tighten the brackets holding the sink against the wall. A follow up observation was made of both sinks on 3/27/2014 at 12:10 PM. New caulking had been placed around the sink in room D11, but the sink remained easily moveable.",2018-03-01
6486,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2014-03-27,272,D,0,1,TPO611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to comprehensively assess 1 resident (#124) with regards to side rails out of 3 residents reviewed for potential physical restraints out of 13 residents with observed with potential physical restraints in place. Findings include: Resident #124 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A side rail assessment dated [DATE] noted that Resident #124 independently uses side rails and expressed a desire for a side rail to assist with bed mobility and transfers. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] noted that Resident #124's bed rail was not used as a restraint. On 03/25/2014 at 1:22 PM, an interview was completed with Nursing Assistant #25 (NA #25) NA #25 stated that Resident #124 turns herself using the side rail. I stand beside her when she transfers out of the bed. On 03/25/2014 at 1:40 PM, an interview was completed with Nurse #70. Nurse #70 stated that Resident #124 did not have an assessment of her side rails as a potential restraint. If the IDT (interdisciplinary team) determines the resident needs a restraint, they would do the initial assessment to determine what was appropriate. Quarterly, I would review the restraint. I'm not sure who would review a restraint if it came from the hospital. The IDT reviews residents after admission for an interim care plan. An interview was completed with Nurse #97 on 03/25/2014 at 2:05 PM. Nurse #97 is a Clinical Care Supervisor (CCS). Nurse #97 said, After admission, IDT reviews the resident. If the floor nurse feels like they need a restraint, IDT reviews it. On admission, the unit charge nurse reviews the resident for restraints. The (staff) nurse fills out a nursing assessment that the RN (Registered Nurse) will complete that reviews for devices. Side rails would be reviewed on the initial assessment. There is no assessment for side rails to see if they are restraints. An interview was completed with MDS Nurse #98 on 03/25/2014 at 2:15 PM. On admission, I look for orders for restraints, I look at the resident for a restraint and I look through notes. Look at the resident for things like a lap belt. That's really the only thing that we use here. There isn't any assessment I do for devices (to determine if the device is a restraint).",2018-03-01
6487,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2014-03-27,280,E,0,1,TPO611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interviews, and record review, the facility failed to ensure that 3 residents (#8, 33, 90) out of 3 residents reviewed for participation in care planning were informed of scheduled appointments and medication changes. Findings include: Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On an annual MDS (Minimum Date Set) assessment dated [DATE], the resident scored a 13 on the Brief Interview of Mental Status which indicated the resident was cognitively intact. During interviews conducted with resident #90 on 3/24/14 and on 3/26/14, the resident stated that he is not informed of medication changes nor is he made aware of upcoming appointments. Resident #90 stated that recently he went to an appointment to get his teeth extracted and he did not know that he was going to have his teeth extracted. He added, They just yanked them out! The resident was also not aware of recent medication changes nor was he aware of ongoing treatments to his leg/foot. During an interview with licensed nursing staff #1 on 3/26/14 at 11:41 AM, staff stated that she informs the resident's daughter of medication changes and of appointments. She stated that she would not inform the resident of upcoming appointments more that 1 day in advance because the resident would forget. During an interview with certified nursing assistant staff #12 on 3/26/14 at 1:58 PM, staff stated that the resident is not forgetful with her and that he does remember what they talk about from day to day. During an interview with medical records staff #39 on 3/26/14 at 2:18 PM, staff stated that she schedules appointments with the residents but she informs the resident of the appointment on the day before the appointment but does not document this anywhere. During an interview conducted with Director of Nursing (DON) staff #92 on 3/26/14, staff stated that the facility had identified that residents were not being informed of upcoming appointments and they had instituted a plan where residents would be informed of upcoming appointments by a sticky note that staff #39 would provide to the resident. Staff #92 also stated that the nurses should be informing residents of their upcoming appointments by the nurse who administers medication as there is an appointment reminder on the MAR (medication administration record) for the three days preceding the appointment. During an interview with staff #39 on 3/26/14, staff did not mention any reminder procedures involving a sticky note. During an interview with licensed nursing staff #28 on 3/26/14, staff stated that the appointment reminder on the MAR indicated [REDACTED]. Resident # 8 was admitted to the facility on [DATE]. During an interview with Resident #8 on 3/25/2014 at 10:38 AM she stated the staff do not advise her when they make outside doctor appointments for her. She stated when the transport people come to her room to pick her up for an appointment is the first time that she is aware that she would be going out for an appointment. Further interview with the Resident #8 on 03/26/14 at 11:20 am revealed she has had a few doctor appointments lately and they did not let her know until a few minutes before she was being transported to her appointment. She said she would like to be advised when the staff have made outside doctor appointments for her and to remind her of the appointment a day or two prior to the day of the actual appointment. During an interview with Resident #33 on 03/24/2014 at 1:46 PM she revealed she is not made aware that she would be leaving the building for a doctor appointment until the transport people come to her room to get her. She stated it would be nice to know when appointments were being made for her. Interview with Staff #39 on 3/26/2014 at 11:10 AM revealed she makes the outside doctor appointments for the residents. She stated she always notifies the POA and tries to notify the residents but she does not document this anywhere. She stated often the residents do not remember even when they are told of the appointments. She verified during this interview that she did not always notify all residents when outside doctor appointments are made for them. During an interview on 03/26/14 at 11:20 AM with the DON revealed the facility had already identified a concern with the lack of residents being notified timely of outside doctor appointments. She stated Staff #39 who makes the appointments for the resident is required to advise the resident of the appointment and to give the resident a sticky note with the date and time of the appointment. When Staff #39 was interviewed on 3/26/2014 at 11:10 AM she did not speak to the fact that she was required to supply the residents with sticky note indicating there date and time of any appointments.",2018-03-01
6488,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2014-03-27,282,D,0,1,TPO611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to implement the accidents care plan for 2 residents (#124, 20) out of 22 residents whose care plans were reviewed. Findings include: Resident #124 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of Resident #124's medical record revealed a physician's orders [REDACTED].#124 was to be transferred with the assistance of 2 staff. Review of progress notes for Resident #124 dated 3/12/2014 revealed that a nursing assistant observed resident #124 attempting an unassisted transfer from the wheelchair to the bed. Resident #124 slide to the floor on her knees. Resident #124 was documented as saying I thought I could do it myself, but I got weak. A care plan dated 3/20/2014, noted that Resident #124 was a fall risk. Interventions included: Ask resident to demonstrate the operation of the call light q (every) shift. Alarm to chair at all times. Transfer bed to chair 2 person physical assist. On 3/25/2014 at 1:22 PM, an interview was completed with Nursing Assistant #25 (NA #25). NA #25 stated, I don't let her up by herself. I stand by when she gets up. NA#25 said that she was not aware of Resident #124 having any falls. She also stated that she can tell who needs transfer assistance by the way they sit up in bed. She said that she could also look in the electronic kiosk to see how residents are to be transferred or if the resident ever had a fall. The kiosk was reviewed with NA # 25. She found no documentation of a fall for Resident #124. I think there is a way to look at the history. I'm not sure. NA #25 reported that Resident #124 does use her call bell, but that she was not asked to demonstrate the use of the call bell each shift. On 3/26/2014 at 9:02 AM, an interview was completed with Resident #124. Resident #124 denied every having a fall. She reported that she gets out of bed with assistance. An interview was completed with NA #75 on 3/27/2014 at 8:30 AM. NA #75 stated that Resident #124 is 1 person assist for transfers. If she is having a good day, she transfers herself. NA #75 also said that she was not aware of Resident #124 having any falls since I have been here over the last two months. NA #75 reported that she does not have Resident #124 demonstrate how to use the call bell. We don't need to remind her. She doesn't have to show us how to use it. She knows, no problem. A review of Resident #124's kiosk Kardex was completed with NA #75 on 3/27/2014 at 8:35 AM. The Kardex noted that Resident #124 was to have 2 people assist with transfers. On 3/27/2014 at 8:44 AM, an interview was completed with the Director of Nurses (DON). The DON stated that there was no where for staff to sign that a resident demonstrated use of the call light. We talk to them when they come in (on admission) and make sure they can use it. Resident #20 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the clinical record revealed Resident #20 had a fall from his bed on 02/18/2014. The resident was documented he slid out of his bed onto his fall mat on the left side of the bed. Again on 03/09/2014 Resident #20 was documented to fall out of his bed with no injury noted. Review of the current fall plan of care dated 01/14/14 documented fall interventions to include a bed alarm, chair alarm, fall mats to the left side of his bed, call light in reach, and to ensure a safe environment. Observation on 3/25/14 at 4:30 PM revealed the resident was in bed with metal tube feeding pole with four large metal legs located on top of the fall mat beside the resident's bed. The mat beside the resident's bed was noted to be placed there to protect the resident from injury due to history of falling out of the bed. The fall care plan documented an intervention indicating the staff should maintain a safe environment. The placement of the large metal tube feeding pole located on top of the fall mat during this observation put Resident #20 at risk for injury due to his history of sliding out of the bed onto this mat. This observation was shared with Staff #95 on 03/25/2014 at 10:50 AM and she verified the metal pole should not be on the fall mat due to potential injury if Resident #20 should fall from the bed. The facility failed to implement Resident #20's fall care plan intervention to ensure a safe environment by placing the metal tube feeding pole on top of the fall mat located next to the resident's bed.",2018-03-01
6489,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2014-03-27,315,D,0,1,TPO611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observations, and record review, the facility failed to ensure that there was a medically justified use of a catheter for 1 resident (#124) out of 3 residents reviewed for catheters out 4 residents identified with catheters in stage 1. Findings include: Resident #124 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #124's medical record revealed a physician's orders [REDACTED]. Resident #124's care plan dated 3/20/2014 noted that she had an indwelling urinary catheter for [MEDICAL CONDITION]. Review of Resident #124's quarterly Minimum Data Set (MDS) assessment dated [DATE] noted no urinary toileting program has been tried since admission. An interview was completed with Nurse #97 on 3/25/2014 at 2:30 PM. Nurse #97 stated she was familiar with Resident #124 and that Resident #124 was not on a toileting program. On 3/25/2014 at 2:55 PM, an interview was completed with Resident #124's physician. The physician stated, We spent a month working on an incisional abscess. We thought she was going to die. In the last 5 weeks, she is better. We should have been doing more to try and get it (urinary catheter) out. We wanted to keep the wounds on her buttocks healed. She hasn't had a (Stage) 3 or 4 (pressure ulcer). Her nutritional status was so bad, I was worried about them getting worse. We should have done more to get the urologist to see about getting it out. When she came back in January, she had a residual volume of over 300 cc (cubic centimeters). She also went to the hospital in February for the abscess. An observation was completed on Resident #124 on 3/26/2014 at 12:00 PM. Resident #124 was noted to have an indwelling urinary catheter. On 03/26/2014 at 12:40 PM, an interview was completed with the Director of Nurses (DON). The DON stated that an appointment has been made for Resident #124 to see a urologist to evaluate for the need of the catheter.",2018-03-01
6490,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2014-03-27,371,E,0,1,TPO611,"Based on interviews and observations, the facility failed to appropriately maintain food items to prevent potential food borne illness. Findings include: On 3/26/2014 at 10:50 AM, an observation of the dry storage area of the kitchen was completed. One bag of pasta and one bag of potato chips noted to be opened but not dated. There was also one bag of lasagna noodles left open to air; not resealed. On 3/26/2014 at 10:52 AM, an interview was completed with Dietary Supervisor #5 (DS #5). DS #5 said the pasta was just opened yesterday. He was observed to put the date on the bag and he threw away the potato chips. He folded the bag of lasagna noodles over to close them and left them on the shelf. On 3/26/2014 at 12:25 PM, the lasagna noodles were still noted on the shelf.",2018-03-01
6491,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2014-03-27,460,E,0,1,TPO611,", Based on observations and interviews, the facility failed to ensure that bed privacy curtains provided full visual privacy. Findings Include: On 3/24/2014 at 9:45 AM observations of rooms were completed with Environmental Supervisor #7 (ES #7). Sampled rooms A3, A6, A13, C16, D7 and D13 noted that privacy curtains would only enclose one resident at a time for privacy. ES #7 said that he would order and install extra curtain panels to cover both residents.",2018-03-01
8102,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,ROUTE 103 VENUS ROAD,GARY,WV,24836,2012-10-30,156,C,0,1,QR3O11,"Based on observation and staff interview, it was determined the facility had not posted the correct addresses for the State survey agency and the Medicaid Fraud Unit. These addresses are to be posted for all residents and the public should an individual wish to contact one of the agencies. Census: 97. Findings include: a) Review of information posted in the hallways on first floor for residents and the public noted the wrong address was listed for the Office of Health Facility Licensure and Certification. This was verified with the administrator, Employee #107, and the social worker, Employee #61, on 10/24/12 at 9:30 a.m. b) Posting of advocacy groups - Medicaid Fraud Control Unit At 10:15 a.m. on 10/25/12, a poster containing the address and telephone number of the State Medicaid Fraud Control Unit was observed on the first floor beside the elevator. An interview with the administrator, on 10/25/12 at 10:30 a.m., confirmed the address of the State Medicaid Fraud Control Unit was incorrect.",2016-10-01
8103,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,ROUTE 103 VENUS ROAD,GARY,WV,24836,2012-10-30,157,D,0,1,QR3O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the resident's health care surrogate of a dental appointment, resulting in the dentist's refusal to see the resident for his scheduled appointment. This was true for one (1) of one (1) resident who triggered notification of changes in Stage II of the Quality Indicator Survey (QIS). Resident identifier: #64. Facility census: 97. Findings include: a) Resident #64 Review of the medical record found an oral evaluation had been completed on 05/12/12. The resident was experiencing oral concerns and the resident's teeth were described as broken and / or had carious. Further review of the medical record found a physician's orders [REDACTED]. The medical record contained no further information regarding the results of the dental appointment. On 10/25/12 at 10:30 a.m., the administrator presented a copy of a pick up order from the local ambulance company which verified the resident had been transported to the dentist on 06/11/12. The administrator stated the dentist had refused to see the resident because his legal representative had not accompanied the resident to the dentist appointment. The administrator stated no follow-up appointment had been scheduled because the resident had refused to go to the dentist and he had said his teeth were not hurting. The resident had been deemed to lack capacity to make health care decisions and his sister had been appointed as his health care surrogate on 08/25/08. On 10/29/12 at 11:00 a.m. the administrator and the director of nursing (DON) verified no further information could be located to verify the resident's sister had been made aware of his dental appointment on 06/11/12.",2016-10-01
8104,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,ROUTE 103 VENUS ROAD,GARY,WV,24836,2012-10-30,279,D,0,1,QR3O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, and record review, the facility's interdisciplinary team failed to develop a comprehensive care that included nonphamacologic interventions for residents receiving psychoactive medications and/or pain medication. Also, a resident's preferences for going outside had not been addressed in the care plan. This was evident for two (2) of fifty-one (51) Stage II sample residents. Resident identifiers: #61 and #82. Facility census: 97. Findings include: a) Resident # 61 Review of the Medication Administration Record [REDACTED]. A review of the comprehensive care plan for Resident #61, at 10:00 a.m. on 10/24/12, found there were care plans for the resident's use of Ambien, use of [MEDICATION NAME], and the use of [MEDICATION NAME]. However, the comprehensive care plan did not include any nonpharmacologic interventions related to the identified reasons for which Ambien, [MEDICATION NAME], and [MEDICATION NAME] were being used. An interview with Employee #61, the Social Worker assigned to Resident #61, at 10:44 a.m. on 10/24/12, revealed she was working to revise the care plan for each resident. She confirmed Resident #61 did not have nonpharmacologic interventions related to the use of Ambien, [MEDICATION NAME] and [MEDICATION NAME] on her current comprehensive care plan. An interview was conducted with Employee #111, Register Nurse Assessment Coordinator for Resident # 61 (RNAC), at 12:50 p.m. on 10/25/12. Employee #111 reported the resident had been admitted to the facility on the psych meds, and this was why there were no nonpharmacologic interventions on the current comprehensive care plan. She reviewed the care plan and confirmed there were no nonpharmacologic interventions contained on the current comprehensive care plan. b) Resident #82 1) Care plan review, on 10/25/12 at 11:00 a.m., found no nonpharmacologic interventions for the resident's chronic pain, anxiety, or depression. There was also no mention of resident's preferences on the care plan. On 10/25/12 at 11:00 a.m., assessments were reviewed. The assessment dated [DATE] at 9:19 a.m. revealed the resident experienced pain frequently. It further identified the pain caused difficulty sleeping and limited activities. On the 07/14/12 and 09/27/12 assessments, pain was present with interventions of [MEDICATION NAME] and [MEDICATION NAME] only attempted for relief. There was no mention of any nonpharmacologic interventions being attempted. Review of the annual Minimum Data Set ((MDS) dated [DATE] on 10/25/12 at 9:25 a.m., found Section J, Health Conditions, had been coded to indicate the resident had not received non-medication interventions for pain. 2) Review of the annual Minimum Data Set ((MDS) dated [DATE] on 10/25/12 at 9:25 a.m., indicated resident preferences for having newspapers, books, and magazines available and the ability to go outside for fresh air as being very important to the resident. Going outside had not been incorporated into the resident's care plan. In an interview, on 10/25/12 at 11:36 a.m., the resident confirmed his strong desire for spending time outside. 3) A staff interview was conducted, on 10/29/12 at 1:06 p.m., with the Director of Nursing (DON-Employee #105) and the Executive Director (Employee #107). Both employees confirmed the absence of nonpharmacologic interventions relating to [DIAGNOSES REDACTED]. Employee #107 further stated she thought they had fixed this because we just went through his care plan.",2016-10-01
8105,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,ROUTE 103 VENUS ROAD,GARY,WV,24836,2012-10-30,329,D,0,1,QR3O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, physician interview, and staff interview, the facility failed to ensure a gradual dose reduction was attempted for the antipsychotic medication, [MEDICATION NAME], to determine whether the resident's symptoms / conditions could be managed by a lower dose of the medication. The resident had received [MEDICATION NAME] since 07/26/10 with no dose reductions. This was true for one (1) of ten (10) residents who triggered unnecessary medication use. Resident identifier: #9. Facility census: 97. Findings include: a) Resident #9 On 07/19/12, the consulting pharmacist had informed the physician in writing the resident was due for an annual gradual dose reduction of [MEDICATION NAME]. (Name of Resident) has been on [MEDICATION NAME] 10 mg (milligrams) HS (at bedtime) since 07/18/10 On 07/30/12, the physician signed the report and wrote, (Symbol for decrease) to 7.5 mg. A hand written note on the pharmacists' report was made by a facility nurse on 08/01/12. The nurse had written, Spoke with (name of physician) on 08/01/12 @ 1:18 p.m Pt (patient) dose of [MEDICATION NAME] was increased to 10 mg on 01/23/12 d/t (due to) failed GDR (gradual dose reduction.) New order to leave dose of [MEDICATION NAME] @ 10 mg PO (by mouth) QHS. Medical record review found the [MEDICATION NAME] had not been reduced to 7.5 mg. on 07/30/12 as directed by the physician. Review of the medical record found the resident had been receiving [MEDICATION NAME] since 07/26/10 for treatment of [REDACTED]. On 07/26/10, the resident had been readmitted to the facility on 5 mg of [MEDICATION NAME] daily. On 12/27/11, the [MEDICATION NAME] had been increased to 7.5 mg daily. On 01/23/12, the [MEDICATION NAME] had been increased to 10 mg. daily. Further review of the medical record found a nursing note from the clinical care supervisor, dated 01/24/12, Patient has had chronic UTI (urinary tract infection) recently and was treated with x (times) 2 with antibiotics, has had increased behaviors and is now on antibiotics for URI (upper respiratory infection) A nursing note, on 01/12/12, included .Resident has had 2 UTI's since the last review, which has increased resident's behaviors of repetitive verbalizations. Resident has otherwise been stable with no significant changes in status or assessment A weekly weight meeting note from 01/12/12 included, .patient has UTI with increase in behaviors On 12/01/11 a urinalysis with culture and sensitivity (UA C&S) was ordered and on 12/03/12 the resident began receiving treatment for [REDACTED]. On 12/10/11, another UA C&S was obtained and the resident continued to receive antibiotic treatment for [REDACTED]. On 01/12/12, the resident again began antibiotic treatment for [REDACTED]. On 01/23/12, the resident received antibiotics for a upper respiratory infection. The director of nursing (DON), Employee #105, was interviewed on 10/25/12 at 1:14 p.m. and was asked to provide evidence the resident had a GDR of [MEDICATION NAME]. On 10/29/12 at 10:30 a.m., the DON stated she was unable to provide evidence the resident had a GDR of [MEDICATION NAME] and was unable to provide evidence the resident's increased behaviors were not a result of the urinary tract infection and an upper respiratory infection. The resident's physician was interviewed at 10:00 a.m. on 10/29/12. He stated he thought the resident had a GDR of [MEDICATION NAME].",2016-10-01
8106,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,ROUTE 103 VENUS ROAD,GARY,WV,24836,2012-10-30,371,F,0,1,QR3O11,"Based on observation and staff interview, it was found the dietary department had not maintained equipment and supplies in a manner that promoted acceptable sanitation practices. The equipment was in need of cleaning, wet rags were not stored in sanitized solution between uses, and items in the nourishment refrigerator were not labeled and/or dated. This had the potential to affect all residents and others who were served from this central location. Facility census: 97. Findings include: a) During the initial tour of the dietary department, at 11:45 a.m. on 10/22/12, the following issues were noted: 1) drip pans under there range top had food debris and were in need of cleaning, 2) the oven range top had food spills and was in need of cleaning, and 3) on 10/25/12, at midmorning, it was noted wet rags were on the counter and not stored in sanitizing solution. b) Observation of the pantry On 10/29/12 at 2:45 p.m., observation of the pantry on the first floor with Employee #110, a registered nurse, found several slices of bologna in an open bag with a manufacturer's stamped date of 07/28/12. Employee #110 stated she did not know if the bologna belonged to a resident or if the kitchen had provided the bologna. She verified the bag was not sealed and she stated she would throw the bologna away. On 10/29/12 at 3:00 p.m. the dietary manager, Employee #6, stated the bologna had not been in the refrigerator since 07/28/12. He stated the bologna had been frozen and was just placed in the refrigerator, but he was unable to prove this as the facility had not dated the bologna when placed in the refrigerator and he agreed the bologna should have been in a sealed bag.",2016-10-01
9681,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-02-25,176,D,0,1,WXCT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, review of the facility's policy and procedure for Self-Administration of Medication, and staff interview, the interdisciplinary team failed to identify who would be responsible for the documentation of administration of medications by a resident who kept medications at her bedside. The resident had physician's orders [REDACTED]. [REDACTED]. One (1) of eighteen (18) current residents on the sample was affected. Resident identifier: #46. Facility census: 101. Findings include: a) Resident #46 Review of the resident's medical record found physician's orders [REDACTED].>- Pro-Air HFA (MDI - multi-dose inhaler) - Use PRN (as needed) as directed; Dx (diagnosis) [MEDICAL CONDITIONS]; Resident may keep medication at bedside; - [MEDICATION NAME] Inhaler ([MEDICATION NAME]-[MEDICATION NAME]) MDI - Use PRN as directed; Dx [MEDICAL CONDITION]; Resident may keep medication at bedside; - [MEDICATION NAME] Propionate 50 mcg Nasal spray 2 sprays into each nostril Q (every) Day and PRN. Resident may keep medication @ bedside; and - Vicks Nasal Inhaler - Use in nostrils as directed. Resident may keep at bedside. The orders for these four (4) medications to be kept at the resident's bedside were dated 11/12/09. There was no evidence to reflect the interdisciplinary team had ascertained whether the resident understood how often each of the medications could be used and in what dosage. Additionally, each of the medications was listed on the Medication Administration Record, [REDACTED]. However, there was no documented evidence to reflect the resident had actually used the medications. This information would be needed to ascertain how often the resident self-administered each medication to ensure proper usage. Also, the number of times the inhaler was used would be needed, as the manufacturer's instructions include the inhaler should not be used for more than two hundred (200) sprays. The facility's policy and procedure for Self-Administration of Medication indicated the unit charge nurse was to interview the resident each shift to verify all ordered self-administered medications were taken. A check mark was to be placed on the Medication Administration Record [REDACTED] The instructions for [MEDICATION NAME] and Pro-Air HFA inhalers included individuals with [MEDICAL CONDITION] or diabetes may need special considerations with regards to dosage. The resident's [DIAGNOSES REDACTED]. Therefore, monitoring the frequency of use of the inhalers was needed. In mid-morning on 02/25/10, the director of nursing was asked how the use of the medications was to be documented. She was unable to provide an answer at that time.",2015-10-01
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
10923,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2011-07-08,278,D,1,0,34ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of the minimum data set (MDS), and staff interview, the facility failed to provide an assessment that accurately reflected the health / functional status of one (1) of five (5) sampled residents. Resident #200's MDS did not reflect the presence of an indwelling urinary catheter. This failure resulted in the absence of goals and interventions for the care and monitoring of the device being included in the care plan. (See F279 for further details.) Resident identifier: #200. Facility census: 106. Findings include: a) Resident #200 Review of the medical record found Resident #200 was admitted to the facility on [DATE] with an indwelling catheter for urinary drainage. Review of the admission MDS, with an assessment reference date (ARD) of 11/16/10, found Section H was marked as ""none of the above"" and did not identify that Resident #200 had an indwelling catheter. Review of the intake / output records for Resident #200 noted that facility staff did not record the amount of urine put out via the indwelling catheter. An interview with a corporate nurse (Employee #118), on the afternoon of 07/08/11, revealed that, due to the failure of the assessor to accurately complete the MDS, the resident's indwelling catheter was not addressed in the resident's comprehensive care plan. .",2014-11-01
10924,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2011-07-08,279,D,1,0,34ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan which included measurable objectives and timetables to meet the medical and nursing needs of one (1) of five (5) sampled residents. Due to the failure to accurately complete the minimum data set (MDS), the care plan for Resident #200 was devoid of interventions related to the use of an indwelling urinary catheter. (See F278 for further details). Resident identifier: #200. Facility census: 106. Findings include: a) Resident #200 Review of the medical record found Resident #200 was admitted to the facility on [DATE] with an indwelling urinary catheter. Review of the admission MDS, with an assessment reference date of 11/16/10, found Section H was marked as ""none of the above"" and did not identify that Resident #200 had an indwelling catheter. Review of the care plan found no mention of the resident's catheter, nor any instructions for the care, assessment, and monitoring of the patency of the catheter or assessment of the color, consistency, and amount or urine excreted by the resident on a daily basis. An interview with a corporate nurse (Employee #118), on the afternoon of 07/08/11, revealed that, due to the failure of the assessor to accurately complete the MDS, the resident's indwelling catheter was not addressed in the resident's comprehensive care plan. Review of the intake / output records found the section for catheter output had been left blank by facility staff. Further review of the medical record found the resident was found nonresponsive on 12/06/10. He was transported to an acute care facility where he was diagnosed with [REDACTED]. .",2014-11-01
10925,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2011-07-08,502,D,1,0,34ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to obtain ordered laboratory services to meet the needs of one (1) of five (5) sampled residents. The facility failed to obtain an ordered Hgb A1c test for Resident #200 following a blood glucose result of 265 mg/dl (normal range 74 gm/dl to 106 gm/dl). Resident identifier: #200. Facility census: 106. Findings include: a) Resident #200 Record review revealed Resident #200 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He received insulin injections of 30 units of [MEDICATION NAME]75/25 in the morning and 10 units of [MEDICATION NAME]in the evenings. Review of a complete blood count (CBC), ordered by the physician on 11/12/10, found the resident's glucose was 265mg/dl (with a normal range for this laboratory of 56 - 99 mg/dl). The nurse practitioner was notified of the report and ordered an Hgb A1c test. A nursing note, written on 11/13/10 at 7:26 a.m., documented the following: ""Hgb A1c No lab pick up on Saturdays."" Further review of the medical record found no evidence that the facility obtained this ordered test. On 12/06/10, the resident was found unresponsive and transported to an acute care facility. A blood test conducted upon admission found the resident's blood glucose was 886 mg/dl. He was diagnosed with [REDACTED].",2014-11-01
10926,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2011-07-08,224,G,1,0,34ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, the facility failed to provide necessary care and services to avoid physical harm for one (1) of five (5) sampled residents. The facility failed to appropriately monitor Resident #200's glucose levels, failed to assess and monitor a reddened area on the resident's penis, and failed to assess and monitor this resident's intake and output. Resident #200 was admitted to the hospital on [DATE], totally unresponsive, with [DIAGNOSES REDACTED]. Resident identifier: #200. Facility census: 106. Findings include: a) Resident #200 1. Record review revealed Resident #200 was an [AGE] year old white male admitted to this facility on 11/09/10 with [DIAGNOSES REDACTED]. Review of the history and physical, completed by his treating physician on 11/15/10 documented, the resident as being alert and oriented x 4. Review of the admission orders [REDACTED]. Further review found no orders for assessment of the resident's blood glucose levels. - Review of facility policy entitled ""Nursing Care of the Adult Diabetes Mellitus Resident"" (revised 05/01/06) found, under the section entitled ""Purpose"", the following language: ""... 2. Prevent recurrence of [MEDICAL CONDITION]/[DIAGNOSES REDACTED]. 3. Recognize, assist and document the treatment of [REDACTED]. The section entitled ""General Guidelines"" contained the following language: ""If you observe a diabetic resident or is a diabetic resident complains of any of the following symptoms, report it to the Unit Chare Nurse immediately. [MEDICAL CONDITION] d. malaise (appears tired)... b. lethargy (drowsiness)..."" The policy did not provide instructions to the charge nurse for what interventions to provide should the above symptoms be observed or reported. - Review of a complete blood count (CBC) laboratory test from 11/12/10 that the resident's glucose was 265 mg/dl. The physician ordered an Hgb A1c test. The medical record found no evidence this ordered test was provided. A nursing note, written on 11/13/10, documented the following: ""Hgb A1c No lab pick up on Saturdays."" There was no subsequent documentation in the record to indicate the ordered test was obtained. (See F502 for further details.) - Review of the facility's documentation of the resident's meal intake found the resident consumed no food from the noon meal on 12/04/10 through the noon meal on 12/06/10. The medical record contained no evidence the resident's glucose level was checked at any time during this time period. - Review of the nursing notes found an entry 11/30/10 recorded at 1:18 p.m. which documented that therapy staff reported that ""resident is sleeping more than usual"". The medical record contained no evidence the physician was notified of this sign / symptom of [MEDICAL CONDITION], nor that the resident's blood glucose was assessed. Further review found a nursing note, written on 12/06/10 at 11:46 a.m. which documented the following (quoted verbatim): ""patient is lethargic today. not following instructions... not participating well in therapy today"". The medical record contained no evidence that the physician was immediately notified of these signs / symptoms of [MEDICAL CONDITION], nor did the record contain evidence that the resident's glucose was assessed. There was no evidence that nursing staff monitored the resident's condition until he was found, at approximately 5:14 p.m. on 12/06/10, with a decreased level of consciousness and an inability to respond to staff when spoken to. The resident was transported to an acute care facility at approximately 5:30 p.m. on 12/06/10. - Review of the medical records from the acute care facility found the resident was nonresponsive upon arrival at the emergency room . Subsequent laboratory testing found the resident's blood glucose level was of 886 gm/dl (normal range 74 gm/dl to 106 gm/dl), a blood urea nitrogen (BUN) of 115 mg/dl (normal range 7 mg/dl to 18 mg/dl). He was diagnosed with [REDACTED]. Review of the admission and history by the acute care physician found the following statement: ""The nursing home could not find a record of his blood sugars."" -- 2. Review of the medical record found a nursing note, written at 12:03 p.m. on 11/24/10, documenting: ""Patient states his 'penis area' is red."" The nurse informed the nurse practitioner, who ordered [MEDICATION NAME] 200 mg every day for seven (7) days. Review of the Medication Administration Record [REDACTED]. Further review of the record found no evidence to reflect that nursing staff assessed or monitored the site following the initial resident complaint on 11/24/10. Review of nursing notes from the acute care facility, to which the resident was transferred on 12/06/10, found the following: ""Patient has purulent drainage noted from penis."" -- 3. Review of the medical record found Resident #200 had an indwelling urinary catheter present upon admission to the facility on [DATE]. Review of the admission MDS, with an assessment reference date of 11/16/10, found Section H was marked as ""none of the above"" and did not identify that Resident #200 had an indwelling catheter. Review of the care plan found no mention of the resident's catheter, nor any instructions for the care, assessment, and monitoring of the patency of the catheter or assessment of the color, consistency, and amount or urine excreted by the resident on a daily basis. An interview with a corporate nurse (Employee #118), on the afternoon of 07/08/11, revealed that, due to the failure of the assessor to accurately complete the MDS, the resident's indwelling catheter was not addressed in the resident's comprehensive care plan. (See also citations at F278 and F279.) Review of the intake / output records found the section for catheter output had been left blank by facility staff. Further review of the medical record found the resident was found nonresponsive on 12/06/10. He was transported to an acute care facility where he was diagnosed with [REDACTED]. In addition to being indicative of impaired renal function, an elevated BUN is indicative of poor hydration status. Monitoring of fluid intake and output would have afforded the opportunity for early identification of a state of fluid imbalance. .",2014-11-01
10927,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2011-09-08,157,D,1,0,34ZP12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to notify the physician when a resident's fingerstick blood glucose level was elevated, in accordance with the physician's orders [REDACTED]. Resident #87 had a physician's orders [REDACTED]."" The result of the fingerstick on 09/05/11 was 314, and there was no evidence to reflect staff notified the physician of this elevated result. This practice affected one (1) of seventeen (17) sampled resident. Resident identifier: #87. Facility census: 98. Findings include: a) Resident #87 Review of the medical record for Resident #87 disclosed a physician's orders [REDACTED]. This order was given to change the parameters by which the doctor was to be notified. The prior order, dated 08/01/11, specified to notify the doctor if the fingersticks were below 60 ml/dl or over 200 ml/dl. Further record review disclosed that, on 09/05/11 at 6:00 a.m., the result of the resident's fingerstick blood sugar was 314 mg/dl. There was no evidence to reflect staff notified the physician of this elevated result, as specified in his order. During an interview with the administrator on 09/07/11 at 3:00 p.m., she reported that she questioned the nurses about this, and she verified that staff did not notify the doctor of this elevated blood sugar as specified in the physician's orders [REDACTED]. .",2014-11-01
10928,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2011-09-08,309,D,1,0,34ZP12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide care for diabetic residents as ordered by the physician for three (3) of fourteen (14) sampled residents who were diabetic. The facility failed to administer Resident #68's insulin as ordered by the physician the day following her admission to the facility. Resident #3's medication was not administered as ordered by the physician, and there was no evidence in the medical record to indicate why this medication was not administered. The physician was not notified of an elevated blood sugar of 314 mg/dl for Resident #87 as directed in the physician's orders [REDACTED]. The facility's failure to follow the physician's orders [REDACTED]. Facility census: 98. Findings include: a) Resident #68 According to the nursing notes, this resident was admitted on [DATE] and arrived at the facility at 11:15 p.m. Her [DIAGNOSES REDACTED]. There was no evidence the resident received the morning dose of 20 units of [MEDICATION NAME] 70/30 Insulin as ordered at 0630 (6:30 a.m.) on 09/06/11. The resident's fingerstick at 1130 (11:30 a.m.) on 09/06/11 was 215 mg/dl. This was then repeated at 4:30 p.m., and her fingerstick blood sugar was 132 mg/dl. She then received her [MEDICATION NAME] 70/30 insulin as ordered at 4:30 p.m. During an interview with the administrator on 09/07/11 at 3:15 p.m., she was questioned about this medication. She called the nurse at home at that time and verified that this medication was not administered that morning at 6:30 a.m. on 09/06/11, because it had not arrived from the pharmacy. The administrator also verified there was no evidence to reflect staff notified the physician that this medication was not available and was not administered as ordered. -- b) Resident #3 Record review revealed this resident had multiple medical conditions including [MEDICAL CONDITION], she was receiving [MEDICAL TREATMENT] three (3) times a week, and she has a [DIAGNOSES REDACTED]. This resident's physician orders, when reviewed, revealed an order for [REDACTED].) This resident's Medication Administration Record [REDACTED]""MNA"", meaning ""medication not available"" according to the code reference for the MAR. During an interview with the administrator on 09/08/11 at 3:00 p.m., she stated she talked to the nurse responsible for this entry (Employee #92), and the nurse said she must have hit the incorrect button - that this coding error incorrectly indicated the medication was not available. The administartor further reported the nurse said her blood sugar was low, which was why the [MEDICATION NAME] was not given. However, the administrator could not locate the results of the fingerstick that indicated the resident's blood sugar was low. Record review verified the nurse responsible for the ""MNA"" entry was Employee #92 (her initials were on the MAR). Employee #92, when interviewed on 09/07/11 at 4:00 p.m., stated she holds the insulin for this resident if her fingerstick is below 100 mg/dl. She stated Resident #3 ""bottoms out"" if her blood sugar is that low and the insulin is given. She reported that, on the day in question (08/29/11), her fingerstick results had been 99 mg/dl, so she did not administer her 9:00 a.m. insulin. There was no evidence to reflect this nurse notified the physician that the scheduled dose of [MEDICATION NAME] was not administered, and there was no record of the blood sugar result (99 mg/dl, as reported by Employee #92) at the time the medication was held. -- c) Resident #87 Review of the medical record for Resident #87 disclosed a physician's orders [REDACTED]. This order was given to change the parameters by which the doctor was to be notified. The prior order, dated 08/01/11, specified to notify the doctor if the fingersticks were below 60 ml/dl or over 200 ml/dl. Further record review disclosed that, on 09/05/11 at 6:00 a.m., the result of the resident's fingerstick blood sugar was 314 mg/dl. There was no evidence to reflect staff notified the physician of this elevated result, as specified in his order. During an interview with the administrator on 09/07/11 at 3:00 p.m., she reported that she questioned the nurses about this, and she verified that staff did not notify the doctor of this elevated blood sugar as specified in the physician's orders [REDACTED]. .",2014-11-01
10929,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2011-09-08,425,D,1,0,34ZP12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to assure that medications were available to meet the needs of the residents. Resident #68 did not receive insulin to treat her diabetes due to this medication not being available in the facility when it was time for her to have it. This practice affected one (1) of seventeen (17) sampled residents. Resident identifier: #68. Facility census: 98. Findings include: a) Resident #68 According to the nursing notes, this resident was admitted on [DATE] and arrived at the facility at 11:15 p.m. Her [DIAGNOSES REDACTED]. It was noted (on 09/06/11) that this medication was not recorded on the medication administration record until 09/06/11 at 1630 (4:30 p.m.). The hospital records indicated that, prior to this resident being discharged , she received her insulin at 5:00 p.m. on 09/05/11. There was no evidence the resident received the morning dose of 20 units of Novolin 70/30 Insulin as ordered at 0630 (6:30 a.m.) on 09/06/11. The resident's fingerstick at 1130 (11:30 a.m.) on 09/06/11 was 215 mg/dl. This was then repeated at 4:30 p.m., and her fingerstick blood sugar was 132 mg/dl. She then received her Novolin 70/30 insulin as ordered at 4:30 p.m. During an interview with the administrator on 09/07/11 at 3:15 p.m., she was questioned about this medication. She called the nurse at home at that time and verified that this medication was not administered that morning at 6:30 a.m. on 09/06/11, because it had not arrived from the pharmacy. The director of nursing, when interviewed on 09/08/11 at 11:00 a.m., was about the facility's procedure for obtaining medications when a resident is admitted late at night . She provided a copy of the facility's procedure for obtaining medications after hours. She verified the nurse should have called the on-call pharmacist's pager number.",2014-11-01
11460,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-11-18,225,E,,,FROJ11,". Based on review of facility documents, family interview, and staff interview, the facility failed to ensure allegations of abuse, neglect, and misappropriation of resident property were reported and investigated in accordance with State law for three (3) of three (3) allegations reviewed. Resident identifiers: #26, #105, and #44. Facility census: 104. Findings include: a) Resident #26 Review of facility documents found that, on 09/23/10, Resident #44 complained to the social worker (Employee #88) that she had given a check received from her daughter for $150.00 to a staff member to deposit into her resident trust account. The resident further stated the check was never credited to her account. On 09/24/10, Employee #88 reached the following conclusion: ""Resident was unable to give specifics of check nor exact time and place when check was allegedly given to (staff). No evidence in place to support existence of check."" Further review found this resident's allegation of misappropriation of property had been handled as an in-house complaint and was not reported to State officials, including the State survey and certification agency, as required. Employee #88 was asked if he had called to daughter to determine whether she had provided the resident with a check for $150.00 prior to reaching this conclusion. He stated, on the afternoon of 11/17/10, he had not contacted the resident's daughter. After this prompting, Employee #88 contacted the resident's daughter and determined the daughter had sent the resident a check for $150.00 on 07/05/10, and the check had been deposited to the resident's account on 09/14/10. The facility failed to assure this allegation of misappropriation of resident property was immediately reported and thoroughly investigated as required. -- b) Resident #105 During an interview on 10/27/10 at 3:45 p.m., a family member stated that, while his mother was a resident at the facility, he had visited and found her soaked with urine. He stated he reported this to the administrator. An interview with the administrator, on 11/17/10 at 4:00 p.m., confirmed Resident #105's family member had complained to her of finding his mother wet. The administrator could provide no evidence that this allegation of neglect had been reported and a thorough investigation conducted. -- c) Resident #44 Review of facility documents found Resident #44 reported that, on 09/02/10, she had asked a nursing assistant to put her in bed, and the nursing assistant pushed her down in the bed by her shoulder. Further review found no evidence that any investigation into the validity of this resident's allegation had been conducted by the facility. The facility could provide no evidence that a statement had been obtained from the alleged perpetrator, the resident, or other staff members working at the time the alleged incident occurred. Additionally, it was determined that the required five-day follow-up report had not been faxed until 09/11/10. .",2014-03-01
11461,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-11-18,240,G,,,FROJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, medical record review, ambulance personnel interviews, and staff interview, the facility failed to promote care for one (1) of nine (9) sampled residents in an environment that enhanced each resident's quality of life. A facility staff member forced Resident #49 to attend an appointment with a psychiatrist against her will, despite the resident's repeated and vocal statements that she did not want to go. The resident was placed on a gurney, loaded into an ambulance, and subjected to a two-hour trip to attend an appointment which she expressly did not want to attend. It was determined the resident arrived at the appointment in extreme emotional and physical distress. Resident identifier: #49. Facility census: 104. Findings include: a) Resident #49 An interview with Resident #49's daughter, on 11/15/10 at 7:42 p.m., found the daughter was present at a psychiatrist's office on 11/02/10 when her mother arrived by ambulance for a scheduled appointment. The daughter stated her mother was very upset, crying, and extremely short of breath. She relayed that her mother reported to her ""they had thrown her out and made her go"". She stated her mother was so upset that she was unable to interact with the psychiatrist and that she (the daughter) had to answer the questions posed to her mother by the psychiatrist due to her mother's emotional distress. She stated that both ambulance personnel told her that her mother had refused to go, but the nurse made them take her. An interview was conducted with the resident's son and medical power of attorney representative (MPOA) at 8:10 p.m. on 11/15/10. He stated that he visited the facility on 11/01/10, and was informed that his mother had an appointment with the psychiatrist the following day. He stated he informed Employee #98 (a licensed practical nurse - LPN), ""If there was any way possible, I would like her to go, but she probably won't."" He stated his mother had regularly refused to attend appointments outside the facility and he had always been notified by nursing staff she was refusing to go. He stated that neither he nor any staff at the facility had forced his mother to attend an appointment against her wished until this incident. He stated that, if the nurse had contacted him, he would have had them cancel the appointment. He stated his mother still refers to the incident and continues to be upset. Review of Resident #49's medical record found [DIAGNOSES REDACTED]. The resident was receiving seven (7) medications for treatment of [REDACTED]. Review of the resident's most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/14/10, found the resident was assessed as having no hearing difficulty, demonstrating clear speech and understanding of others, and displaying the ability to make herself understood. Her cognitive skills were assessed as modified independence - with some difficulty in new situations only. Review of the nursing notes found the resident was afforded the right to refuse physician appointments on 05/03/10, 05/12/10, 06/04/10, 07/20/10, 07/29/10, 08/19/10, and 09/28/10. An interview with a member of the ambulance crew (AC) who took the resident to the 11/02/10 appointment (AC #1) was conducted at 12:20 p.m. on 11/17/10. He relayed that Resident #49 was alert and oriented and able to answer questions appropriately. He stated the resident repeatedly verbalized that she did not want to go. He stated she was very upset when they arrived at the appointment and accused them of throwing her on a cot and kidnapping her. He stated that neither he nor the second AC personnel wanted to take the resident after she had refused, but the nurse insisted that they take her. He stated the nurse told them that the POA wanted her to go so they had to take her. An interview with AC #2 was conducted via telephone at 3:30 p.m. on 11/18/10. He stated that, when he arrived with AC #1, the resident was using the porta potty. He stated the resident said four (4) or five (5) times that she did not want to go. He stated the resident was alert and oriented and answered questions appropriately. He stated the nurse insisted that the resident had to go, that her son was POA and wanted her to go, and that they had to take her. He stated that, when they arrived at the appointment, the resident could hardly breath and told her daughter that she had been kicked out of the nursing home. An interview with Employee #98 was conducted at 2:40 p.m. on 11/18/10. She confirmed she was the nurse who sent the resident out for the appointment on 11/02/10. She confirmed that Resident #49 had refused to go when the ambulance crew came to pick her up. She agreed she told the ambulance crew that the family wanted her to go and they had to take her. She stated that the resident had been yelling out constantly for help and calling the family in the middle of the night. She stated the son was in wanting a ""psych"" evaluation to get medicine to make her sleep. When inquiry was made concerning a resident's right to refuse treatment, Employee #98 stated that, if they do not have capacity and the family wants them to go to an appointment, ""then I make them go unless the family calls and tells me that the resident does not have to go."" She stated that, since the family did not call, she forced the resident to go. When asked if she made any attempts to call the family to inform them that the resident had refused to go to the appointment, she stated that she did not try to call them. An interview was conducted with the administrator and director of nursing at 4:45 p.m. on 11/18/10. Both stated that a resident cannot be forced to go to an appointment if they refuse. The DON stated the family should be notified and the appointment rescheduled. .",2014-03-01
11462,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-11-18,246,E,,,FROJ11,". Based on resident interview and review of facility records,the facility failed to assure nine (9) of nine (9) sampled residents received prompt assistance when their call bells were activated. Resident identifiers: #95, #78. #58, #67, #6, #25, #49, #44, and #105. Facility census: 104. Findings include: a) Resident #95 In an interview conducted on 11/17/10 at 9:15 a.m., Resident #98 stated that she has great difficulty, at times, getting staff to answer her call light. She stated she has had to wait on occasion from thirty (30) minutes to one (1) hour for assistance. Following the resident interview, a licensed practical nurse (LPN - Employee #99) was noted to be outside the resident's room with a medication cart. When asked how she supervised the unlicensed staff to assure that resident call lights were answered in a timely manner, Employee #99 stated that staff members carry beepers to let them know when a resident's light has gone off. When asked to inspect her beeper, the nurse stated that she had let the nursing assistant (NA) use it. On 11/18/10 at 2:05 p.m., the administrator provided a document which identified how the beeper system operates. Review of the document found that, when a resident activates a call light, the beeper of the NA assigned to the resident goes off. If the call light is not answered after 2.8 minutes, the beepers of NAs on the second wing sound. If the call light is not answered after 8.4 minutes, the nurse's beeper sounds. If the call light is not answered after 11.2 minutes, the beeper of the clinical care supervisor (CCS) sounds. If the call light is not answered within 14 minutes, the beeper of the director of nursing (DON) sounds. The administrator was asked to provide documentation of the wait times for assistance after the call light was activated by Resident #95 for 10/19/10, 10/30/10, and 11/06/10. Review of the information provided found Resident #95's call light was not answered in a timely manner, with the following intervals found between the time the resident activated her call light and the time it was answered by staff: 10/19/10 at 10:54 a.m. - 20.6 minutes 10/30/10 at 6:24 p.m. - 33.9 minutes 10/30/10 at 7:13 p.m. - 26.0 minutes 11/06/10 at 9:27 a.m. - 25.6 minutes 11/06/10 at 12:12 p.m. - 54.4 minutes 11/06/10 at 1:25 p.m. - 80.6 minutes 11/06/10 at 7:09 p.m. - 25.0 minutes -- b) Resident #78 Review of the wait times for assistance after activating the call bell found the resident's call bell was activated for 123.2 minutes on 11/06/10 at 8:06 p.m., before staff responded. -- c) Resident #58 Review of the call bell activation document provided by the administrator found the resident experienced the following wait times: 11/06/10 at 10:23 a.m. - 111.6 minutes 11/06/10 at 7:07 a.m. - 82.1 minutes 11/06/10 at 9:33 p.m. - 35.5 minutes 11/06/10 at 8:38 p.m. - 31.0 minutes 11/06/10 at 5:14 a.m. - 35.4 minutes -- d) Resident #67 Review of the call bell activation document provided by the administrator found the resident experienced the following wait times: 11/06/10 at 11:37 a.m. - 57.5 minutes 10/30/10 at 10:26 p.m. - 23.4 minutes -- e) Resident #6 Review of the call bell activation document provided by the administrator found the resident experienced the following wait times: 11/06/10 at 9:10 p.m. - 38.1 minutes 10/30/10 at 8:44 a.m. - 33.6 minutes -- f) Resident #25 Review of the call bell activation document provided by the administrator found the resident experienced the following wait times: 10/30/10 at 12:03 p.m. - 39.4 minutes 10/30/10 at 12:57 p.m. - 35.6 minutes 11/06/10 at 1:27 p.m. - 21.5 minutes -- g) Resident #49 Review of the call bell activation document provided by the administrator found the resident experienced the following wait times: 11/06/10 at 3:30 a.m. - 27.2 minutes 11/06/10 at 7:26 a.m. - 23.0 minutes 10/30/10 at 5:52 p.m. - 20.5 minutes -- h) Resident #105 Review of the call bell activation document provided by the administrator found the resident waited 41.0 minutes on 10/11/10 at 2:16 p.m. after the call bell was activated. -- i) Resident #44 Review of the call bell activation document provided by the administrator found the resident waited 16.5 minutes on 10/19/10 at 6:17 p.m. after the call bell was activated.",2014-03-01
2724,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2017-06-13,157,E,0,1,QOJB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to notify the physician and/or the resident's legal representative of a change in medical condition for two (2) of two (2) residents reviewed for notification of change during the Quality Indicator Survey (QIS). For Resident #79, the facility failed to promptly notify the physician of the resident's high glucose results (over 400) on multiple occasions. For Resident #5, the facility failed to promptly notify the resident's physician when her medication ([MEDICATION NAME]) was unavailable for administration. Resident identifiers: #79 and #5. Facility census: 55. Findings include: a) Resident #79 A review of Resident #79's medical record beginning at 10:00 a.m. on 06/12/17 found the following physician's orders [REDACTED]. -- Order with start date of 12/19/16 (date of admission to the facility) - Obtain blood sugar (BS) twice a day. (Standing order was to notify the physician if the blood sugar was less than 60 or greater than 400). Review of Resident #79's Medication Administration Record [REDACTED] -- Resident #79's blood sugar (BS) at 5:00 p.m. on 12/30/16 was 537. The Family Nurse Practitioner (FNP) was notified at 5:47 p.m. and new order received to recheck the blood sugar at bedtime (9:00 p.m.). No blood sugars were recorded for Resident #79 for 9:00 p.m. on 12/30/16. -- 01/01/17 at 5:00 p.m. - BS was 503. -- 01/02/17 at 5:00 p.m. - BS was 517 and at 9:00 p.m. BS - was 490. Physician not notified until 01/03/17 at 12:17 a.m. -- 01/04/17 at 7:00 a.m. - BS was 406. -- 01/04/17 at 9:00 p.m. - BS was 417. -- 01/05/17 at 5:00 p.m. - BS was 420. -- 01/06/17 at 11:30 a.m. - BS was 411 and at 5:00 p.m. - BS was 432. Physician was notified but not until 01/06/17 at 11:51 p.m. -- 01/07/17 at 5:00 p.m. - BS was 456. -- 01/08/17 at 5:00 p.m. - BS was 597. -- 01/09/17 at 9:00 p.m. - BS was 501. -- 01/11/17 - BS was 444 at 7:00 a.m. -- 01/12/17 - BS was 585 at 7:00 a.m. -- 01/13/17 - BS was 567 at 5:00 p.m. -- 01/14/17 - BS was 50 at 7:00 p.m. During an interview at 12:30 p.m. on 06/13/17, when asked to review the resident's orders, the Director of Nursing (DON) agreed the orders for Resident #79's diabetes management had not been followed. She confirmed the nursing staff did not notify the physician when the resident's blood sugar was less than 60 and/or greater than 400 b) Resident #5 A review of Resident #5's medical record beginning at 11:13 a.m. on 06/08/17 found a physician's orders [REDACTED]. This order also specified to hold the [MEDICATION NAME] if the resident's Hemoglobin (HGB) was greater than 10.0. Review of the Medication Administration Record [REDACTED]. Review of the nursing progress notes found the medication was held on both days because it had not arrived at the facility from the pharmacy. Further review of the nursing progress notes found a note dated 10/08/16 which indicated the nurse had telephoned the Nurse Practitioner and informed her the medication was not available. At which time the NP gave orders to give the medication when available. This dose of [MEDICATION NAME] was administered on 10/09/16. The medical record contained no evidence to suggest the NP or the Physician was ever notified that the dose of [MEDICATION NAME] scheduled to be administered on 10/22/16 was unavailable for administration. However, despite failing to notify the physician and/or NP the facility administered Resident #5's [MEDICATION NAME] on 10/23/16 when it was delivered to the facility. An excerpt from the facility's Pharmacy policy and procedures stated the following, .If an ordered medication is not available for dispensing, . B. Nursing Staff Shall: 1) Notify the attending physician of the situation and explain circumstances, expected availability and optimal therapy(ies) that are available. 2. Document and implement any orders obtained from the physician. 3. Communicate order changes to the provider pharmacy. Further review of the medical record found a physician's orders [REDACTED]. A review of the (MONTH) (YEAR) MAR found that Resident #5's [MEDICATION NAME] was held on 05/16/17 and 05/30/17. Review of the nursing progress notes found two (2) progress notes dated 05/16/17 and 05/30/17 which indicated that Resident #5's [MEDICATION NAME] was held on these days because the Hemoglobin results were unavailable for review. The progress notes also contained notes dated 05/17/16 and 05/31/17 which indicated the [MEDICATION NAME] was administered to Resident #5 on these days. Both of which were the day after it was ordered. The medical record contained no evidence to suggest the NP and/or physician were notified Resident #5's did not receive her [MEDICATION NAME] until the day after it was scheduled. During interviews with the Director of Nursing (DON) on 06/08/17 at 2:07 p.m. and on 06/12/17 at 10:33 a.m., she confirmed the medical record contained no evidence to suggest the NP and/or attending physician was notified when Resident #5's [MEDICATION NAME] had to be administered the day after it was scheduled.",2020-09-01
2725,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2017-06-13,272,D,0,1,QOJB11,"Based on record review and staff interview, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment accurately reflected the resident's status for one (1) of three (3) residents reviewed for the care area of dental status. The Care Area Assessment (CAA) Worksheet, a part of the comprehensive assessment, did not identify the reasons why the facility did not care plan dental status for Resident #30. Resident identifier: #30. Facility census: 55. Findings include: a) Resident #30 Observation of the resident during Stage 1 of the Quality Indicator Survey found the resident did not have any natural teeth or dentures. Review of the resident's most recent MDS, an annual, with an assessment reference date (ARD) of 03/01/17, found the facility coded the resident as having no natural teeth or tooth fragments (edentulous.) The CAA summary noted the resident triggered dental care. On the CAA Worksheet utilized by the facility, the assessor responded, No to whether dental care would be addressed in the resident's care plan. The worksheet directed, 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 facility provided no rationale for the reason dental care would not be addressed in the resident's care plan. At 10:27 a.m. on 06/12/17, Registered Nurse Assessment Coordinator (RNAC) #91 said she thought she described why the resident's dental status would not be care planned, but she guessed she did not.",2020-09-01
2726,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2017-06-13,278,D,0,1,QOJB11,"Based on record review and staff interview, the facility failed to ensure Resident #5's quarterly Minimum Data Set (MDS) accurately reflected how many injections Resident #5 received during the seven (7) day look back period. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #5. Facility Census: 55. Findings Include: a) Resident #5 A review of Resident #5's medical record beginning at 11:13 a.m. on 06/08/17, found a quarterly MDS with an assessment reference date (ARD) of 04/11/17. According to the assessment, the resident received no injections of any type during the 7-day look back period. The 7-day look back period for this MDS would be 04/05/17 through 04/11/17. A review of the Medication Administration Record [REDACTED]. An interview with the Clinical Reimbursement Coordinator (CRC) at 10:56 a.m. on 06/12/17 confirmed she had inaccurately completed the question about injections on the MDS with an ARD of 04/11/17. She stated I just missed that on the MAR.",2020-09-01
2727,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2017-06-13,279,D,0,1,QOJB11,"Based on record review and staff interview, the facility failed to develop a comprehensive care plan for one (1) of two (2) residents who experienced a decline in urinary continence after admission to the facility. Resident identifier: #63. Facility census: 55. Findings include: a) Resident #63 Review of the resident's medical record found the resident assessed as always continent of urine on her admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 03/06/17. According to the care area assessment (CAA) summary, urinary incontinence triggered for further assessment because the resident required extensive assistance for toileting. The CAA Worksheet indicated the facility would not care plan urinary incontinence because, Resident needs assist with her toileting, she has been continent at all times during observation period. No need for additional continence care plan. The resident's most recent quarterly MDS, with an ARD of 05/26/17 identified the resident as occasionally incontinent of urine. Both the admission and the quarterly MDS coded the resident as requiring extensive assistance of two (2) staff persons for toilet use. Review of the current care plan, updated on 03/07/17 found the facility care planned the following problem: - Resident has an ADL (activities of daily living) self care performance deficit related to recent hospitalization . - The goal was the resident will improve current level of function in (bed mobility extensive, Transfers extensive, eating independent, dressing extensive, toilet use extensive and personal hygiene extensive. - Interventions associated with the problem included: Toilet use self-performance: Patient requires 2 assist. The care plan did not address the resident's decline from always continent to occasionally incontinent of urine. At 4:00 p.m. on 06/12/17, the director of nursing (DON) said the resident only had one occasion of urinary incontinence on the look back period for the completion of the 05/26/17 MDS, so the issue was not addressed. Review of the nursing assistant documentation of the resident's daily urinary continence status with the DON found the resident had experienced another episode of urinary incontinence on 06/06/17. This date was after completion of the 05/26/17 MDS; therefore, the incontinence episode was not just one isolated occasion. The DON was asked if she could provide any further evidence, such as nurses' notes, etc. to explain the incontinence or information to support the facility was aware or had addressed the resident's decline. At 4:33 p.m. on 06/12/17, the Registered Nurse Assessment Coordinator (RNAC) said she did not care pan the resident's decline in urinary continence. The facility provided no additional information as of the close of the survey on 06/13/17 at 4:00 p.m.",2020-09-01
2728,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2017-06-13,280,D,0,1,QOJB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review, and staff interview, the facility failed to ensure Resident #53's care plan was updated and revised to reflect current treatment and status of the resident's pressure ulcers. The facility failed to revise the care plan for Resident #9 to reflect his wishes in relation to his desired weight. This was true for two (2) of fourteen (14) residents whose care plans were reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #53 and #9. Facility census: 55. Findings include: a) Resident #53 A care plan was initiated for a potential for skin breakdown on 12/01/16. The goal was, Skin integrity will be maintained or improved during the transition period. Interventions included: Float heels while in bed. This care plan was resolved on 12/07/16. A second care plan was initiated on 12/07/16 for a potential for pressure ulcer development. The goal associated with the problem was: Patient will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions included: Assist patient to turn and reposition herself in bed using 1/2 bed rails. float (left/right heel while in bed, and pressure relieving device while up in wheelchair and when in bed. This care plan was resolved on 05/10/17. On 06/06/17 a new care plan was formulated noting the resident had a pressure ulcer to right heel x 2 and was at risk for new pressure areas and had a history of [REDACTED]. (There was no care plan initialed for the development of the pressure ulcer to the right outer foot when the area developed on 05/01/17). The goal was, Patients pressure ulcer will show signs of healing and remain free from infection. Interventions included: Administer medication as ordered to promote wound healing. Monitor/document for side effects and effectiveness. Pressure relieving devices on bed and when up in wheelchair. A care plan was initiated for [MEDICAL CONDITION] of the right outer foot on 05/02/16, and was resolved on 05/02/17. A care plan was initiated on 05/23/17 and resolved on 05/23/17 [MEDICAL CONDITION] to her right outer foot. When the unstageable pressure ulcer developed to the right outer foot on 05/01/17, the care plan was not updated to include this pressure area. Only a care plan for a potential for pressure ulcer development was in effect at that time. At the time of the survey, the resident had a pressure area to her right outer foot and the current care plan only addressed a history of a pressure ulcer to the right outer foot. A physician's orders [REDACTED]. The care plan for ADL (activities of daily living) self-care was updated on 06/07/17 with an intervention to wear no shoes, anti grip socks only. Yet a current care plan, dated 12/07/16, addressing falls directed the patient wear non-skid socks or shoes when ambulating or when up in wheelchair. At 1:24 p.m. on 06/12/17, the director of nursing was asked if she could locate a care plan in effect for the pressure ulcer that developed on the right outer foot on 05/01/17. She was unable to find a specific care plan for the 05/01/17 pressure ulcer. During an interview about the resident's care plan at 2:03 p.m. on 06/12/17, Registered Nurse Assessment Coordinator (RNAC) #91 said the intervention to float the resident's heels was discontinued on the care plan on 05/10/17, but the intervention remained on the nursing assistants flow sheet so the nursing assistants were initialing daily the floating of the resident's heels. She stated she had updated the care plan with the physician's orders [REDACTED]. She was advised the care plan still contained an intervention to wear shoes as an intervention for fall prevention. The facility failed to revise the resident's care plan with the development of a pressure ulcer related to floating heels for Resident #53. b) Resident #9 A review of Resident #9's medical record at 10:54 a.m. on 06/12/17 found the following Weight and Nutrition meeting notes: -- Note dated 04/11/17 - Patient prefers to weigh between 165 - 166 States he feels better at this weight. -- Note dated 04/26/17 - Patient has good appetite and desires to only weigh between 165 -166 States he feels better at this weight -- Note dated 05/03/17 - Patient desires to weigh between 165 - 166 States he feels better at this weight. Daughter (First name of Daughter) in agreement and states as long as he doesn't get any heavier than 170 lbs (pounds) they will be pleased. -- Note dated 05/10/17 - Patient and daughter prefers he does not weigh more than a 170 pounds since he feels better if he weighs between 165 - 166 -- Note dated 05/17/17 - Patient desires to weigh no more than 170 lbs and states he feels best at 165 - 166 lbs. -- Note dated 05/23/17 - Patient stated to this nurse that he feels his best with his weight around 165 lbs, no more than 170 lbs. A review of Resident #9's care plan found the goal associated with his nutrition care plan was, Patient will maintain adequate nutritional status as evidenced by maintaining weight between 170 - 180 lbs. through review date. This goal had an initiation date of 04/03/17 and a target date of 08/16/17. During an interview on 06/13/17 at 8:48 a.m., the Clinical Care Supervisor (CCS) and the Director of Nursing (DON) confirmed the resident's care plan goal was not revised to reflect the desired weight the resident and daughter had voiced to the facility staff. The CCS stated the resident and his daughter had told her on multiple occasions that he felt his best when he weighed 165 - 166 pounds and no more than 170 pounds. She stated, We wanted him to be involved in his plan of care. When asked why the care plan goal was for his weight to be maintained between 170 - 180 pounds when that was more than his desired weight she stated, That is what his Ideal Body Weight would be.",2020-09-01
2729,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2017-06-13,309,E,0,1,QOJB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide Resident #79's diabetic management as ordered by the physician. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Additionally, Resident #5 was not administered her [MEDICATION NAME] as ordered by the physician for the treatment of [REDACTED]. Resident identifiers: #79 and #5. Facility census: 55. Findings include: a) Resident #79 A review of Resident #79's medical record beginning at 10:00 a.m. on 06/12/17 found the following physician's orders [REDACTED]. -- Order with start date of 12/19/16 (date of admission to the facility) - Obtain blood sugar (BS) twice a day. (Standing order to notify the physician if blood sugar was less than 60 or greater than 400). Review of Resident #79's medication administration records (MAR) for 12/20/16 through 01/04/17 found the following dates and times when nursing failed to implement the physician orders [REDACTED].>-- Resident #79's blood sugar at 5:00 p.m. on 12/30/16 was 537. The Family Nurse Practitioner (FNP) was notified at 5:47 p.m. and new order received to recheck the blood sugar at bedtime (9:00 p.m.). No blood sugars were recorded for Resident #79 for 9:00 p.m. on 12/30/16. -- Blood sugar at 5:00 p.m. on 01/01/17 was 503. No evidence of physician notification. -- Blood sugar at 5:00 p.m. on 01/02/17 was 517 and blood sugar at 9:00 p.m. was 490. Physician not notified until 01/03/17 at 12:17 a.m. -- Blood sugar at 7:00 a.m. on 01/04/17 was 406. No evidence of physician notification. -- Order with start date of 12/19/16, [MEDICATION NAME] 100 milligrams (mg) by mouth (po) daily. -- Order with start date of 12/21/16, Tresiba insulin 10 units sq (subcutaneously) daily. -- Order with start date of 01/03/17, Tresiba insulin 12 units sq daily. -- Order with start date of 01/04/17, [MEDICATION NAME] regular (R) insulin, inject as per sliding scale: 0-60 = 0 units, initiate standing orders for [DIAGNOSES REDACTED] and notify the doctor; 61-200 = 0 units; 201-250 = 3 units; 251-300 = 4 units; 301-350 = 6 units; 351-400 = 9 units; 401- 9999= 10 units and notify physician, Sq (subcutaneously) before meals and at bedtime. Review of Resident #79's MAR found on the following dates and times blood sugar was above 400 with no evidence of physician notification: -- 01/04/17 at 9:00 p.m. BS was 417. -- 01/05/17 at 5:00 p.m. BS was 420. -- 01/06/17 at 11:30 a.m. BS was 411 and at 5:00 p.m. BS was 432. Physician was notified but not until 01/06/17 at 11:51 p.m. -- 01/07/17 at 5:00 p.m. BS was 456. -- 01/08/17 at 5:00 p.m. BS was 597. -- 01/09/17 at 9:00 p.m. BS was 501. -- Order with start date of 01/04/17, [MEDICATION NAME]four (4) units (sq) three (3) times daily. Hold if 50% of meal not consumed. Review of MAR for 01/04/17 found Resident #79 was administered [MEDICATION NAME] 4 units 8:00 a.m. although the resident ate only 40% of her breakfast. -- Order with start date of 01/11/17 - Obtain blood sugar twice a day. Notify the physician if blood sugar is less than 60 or greater than 400. Review of Resident #79's MAR found blood sugars was below 60 or greater than 400 without physician notification: -- 01/11/17- BS was 444 at 7:00 a.m. -- 01/12/17- BS was 585 at 7:00 a.m. -- 01/13/17 - BS was 567 at 5:00 p.m. -- 01/14/17- BS was 50 at 7:00 p.m. During an interview at 12:30 p.m. on 06/13/17, when asked to review the resident's orders, the Director of Nursing (DON) agreed the physician's orders [REDACTED]. She confirmed the nursing staff did not notify the physician when the resident's blood sugar was less than 60 and/or greater than 400. She also confirmed the 01/04/17 dose of [MEDICATION NAME] 4 units should not have been given due to the resident only consumed 40% of her breakfast. b) Resident #5 A review of Resident #5's medical record at 11:13 a.m. on 06/08/17 found a physician's orders [REDACTED]. Hold if Hemoglobin (HGB) is greater than 10. A review of the 01/2017 Medication Administration Record [REDACTED]. A review of the HGB results which were obtained on 01/05/17 and reported to the facility on [DATE] found Resident #5's HGB was 9.7. Since her HGB was below 10, her [MEDICATION NAME] should have been administered on 01/07/17. Review of the nursing progress notes found a note dated 01/07/17 which indicated Resident #5's [MEDICATION NAME] was not available for administration and that was why it was held. Further review of the progress notes and MAR found the medication was never administered to the resident. An interview with the Director of Nursing at 11:47 a.m. on 06/13/17 confirmed Resident #5's 01/07/17 dose of [MEDICATION NAME] was never administered and should have been when it became available from the pharmacy.",2020-09-01
2730,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2017-06-13,314,D,0,1,QOJB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review and staff interview, the facility failed to identify the presence of a pressure ulcer, failed provide clear and consistent documentation regarding the location and status of a second pressure ulcer, and failed to update and revise the resident's care plan to reflect current treatment and status of the resident's pressure ulcers. This was true for one (1) of three (3) residents reviewed for the care area of pressure ulcers during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #53. Facility census: 55. Findings include: a) Resident #53 Record review on 06/08/17 at 11:45 a.m. found this eighty-four (84) year old female resident, admitted to the facility on [DATE], had not been discharged since her admission. Her admitting [DIAGNOSES REDACTED]. She did not have [DIAGNOSES REDACTED]. The initial nursing assessment, completed on 12/01/16, noted the following skin conditions: - Redness to inside of nostrils due to nasal cannula. Redden area under right side of breast. Bruise to left forearm (previous IV (intravenous) site). Bruise to right abdomen. Bruise to top of right hand. Bruise to back of right, lower leg. Old scar to left hip area. Old scar to left knee, Redden area to middle of back. Redden area between buttocks. The resident had no pressure areas identified upon admission. A Braden Risk Assessment (an assessment for the resident's risk of developing pressure ulcers), completed on 12/07/16, noted the resident was at very low risk of developing a pressure ulcer. The assessment noted the resident had no impairment in sensory perception that would limit her ability to feel or voice pain or discomfort and she responded to verbal commands. According to the assessment, the resident had no limitation for mobility, and could make major and frequent changes in position. A second Braden Risk Assessment completed on 12/29/16 identified the resident was at mild risk for pressure ulcer development. Braden Risk Assessments continued to be completed on 12/14/16, 12/21/17, 12/29/17, 01/05/17 and 06/06/17, all indicating the resident was a mild risk for pressure ulcer development. 1. Area to right Achilles heel On 04/27/17, the resident developed an area to her right heel. The description of the wound was, Reddened area to right heel measures 1.5 cm x 1.5 cm surrounding area pink and blanches. Additional notes: Patient states back of shoes has been rubbing area above right heel. Area cleansed and border foam dressing applied. The wound was assessed as a non-pressure wound. The area to the right heel continued to be described as a non-pressure area on the following dates: -- 05/04/17 - Reddened area to right heel measuring the same this week 1.5 cm X 1.5 cm. Bloody drainage noted to previous dressing. Surrounding tissue pink, blanching and intact. Patient states that the back of her shoe has been rubbing area above right heel. Area cleansed and border foam dressing applied per order. -- 05/10/17 - Area to right heel has red/brown scabbed appearance and remains fragile. Small amount of bloody drainage noted to previous dressing. Surrounding tissue pink, blanching, and intact. -- 05/18/17 - Proximal right heel-area measures the same this week 1.0 cm by 1.0 cm. Area continues to have a yellow wound bed with moderate amount of yellow drainage noted to previous dressing. Surrounding tissue pink, blanching and intact. -- 05/25/17 - Area continues to remain 1 cm. in size, wound also has a yellow drainage wound bed with no drainage noted at this time. Surrounding tissue pink intact and blanching. -- 06/01/17 - Area to the right heel has red/brown scabbed appearance and remains fragile. Small amount of bloody drainage noted to previous dressing. Surrounding tissue pink, blanching and intact. -- On 06/06/17 - the facility completed a Wound Assessment-Initial Pressure Ulcer Assessment, noting a newly acquired pressure area, a Stage III to the right Achilles area to heel superior area. A second Wound Assessment-Initial Pressure Ulcer Assessment was also completed for an area to the left heel Achilles area inferior. At 1:15 p.m. on 06/09/17, Registered Nurse Clinical Care Supervisor (CCS) #92 confirmed the newly acquired pressure ulcer to the right Achilles area of the heel was the same area described on the non-pressure ulcer wound evaluations completed on 04/27/17 through 06/01/17. CCS #92 said the facility noted a problem with staging of pressure areas on 06/09/17 and the wound was evaluated and staged as a pressure ulcer. CCS #92 said the area was questionable on 04/27/17 as to whether the area should have been staged as pressure. CCS #92 said she believed the area should definitely have been staged as a pressure area on 05/04/17. She said the wound assessment for the left Achilles heel was completed in error. The guidance to surveyors describes a pressure ulcer as any lesion caused by unrelieved pressure that results in damage to the underlying tissue(s). 2. Area to right outer foot On 05/01/17 the resident acquired an in-house pressure ulcer to the right outer foot. The area was 0.2 cm in length and 0.4 cm in width, with no depth. The pressure area was staged as a suspected deep tissue injury. Additional notes: Patient has blanchable reddened area with small purple area to center that does not blanch. Surrounding area pink and blanches. Area cleansed and border foam dressing applied. Area has some drainage observed. Is on bony area of foot and denies that shoes are rubbing foot. -- A wound assessment completed on 05/04/17 noted the wound now measured 0.5 cm x 0.7 cm, with 0 depth. The area was described as reddened in appearance with a pinpoint hole to the center that had yellow drainage. The surrounding tissue was dark pink in color and blanching. -- The next assessment, completed on 05/18/17, noted the area remained a Stage II (2) pressure ulcer measuring 0.7 cm x 0.4 cm x 0.1 depth. [MEDICATION NAME] ointment (an antibiotic ointment) was applied. -- On 05/03/17, the facility cultured the left outer foot and found the resident had [MEDICAL CONDITION] (MRSA). On 05/08/17 the facility received a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. -- A second order, dated 05/09/17, required treatment of [REDACTED]. The treatment was initialed as being applied daily on the MAR. -- On 06/06/17, a newly acquired pressure ulcer assessment was completed for an area to the left heel Achilles area inferior. There was no indication in the medical record the resident ever had an area to the left outer foot, yet treatment was applied to the left outer foot as well as the right outer foot. The culture indicating the resident [MEDICAL CONDITION] was also obtained from the left outer foot. Observation of the resident's feet at 1:15 p.m. 06/09/17 with the director of nursing (DON), CCS #92, and a nurse surveyor found the resident had no pressure or non-pressure areas to her left foot. There were two (2) dressings to the resident's right foot - one to the Achilles heel area and one to the outer foot. CCS #92 said the area to outer foot had a scab and a new pressure wound assessment would need to be completed to indicate an unstageable pressure ulcer to the right outer foot, instead of the current assessment of a Stage II pressure ulcer to the right outer foot. The resident said her shoe rubbed her right foot causing the area to her heel. CCS #92 said the pressure ulcer assessment, completed on 06/06/17, indicating a newly acquired area to the left heel, Achilles area inferior was made in error. She provided a nurse's note, dated 06/06/17, indicating the left Achilles heel did not have a pressure area, the area was to the right Achilles heel. She said the facility realized there was a problem with staging pressure ulcers and an in service had been held with nursing. She said the area to the right Achilles heel should have been staged as a pressure area on 05/04/17 and not as a non-pressure area. 3. Care plan A care plan was initiated for a potential for skin breakdown on 12/01/16. The goal was, Skin integrity will be maintained or improved during the transition period. Interventions included: Float heels while in bed. This care plan was resolved on 12/07/16. A second care plan was initiated on 12/07/16 for a potential for pressure ulcer development. The goal associated with the problem was: Patient will have intact skin, free of redness, blisters or discoloration by/through review date. Interventions included: Assist patient to turn and reposition herself in bed using 1/2 bed rails. float (left/right heel while in bed, and pressure relieving device while up in wheelchair and when in bed. This care plan was resolved on 05/10/17. On 06/06/17 a new care plan was formulated noting the resident had a pressure ulcer to right heel x 2 and was at risk for new pressure areas and had a history of [REDACTED]. (There was no care plan initialed for the development of the pressure ulcer to the right outer foot when the area developed on 05/01/17). The goal was, Patients pressure ulcer will show signs of healing and remain free from infection. Interventions included: Administer medication as ordered to promote wound healing. Monitor/document for side effects and effectiveness. Pressure relieving devices on bed and when up in wheelchair. A care plan was initiated for [MEDICAL CONDITION] of the right outer foot on 05/02/16, and was resolved on 05/02/17. A care plan was initiated on 05/23/17 and resolved on 05/23/17 [MEDICAL CONDITION] to her right outer foot. When the unstageable pressure ulcer developed to the right outer foot on 05/01/17, the care plan was not updated to include this pressure area. Only a care plan for a potential for pressure ulcer development was in effect at that time. At the time of the survey, the resident had a pressure area to her right outer foot and the current care plan only addressed a history of a pressure ulcer to the right outer foot. The intervention to float the resident's heels while in bed had been resolved since 05/10/17. A physician's orders [REDACTED]. The care plan for ADL (activities of daily living) self care was updated on 06/07/17 with an intervention to wear no shoes, anti grip socks only. Yet a current care plan, dated 12/07/16, addressing falls directed the patient wear non-skid socks or shoes when ambulating or when up in wheelchair. A nurse's note, dated 05/02/17, noted the resident's son removed the old shoes from the facility and brought in a new pair. There was no further documentation about the new shoes or if they also caused issues to the resident's right heel. The next documentation was from the physician who directed the resident to wear no shoes on 06/06/17. At 1:24 p.m. on 06/12/17, the director of nursing was asked if she could locate a care plan in effect for the pressure ulcer that developed on the right outer foot on 05/01/17. She was unable to find a specific care plan for the 05/01/17 pressure ulcer. During an interview about the resident's care plan at 2:03 p.m. on 06/12/17, Registered Nurse Assessment Coordinator (RNAC) #91 said the intervention to float the resident's heels was discontinued in the care plan on 05/10/17, but the intervention remained on the nursing assistants flow sheet so the nursing assistants were initialing daily the floating of the resident's heels. She stated she had updated the care plan with the physician's orders [REDACTED]. She was advised the care plan still contained an intervention to wear shoes as an intervention for fall prevention. RNAC #91 was asked about the physician's orders [REDACTED]. She stated the facility did not need a physician's orders [REDACTED]. Although a physician's orders [REDACTED]. plan. The facility failed to revise the resident's care plan with the development of a pressure ulcer related to floating heels for Resident #53.",2020-09-01
2731,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2017-06-13,315,D,0,1,QOJB11,"Based on record review and staff interview, the facility failed to identify, assess, and address a decline in urinary continence for Resident #63. This was true for one (1) of two (2) residents reviewed for the care area of urinary incontinence. Resident identifier: #63. Facility census: 55. Findings include: a) Resident #63 Review of the resident's medical record found the resident coded as always continent of urine on her admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 03/06/17. According to the Care Area Assessment (CAA) summary, the resident triggered the care area of urinary incontinence for further assessment on the 03/06/17 MDS to requiring extensive assistance for toilet. The CAA Worksheet indicated the facility would not care plan urinary incontinence because, Resident needs assist with her toileting, she has been continent at all times during observation period. No need for additional continence care plan. The resident's most recent quarterly MDS, with an ARD of 05/26/17 identified the resident as occasionally incontinent of urine. Both the admission and the quarterly MDS coded the resident as requiring extensive assistance of two (2) staff persons for toilet use. Review of the current care plan, updated on 03/07/17, found the facility care planned a problem as, Resident has an ADL (activities of daily living) self care performance deficit related to recent hospitalization . The goal was for the resident to improve her current level of function in (bed mobility extensive, Transfers extensive, eating independent, dressing extensive, toilet use extensive and personal hygiene extensive). Interventions associated with the problem included: Toilet use self-performance: Patient requires 2 assist. The care plan did not address the resident's decline from always continent to occasionally incontinent of urine. At 4:00 p.m. on 06/12/17, the director of nursing (DON) said the resident only had one occasion of urinary incontinence on the look back period for the completion of the 05/26/17 MDS, so the issue was not addressed. Review of the nursing assistant documentation of the resident's daily urinary continence status with the DON found the resident had experienced another episode of urinary incontinence on 06/06/17. This date was after completion of the 05/26/17 MDS, therefore the incontinence episode was not just one isolated occasion. The DON was asked to provide any further evidence, such as nurses notes, etc, to explain the incontinence or information to support the facility had addressed the resident's decline. The facility failed to identify the resident's decline in urinary continence, failed to attempt to identify causative factors, and failed to promptly intervene in an effort to restore her to her status of continent. At the close of the survey on 06/13/17 at 4:00 p.m. no further information had been provided.",2020-09-01
2732,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2017-06-13,329,E,0,1,QOJB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #5 only received [MEDICATION NAME] injections and Resident #79 only received an insulin injection when indicated. This was true for two (2) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifiers: #5 and #79. Facility Census: 55. Findings include: a) Resident #5 A review of Resident #5's medical record at 11:13 a.m. on 06/08/17 found a physician's orders [REDACTED]. Hold if Hemoglobin (HGB) is greater than 10.0. Further review of Resident #5's medical record found the following HGB results: -- HGB drawn on 12/01/16 and reported to the facility on [DATE] was 10.3. -- HGB drawn on 12/15/16 and reported to the facility on [DATE] was 10.9. -- HGB drawn on 12/29/17 and reported to the facility on [DATE] was 10.4. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. On these three (3) occasions, the dose of [MEDICATION NAME] should not have been administered according to the physician's orders [REDACTED]. During an interview with the Director of Nursing (DON) at 2:07 p.m. on 06/08/17, she confirmed Resident #5's should not have received a [MEDICATION NAME] injection on 12/03/16, 12/17/16, and 12/31/16 because the resident's HGB was greater than 10.0. b) Resident #79 A review of Resident #79's medical record beginning at 10:00 a.m. on 06/12/17 found a physician's orders [REDACTED]. Hold if 50% of meal not consumed. Review of the MAR for 01/04/17 found Resident #79 was administered [MEDICATION NAME] 4 units sq at 8:00 a.m. although the resident ate only 40% of breakfast on 01/04/17. During an interview at 12:30 p.m. on 06/13/17, when asked to review the resident's orders, The Director of Nursing (DON) confirmed the 01/04/17 dose of [MEDICATION NAME] 4 units should not have been given due to the resident only consumed 40% of her breakfast.",2020-09-01
2733,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2017-06-13,333,E,0,1,QOJB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #49 was free from significant medication errors. Resident #49 received the wrong dosage of [MEDICATION NAME] (a blood thinner) from 04/21/17 through 06/07/17 (the date of his discharge). This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #49. Facility Census: 55. Findings Include: a) Resident #49 A review of Resident #49's medical record at 2:05 p.m. on 06/12/17 found two (2) copies of the results for a [MEDICATION NAME]/International Normalized Ratio (PT/INR) obtained on 04/17/17. On the first copy of the laboratory (lab) results was a handwritten note, On [MEDICATION NAME] 4.5 mg (milligrams) presently hold X1 (hold one dose) decrease (indicated by a downward pointing arrow) 4 mg (Indicating to decrease to 4 mg daily). This handwritten note was not dated or signed by the nurse. Review of the nursing progress notes found an entry dated 04/18/17 written by Registered Nurse (RN) #95 noting, INR -- 3.3 on [MEDICATION NAME] 4.5 mg daily presently. Dr. (last name of attending physician) notified. Hold X1 dose then start [MEDICATION NAME] 4 mg po (by mouth) daily. (Therapeutic range for most laboratories and conditions is 2.0 to 3.0. [MEDICATION NAME] has a narrow therapeutic index.) On the second copy of the lab results was a handwritten note by Licensed Practical Nurse (LPN) #69 dated 04/19/17, stating, Dr. (last name of attending physician) notified of PT/INR gave orders to hold X1 decrease [MEDICATION NAME] to 3.5 mg Recheck on Monday. Review of the nursing progress notes found an entry dated 04/19/17 written by LPN #69, BMP (basic metabolic panel) PT/INR Osmolality Glucose Serum 152 high Creatinine Serum 1.56 high egfr (estimated glomerular filtration rate) .INR 3.3 high. (First and Last Name of Attending Physician) notified of PT/INR gave orders to hold one dose decrease [MEDICATION NAME] to 3.5 mg recheck PT/INR on Monday Review of the Medication Administration Record (MAR) for (MONTH) (YEAR) found Resident #49's [MEDICATION NAME] was held on 04/18/17 as directed by the physician on 04/18/17. However, Resident #49's [MEDICATION NAME] was also not administered on 04/19/17 because of the orders obtained by LPN #69 on 04/19/17 also directed to hold one (1) dose of [MEDICATION NAME]. On 04/20/17, Resident #49 was administered 3.5 mg of [MEDICATION NAME] as directed by the physician on 04/19/17. However, on 04/21/17 the order for 3.5 mg was discontinued from the MAR and an order for [REDACTED]. On 04/21/17 through 06/06/17 Resident #49 was administered 4 mg of [MEDICATION NAME] daily. Review of the record found no additional notes that indicated the attending physician had been contacted and had given new orders after the order for 3.5 mg of [MEDICATION NAME] was obtained by LPN #69 on 04/19/17. An interview with the Director of Nursing (DON) at 4:21 p.m. on 06/12/17 confirmed the order obtained by LPN #69 for 3.5 mg of [MEDICATION NAME] should have been the order in effect from 04/19/17 through 06/07/17 when the resident was discharged from the facility. She confirmed there was no indication the attending physician had given an order to change the [MEDICATION NAME] back to 4 mg after the 04/19/17 order for 3.5 mg. She agreed Resident #49 had been receiving the wrong dose of [MEDICATION NAME] from 04/21/17 through the evening dose on 06/06/17.",2020-09-01
2734,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2017-06-13,364,F,0,1,QOJB11,"Based on observation of meal distribution, food temperature measurements, resident interview, review of resident council minutes, and staff interview, the facility failed to ensure food was served at proper temperatures upon receipt by the residents. This had the potential to affect all residents. Resident identifiers: #46, #69, and #36. Facility census: 55. Findings include: a) Food temperatures at the point of service 1. Observations at 7:35 a.m. on 06/13/17 noted a two-door food cart was on the B-Hall of the facility. Continued observation found nurse aides (NA) were busy answering call lights and getting residents ready to receive their meals. At approximately 7:50 a.m. a second one-door food cart arrived on the B-Hallway. At 8:05 a.m., Dietary Services Assistant (DSA) #63 was asked to take the temperature of the last tray served from the two-door food cart on B-Hall. DSA #63 said the two-door food cart was sent to the B-Hallway at 7:30 a.m. At 8:10 a.m. on 06/13/17, DSA #63 had to leave the hallway to return to the kitchen to get requested food items for residents. DSA #63 was not available when the last tray out of the food cart was ready for service at 8:15 a.m. The food temperatures were obtained by the surveyor with the facility's thermometer at 8:10 a.m. on 06/13/17 with NA #94 present. Resident #2's tray was the last tray on the cart. The food temperatures obtained were (all temperatures are in degrees Fahrenheit): - Coffee, 128.4 degrees - Milk, 53.2 degrees - Biscuits and gravy, 88.9 degrees - Sausage patties, 87.2 degrees - Apple Juice, 58.4 degrees At 8:45 a.m. on 06/13/17, Dietary Manager (DM) #93, a dietary manager from another company facility, was asked to obtain the temperatures of the last food tray served from the one-door food cart on B Hall. The last tray on the cart belonged to Resident #69. The food temperatures were as follows: - Cranberry juice, 59.9 degrees - apple Juice, 60.4 degrees - Chocolate Milk, 57.4 degrees - Biscuits and gravy, 90.9 degrees - Boiled egg, 85.9 degrees DM #93 said the food temperatures at the time of service should be at least 130 degrees for hot food and no more than 50 degrees for cold foods. She stated the temperatures were unacceptable and she would prepare another tray for Resident #69. At 9:10 a.m. on 06/13/17, DSA #63 provided a copy of the food temperatures obtain by the kitchen staff before the carts were sent to the floor. Those temperatures were: - Eggs, boiled 189 degrees - eggs, scrambled 189 degrees - sausage, 200 degrees - gravy, 205 degrees - Biscuit, 189 degrees - Juice, apple 36 degrees - milk 34 degrees - Coffee 161 degrees. At 11:40 a.m. on 06/14/17, the facility's DM, DM #41 said the requirement for the hot foods at the time of service was 120 degrees, not 130 degrees as stated by DM #93. 2. Review of last six (6) months of resident council minutes found the following complaints regarding food temperatures: At each meeting residents were asked, When food is delivered, are hot foods hot and the cold foods cold? When asked these questions during the monthly meetings, the residents responded: -- 12/05/16 - A resident reported the eggs were cold. -- 01/03/17 - Breakfast is cold, carts are left on floor 30 plus mins. (minutes). -- 02/06/17 - Breakfast is cold on B-Hall .Others states egg are cold. -- 03/06/17 - The answer was, No, to the question with a response, Sometime in evening and at breakfast. -- 04/03/17 - Coffee is cold - Food temp (temperature) has improved. -- 05/01/17 - Coffee is cold at morning. -- 06/05/17 - Breakfast has been cold and the coffee was really cold on 06/04/17. At each meeting the resident council expressed concerns with food temperatures. At 1:00 p.m. on 06/13/17, the administrator was asked how the facility had addressed resident council's concerns regarding food temperatures. The administrator said the facility had purchased insulated food carts and were gradually replacing plate warmers. The administrator was unable to provide any written evidence the residents were informed about the facility's interventions, although the resident council minutes required a response to, Old Business (List follow-up on last month's minutes and identify staff person responsible). The administrator suggested resident council members be asked about the food issues. Resident #36 was selected randomly for interview as this resident attended the meetings. (The facility's resident council did not have a president.) At 1:05 p.m. on 06/13/17, Resident #36, when interviewed by the surveyor and the administrator. Resident #36 did acknowledge the facility had purchased new food carts and were purchasing plate warmers. She said, You can buy a new cart, but if the food sets too long it's going to be cold. She added without any prompting, That is what happened this morning. Residents expressed cold food temperatures were too high and hot food temperatures were too low. Both hot and cold foods were not served in accordance with generally accepted temperatures of hot foods at no less than 120 degrees and cold foods at no greater than 50 degrees Fahrenheit at the time of receipt by the resident.",2020-09-01
2735,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2017-06-13,425,D,0,1,QOJB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #5's medication (Procrit) was available for administration on the date it was due. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #5. Facility Census: 55. Findings Include: a) Resident #5 A review of Resident #5's medical record at 11:13 a.m. on 06/08/17 found a physician's orders [REDACTED]. A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. A review of the nursing progress notes found the following notes: -- A note dated 10/08/16, identified Resident #5's Procrit was held on that date because they were awaiting its arrival from the pharmacy. -- A note dated 10/09/16, documented Resident #5 received her Procrit on that date at 4:19 p.m. in the right lower quadrant of her abdomen. -- A note dated 10/22/16, noted Resident #5's Procrit was held on that date because they were awaiting its arrival from the pharmacy. -- A note dated 10/23/16, indicated Resident #5 received her Procrit on that date at 1:51 p.m. the left abdomen. During an interview with the Director of Nursing (DON) at 10:43 a.m. on 06/12/17, she confirmed Resident #5's Procrit scheduled for administration on 10/08/16 and 10/22/16 were administered a day late because the medication had not arrived at the facility from the pharmacy.",2020-09-01
2736,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2017-06-13,502,E,0,1,QOJB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to promptly obtain all physician ordered laboratory (lab) services to meet the needs of each resident. Resident #79 had orders for a Basic Metabolic Panel (BMP) to be done 'today that was not obtained until the next day. Resident #60 had an order for [REDACTED].#5 as ordered causing a delay in the resident receiving [MEDICATION NAME]. This was true for three (3) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #79, #60, and #5. Facility census: 55. Findings include: a) Resident #79 A review of Resident #79's medical record on 06/12/17 at 12:34 p.m. found a physician's orders [REDACTED]. The BMP was not obtained until 01/10/17. On 06/12/17 at 1:08 p.m., the DON confirmed the BMP ordered for 01/09/17 was not obtained until 01/10/17. b) Resident #60 A review of Resident #60's medical record on 06/12/17 at 11:34 a.m. found a physician's orders [REDACTED]. The magnesium level, hepatic function test, and lipid panel were not obtained. During an interview on 06/12/17 at 11:48 a.m., the Director of Nursing (DON) confirmed the magnesium level, hepatic function test, and lipid panel were not obtained on 04/06/17. c) Resident #5 A review of Resident #5's medical record at 11:13 a.m. on 06/08/17 found a physician's orders [REDACTED]. Resident #5 should have had a CBC completed on Monday, 05/15/17. However, the lab result contained in Resident #5's medical record indicated the CBC was not obtained until 05/16/17 and the results were not reported to the facility until 05/17/17. Resident #5 was scheduled to receive [MEDICATION NAME] (a medication with parameters to hold if Hemoglobin (HBG) is greater than 10) on 05/16/17. This medication was held and the nurse noted it was held due to the result of the CBC not being available. During an interview with the Director of Nursing on 06/12/17 at 10:33 a.m., she confirmed Resident #5's CBC ordered for 05/15/17 was obtained a day late. She stated she could not find any documentation as to why it was not obtained on 05/15/17 as ordered. She agreed obtaining the lab a day late caused a delay in Resident #5 receiving her scheduled dose of [MEDICATION NAME].",2020-09-01
2737,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2017-06-13,504,E,0,1,QOJB11,"Based on record review and staff interviews, the facility failed to obtain laboratory services only when ordered by a physician/nurse practitioner. The facility obtained laboratory (lab) tests for Resident #79 without an order from the physician or nurse practitioner. Resident identifier: #79. Facility census: 55. Findings include: a) Resident #79 A review of Resident #79's medical record on 06/12/17 at 12:34 p.m. found laboratory results for a complete metabolic panel (CMP) with osmolality obtained on 12/22/16 and a BMP obtained on 01/11/17. No physician or nurse practitioner orders could be found. On 06/12/17 at 1:08 p.m., the DON confirmed there were no physician or nurse practitioner orders for the CMP with osmolality obtained on 12/22/16 and the BMP obtained on 01/11/17.",2020-09-01
2738,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2017-06-13,505,E,0,1,QOJB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the attending physician was promptly notified of laboratory (lab) results for Residents #79 and #60. This was true for two (2) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #79 and #60. Facility census: 55. Findings include: a) Resident #79 A review of Resident #79's medical record on 06/12/17 at 12:34 p.m. found a lab result for an osmolality dated 12/22/16 with no indication the physician had been notified of the results. Additionally, the facility did not notify the physician of the results of a basic metabolic panel (BMP) dated 01/10/17 until 01/13/17. During an interview on 06/12/17 at 1:08 p.m., the DON confirmed the physician was not given the osmolality results dated 12/22/16, and the BMP results dated 01/10/17 were not given to the physician timely. The facility provided no further information regarding these findings. b) Resident #60 A review of Resident #60's medical record on 06/12/17 at 11:34 a.m. found the physician was not notified of the results of a [MEDICATION NAME] level obtained on 04/10/17 until 04/14/17. There was no evidence the results of the hepatic function test obtained on 04/13/17, were given to the physician until 04/15/17. During an interview on 06/12/17 at 11:48 a.m., the Director of Nursing (DON) confirmed the results for [MEDICATION NAME] level obtained on 04/10/17 and the hepatic function test on 04/13/17 had not been reported to the physician timely.",2020-09-01
2739,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2017-06-13,514,D,0,1,QOJB11,"Based on record review and staff interview, the facility failed to ensure Resident #9's medical record was complete and accurate. The resident's weight was not accurately recorded on his admission History and Physical. This was true for one (1) of three (3) residents reviewed for the care area of nutrition during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #9. Facility Census: 55. Findings Include: a) Resident #9 A review of Resident #9's electronic medical record at 10:54 a.m. on 06/12/17 found the following recorded weights: -- 04/03/17 - 176.5 pounds (lb) -- 04/09/17 - 177.9 lb -- 04/16/17 - 174.8 lb -- 04/23/17 - 172.2 lb -- 04/30/17 - 173.0 lb -- 05/07/16 - 171.8 lb -- 05/15/17 - 176.8 lb -- 05/21/17 - 181.6 lb -- 05/28/17 - 181.8 lb -- 06/04/17 - 184.8 lb -- 06/05/17 - 182.8 lb Further review of the medical record found an admission history and physical completed by Resident #9's attending physician on 04/03/17. Under the section titled, Vital Signs, Resident #9's weight was listed as 123.9 pounds and further indicated the resident was underweight with a Body Mass Index of 15.1. An interview with the Director of Nursing (DON) on 06/13/17 at 8:48 a.m., confirmed the weight of 123.9 lbs. as recorded on the attending physician's History and Physical was incorrect. She agreed Resident #9's correct weight on 04/03/17 was 176.5 lb, as recorded in his electronic medical record. .",2020-09-01
2740,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2019-07-31,580,D,0,1,8F0D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to promptly notify Resident #18's attending physician when the residents blood sugar was greater than 350. This was true for one (1) of five (5) residents reviewed for the care area of Unnecessary Medications during the Long Term Care Survey. Resident Identifier: #18. Facility Census: 58. Findings Include: a) Resident #18 A review of Resident #18's medical record on 07/30/19 at 1:28 p.m. found a physician's orders [REDACTED]. A review of the Medication Administration Record (MAR) for the month of (MONTH) 2019, found on 04/27/19 at 9:00 p.m. Resident #18's blood sugar was 409. A review of the nursing progress notes found the following notes in regards to physician notification of this elevated blood sugar, -- Note with an effective date and time of 4/28/2019 at 12:06 a.m. read as follows, Physician/NP Contact Note Patient Concern: blood sugar at 2314 (11:14 p.m.) 407, reading at 2357 (11:57 p.m.) 409. Nursing Assessment: resident alert. Communication of concern or assessment to physician/NP: Attempted contact with Dr (Last name of Attending physician, no answer at this time. Physician/NP Response or Order given: unable to contact. Confirmation of orders: unable to contact. Patient/Decision Maker Communication: (First and Last name of Resident Representative. -- Note with an effective date and time of 4/29/2019 3:39 p.m., read as follows, Physician/NP in Facility. Summary of Visit: Dr (Last name of attending physician) notified of BS at 2314 (11:14 p.m.) on 4-28-19 at 407, repeated at 2357 (11:57 p.m.) and it was 409, no new orders. Please note the Blood Sugar referred to in the note on 04/29/19 was actually obtained on 04/27/19 and not on 04/28/19. This is evident on the MAR and also in the previous note that was written shortly after midnight on 04/28/19 which refers to the same blood sugars at the same times indicating they were obtained on 04/27/19. An interview with the Director of Nursing (DON) at 1:56 p.m. on 07/30/19 confirmed Resident #18's attending physician was not promptly notified when his blood sugar was greater than 350 on 04/27/19 until 3:39 p.m. on 04/29/19. She agreed the blood sugars referred to in the note dated 04/29/19 were the blood sugars obtained on 04/27/19 and not on 04/28/19 as the note indicated. She agreed the notification was not prompt.",2020-09-01
2741,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2019-07-31,656,D,0,1,8F0D11,"**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 17 residents reviewed during the long-term care survey process. Resident #35's comprehensive care plan was not developed in the area of non-pharmacological interventions for the focus of anxiety. Resident identifier: #35. Facility census: 58. Findings included: a) Resident #35 Resident #35 had a [DIAGNOSES REDACTED]. Resident #35's comprehensive care plan had the following focus initiated on 02/21/17: (Resident's name) receives anti-anxiety medications ([MEDICATION NAME]) r/t (related to) Anxiety disorder. The goals were as follows: - Patient will be free from discomfort or adverse reactions related to anti-anxiety therapy. - Patient will show decreased episodes of s/sx (signs and symptoms) of anxiety through the review date. The interventions were as follows (typed as written: - Attempt gradual dose reduction of ([MEDICATION NAME]) in accordance with physician orders [REDACTED].>pharmacist recommendation. Document patient's response to dose reduction. Contact physician as necessary. - Give anti-anxiety medications ordered by physician--[MEDICATION NAME]-- Monitor/document effectiveness and side effects, specifically: Drowsiness, lack of energy, Clumsiness, slow reflexes, Slurred speech, Confusion and disorientation, Depression, Dizziness, lightheadedness, Impaired thinking and judgment, Memory loss, forgetfulness, Nausea, stomach upset, Blurred or double vision. CALL PHYSICIAN IMMEDIATELY IF THESE SIDE EFFECTS ARE SEEN: Mania, Hostility and rage, Aggressive or impulsive behavior, Hallucinations. - Observe patient for target behavior symptoms Feeling anxious with tremors and jitters and document occurrence and alterability of symptoms. During an interview on 07/31/19 at 9:17 AM, the Director of Nursing (DoN) stated Resident #35 responded to non-pharmacological interventions for anxiety consisting of talking and visiting with others and nature watching. The DoN provided documentation Resident #35 had participated in these activities. She acknowledged non-pharmacological interventions for anxiety were not included on the resident's care plan. On 07/31/19 at 11:05 AM, the Administrator was informed of the above-referenced findings. She had no further information regarding the matter. No further information was provided through the completion of the survey.",2020-09-01
2742,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2019-07-31,657,D,0,1,8F0D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to update the comprehensive care plan when the resident's condition changed for one (1) of 17 residents reviewed during the long-term care survey process. Resident #24's comprehensive care plan was not revised in the area of [MEDICAL CONDITION] related to [MEDICAL CONDITION]. Resident identifier: #24. Facility census: 58. Findings included: a) Resident #24 Resident #24 had [DIAGNOSES REDACTED]. She began [MEDICAL TREATMENT] treatments in (MONTH) (YEAR). Resident #24's comprehensive care plan had the following focus initiated on 08/13/17: [MEDICAL CONDITION] r/t (related to) [MEDICAL CONDITION]. The following intervention was also initiated on 08/13/17 (typed as written): Monitor/document/report for signs/symptoms of acute failure: Oliguria (urine output (greater than) 500 ml/24 hr) the BUN and Creatinine level out. During an interview on 07/31/19 at 10:49 AM, the Director of Nursing (DoN) stated, No, we are not measuring her urine. I had the RNAC (Registered Nurse Assessment Coordinator) remove it. On 07/31/19 at 11:05 AM, the Administrator was informed of the above-referenced findings. She had no further information regarding the matter. No further information was provided through the completion of the survey.",2020-09-01
2743,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2019-07-31,779,D,0,1,8F0D11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to maintain Resident #15's Radiology report in the medical record. Upon a review of Resident #15's medical record the Radiology Results for a physician ordered chest x- ray were not contained in the medical record. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during the long term care survey. Resident Identifier: #15. Facility Census: 58. Findings Include: a) Resident #15 A review of Resident #15's medical record on 07/30/19 at 11:14 a.m. found a physician's orders [REDACTED]. Further review of the record found a nursing progress note dated 01/15/19 at 9:37 p.m. which indicated the attending physician was notified of the X- Ray results that had been received by the facility. A further review of the electronic medical record found the X-Ray results for 01/15/19 were not contained in the medical record. At 10:15 a.m. on 07/30/19 the Director of Nursing (DON) was asked to provide the x-ray results for the chest x-ray ordered on [DATE]. At 10:35 a.m. she presented the results and confirmed they were not filed in the residents record. She stated she had to reprint from the website and she is not sure where the original went. 07/30/19 11:14 AM 07/30/19 09:14 AM Review of the residents records found the resident takes the following medications which are pertinent to this review:,2020-09-01
2744,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2019-07-31,842,D,0,1,8F0D11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #33's medical record was complete and accurate. Resident #33 was ordered to .25 milligrams (MG) of [MEDICATION NAME] three times a day. However the physician order [REDACTED]. This was true for one (1) of five (5) residents reviewed for the care area of Unnecessary Medications during the long term care survey process. Resident Identifier: #33. Facility Census: 58. Findings Include: a) Resident #33 A review of Resident #33's medical record at 2:59 p.m. on 07/30/19 found a physician progress notes [REDACTED].#33 was seen due to [MEDICAL CONDITION]. Under the section titled care plan the attending physician wrote the following: [MEDICAL CONDITION]: Continue [MEDICATION NAME] as directed. Patient offered ear plugs but declined at this time. GAD: (generalized anxiety disorder) [MEDICATION NAME] .25 mg by mouth BID (twice a day). Continue behavior/affect monitoring. A review of the physician's orders [REDACTED]. give 1/2 of .5 mg tab to equal .25 mg The medication to be administered was listed as a .5 mg [MEDICATION NAME] tablet. The dose or quantity to administer was .25 tablet two times a day. Please note .25 of a .5 mg tablet would only equal .125 mg and not .25 mg. An interview with the Director of Nursing (DON) at 3:10 p.m. on 07/30/19 confirmed the ordered needed to be clarified. She agreed the resident was to receive 1/2 or .5 of a .5 mg [MEDICATION NAME] tablet to equal .25 mg. She agreed this order was put into the computer incorrectly.,2020-09-01
2745,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2019-07-31,880,E,0,1,8F0D11,"Based on observation and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. A clean mop head was hung for drying in the dirty laundry room. This was a random opportunity for discovery and had the ability to affect more than a limited number of residents. Facility census: 58. Findings included: a) Laundry room On 07/30/19 at 3:00 PM, a tour of the laundry services was conducted accompanied by Environmental Services Staff #59. The laundry services consisted of two (2) separate rooms, a dirty room and a clean room. The dirty room contained an area for receiving and sorting the dirty laundry. A mop head was hanging in this area of the dirty room. Environmental Services Staff #59 stated the mop head had been cleaned and was hanging to dry. He was informed the clean mop head could be exposed to contamination by the dirty laundry that was being sorted in this area. Environmental Services Staff #59 stated the mop head would be re-washed before it was used by the housekeeping staff. On 07/30/19 at 3:07 PM, the administrator was informed of the above-referenced findings. She had no further information regarding the matter. No further information was provided through the completion of the survey.",2020-09-01
2746,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2018-08-01,584,D,0,1,VC1411,"Based on observation and staff interview, the facility did not ensure a homelike environment for two (2) of 32 rooms. The metal housing of the heat/air unit was in poor repair in Room B#14 and B#16. The facility also did not ensure a clean environment for all residents. Room Numbers: B#14 and B#16. Facility census: 54. Findings included: a) B#14 and B#16 On 07/30/18 at 2:09 PM, an observation of the heat/air condition units in Room B#14 and B#16 revealed both units were in poor repair. The metal housing of the units were bent and had peeling paint. During an interview with Environmental Supervisor (ES) #56 on 08/01/18 the ES said he could have these units changed out. b) Exhaust Vent An observation, on 08/01/18 at 2:25 PM, of the exhaust vent outside the Resident Nursing Assistant Coordinator's (RNAC) office revealed a vent cover with dust and debris. On 08/01/18, at 2:27 PM ES #56, said he could clean the vent with a broom.",2020-09-01
2747,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2018-08-01,622,D,0,1,VC1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to communicate appropriate information to the receiving institution when the resident was transferred to the hospital after a fall. The facility failed to provide evidence the hospital was provided with the contact information of the practitioner responsible for the care of the resident; the Resident representative information including contact information; advance directive information; medications; diagnosis; any allergies [REDACTED]. This was true for one (1) of five (5) residents reviewed for hospitalization . Resident identifier: #2. Facility census: 54. Findings included: a) Resident #2 Review of the resident's medical record found the resident fell from bed on 06/23/18 at 8:20 p.m. According to the incident report, the alarm sounded in patients room. (typed as written) .Patient was on left side of fall mat, bleeding from left brow, 2 mm x 1 mm laceration to the left brow, cleaned area, 4 x 4 gauze with NS (normal saline) applied, reinforced with 4 x 4 gauze, bleeding stopped, no loss of consciousness, both pupils 3 mm diameter, bruise to left knee observed, vital signs taken of patient, helped back to bed, dr (doctor) notified with orders to send to ER (emergency room ) I don't know what happened, I fell . Review of the nursing notes, dated 06/24/18 at 3:01 a.m. found the resident had returned to the facility with adhesive strips covering 4 sutures to the laceration above the left eye with no redness or swelling. At 2:46 p.m. on 08/01/18, the Regional Executive Director, Employee #87 was unable to provide a copy of the discharge information sent with the resident when she was transferred to the emergency roiagnom on [DATE]. According to [NAME] #87, an acute Care Transfer Form should have been sent with the resident at the time of transfer. E#87 said she could not find the information. E#87 confirmed she could not find evidence of any information sent with the resident or verbally communicated to the hospital at the time of the resident's discharge. Review of the facility's policy entitled, Bed Hold and Readmission Right, requires written notice to be provided in the form of the Acute Care Transfer Form to be provided. .Should it become necessary to transfer a resident to a hospital or other acute care facility for medical or emergency care, the facility will: . d. Prepare transfer documentation to send with the resident . g. Document the details of the transfer, including the reason for the transfer, in the resident's clinical record using the approved document, the Acute Care Transfer form .",2020-09-01
2748,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2018-08-01,636,D,0,1,VC1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to complete an accurate minimum data set (MDS) assessment for Resident #7. The MDS for Resident #7 did not reflect the correct medical [DIAGNOSES REDACTED]. This was found true for one (1) of eighteen (18) resident assessments reviewed during the investigation process of the survey. Resident identifier: #7. Facility census: 54 Findings included: a) Resident #7 A review of the medical record for Resident #7 on 08/01/18 at 10:24 AM, revealed the MDS with a quarterly assessment reference date (ARD) of 05/10/18 did not accurately record the [DIAGNOSES REDACTED]. During an interview on 08/01/18 at 11:48 AM with the MDS Coordinator, verified she had not include the [DIAGNOSES REDACTED].",2020-09-01
2749,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2018-08-01,656,E,0,1,VC1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to develop or implement a person-centered comprehensive care plan for eleven (11) of eighteen (18) residents reviewed in the survey sample. A person-centered comprehensive care plan was not developed in the area of pain management for Residents #31, #27, #7, #39, and #36. A person-centered comprehensive care plan was not developed in the area of pressure ulcer care for Residents #11 and #16. A person-centered comprehensive care plan was not developed in the area of oxygen therapy for Residents #16 and #253. A person-centered comprehensive care plan was not developed in the area of [MEDICAL CONDITION] medication monitoring for Resident #17. A person-centered comprehensive care plan was not developed in the area of infections for Resident #9. A person-centered comprehensive care plan was not implemented in the area of pressure ulcer prevention for Resident #17. A person-centered comprehensive care plan was not implemented in the area of activities of daily living for Resident #2. A person-centered comprehensive care plan was not implemented in the area of non-pharmacological interventions for pain management for Resident #39. A person-centered comprehensive care plan was not implemented in the area of pressure ulcer care for Resident #16. Resident identifiers: #31, #27, #7, #39, #36, #11, #16, #253, #17, #9, #2. Facility census: 54. Findings included: a) Resident #31 Resident #31 had [DIAGNOSES REDACTED]. He had the following oral medication orders [REDACTED]. Resident #31 also had an order for [REDACTED]. Resident #31's comprehensive care plan included the focus, (Resident's name) has acute/chronic pain r/t (related to) DM (diabetes mellitus), [MEDICAL CONDITIONS]. The interventions included, Administer scheduled pain management medication per orders. The specific pain medications were not included. Resident #31's comprehensive care plan also included the focus, Gout. The interventions included, Administer medications per physician's orders [REDACTED]. During an interview on 08/01/18 at 11:18 AM, Registered Nurse Assessment Coordinator (RNAC) #54 agreed Resident #31's comprehensive care plan was not individualized to include specific pain medications. RNAC #54 stated she thought individual medications did not need included because physician orders [REDACTED]. b) Resident #11 Resident #11 had a pressure ulcer on his left elbow. He had an order to cleanse area to left elbow with wound cleanser, pat dry, apply Silver powder and cover with borderfoam dressing every three (3) days and as needed until resolved. Resident #11's care plan contained the focus, (Resident name) has a pressure ulcer to his left elbow, r/t (related to) disease process, hx (history) of ulcers, and immobility. The interventions included, Administer treatments as ordered and monitor for effectiveness. The specific treatment and frequency were not included. During an interview on 08/01/18 at 11:18 AM, Registered Nurse Assessment Coordinator (RNAC) #54 agreed Resident #11's comprehensive care plan was not individualized to include specific information regarding his dressing changes. RNAC #54 stated she thought specific information regarding dressing changes did not need included because physician orders [REDACTED]. c.1) Resident #17 A review of the medical record for Resident #17 on 07/31/18 revealed the care plan had not been implemented for the intervention to float resident's heels while in bed. An observation on 07/31/18 at 2:28 PM with Employee #24, licensed practical nurse (LPN) verified Resident #17's heels were not being floated while in bed. c.2) Resident #17 A review of the medical record for Resident #17 on 07/31/18 revealed the care plan had not been developed to provide the interventions for the anti-[MEDICAL CONDITION] medication. The interventions did not include any side effects or adverse reactions for [MEDICATION NAME]. In an interview on 08/01/18 with Employee #54, registered nurse (RN), verified she had not provided any side effects or adverse reaction as interventions on the care plan for the medication [MEDICATION NAME]. d) Resident #27 A review of the medical record on 07/31/18 for Resident #27 revealed she was taking [MEDICATION NAME] Gel 1% 4 gram [MEDICATION NAME] every evening shift for [MEDICAL CONDITION] pain, to be applied to each knee and to the top of feet only, do not exceed 4 gram start date 10/16/17. The care plan had not been developed to include this as an [MEDICATION NAME] medication. During an interview on 07/31/18 at 4:47 PM with Employee #54, registered nurse (RN) reported she had not included [MEDICATION NAME] Gel as an [MEDICATION NAME] e) Resident #7 A review of the medical record on 07/31/18 for Resident #7 revealed the care plan did not address the non-pharmalogical medication of [MEDICATION NAME] Gel to right shoulder at bedtime. During an interview on 07/31/18 at 4:47 PM with Employee #54, RN verified the care plan for Resident #7 did not address the non-pharmalagical [MEDICATION NAME] medication [MEDICATION NAME] Gel. f) Resident #2 Review of the residents current plan of care found the following focus/Problem: (Name of resident) requires assist with ADL's (activities of daily living) due to impaired mobility. The goal associated with the problem: Needs met during review period. Interventions included: Half side rail-left and right. Review of the physician's orders [REDACTED]. Numerous observations of the resident while in bed, on the morning of 08/01/18 found the resident only had the left side rail in the upright position. The rail on the side of the bed facing the wall was not in an upright position. Observation with the Director of Nursing (DON) on 08/01/18, at 1:17, found the resident in bed with only the left side rail in the up position. The DON confirmed both rails were to be up when the resident was in bed. g) Resident #9 Record of the physician's orders [REDACTED]., give 1 tablet by mouth 2 times a day, for bacterial infection. Review of the care plan found the current focus/problem: Infection Bacterial. The goal associated with the problem was: Infection will be resolved without complications by review date. Interventions included: Give antibiotics as ordered. Report observed side effects to prescriber. Notify physician if signs/symptoms do not improve during treatment. At 12:54 p.m. on 08/01/18, the DON confirmed the care plan did not identify the source of the infection. Further record review found the results of an aerobic bacterial culture noting the resident had [DIAGNOSES REDACTED] pneumonia, heavy growth. At 3:32 p.m. on 08/01/18, the DON said the infection was in a wound to the peri-area. The DON confirmed the care plan did not identify the source of infection or the antibiotic being used to treat the infection. The DON was asked how staff could follow the care plan to identify any adverse effects of the antibiotic if the antibiotic was not identified? How would staff know when the infection was resolved if the source of the infection was not identified? No further information was provided by the DON. h) Resident #39 Record review found the resident began receiving Hospice Services on 06/19/18. Review of the physician's orders [REDACTED]. [MEDICATION NAME] Solution, 100 mg/5ml, give 0.25 ml by mouth, every 2 hours, as needed for pain. [MEDICATION NAME] gel to right knee twice a day, for [MEDICAL CONDITION] pain, every 2 hours PRN (as needed.) Review of the current care plan found the following focus/problem: (Name of Resident) has acute/chronic pain r/t/ [MEDICAL CONDITIONS], gastritis, chronic abdominal pain and muscle spasms. The goal associated with the problem: Patient will verbalize adequate relief of pain through review date. Interventions included: Administer scheduled pain management medications per orders, Provide patient with reassurance that pain is time limited. Encourage patient to try different pain relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, ultra-sound. Involve family members as appropriate in non-pharmacological interventions. At 11:31 a.m. on 07/31/18 the Registered Nurse Clinical Care Supervisor (CCS) #45 said the facility does not document the non-pharmacological interventions tried before administering the prn pain medication. She said administering non-pharmacological interventions is a standard of practice. She said the care plan listed the interventions to be provided. The care plan was reviewed with the CCS #45 at 11:31 a.m. on 07/31/18. CCS #45 said the nurse would decide which interventions to provide before giving the pain medication. At 11:37 a.m. on 07/31/18, the Registered Nurse Assessment Coordinator (RNAC) #54 confirmed the care plan did not list the specific medications used to treat pain. RNAC #54 did not think the care pain needed to be that specific. In addition, RNAC #54 was not aware how the nursing staff documented the non-pharmacological interventions implemented to address the resident's pain. On 07/31/18, at 3:47 p.m. the residents Licensed Practical Nurse (LPN) #24, reviewed the non-pharmacological interventions listed on the care plan. LPN #24 said she thought therapy would do ultrasound on the resident. LPN #24 said the resident was not receiving therapy at this time. She did not know exactly what progressive relaxation would entail. She said she had no special training in relaxation therapy. She was unsure about heat and cold application, but said she had given the resident a cold wash cloth at some point. At 3:48 p.m. on 07/31/18 the Director of Nursing (DON) confirmed nursing staff did not document the non-pharmacological interventions implemented before providing the resident's pain medication. She verified her staff were not trained in relaxation therapy. There was no documentation to support who provided the non-pharmacological interventions, what non-pharmacological interventions were provided and if the interventions were effective or not. In addition, the DON confirmed the resident's care plan did not entail the specific pain medications provided. i.1) Resident #16 Review of medical record review it was revealed that the facility failed to implement the care plan for this resident by not repositioning him, side to side only and every two hours. During an observation on 07/30/18 at 10:00 AM, Resident #16 was lying on his left side facing the window. Observation on 07/30/18 at 3:07 PM, Resident #16 is still lying on his left side. Another surveyor also noticed him be have been on his left side facing the window though out the day. Observation on 07/31/18 at 8:08 AM, Resident #16 was lying on his back with a wedge under his left shoulder. Observation on 07/31/18 at 11:49 AM, Resident #16 was lying on his back with the wedge under his left shoulder. Observation on 07/31/18 at 3:50 PM, Resident #16 was lying on his back with the wedge under his left shoulder. During an interview with Nursing Assistant (NA) #74 and NA #9 on 07/31/18 at 3:51 PM, they said they have moved him several times today last time at 1:00 PM. They were told that this surveyor has been monitoring his position changes and he has not been moved, but even if he was moved at 1:00 PM it has been more than two hours now and they said that they are not his NAs anymore they were going home. They were informed he was facing the window the entire time I was here yesterday. NA#9 said she was not here yesterday. Observation on 07/31/18 at 4:28 PM, revealed Resident #16 was lying on his left side facing the window. During an interview on 07/31/18 at 3:29 PM, Director of Nursing (DON) stated, it is a standard of practice for residents to be turned every two (2) hours and they do not document that every two hours because it is a standard. She was unaware that Resident #16 was not repositioned every two (2) hours yesterday or today. Observation on 08/01/18 at 8:08 AM, Resident #16 was lying on his left side facing the window. Observation on 08/01/18 at 9:19 AM, Resident #16 was lying on his left side left side facing the window. Observation on 08/01/18 at 10:40 AM, revealed Resident #16 was lying on his left side lying facing the window. Observation on 08/01/18 at 11:10 AM, revealed Resident #16 was lying on his left side facing the window. Observation on 08/01/18 at 11:42 AM, revealed Resident #16 was lying on his left side facing the window, position unchanged from this morning. On 08/01/18 at 2:42 PM, while observing Foley catheter care Resident #16 repeatedly asked NA #68 and NA #83 if they would please move him off his left side because his shoulder was hurting bad. During an interview on 08/01/18 at 4:38 PM, DON was informed of observations. She said she knows that he refuses at times. She also said that the Dolphin bed displaces his weight even if he is not repositioned. She agrees that because he has the Dolphin bed it does not replaced the need for repositioning every 2 hours. DON said that the facility is aware this Residents Pressure ulcers and the steps they have taken to help prevent acquiring more and promote healing for him is a Registered Nurse (RN) is to looks at pressure ulcers daily. He is on a Dolphin bed (which is used to help decrease pressure ulcers. She was asked if anyone checks to see if the NA are turning this resident very two hours. She said yes, they have two Registered Nurses (RNs) on the floor that do spot checks. When she was informed of the multicable observations of him lying in the same position. Resident #16 has acquired four (4) new pressure ulcers in the last six (6) months and has had one on his coccyx for more than one year that improves and worsens but has not healed at this time. Review of medical records revealed physician's orders [REDACTED]. Obtain Nursing Assistant electronic charting record revealed: On 07/30/18 at 2:59 PM, at the end of shift report NA # 89 reported YES that Resident #16 was repositioned every two hours. On 07/31/18 at 2:59 PM, NA# 9 recorded YES that Resident #16 was repositioned every two hours. Care Plan no date available reads Assist patient to reposition himself in bed at least every two hours. Side to side turns only. Position, Mobility i.2) Resident #16 During a review of medical records, it was revealed that the facility failed to developed a person centered care plan in regards to this residents many facility acquired pressure ulcers. This resident had developed six (6) new pressure ulcers in the last 6 months, the only pressure ulcer care planned for was the one to the left gluteal area there were no dates on the care plan to indicate when it was initiated and/or revised and reads as follows: -administer treatments/medications as ordered and monitor for effectiveness. -assist patient to turn and reposition himself in bed at least every 2 hours. Document every shift. Side to side turns only. - float heels while in bed. Non-skid material in chair during use. -Preventative treatments as ordered. No mention of any of the newly developed pressure ulcers. Orders reviewed were as follows: - Start Date 07/30/18 Cleanser left gluteal pressure ulcer with wound cleanser and apply silver sponge with wound vac set at 125 mmHg continuous pressure. change Monday- Wednesday-Friday. -Start Date 07/26/18 Dolphin mattress to bed -Start Date 07/22/18 Bactrim DS Tablet 800-160 MG ([MEDICATION NAME]-[MEDICATION NAME]) Give 0ne (1) Tablet by mouth two (2) times a day [MEDICAL CONDITIONS] for 21 days. During an interview on 08/01/18 at 11:48 AM, Registered Nurse #54 was shown many areas of the care plan was fag and not personalized for this resident. She agreed it should and could contain more information for the direction of care for this resident. i.3) Resident #16 Record review revealed the facility failed to complete a person-centered care plan, for Resident # 16 regarding administering oxygen. The care plan did not indicate when this was initiated was as follows: -Give medications, oxygen as ordered by physician. -May remove 02 for transports and showers. This care plan did not give guidance to the rate that the oxygen was to be delivered or what device was to be used, Mask, nasal cannula etc Orders dated 06/21/17 were as follows: - 02@3L/min via NC (nasal cannula) continuously -Change humidifier bottle and tubing weekly -clean filters and concentrators weekly every Sunday night shift -Change nebulizer updraft tubing every Sunday night shift During an interview on 08/01/18 at 11:48 AM, Registered Nurse #54 was shown many area of the care plan was fag and not personalized for this resident. She agreed it should and could contain more information for the direction of care for this resident. j) Resident #253 Respiratory Care During record review it was revealed the facility failed to complete a person-centered care plan, for Resident # 253 in regards to oxygen. Care Plan review for Oxygen had no date to indicate when this was initiated and/or revised, was as follows: - Focus- [MEDICAL CONDITION] -Goal-Will be free of s/sx (signs or symptoms) of respiratory infections through review date. -Interventions- Give aerosol or [MEDICATION NAME][MEDICATION NAME] as ordered. Monitor/document any side effects and effectiveness. -Give oxygen therapy as ordered by physician. oxygen may be removed for transports and showers. -Head of bed to elevated or out of bed upright chair during episodes of difficulty breathing. Orders for oxygen therapy were as follows: -Dated 07/13/18, 02@ L/min via nasal cannula continuously -Dated 04/26/18, 02 saturation (the measurement of oxygen being carried by the blood cells) every shift and as needed. -Dated 07/13/18, foam ear protectors to 02 tubing at all times and change weekly on Sunday night shift. -Dated 07/13/18, Change humidifiers bottle and tubing weekly on Sunday night shift -Dated 07/13/18, Clean filters on concentrator weekly on Sunday night shifts. During an interview on 07/31/18 at 11:36 PM, Register Nurse (RN) # 54 was asked about care plan for Resident # 253 concerning his oxygen therapy. She agreed it was lacking a great deal of information and should have had more detail. She also agreed it was not personalized to this resident. k) Resident #36 A care plan review for Resident #36 revealed a focus area which stated, (Resident #36) is at risk for generalized pain r/t (related to) Hx (history)[MEDICAL CONDITION](cardiovascular accident). The goal stated, Will verbalize adequate relief of pain or ability to cope with incompletely relieved pain. A review of the Resident #36's physician's orders [REDACTED]. The resident's care plan was not individualized in relation to the interventions used to treat the resident's pain. Interventions related to the focus area of generalized pain were listed as, Anticipate need for pain relief, Give [MEDICATION NAME]/medications as ordered. The intervention did not state the specific medication used to treat the resident's pain. On 08/01/18 at 9:13 AM Resident Nursing Assessment Coordinator #54 said she thought the physician's orders [REDACTED].",2020-09-01
2750,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2018-08-01,657,D,0,1,VC1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, observation, and resident interview, the facility failed to revise the care plans of two (2) of eighteen (18) residents whose care plans were reviewed. Resident #39's care plan was not revised when weights were discontinued. Resident #16's care plan was not revised regarding the status of current pressure ulcers. Resident identifiers: #39 and #16. Facility census: 54. Findings included: a) Resident #39 Record review found the resident was receiving Hospice Services for a terminal [DIAGNOSES REDACTED]. Review of the current care plan found the focus/Problem: Has had a weight loss. The goal associated with the problem is: Patient will have no complaints of hunger this review and hospice services will be followed. Interventions included: Weigh Patient as ordered and record. Review of the physician's orders [REDACTED]. At 11:51 a.m. on 08/01/18, the Registered Nurse Assessment Coordinator (RNAC) confirmed weights were no longer being obtained and the care plan would be updated to reflect this order. b) Resident #16 During an interview on 07/30/18 at 10:35 AM, Resident #16 stated he had a wound vac for a bed sore (pressure ulcer) on buttock. It was noticed he was lying on a pressure ulcer prevention mattress, OneCare Dolphin fluid Immersion Simulation. He was tilted to his left side facing the window. Review of records revealed the following: Pressure Ulcer #1 Left Lower Leg Newly Acquired 01/09/18, Risk factors Impaired mobility or transfer last Braden Score on 12/21/17, 15-18 mild risk. Stage II, length 2.0 centimeters (cm), width 1 cm, depth 0 cm. Resolved 04/25/18. Pressure Ulcer #2 right upper back newly acquired 02/04/18, Stage II, Length 3.8 cm Width 2.2 cm Depth 0.1 cm. Resolved on 02/21/18. Pressure Ulcer #3 right top of foot Newly Acquired 05/01/18, Stage II, Length 1.8 cm, Width 1.4 cm, Depth 0 cm, noted to resolve on 5/23/18. Pressure Ulcer #4 left buttock returned to facility with the Pressure ulcer on 04/28/17, Stage III, 3cm length, 3.5 cm width and 1. cm depth. -05/05/17, Stage III, 5.5 cm length, 3.5 cm width, 1 cm depth Pressure ulcer #5 left inner heel. Present on readmission 05/31/17, Stage as Suspected Deep Tissue Injury, 3.5 cm length, 4.8 cm width, resolved 01/13/18. Pressure Ulcer #6 right upper gluteal muscle Newly Acquired 08/1/18, Stage II, 1.5 cm length, 1.0 cm width, 0 .1 cm depth. During an interview on 08/01/18 at 10:19 AM, Director of Nursing (DON) clarified that the Nursing Assistance (NA) do not document when they reposition residents until at the end of their shift. During an interview and observation of wound care on 08/01/18 at 9:18 AM, Registered Nurse (RN) #27 informed Resident # 16 about what she was doing. Resident #16 was lying on his left side. RN #27 removed the dressing and wound vac from his coccyx, noting there was another dressing on the right buttock. RN #27 stated that this was a new area from last week. She left the room to call the attending Physician for new orders and to notify him of the new pressure ulcer. She measures this new wound as 1.4 cm length and 1cm width. The wound the wound vac was being used on was large beefy red deep wound on the coccyx. During an interview on 08/01/18 at 4:29 PM, DON said that the facility is aware this Residents Pressure ulcers and the steps they have taken to promote healing and prevention for him is: (1) A Registered Nurse (RN) is to looks at pressure ulcers daily. (2) He is on a Dolphin bed (which is used to help decrease pressure ulcers). She was asked if anyone checks to see if the NA are turning this resident very two hours. She said yes, they have two (2) RN's on the floor that do spot checks. When she was informed of the multicable observations of him lying in the same position. She said she knows that he refuses at times. She also said that the Dolphin bed displaces his weight even if he is not repositioned. She agrees that because he has the Dolphin bed it does not replaced the need for repositioning every 2 hours. As shown above this Resident has acquired four (4) new pressure ulcers in the last six (6) months and pressure ulcer # 4 is over a year old, it has worsened many time and has not healed as of to date. During an interview on 08/1/18 at 11:48 AM, Registered Nurse #54 agreed that the care plan for this resident was not personalized for him. The newly acquired pressure ulcers were not added to the care plan nor was the treatments for each pressure ulcer.",2020-09-01
2751,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2018-08-01,675,D,0,1,VC1411,"Based on observation and staff interview, the facility failed to ensure Resident #253 was positioned at the dining table to allow easy access to his food during dining. This was a random observation discovered during the first meal observed upon entrance to the facility. Resident identifier: #235. Facility census: 54. Findings included: a) Resident #253 Observation of the noon meal at 12:18 p.m. on 07/30/18 found Resident #253 seated at a table in the dining room. The resident was seated in a wheelchair with foot rests. The Residents feet were on the foot rests. The table was not high enough to allow the resident's legs to fit under the table. He was approximately a foot away from the table. He was stretching is arms to reach for the foot on his plate. The Resident was eating with a spoon and had spilled some of his food onto his lap. The resident continued to eat his meal in this position. At 12:33 p.m. on 07/30/18, Employee #35, the activity assistant, was alerted of the situation. The foot rests on the wheelchair were lowered allowing the resident's legs to easily pass under the table. At 4:44 p.m. on 08/01/18, the Director of Nursing (DON) said she was unaware of the issue.",2020-09-01
2752,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2018-08-01,677,D,0,1,VC1411,"Based on observation, record review and staff interview the facility failed to ensure they provided nail care for one (1) of one (1) dependent residents reviewed for the area of activities of daily living (ADL). Resident identifier: #47. Facility census: 54. Findings included: a) Resident #47 07/31/18 at 8:35 AM during an observation of Resident #47 revealed long painted fingernails and long toe nails. Resident #47 said she needed her fingernails cut because they were long and they would bend, break and snag. Care plan review revealed a focus area of needing assistance with ADLs. During an interview with interview with Resident #47 The facility failed to ensure nail care for a dependent resident. 1 of 1 residents reviewed for the care area of ADLs. During an interview with Nurse Aide (NA) #8, on 07/31/18 at 9:36 AM she said the nurse aides do nail care for their assigned residents. would try and trim the resident's nails. 07/31/18 09:36 AM talked with[NAME](nurse aide) and asked her about Resident #47's nails. She said the nurse aides do their own nail care. NA #8 also said one of the nurse aides at the facility was very good an trimming nails and she would get this NA to trim Resident #47's nails. NA $#8 was also told about the resident's toenails being long. On 08/01/18 at 1:00 PM during an observation of Resident #47 with NA #8 revealed the resident's nails were trimmed. NA #8 said she hadf trimmed the residents nails",2020-09-01
2753,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2018-08-01,684,D,0,1,VC1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews and staff interviews the facility failed to provide needed care and services to promote the highest practicable physical, mental, and psychosocial well-being. Resident #17 did not have the activities apron on while in bed and Resident #16 had not been turned and repositioned. This was true for two (2) of eighteen (18) residents reviewed during the investigation process of the survey. Resident identifiers: #17 and #16. Facility census: 54. Findings included: a) Resident #17 In a medical record review on 07/31/18 revealed Resident #17 had an order to wear an activity apron while in bed with a start date of 07/25/18. During an observation on 07/31/18 at 2:20 PM with Employee #24, licensed practical nurse (LPN) verified the activity apron had not been placed on Resident #17 while she was in bed, she also verified the physician's orders [REDACTED]. b) Resident #16 Position, Mobility During an observation on 07/30/18 at 10:00 AM, Resident #16 was lying on his left side facing the window. Observation on 07/30/18 at 3:07 PM, Resident #16 is still lying on his left side. Another surveyor also noticed him be have been on his left side facing the window though out the day. Observation on 07/31/18 at 8:08 AM, Resident #16 was lying on his back with a wedge under his left shoulder. Observation on 07/31/18 at 11:49 AM, Resident #16 was lying on his back with the wedge under his left shoulder. Observation on 07/31/18 at 3:50 PM, Resident #16 was lying on his back with the wedge under his left shoulder. During an interview with Nursing Assistant (NA) #74 and NA #9 on 07/31/18 at 3:51 PM, they said they have moved him several times today last time at 1:00 PM. They were told that this surveyor has been monitoring his position changes and he has not been moved, but even if he was moved at 1:00 PM it has been more than two hours now and they said that they are not his NAs anymore they were going home. They were informed he was facing the window the entire time I was here yesterday. NA#9 said she was not here yesterday. Observation on 07/31/18 at 4:28 PM, revealed Resident #16 was lying on his left side facing the window. During an interview on 07/31/18 at 3:29 PM, Director of Nursing (DON) stated, it is a standard of practice for residents to be turned every two (2) hours and they do not document that every two hours because it is a standard. She was unaware that Resident #16 was not repositioned every two (2) hours yesterday or today. Observation on 08/01/18 at 8:08 AM, Resident #16 was lying on his left side facing the window. Observation on 08/01/18 at 9:19 AM, Resident #16 was lying on his left side left side facing the window. Observation on 08/01/18 at 10:40 AM, revealed Resident #16 was lying on his left side lying facing the window. Observation on 08/01/18 at 11:10 AM, revealed Resident #16 was lying on his left side facing the window. Observation on 08/01/18 at 11:42 AM, revealed Resident #16 was lying on his left side facing the window, position unchanged from this morning. On 08/01/18 at 2:42 PM, while observing Foley catheter care Resident #16 repeatedly asked NA #68 and NA #83 if they would please move him off his left side because his shoulder was hurting bad. During an interview on 08/01/18 at 4:38 PM, DON was informed of observations. She said she knows that he refuses at times. She also said that the Dolphin bed displaces his weight even if he is not repositioned. She agrees that because he has the Dolphin bed it does not replaced the need for repositioning every 2 hours. DON said that the facility is aware this Residents Pressure ulcers and the steps they have taken to help prevent acquiring more and promote healing for him is a Registered Nurse (RN) is to looks at pressure ulcers daily. He is on a Dolphin bed (which is used to help decrease pressure ulcers. She was asked if anyone checks to see if the NA are turning this resident very two hours. She said yes, they have two RN's on the floor that do spot checks. When she was informed of the multicable observations of him lying in the same position. Resident #16 has acquired four (4) new pressure ulcers in the last six (6) months and has had one on his coccyx for more than one year that improves and worsens but has not healed at this time. Review of medical records revealed physician's orders [REDACTED]. Obtain Nursing Assistant electronic charting record revealed: On 07/30/18 at 2:59 PM, at the end of shift report NA # 89 reported YES that Resident #16 was repositioned every two hours. On 07/31/18 at 2:59 PM, NA# 9 recorded YES that Resident #16 was repositioned every two hours. Care Plan no date available reads Assist patient to reposition himself in bed at least every two hours. Side to side turns only.",2020-09-01
2754,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2018-08-01,686,D,0,1,VC1411,"The facility failed to provide care and services to promote healing of pressure ulcers. For one (1) of three (3) residents reviewed for the care area of pressure ulcers. Resident identifier: #16. Facility census 54. Findings included: a) Resident #16 During an interview on 07/30/18 at 10:35 AM, Resident #16 stated he had a wound vac for a bed sore (pressure ulcer) on buttock. It was noticed he was lying on a pressure ulcer prevention mattress, OneCare Dolphin fluid Immersion Simulation. He was tilted to his left side facing the window. Review of records revealed the following: Pressure Ulcer #1 Left Lower Leg Newly Acquired 01/09/18, Risk factors Impaired mobility or transfer last Braden Score on 12/21/17, 15-18 mild risk. Stage II, length 2.0 centimeters (cm), width 1 cm, depth 0 cm. Resolved 04/25/18. Pressure Ulcer #2 right upper back newly acquired 02/04/18, Stage II, Length 3.8 cm Width 2.2 cm Depth 0.1 cm. Resolved on 02/21/18. Pressure Ulcer #3 right top of foot Newly Acquired 05/01/18, Stage II, Length 1.8 cm, Width 1.4 cm, Depth 0 cm, noted to resolve on 5/23/18. Pressure Ulcer #4 left buttock returned to facility with the Pressure ulcer on 04/28/17, Stage III, 3cm length, 3.5 cm width and 1. cm depth. -05/05/17, Stage III, 5.5 cm length, 3.5 cm width, 1 cm depth. -05/19/17, Unstageable, 5.5 cm length, 3.0 cm width, 1.3 cm depth. -06/06/17, Unstageable, 8 cm length, 4 cm width, 4 cm depth. -06/29/17, Unstageable, 6 cm length, 6 cm width, 4.4 cm depth. -07/06/17, Unstageable, 5 cm length, 7 cm width, 4 cm depth. -07/12/17, Unstageable, 8 cm length, 4.5 cm width, 3 cm depth. -07/19/17, Unstageable, 6.5 cm length, 6 cm width, 3 cm depth. -07/26/17, Unstageable, 7 cm length, 5.5 cm width, 2.8 cm depth. -08/02/17, Unstageable, 8.2 cm length, 5 cm width, 2.6 cm depth. -08/09/17, Stage IV, 8 cm length, 4.4 cm width, 3 cm depth. -08/16/17, Stage IV, 8.5 cm length, 5.5 cm width, 3.8 cm depth. -08/23/17, Stage IV, 8.2 cm length, 4 cm width, 3.8 cm depth. -08/30/17, Stage IV, 6 cm length, 7 cm width, 3.8 cm depth. -09/06/17, Stage IV, 7.6 cm length, 5.5 cm width, 3.5 cm depth. -09/13/17, Stage IV 7 cm length, 3.8 cm width, 2.5 cm depth. -09/20/17, Stage IV, 7 cm length, 3.5 cm width, 2.5 cm depth. -10/04/17, Stage IV, 7 cm length, 3 cm width, 3 cm depth. -10/11/17, Stage IV, 7 cm length, 3 cm width, 2.6 cm depth. -10/18/17, Stage IV, 6.9 cm length, 3 cm width, 2.3 cm depth. -10/25/17, Stage IV, 6.9 cm length, 3 cm width, 2 cm depth. -11/01/17, Stage IV, 6.5 cm length, 2.7 cm width, 1.6 cm depth. -11/08/17, Stage IV, 5.5 cm length, 3.2 cm width, 1.3 cm depth. -11/15/17, Stage IV, 5.8 cm length, 3.6 cm width, 1.6 cm depth. -11/22/17, Stage IV, 5.5 cm length, 3.5 cm width, 1.3 cm depth. -11/29/17, Stage IV, 5.4 cm length, 3.2 cm width, 1.4 cm depth. -12/06/17, Stage IV, 5.3 cm length, 3.2 cm width, 1.1 cm depth. -12/13/17, Stage IV, 5 cm length, 2.6 cm width, 1.3 cm depth. -12/20/17, Stage IV, 4.5 cm length, 2.5 cm width, 1.3 cm depth. -12/27/17, Stage IV, 4.5 cm length, 2.4 cm width, 1.3 cm depth. -01/03/18, Stage IV, 4.5 cm length, 2.3 cm width, 0.7 cm depth. -01/10/18, Stage IV, 4.5 cm length, 2.6 cm width, 0.7 cm depth. -01/17/18, Stage IV, 4.4 cm length, 2.5 cm width, 0.6 cm depth. -01/24/18, Stage IV, 4.9 cm length, 3 cm width, 1.8 cm depth. -01/31/18, Stage IV, 4.9 cm length, 3.8 cm width, 2.4 cm depth. -02/14/18, Stage IV, 5 cm length, 3.2 cm width, 2.1 cm depth. -02/21/18, Stage IV, 5.3 cm length, 3.3 cm width, 2.4 cm depth. -02/28/18, Stage IV, 4.9 cm length, 3.2 cm width, 2.1 cm depth. -03/07/18, Stage IV, 4.7 cm length, 3.1 cm width, 2.2 cm depth. -03/14/18, Stage IV, 4.5 cm length, 3 cm width, 1.8 cm depth. -03/21/18, Stage IV, 4.3 cm length, 3. cm width, 1.8 cm depth. -03/28/18, Stage IV, 4.3 cm length, 3 cm width, 1.5 cm depth. -04/04/18, Stage IV, 5 cm length, 3 cm width, 2.5 cm depth. -04/11/18, Stage IV, 5 cm length, 3 cm width, 2 cm depth. -04/18/18, Stage IV, 4.7 cm length, 3 cm width, 1.7 cm depth. -04/25/18, Stage IV, 4.5 cm length, 3 cm width, 1.5 cm depth. -05/02/18, Stage IV, 3.8 cm length, 2.6 cm width, 1.1 cm depth. -05/09/18, Stage IV, 3.9 cm length, 3 cm width, 1 cm depth. -05/16/18, Stage IV, 3.6 cm length, 3 cm width, 0.7 cm depth. -05/23/18, Stage IV, 3.4 cm length, 3 cm width, 0.7 cm depth. -05/29/18, Stage IV, 3.3 cm length, 3 cm width, 0.7 cm depth. -06/03/18, Stage IV, 3.2 cm length, 3 cm width, 0.7 cm depth. -06/06/18. Stage IV, 3.2 cm length, 2 cm width, 1 cm depth. -06/13/18, Stage IV, 3.1 cm length, 1.9 cm width, 0.9 cm dept. -06/20/18, Stage IV, 3.3 cm length, 1.7 cm width, 0.7 cm depth. -06/27/18, Stage IV, 3.1 cm length, 1.5 cm width, 0.8 cm depth. -07/04/18, Stage IV, 3 cm length, 1.5 cm width, 0.7 cm depth. -07/11/18, Stage IV, 3 cm length, 1.7 cm width, 0.9 cm depth. -07/18/18, Stage IV, 4 cm length, 2.7 cm width, 1.8 cm depth. -07/25/18, Stage IV, 5.8 cm length, 3.3 cm width, 3 cm depth. -08/01/18, Stage IV, 4.5 cm length, 2.2 cm width, 1.5 cm depth. Pressure ulcer #5 left inner heel. Present on readmission 05/31/17, Stage as Suspected Deep Tissue Injury, 3.5 cm length, 4.8 cm width, resolved 01/13/18. Pressure Ulcer #6 right upper gluteal muscle Newly Acquired 08/1/18, Stage II, 1.5 cm length, 1.0 cm width, 0 .1 cm depth. During an interview on 08/01/18 at 10:19 AM, Director of Nursing (DON) clarified that the Nursing Assistance (NA) do not document when they reposition residents until at the end of their shift. During an interview and observation of wound care on 08/01/18 at 9:18 AM, Registered Nurse (RN) #27 informed Resident # 16 about what she was doing. Resident #16 was lying on his left side. RN #27 removed the dressing and wound vac from his coccyx, noting there was another dressing on the right buttock. RN #27 stated that this was a new area from last week. She left the room to call the attending Physician for new orders and to notify him of the new pressure ulcer. She measures this new wound as 1.4 cm length and 1cm width. The wound the wound vac was being used on was large beefy red deep wound on the coccyx. During an interview on 08/01/18 at 4:29 PM, DON said that the facility is aware this Residents Pressure ulcers and the steps they have taken to promote healing and prevention for him is: (1) A Registered Nurse (RN) is to looks at pressure ulcers daily. (2) He is on a Dolphin bed (which is used to help decrease pressure ulcers). She was asked if anyone checks to see if the NA are turning this resident very two hours. She said yes, they have two (2) RN's on the floor that do spot checks. When she was informed of the multicable observations of him lying in the same position. She said she knows that he refuses at times. She also said that the Dolphin bed displaces his weight even if he is not repositioned. She agrees that because he has the Dolphin bed it does not replaced the need for repositioning every 2 hours. As shown above this Resident has acquired four (4) new pressure ulcers in the last six (6) months and pressure ulcer # 4 is over a year old, it has worsened many time and has not healed as of to date.",2020-09-01
2755,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2018-08-01,697,D,0,1,VC1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and record review, the facility failed to ensure non-pharmacological interventions/approaches to pain management were implemented in addition to providing the (PRN) as needed, pain medication. This was true for one (1) of five (5) residents reviewed for the care area of pain. Facility census: 54. Resident identifier: #39. Findings included: a) Resident #39 At 10:54 a.m. on 07/30/18 10:54, the resident said she had some pain occasionally. She said the facility, Has to try to keep up with my pain, if I wait too long it gets out of control. Once in a while this happens, but not often. The resident said she gets as needed pain medication for her pain. She said sometimes she asks for the medication and receives it and sometimes the staff ask her if she needs the medication. Record review found a sixty-six (66) year old resident receiving Hospice services for a [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED] [MEDICATION NAME] Tablet 5-325 mg. every 2 hours PRN (as Needed). (The medication was discontinued on 07/16/18.) Administered on the following dates and times from 07/01/18-07/16/18: 07/01/18 at 5:06 a.m. and 10:42 a.m. 07/02/18 at 12:50 a.m., 11:01 a.m., and 8:58 p.m. 07/03/18 at 10:24 a.m. 07/04/18 at 2:12 a.m. 07/05/18 at 2:24 a.m. and 9:41 p.m. 07/06/18 at 10:36 a.m. and 9:37 p.m. 07/07/18 at 1:48 p.m. 07/08/18 at 10:42 a.m. and 9:12 p.m. 07/09/18 at 12:00 p.m. 07/10/18 at 4:00 a.m., 1:53 p.m., and 10:29 p.m. 07/11/18 at 5:49 a.m., 1:53 p.m. and 10:19 p.m. 07/12/18 at 6:00 a.m., 10:20 a.m., and 1:28 p.m. 07/13/18 at 11:56 a.m. and 8:25 p.m. 07/16/18 at 5:03 p.m. On 07/17/18 the physician ordered [MEDICATION NAME] 20 mg/5 ml, give 0.25 mi by mouth every 2 hours PRN (as needed) for pain. The [MEDICATION NAME] was administered on the following dates and times from 07/17/18-07/25/18: 07/17/18 at 8:29 a.m., 12:31 a.m., 3:49 p.m., 6:12 p.m. 07/18/18 at 4:17 a.m., 7:33 p.m. 07/19/18 at 12:00 a.m. 12:02 p.m. 07/20/18 1:29 p.m. and 7:38 p.m. 07/21/18 at 11:17 a.m., 3:49 p.m ., 10:39 p.m. 07/22/18 10:00 a.m., 3:52 p.m., 9:06 p.m. and 11:35 p.m. 07/23/18 at 3:08 p.m. 07/24/18 at 6:34 p.m. 07/25/18 at 10:32 p.m. (This medication was discontinued on 07/26/18) On 07/26/18 the [MEDICATION NAME] was increased to 100 mg/5 ML every 2 hours as needed for pain. The [MEDICATION NAME] was administered on the following dates and times: 07/26/18 at 9:30 a.m. 07/27/18 at 3:48 p.m. and 11:27 p.m. 07/28/17 at 5:53 a.m. and 5:14 p.m. 07/29/17 at 2:40 p.m. and 11:58 p.m. 07/30/17 at 10:11 a.m., 5:30 p.m and 10:53 p.m. At 11:31 a.m. on 07/31/18 the Registered Nurse Clinical Care Supervisor (CCS) #45 said the facility does not document the non-pharmacological interventions used in addition to the pain medication. She said administering non-pharmacological interventions is a standard of practice. She said the care plan listed the interventions to be provided. The care plan was reviewed with the CCS #45 during the interview. Review of the current care plan found the following focus/problem: (Name of Resident) has acute/chronic pain r/t/ [MEDICAL CONDITIONS], gastritis, chronic abdominal pain and muscle spasms. The goal associated with the problem: Patient will verbalize adequate relief of pain through review date. Interventions included: Provide patient with reassurance that pain is time limited. Encourage patient to try different pain relieving methods i.e. positioning, relaxation therapy, progressive relaxation, bathing, heat and cold application, muscle stimulation, ultra-sound. Involve family members as appropriate in non-pharmacological interventions. CCS #45 said the nurse would decide which of the above interventions to provide before giving the pain medication. On 07/31/18, at 3:47 p.m. the residents Licensed Practical Nurse (LPN) #24 reviewed the non-pharmacological interventions listed on the care plan. LPN #24 said she thought therapy would do ultrasound on the resident. LPN #24 said the resident was not receiving therapy at this time. She did not know exactly what progressive relaxation would entail. She said she had no special training in relaxation therapy. At 3:48 p.m. on 07/31/18, the Director of Nursing (DON) confirmed nursing staff did not document the non-pharmacological interventions implemented before providing the resident's pain medication. She verified her staff were not trained in relaxation therapy. There was no documentation to support who provided the non-pharmacological interventions, what non-pharmacological interventions were provided and if the interventions were effective or not.",2020-09-01
2756,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2018-08-01,756,D,0,1,VC1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and physician interview the facility failed to ensure one (1) of five residents whose medications were reviewed had a drug regimen that was free from irregularities. Resident #36's phsyciain orders reveaeld a multivitmain prescribed for irregular menstration. Resident identifier: #36. Facility census: 54. Findings included: a) Resident #36 A review of Resident #36's physician's orders [REDACTED]. During a telephone interview with the resident's physician, on 08/01/18 at 10:00 AM, he stated their was no medical basis for the [DIAGNOSES REDACTED]. The physician stated it was possible the resident's daughter had said the Multivital-M tablet helped with the resident's irregular menstruation when she was living at home. A progress note, dated 08/01/18 at 10:37 AM, created by Clinical Care Supervisor #45 reflected, Patient has a Dx (diagnosis) of Irregular Menstruation for MVI (Mulitvital-M) with minerals Spoke with (name of Family Nurse Practicioner) in facility and states to change Dx from irregular menstruation to supplement. A review of the pharmacy consultation reports for the months of April, May, and (MONTH) (YEAR) did not reflect the pharmacist's identificatin of the Multivital-M tablet being prescribed for Irregular Menstration.",2020-09-01
2757,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2018-08-01,867,D,0,1,VC1411,"Based on observation, medical record review and staff interview the facility failed to ensure they identified and corrected quality deficiencies of which they should have been aware. The facility did not provide services to prevent the development and worsening of pressure ulcers for Resident #16. Resident identifier: #16. Facility census: 54. Findings included: a) Resident #16 On 08/01/18 at 4:28 PM an interview with the Director of Nursing (DoN) revealed the facility had made some changes in their wound care protocols. The DoN said now Registered Nurses do wound observations on day shift now everyday. She said they discuss all the in house wounds, healed wounds and those making progress daily. The DoN said they inform the medical director of any changes to the wounds. They keep the medical director updated on the status of the residents' wounds. According to the DoN the registered nurses do weekly summary notes on resident's who have wounds once a week. The DoN said at least every other week the registered nurses do a full body audit. The DoN said the registered nurses do spot checks to ensure residents are receiving the care they need. The DoN said Resident #16 was on a speciality mattress called a Dolphin Mattress. She explained that this mattress redistributed the air flow/pressure. She said this helped because the resident often did not want turned and repositioned. The DoN was asked how the facility ensured the resident was turned and repositioned or re-approached if previously he had refused to be turned and/or repositioned The DoN said the nursing staff document once per shift they have completed the necessary turning and repositioning. She emphasized that was why the resident had the Dolphin mattress. The DoN said the Dolphin mattress basically ensured pressure was redistributed even if the resident was not turned/repositioned.",2020-09-01
2758,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2018-08-01,880,D,0,1,VC1411,"Based on observation, staff interview and policy review the facility failed to ensure implementation of an ongoing infection control program to prevent the spread of infection. A staff member was observed touching the rim of the water pitcher lids with the ice scoop used to scoop ice. This practice had the potential to affect more than an isolated number of residents. (Touched the side of plastic water pitcher with the ice scoop.) Facility census: 54. Findings included: a) On 08/01/18 at 2:55 PM an observation of Nurse Aide (NA #200 revealed the NA was scooping ice out of the ice cart for residents on B hallway. NA #17 and another unidentified NA was observed getting the plastic water pitchers from rooms on B hall and bringing them to NA #200 to fill with ice. NA #200 took the scoop out of the ice cart and touched the rim of each pitcher with the scoop when filling it with ice. At 3:15 PM on 08/01/18 the Director of Nursing (DoN) was asked if the facility had a policy for the procedures followed during ice pass. The DoN was told about the observation of the ice pas at 2:55 PM on 08/01/18. A review of the policy titled, Serving Drinking Water revealed the following under the Infection Control Protocol and Safety section, 4. Do not touch the water pitcher with the ice scoop.",2020-09-01
2759,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2018-08-01,883,D,0,1,VC1411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure the pneumococcal immunization consent was complete for Resident #36. This was true for one (1) of five (5) residents reviewed for the care area of immunization. Facility census was 54. Findings included: a) Resident #36 Review of medical records revealed a consent for the pneumococcal immunization was not complete, there was not a mark to indicate if this resident was consenting or refusing the immunization. During an interview on 07/31/18 at 3:00 PM, Director of Nursing (DON) was asked about the pneumonia consent not being checked. She said, Well Resident #36 has capacity and would not have signed it if she didn't want it. She was asked if they are required the sign this same form if they would want to refuse the immunization? She said, yes she would. She agreed it was left blank and was not checked to indicate Give my consent to administration of this vaccination or Decline the administration of this vaccination. Records revealed received the vaccine on 10/24/17, [MEDICATION NAME] 23.",2020-09-01
4614,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2016-06-23,253,E,0,1,FTTJ11,"Based on observation, resident interview, and staff interview, the facility failed to provide effective housekeeping and maintenance services for eleven (11) of twenty-three (23) resident rooms observed during Stage 1 of the Quality Indicator Survey (QIS). These cosmetic imperfections affected more than an isolated number of residents. Room identifiers: A4, A14B, A16, B2, B3, B4, B7, B8, B13, B14, and B16. Facility census: 59. Findings include: a) Cosmetic imperfections -- Room A4 - observed on 06/21/16 at 11:46 a.m. - had a light under the sink with the glass pushed in exposing the rust inside the light fixture and the corner molding beside the sink needed repaired. -- Room A14B - observed on 06/21/16 at 11:29 a.m. - had paint peeling off the wall behind bed. -- Room A16 - observed on 06/21/16 at 10:58 a.m. - had a light under the sink which was rusted and the bathroom light bulb needed replaced. -- Room B2 - observed on 06/21/16 at 3:23 p.m. - had a chipped commode tank cover, caulking around the commode needed replaced, and a light cover that had pulled away from the wall. -- Room B3 - observed on 06/21/16 at 1:54 p.m. - had a light under the sink with the glass pushed in exposing the rust and sharp edges. -- Room B4 - observed on 06/21/16 at 3:18 p.m. - had the cover missing on the paper towel holder. -- Room B7 - observed on 06/21/16 at 3:32 p.m. - had a bathroom door with peeling paint and the privacy curtain was missing hooks. -- Room B8 - observed on 06/21/16 at 4:00 p.m. - had a bathroom door with peeling paint and scratches. -- Room B13 - observed on 06/21/16 at 12:01 p.m. - had a large yellow stain on the floor tiles between the residents' beds, the bathroom ceiling vent cover was hanging down and there was a water stain on the bathroom ceiling. -- Room B14 - observed on 06/21/16 at 2:02 p.m. - had a water stain on the bathroom ceiling, the light under the sink had the glass pushed in which exposed rust and rough edges, and the corner molding at the sink had pulled away from the wall. -- Room B16 - observed on 06/21/16 at 2:32 p.m. - had privacy curtains with missing hooks and section of privacy curtains was torn and needed to be replaced. b) Observation and interview with the Maintenance Supervisor During observations with the Maintenance Supervisor on 06/23/16 at 11:25 a.m., he verified the cosmetic imperfections in Rooms A4, A14, A16, B2, B3, B4, B7, B8, B13, B14, and B16 needed to be repaired or replaced.",2019-09-01
4615,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2016-06-23,353,E,0,1,FTTJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, resident interview, and staff interview, the facility failed to deploy qualified staff to ensure staff responded to the residents' call lights in a timely manner. This was true for three (3) of three (3) residents reviewed for call light response times. This practice had the potential to affect all residents who were able to use their call lights and required staff assistance. Resident identifiers: #6, #79, and #82. Facility census: 59. Findings include: a) Resident #6 An interview with Resident #6 on 06/21/16 at 04:28 p.m., revealed the resident did not think the facility had enough staff to provide care in a timely manner to all the residents at times. Resident #6 reported, When I need help and push the call light, I have had to wait some times more than thirty (30) minutes for a nurse aide (NA), I've checked them (the times). Sometimes they (NA) walk by my room when my light is on, turn their heads the other way, and walk on by. I tell them I am going to report them, they say go ahead. When asked if she had reported the aides to the nurse, Resident #6 replied, No, not this time. They do not pay me no mind or do anything about it, so I quit telling them things. b) Interview with Social Worker On 06/22/16 at 8:45 a.m., an interview with the Social Worker (SW) concerning Resident #6's allegations revealed the SW was not aware of any of the issues Resident #6 had discussed with the surveyor concerning the NAs. The SW stated Resident #6, . has chronic issues she (Resident #6) does complain about a lot of different things and I always investigate them. An interview with the SW, on 06/23/16 10:35 a.m., revealed the SW initiated an investigation after becoming aware of the allegation, reported to appropriate agencies, and suspended the NA involved in the allegation until the outcome of the investigation is completed. The SW provided copies of the of the investigation paperwork for review. c) Interview with the Director of Nursing (DON) An interview with the DON on 06/23/16 at 10:22 p.m. revealed call light audits were reviewed at morning meetings and any issues identified were addressed at that time. The DON stated, We tell staff call lights need to be answered within 20 minutes. The DON revealed NA had two (2) different recent in-service trainings concerning answering call lights promptly. A training on 04/20/16 which included: #3 Timely answering of call lights, and another training on 05/13/16, Respond to patient's needs/request - #3 Answer call lights in a timely manner. d) Call bell/light audits Resident #6 During the interview with the DON, all bell audits were requested from the last in-service on answering call bells (05/13/16) to present time (06/22/16), for Resident #6 and two (2) randomly chosen residents (#79 and #82) residing on A hall. 1. Resident #6 On 06/23/16 at 11:14 a.m. review of call bell audits revealed fourteen (14) different times the response to the resident's call bell was more than 20 minutes for Resident #6: - The response time was sixty-five (65) minutes at 6:28 p.m. on 05/27/16. - The response time was forty-eight (48) minutes at 08:05 p.m. on 06/09/16. - The response time was forty-four (44) minutes at 08:07 a.m. on 06/14/16. - The response time was forty-two (42) minutes at 10:41 a.m. on 06/16/16. - The response time was forty-one (41) minutes at 7:11 p.m. on 06/22/16. - The response time was thirty-four (34) minutes on 05/15/16 at 7:30 p.m. - The response time was thirty-four (34) minutes at 6:28 p.m. on 05/28/16. - The response time was twenty-five (25) minutes at 7:41 p.m. and 8:59 p.m. on 06/07/16 - The response time was twenty-five (25) minutes at 06:26 a.m. on 06/17/16. - The response time was twenty-three (23) minutes at 6:29 p.m. on 06/07/16 - The response time was twenty-three (23) minutes and at 6:46 p.m. on 06/08/16. - The response time was twenty-two (22) minutes on 05/14/16 at 12:45 p.m. - The response time was twenty-two (22) minutes at 7:50 p.m. on 06/13/16. 2. Resident #79 On 06/23/16 at 11:14 a.m. review of call bell audits revealed seventeen (17) different times the call bell response time was more than 20 minutes for Resident #79: - The response time was forty-six (46) minutes at 9:32 a.m. on 05/17/16 - The response time was forty-six (46) minutes at 6:08 on 06/16/16. - The response time was forty-five (45) minutes at 12:42 p.m. on 05/24/16. - The response time was forty-four (44) minutes at 06:17 a.m. on 06/10/16. - The response time was forty-three (43) minutes at 06:21 a.m. on 06/15/16. - The response time was thirty-five (35) minutes at 8:14 p.m. on 05/22/16. - The response time was thirty-two (32) minutes at 6:00 p.m. on 06/09/16. - The response time was thirty-one (31) minutes at 6:11 a.m. on 06/21/16. - The response time was thirty (30) minutes at 8:56 a.m. on 06/02/16. - The response time was twenty-eight (28) minutes at 9:04 a.m. on 06/13/16 - The response time was twenty-eight (28) minutes at 8:37 a.m. on 06/05/16. - The response time was twenty-six (26) minutes at 3:31 p.m. on 05/15/16. - The response time was twenty-five (25) minutes at 8:40 a.m. on 05/18/16. - The response time was twenty-four (24) minutes at 1:17 p.m. on 06/19/16. - The response time was twenty-three (23) minutes at 6:19 p.m. on 06/07/16. - The response time was twenty-one (21) minutes on 06/22/16 at 12:46 p.m. - The response time was twenty-one (21) minutes at 9:07 a.m. on 06/14/16. 3. Resident #82 On 06/23/16 at 11:14 a.m. review of records and call bell audits revealed Resident #82 was admitted to the facility on [DATE], and during the twelve (12) days the resident resided in the facility, there were two (2) times the call bell response time was more than 20 minutes: - The response time was twenty-nine (29) minutes at 7:47 a.m. on 06/11/16. - The response time was twenty-three (23) minutes at 6:50 a.m. on 06/17/16. e) Follow up interview with the DON At 12:01 p.m. on 06/23/16, the DON confirmed the problem of staff not answering call lights in a timely manner continued, even after staff in-service trainings on 04/20/16 and 05/13/16. When asked how the facility addressed the ongoing issue, the DON stated she would verbally remind staff from time to time, but she did not have any evidence that it was addressed since the last training on 05/13/16. The DON stated there was a Nurse Aid meeting scheduled for that afternoon, and she would include answering call bells in a timely manner on the agenda.",2019-09-01
4616,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2016-06-23,386,D,0,1,FTTJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure the Certified Family Nurse Practitioner (CFNP) accurately assessed Resident #15 when completing face to face visits. Resident #15's physician progress notes [REDACTED]. This was true for one (1) of one (1) residents reviewed for the care area of tube feeding during Stage 2 of the Quality Indicator Survey. Resident Identifier: #15. Facility Census: 59. Findings Include: a) Resident #15 At 3:00 p.m. on 06/22/16, review of the physician progress notes [REDACTED]. CFNP #99 made all of Resident #15's visits except for two (2) visits. Those visits, on 06/06/16 and 06/13/16, were made by CFNP #100. Review of CFNP #99's physician progress notes [REDACTED]. -- CFNP #99 saw Resident #15 on 10/05/15, for follow up related to her cachexia (a profound and marked state of constitutional disorder; general ill health and malnutrition). CFNP #99 noted the resident was awake, alert, well developed, well groomed, and well nourished. She indicated the resident's weight was stable. The CFNP noted her treatment plan for Resident #15's cachexia was (typed as written), Improved. Staff to allow consumer to feed himself, then when he stops eating during meal staff are to prompt and feed him to finish meal. -- CFNP #99 again saw Resident #15 on 11/09/15, for a follow up related to her cachexia. CFNP #99 again noted the resident was awake, alert, well developed, well groomed, and well nourished. She indicated that her weight was stable. The CFNP noted her treatment plan for Resident #15's cachexia was (typed as written), Staff to allow consumer to feed himself, then when he stops eating during meal staff are to prompt and feed him to finish meal. -- On 12/14/15, CFNP #99 saw the resident for another follow up to her cachexia. CFNP #99 again noted the resident awake, alert, well developed, well groomed, and well nourished. She indicated that her weight was stable. The CFNP noted her treatment plan for Resident #15's cachexia was (typed as written), Improved. Staff to allow consumer to feed himself, then when he stops eating during meal staff are to prompt and feed him to finish meal. It should be noted that Resident #15 was a female who received her nutrition via a [DEVICE] (gastrostomy tube - a tube inserted into the stomach). The resident did receive pleasure liquids by mouth, but did not have orders for, or receive, pleasure foods. She was also totally dependent on staff for all care and could not feed herself even if she took food by mouth. However, despite these facts, CFNP #99 referred to the resident as a man and her plan of treatment involved the resident feeding self and the staff providing encouragement for the resident to finish eating meals for three (3) consecutive months. When reviewed with the Director of Nursing (DON) at 4:12 p.m. on 06/22/16, she confirmed CFNP #99's notes did not accurately reflect Resident #15.",2019-09-01
4617,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2016-06-23,387,E,0,1,FTTJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the Centers for Medicaid and Medicare Service's (CMS) Guidance to Surveyors, and review of Rule ,[DATE] - West Virginia (WV) Nursing Home Licensure, the facility failed to ensure the physician made face-to-face visits every sixty (60) days following the first ninety (90) days after admission. This was true for thirteen (13) of fourteen (14) residents reviewed for physician visits during Stage 2 of the Quality Indicator Survey (QIS). This practice had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: #10, #19, #74, #2, #24, #70, #66, #52, #6, #29, #15, #32, and #21. Facility census: 59. Findings include: a) Review of Guidance to Surveyors and West Virginia Licensure: On [DATE] at 4:00 p.m., review of the guidance to surveyors from CMS, found the guidelines include visits by the physician will be made within the first 30 days, and then at 30 day intervals up until 90 days after the admitted . Visits will then be at 60 day intervals. Permitting up to 10 days slippage of a due date will not affect the next due date. After the initial physician visit in skilled nursing facilities (SNFs), where States allow their use, a qualified nurse practitioner (NP), clinical nurse specialist or physician assistant (PA) may make every other required visit. The timing of physician visits is based on the admitted the resident. On [DATE] at 4:15 p.m., review of the West Virginia Licensure Rule ,[DATE] effective [DATE], found: -- 8.16.3 includes, After the ninety (90) day requirement has expired, the physician shall visit every sixty (60) days and as the resident's condition warrants, and -- 8.16.f includes, After the initial visit, at the option of the physician, the required visit every 60 days may be alternated between personal visits by the physician and visits by the physician assistant, nurse practitioner or clinical specialist under the provisions of this rule. The following residents did not have physician visits as required: 1. Resident #10 Review of Resident #10's medical records on [DATE] at 2:30 p.m., found the last visit by the physician was on [DATE]. 2. Resident #19 On [DATE] at 2:45 p.m., medical record review revealed the last physician visit by the physician was on [DATE]. 3. Resident #74 Medical record review at 4:00 p.m. on [DATE] found this resident, admitted on [DATE], had an admission history and physical by the physician, but no other visits by the physician or certified family nurse practitioner were found. 4. Resident #2 Medical record review on [DATE] at 4:10 p.m., found this resident, admitted on [DATE], found the only documented note by the physician was on [DATE]. No other notes were found until [DATE], which was by the certified family nurse practitioner. 5. Resident #24 Medical record review at 4:20 p.m. on [DATE], found this resident, admitted on [DATE], had no notes by either the physician or certified family nurse practitioner since admission. 6. Resident #70 Medical record review on [DATE] at 4:30 p.m., found this resident, admitted on [DATE], contained a 30 day progress note by the physician on [DATE]. There was no evidence of visits every 30 days for the first 90 days. 7. Resident #66 A review of the resident's medical record on [DATE] at 9:45 a.m. revealed her physician did not see the resident from [DATE] to [DATE]. 8. Resident #52 A review of the medical record on [DATE] at 3:11 p.m., found this resident was not been seen by her physician from [DATE] to [DATE]. 9. Resident #6 Review of the resident's medical records on [DATE] at 5:40 p.m., found a 90 Day Progress Encounter by the physician dated [DATE]. There was no evidence the physician saw the resident after [DATE]. 10. Resident #29 Review of medical records on [DATE] at 6:08 p.m., revealed a 90 Day Progress Encounter by the physician dated [DATE]. There was no evidence the physician had seen the resident after [DATE]. 11. Resident #15 A review of Resident #15's medical record beginning at 9:33 a.m. on [DATE] found no evidence the resident's physician had seen the resident since [DATE]. The Certified Family Nurse Practitioner (CFNP) made all physician notes in the medical record from [DATE] through time of this review. On [DATE] at 1:06 p.m., the Director of Nursing was asked to provide any evidence Resident #15's attending physician had completed a face-to-face visit with the resident since [DATE]. All she was able to provide was a visit that he made on the night of [DATE] following surveyor intervention. 12. Resident #32 A review of Resident #32's medical record at 3:00 p.m. on [DATE] found no evidence her attending physician had made a face-to-face visit with her since [DATE]. A CFNP and not the attending physician made all visits from [DATE] through present. On [DATE] at 1:06 p.m., the Director of Nursing was asked to provide any evidence to show that Resident #32's attending physician had completed a face-to-face visit with resident since [DATE]. At the time of exit at 3:45 p.m. on [DATE], the facility provided no further information. 13. Resident #21 A review of Resident #21's physician progress notes [REDACTED]. Certified Family Nurse Practitioner #99 made visits to the resident from [DATE] through [DATE]. b) During an interview on [DATE] at 5:50 p.m., the director of nursing (DON) stated, The physician just told me on the phone he must have misinterpreted the regulation. He told her that he thought that after the 90 days, the Family Nurse Practitioner could take over the resident's care and make all of the visits. She further verified the last physician visit dates of the thirteen (13) residents (#10, #19, #74, #2, #24, #70, #66, #52, #6, #29, #15, #32, #21) reviewed were accurate. c) Interview with the Attending Physician/Medical Director at 10:45 a.m. on [DATE], revealed he had misinterpreted the regulation. He stated, I will correct that immediately. I thought the FNP could see the residents after the first 90 days. That is my fault.",2019-09-01
4618,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2016-06-23,390,E,0,1,FTTJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the Centers for Medicaid and Medicare Service's (CMS) Guidance to Surveyors, and review of Rule ,[DATE] - West Virginia Nursing Home Licensure, the facility failed to ensure the physician made required face-to-face visits. Required physician visits were delegated to the Family Nurse Practitioner (FNP) working with the physician. This was true for eight (8) of fourteen (14) residents reviewed for physician visits during Stage 2 of the Quality Indicator Survey (QIS). This practice had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: #70, #66, #52, #6, #29, #15, #32, and #21. Facility census: 59. Findings include: a) Review of Guidance to Surveyors and West Virginia Licensure Rule ,[DATE]: On [DATE] at 4:00 p.m., review of the guidance to surveyors from CMS, found the guidelines include visits by the physician will be made within the first 30 days, and then at 30 day intervals up until 90 days after the admitted . Visits will then be at 60 day intervals. Permitting up to 10 days slippage of a due date will not affect the next due date. After the initial physician visit in skilled nursing facilities (SNFs), where States allow their use, a qualified nurse practitioner (NP), clinical nurse specialist or physician assistant (PA) may make every other required visit. The timing of physician visits is based on the admitted the resident. On [DATE] at 4:15 p.m., review of the West Virginia Nursing Home Licensure Rule ,[DATE] effective [DATE], found: -- 8.16.3 includes, After the ninety (90) day requirement has expired, the physician shall visit every sixty (60) days and as the resident's condition warrants, and -- 8.16.f includes, After the initial visit, at the option of the physician, the required visit every 60 days may be alternated between personal visits by the physician and visits by the physician assistant, nurse practitioner or clinical specialist under the provisions of this rule. The following residents had physician required delegated to a Nurse Practitioner: 1. Resident #70 Medical record review on [DATE] at 4:30 p.m., found this resident, admitted on [DATE], contained a progress note by the physician on [DATE]. There was no evidence of visits every 30 days for the first 90 days. There were six notes after this, completed by the certified family nurse practitioner. 2. Resident #66 A review of the medical record for Resident #66 on [DATE] at 9:45 a.m. revealed the Certified Family Nurse Practitioner (CFNP) saw the resident from [DATE] to [DATE]. Further review found the resident's physician had not documented a visit during this time span. 3. Resident #52 A review of the medical record for Resident #52 on [DATE] at 3:11 p.m. revealed the CFNP saw the resident from [DATE] to [DATE]. Further review found the resident's physician had not documented a visit during this time span. 4. Resident #6 Review of the resident's medical records on [DATE] at 5:40 p.m., found a 90 Day Progress Encounter by the physician dated [DATE]. There was no evidence the physician saw the resident after [DATE]. A Family Nurse Practitioner (FNP) saw the resident, on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 5. Resident #29 Review of medical records on [DATE] at 6:08 p.m., revealed a 90 Day Progress Encounter by the physician dated [DATE]. There was no evidence the physician had seen the resident after [DATE]. A Family Nurse Practitioner saw the resident after on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. 6. Resident #15 A review of Resident #15's medical record beginning at 9:33 a.m. on [DATE] found no evidence the resident's physician had seen the resident since [DATE]. The Certified Family Nurse Practitioner (CFNP) made all physician notes in the medical record from [DATE] through time of this review. On [DATE] at 1:06 p.m., the Director of Nursing was asked to provide any evidence Resident #15's attending physician had completed a face-to-face visit with the resident since [DATE]. All she was able to provide was a visit that he made on the night of [DATE] following surveyor intervention. 7. Resident #32 A review of Resident #32's medical record at 3:00 p.m. on [DATE] found no evidence her attending physician had made a face-to-face visit with her since [DATE]. A CFNP and not the attending physician made all visits from [DATE] through present. On [DATE] at 1:06 p.m., the Director of Nursing was asked to provide any evidence to show that Resident #32's attending physician had completed a face-to-face visit with resident since [DATE]. At the time of exit at 3:45 p.m. on [DATE], the facility provided no further information. 8. Resident #21 A review of Resident #21's physician progress notes [REDACTED]. Certified Family Nurse Practitioner #99 made visits to the resident from [DATE] through [DATE]. b) During an interview on [DATE] at 5:50 p.m., the director of nursing (DON) stated, The physician just told me on the phone he must have misinterpreted the regulation. He told her that he thought that after the 90 days, the Family Nurse Practitioner could take over the resident's care and make all of the visits. She further verified the last physician visit dates of the thirteen (13) residents (#70, #66, #52, #6, #29, #15, #32, and #21) reviewed were accurate. c) Interview with the Attending Physician/Medical Director at 10:45 a.m. on [DATE], revealed he had misinterpreted the regulation. He stated, I will correct that immediately. I thought the FNP could see the residents after the first 90 days. That is my fault.",2019-09-01
4619,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2016-06-23,441,D,0,1,FTTJ11,"Based on observation, resident interview, and staff interviews, the facility failed to implement practices and processes designed to prevent infection and/or cross-contamination for one (1) of thirty (30) residents reviewed in Stage 1 of the Quality Indicator Survey (QIS). The facility failed to ensure a resident's oxygen tubing was dated when tubing was last changed. This practice had the potential to affect all residents who received oxygen therapy. Resident identifier: #83. Facility census: 59. Findings include: Observations of Resident #82's room on 06/21/16 at 11:23 a.m., revealed the oxygen tubing to the resident's oxygen machine did not have a date on it indicating when it was last changed. At that time, the resident was asked when the tubing was last changed, but the resident was unable to say when it was changed. Resident #83 said, They come in now and then, and change it, I am not sure when. At 12:01 p.m. on 06/23/16, the director of nursing (DON) confirmed the oxygen tubing was to be labeled and dated. The DON stated, The staff is to change, label, and date the tubing and water bottles every Sunday evening. They know this, they have been told. The DON agreed this was an infection control issue.",2019-09-01
4620,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2016-06-23,463,D,0,1,FTTJ11,"Based on observation, resident interview, and staff interview, the facility failed to ensure the call light was functioning for one (1) of thirty (30) residents reviewed in Stage 1 of the Quality Indicator Survey (QIS). Resident identifier: #82. Facility census: 59. Findings include: a) Resident #82 On 06/21/16 at 1:59 p.m., during Stage 1 observations of Resident #82's room, it was discovered that the call bell did not work. Resident #82 stated, I rang it all morning and no one came. I wanted a cup of coffee. Environmental Services Supervisor was immediately notified and came in to the room with Life Safety to inspect the call light. Environmental Services Supervisor found the call bell had become unplugged. After plugging the call light in, it became functional.",2019-09-01
4621,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2016-06-23,490,E,0,1,FTTJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the Centers for Medicaid and Medicare Service's (CMS) Guidance to Surveyors, and review of Rule ,[DATE] - West Virginia (WV) Nursing Home Licensure, the facility's administrative staff failed to ensure the physician made face-to-face visits every sixty (60) days following the first ninety (90) days after admission. This was true for thirteen (13) of fourteen (14) residents reviewed for physician visits during Stage 2 of the Quality Indicator Survey (QIS). This practice had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: #10, #19, #74, #2, #24, #70, #66, #52, #6, #29, #15, #32, and #21. Facility census: 59. Findings include: a) Review of Guidance to Surveyors and West Virginia Licensure Rule ,[DATE]: On [DATE] at 4:00 p.m., review of the guidance to surveyors from CMS, found the guidelines include visits by the physician will be made within the first 30 days, and then at 30 day intervals up until 90 days after the admitted . Visits will then be at 60 day intervals. Permitting up to 10 days slippage of a due date will not affect the next due date. After the initial physician visit in skilled nursing facilities (SNFs), where States allow their use, a qualified nurse practitioner (NP), clinical nurse specialist or physician assistant (PA) may make every other required visit. The timing of physician visits is based on the admitted the resident. On [DATE] at 4:15 p.m., review of the West Virginia Licensure Rule ,[DATE] effective [DATE], found: -- 8.16.3 includes, After the ninety (90) day requirements has expired, the physician shall visit every sixty (60) days and as the resident's condition warrants, and -- 8.16.f includes, After the initial visit, at the option of the physician, the required visit every 60 days may be alternated between personal visits by the physician and visits by the physician assistant, nurse practitioner or clinical specialist under the provisions of this rule. The following residents did not have physician visits as required: 1. Resident #10 Review of Resident #10's medical records on [DATE] at 2:30 p.m., found the last visit by the physician was on [DATE]. 2. Resident #19 On [DATE] at 2:45 p.m., medical record review revealed the last physician visit by the physician was on [DATE]. 3. Resident #74 Medical record review at 4:00 p.m. on [DATE] found this resident, admitted on [DATE], had an admission history and physical by the physician, but no other visits by the physician or certified family nurse practitioner were found. 4. Resident #2 Medical record review on [DATE] at 4:10 p.m., found this resident, admitted on [DATE], found the only documented note by the physician was on [DATE]. No other notes were found until [DATE], which was by the certified family nurse practitioner. 5. Resident #24 Medical record review at 4:20 p.m. on [DATE], found this resident, admitted on [DATE], had no notes by either the physician or certified family nurse practitioner since admission. 6. Resident #70 Medical record review on [DATE] at 4:30 p.m., found this resident, admitted on [DATE], contained a 30 day progress note by the physician on [DATE]. There was no evidence of visits every 30 days for the first 90 days. 7. Resident #66 A review of the resident's medical record on [DATE] at 9:45 a.m. revealed her physician did not see the resident from [DATE] to [DATE]. 8. Resident #52 A review of the medical record on [DATE] at 3:11 p.m., found this resident was not been seen by her physician from [DATE] to [DATE]. 9. Resident #6 Review of the resident's medical records on [DATE] at 5:40 p.m., found a 90 Day Progress Encounter by the physician dated [DATE]. There was no evidence the physician saw the resident after [DATE]. 10. Resident #29 Review of medical records on [DATE] at 6:08 p.m., revealed a 90 Day Progress Encounter by the physician dated [DATE]. There was no evidence the physician had seen the resident after [DATE]. 11. Resident #15 A review of Resident #15's medical record beginning at 9:33 a.m. on [DATE] found no evidence the resident's physician had seen the resident since [DATE]. The Certified Family Nurse Practitioner (CFNP) made all physician notes in the medical record from [DATE] through time of this review. On [DATE] at 1:06 p.m., the Director of Nursing was asked to provide any evidence Resident #15's attending physician had completed a face-to-face visit with the resident since [DATE]. All she was able to provide was a visit that he made on the night of [DATE] following surveyor intervention. 12. Resident #32 A review of Resident #32's medical record at 3:00 p.m. on [DATE] found no evidence her attending physician had made a face-to-face visit with her since [DATE]. A CFNP and not the attending physician made all visits from [DATE] through present. On [DATE] at 1:06 p.m., the Director of Nursing was asked to provide any evidence to show that Resident #32's attending physician had completed a face-to-face visit with resident since [DATE]. At the time of exit at 3:45 p.m. on [DATE], the facility provided no further information. 13. Resident #21 A review of Resident #21's physician progress notes [REDACTED]. Certified Family Nurse Practitioner #99 made visits to the resident from [DATE] through [DATE]. b) During an interview on [DATE] at 5:50 p.m., the director of nursing (DON) stated, The physician just told me on the phone he must have misinterpreted the regulation. He told her that he thought that after the 90 days, the Family Nurse Practitioner could take over the resident's care and make all of the visits. She further verified the last physician visit dates of the thirteen (13) residents (#10, #19, #74, #2, #24, #70, #66, #52, #6, #29, #15, #32, #21) reviewed were accurate. c) Interview with the Attending Physician/Medical Director at 10:45 a.m. on [DATE], revealed he had misinterpreted the regulation. He stated, I will correct that immediately. I thought the FNP could see the residents after the first 90 days. That is my fault.",2019-09-01
4622,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2016-06-23,514,E,0,1,FTTJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #15's medical record was complete and accurate. Resident #15's record contained inaccurate information related to her height, her Body Mass Index (BMI), and her enteral feeding orders. This was true for one (1) of one (1) resident reviewed for the care area of feeding tubes during Stage 2 of the Quality Indicator Survey. Resident Identifier: #15. Facility Census: 59. Findings Include: a) Resident #15 1. A review of Resident #15's medical record, beginning at 9:33 a.m. on 06/22/16, found this [AGE] year-old female, admitted to the facility on [DATE], had her admission height recorded as 60 inches (in) on the day of admission. On 06/22/16 at 4:15 p.m., the Director of Nursing (DON) was asked if the resident's height of 52 inches, which was first obtained on 01/25/15 was correct. She stated she would have to measure the resident to determine if that was an accurate height. The DON went to Resident #15's room and measured the resident using the wingspan technique. The resident's contractures at the knees and hips prevented her from being measured in a traditional method. The height obtained was 58 inches The DON, confirmed it was not likely the height of 52 inches was correct. 2. Enteral feeding Order Further review of the medical record, beginning at 9:33 a.m. on 06/22/16, found a physician's orders [REDACTED]. For a total of 525 ml, 1050 calories, 44 grams of protein, and 368 ml of free water. This was the enteral feeding order that was in effect at the start of this review. If staff ran the feeding for 30 ml an hour for 15 hours, the resident would only receive 450 ml for a total of 900 calories. However; the order directed the resident was to receive 525 ml for a total of 1050 calories. An interview with the DON at 4:12 p.m. on 06/22/16, confirmed this order needed clarified. 3. Licensed Dietitian (LD) Review Notes Further review of the record beginning at 9:33 a.m. on 06/22/16, found the facility's LD evaluated the resident using the incorrect height of 52 inches, resulting in inaccurate calculations of the resident's Body Mass Index (BMI) and nutrition/fluid needs on the following occasions since 09/01/15: -- On 11/10/15 - the LD saw the noted the resident's weight was 116 lb (pounds) and her BMI (body mass index) was 30.8. The LD indicated the resident was obese. Resident #15's BMI calculated using her correct height of 58 inches would be 24.2. -- On 12/21/15 - the LD, using a height of 52 inches, noted her current body weight was 112.7 lbs. and that she was overweight based on a BMI of 29.3 Resident #15's BMI, calculated using her correct height of 58 inches, was actually 23.6. -- On 01/27/16 - the LD noted the resident's weight was 110 pounds and her BMI was 28.6. However, Resident #15's BMI calculated using her correct height of 58 inches was 23. -- On 02/11/16 - the LD noted the resident's weight was 109.2 lb and her BMI was 28.4. Resident #15's BMI calculated using her correct height of 58 inches was 22.8. -- On 02/22/16 - the LD noted the resident weighed 110.4 lb and her BMI was 28.7. The LD again noted the resident was overweight. Resident #15's BMI calculated using her correct height of 58 inches was 23. -- On 03/10/16 - the LD noted she was seeing Resident #15 because of a weight loss. She noted the resident's weight was 108.7 lb and her BMI, again calculated using a height of 52 inches, was 28.3. Resident #15's BMI calculated using her correct height of 58 inches was 22.7. -- On 04/26/16 - the LD saw Resident #15 and noted that her current weight was 108.5 lb and that her BMI was 28.4. Resident #15's BMI calculated using her correct height of 58 inches was 22.7. -- On 05/24/16 - The LD last saw Resident #15 on 05/24/16, at which time she noted that the resident's current weight was 107.6 and that her BMI was 28. Resident #15's BMI calculated using her correct height of 58 inches was 22.5. 4. An interview with the Corporate Licensed Dietitian (C-LD) #101 at 1:06 p.m. on 06/23/16, found the resident's BMI was calculated by the facility's electronic medical records software using the formula, Imperial BMI = (weight in pounds/((Height in inches X Height in inches)) X 703. (All BMIs calculated using the appropriate height of 58 inches were calculated using this formula.) C-LD #100 agreed that the BMIs in the LD's notes were calculated using the wrong height which skewed the BMIs. (Note: Imperial BMI is the BMI using measurements used in the United States (inches and pounds) rather than metric measurements.)",2019-09-01
4623,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2016-06-23,520,E,0,1,FTTJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the Centers for Medicaid and Medicare Service's (CMS) Guidance to Surveyors, and review of Rule ,[DATE] - West Virginia (WV) Nursing Home Licensure, the facility's quality assurance (QA) committee failed to identify and correct a quality deficiency regarding required physician visits and the appropriate delegation of required visits to the Family Nurse Practitioner. This was true for thirteen (13) of fourteen (14) residents reviewed for physician visits during Stage 2 of the Quality Indicator Survey (QIS). This practice had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: #10, #19, #74, #2, #24, #70, #66, #52, #6, #29, #15, #32, and #21. Facility census: 59. Findings include: a) Review of Guidance to Surveyors and West Virginia Licensure: On [DATE] at 4:00 p.m., review of the guidance to surveyors from CMS, found the guidelines include visits by the physician will be made within the first 30 days, and then at 30 day intervals up until 90 days after the admitted . Visits will then be at 60 day intervals. Permitting up to 10 days slippage of a due date will not affect the next due date. After the initial physician visit in skilled nursing facilities (SNFs), where States allow their use, a qualified nurse practitioner (NP), clinical nurse specialist or physician assistant (PA) may make every other required visit. The timing of physician visits is based on the admitted the resident. On [DATE] at 4:15 p.m., review of the West Virginia Licensure Rule ,[DATE] effective [DATE], found: -- 8.16.3 includes, After the ninety (90) day requirements has expired, the physician shall visit every sixty (60) days and as the resident's condition warrants, and -- 8.16.f includes, After the initial visit, at the option of the physician, the required visit every 60 days may be alternated between personal visits by the physician and visits by the physician assistant, nurse practitioner or clinical specialist under the provisions of this rule. The following residents did not have physician visits as required: 1. Resident #10 Review of Resident #10's medical records on [DATE] at 2:30 p.m., found the last visit by the physician was on [DATE]. 2. Resident #19 On [DATE] at 2:45 p.m., medical record review revealed the last physician visit by the physician was on [DATE]. 3. Resident #74 Medical record review at 4:00 p.m. on [DATE] found this resident, admitted on [DATE], had an admission history and physical by the physician, but no other visits by the physician or certified family nurse practitioner were found. 4. Resident #2 Medical record review on [DATE] at 4:10 p.m., found this resident, admitted on [DATE], found the only documented note by the physician was on [DATE]. No other notes were found until [DATE], which was by the certified family nurse practitioner. 5. Resident #24 Medical record review at 4:20 p.m. on [DATE], found this resident, admitted on [DATE], had no notes by either the physician or certified family nurse practitioner since admission. 6. Resident #70 Medical record review on [DATE] at 4:30 p.m., found this resident, admitted on [DATE], contained a 30 day progress note by the physician on [DATE]. There was no evidence of visits every 30 days for the first 90 days. 7. Resident #66 A review of the resident's medical record on [DATE] at 9:45 a.m. revealed her physician did not see the resident from [DATE] to [DATE]. 8. Resident #52 A review of the medical record on [DATE] at 3:11 p.m., found this resident was not been seen by her physician from [DATE] to [DATE]. 9. Resident #6 Review of the resident's medical records on [DATE] at 5:40 p.m., found a 90 Day Progress Encounter by the physician dated [DATE]. There was no evidence the physician saw the resident after [DATE]. 10. Resident #29 Review of medical records on [DATE] at 6:08 p.m., revealed a 90 Day Progress Encounter by the physician dated [DATE]. There was no evidence the physician had seen the resident after [DATE]. 11. Resident #15 A review of Resident #15's medical record beginning at 9:33 a.m. on [DATE] found no evidence the resident's physician had seen the resident since [DATE]. The Certified Family Nurse Practitioner (CFNP) made all physician notes in the medical record from [DATE] through time of this review. On [DATE] at 1:06 p.m., the Director of Nursing was asked to provide any evidence Resident #15's attending physician had completed a face-to-face visit with the resident since [DATE]. All she was able to provide was a visit that he made on the night of [DATE] following surveyor intervention. 12. Resident #32 A review of Resident #32's medical record at 3:00 p.m. on [DATE] found no evidence her attending physician had made a face-to-face visit with her since [DATE]. A CFNP and not the attending physician made all visits from [DATE] through present. On [DATE] at 1:06 p.m., the Director of Nursing was asked to provide any evidence to show that Resident #32's attending physician had completed a face-to-face visit with resident since [DATE]. At the time of exit at 3:45 p.m. on [DATE], the facility provided no further information. 13. Resident #21 A review of Resident #21's physician progress notes [REDACTED]. Certified Family Nurse Practitioner #99 made visits to the resident from [DATE] through [DATE]. b) During an interview on [DATE] at 5:50 p.m., the director of nursing (DON) stated, The physician just told me on the phone he must have misinterpreted the regulation. He told her that he thought that after the 90 days, the Family Nurse Practitioner could take over the resident's care and make all of the visits. She further verified the last physician visit dates of the thirteen (13) residents (#10, #19, #74, #2, #24, #70, #66, #52, #6, #29, #15, #32, #21) reviewed were accurate. c) Interview with the Attending Physician/Medical Director at 10:45 a.m. on [DATE], revealed he had misinterpreted the regulation. He stated, I will correct that immediately. I thought the FNP could see the residents after the first 90 days. That is my fault.",2019-09-01
5558,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2015-06-04,278,D,0,1,Y0EB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the quarterly minimum data set (MDS) assessment accurately reflected a [DIAGNOSES REDACTED]. Staff who completed Section I3400 for [MEDICAL CONDITION] disorders certified the accuracy of that portion; however, the section did accurately reflect the resident's [MEDICAL CONDITION] disorder. Resident identifier: #12. Facility census: 60 Findings include: a) Resident #12 A review of the medical record for Resident #12, on 06/04/15 at 8:48 a.m., revealed the quarterly MDS assessment with an assessment reference date (ARD) of 03/18/14, did not accurately reflect a [DIAGNOSES REDACTED]. The current physician's orders [REDACTED].#12 had a current order for [MEDICATION NAME] 100 micrograms (mcg) once daily for [MEDICAL CONDITION]. Review of the Medication Administration Record [REDACTED]. An interview, on 06/04/15 at 12:40 p.m., with the MDS Coordinator, verified Section I Active [DIAGNOSES REDACTED].#12.",2018-10-01
5559,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2015-06-04,431,D,0,1,Y0EB11,"Based on observation, staff interview, and review of the guidelines in Appendix PP of the state operation manual (SOM), the facility in coordination with the consultant pharmacist, failed to ensure the safe storage of controlled medications which were subject to abuse. Refrigerated medications subject to abuse were stored in a clear box in the refrigerator, which was not permanently affixed to the refrigerator. This practice had the potential to affect a limited number of residents. Facility census: 60 Findings include: a) Observation of the medication storage room, on 06/01/15 at 12:30 p.m., with the director of nursing (DON), revealed the medication refrigerator contained one (1) clear box with a lock and a tag numbered 9 on the box. The box was freely moveable in the refrigerator, and there was no lock on the outside of the refrigerator. The box contained a package of Marinol (Cannabinoid) 2.5 milligrams (mg) which contained seventeen (17) pills for Resident #5. There was also a package of twenty-eight (28) Marinol 5 mg for Resident #37. Resident #37 had another package of Marinol five (5) mg with one (1) pill in the package. In an interview, on 06/01/15 at 12:36 p.m., with the DON, she agreed the clear box was not permanently affixed to the refrigerator. The SOM, appendix PP includes: The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse . Observation of the medication room with the DON, on 06/01/15 at 4:14 p.m., found the clear box affixed to the refrigerator. The DON said they . already fixed the box in the refrigerator so it would be permanently affixed for securing the storage of controlled mediations in the refrigerator.",2018-10-01
7127,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2014-01-10,157,D,0,1,XBZ111,"Based on record review, staff interview, and resident interview, the facility failed to inform the physician of changes in health status for one (1) of fifteen (15) Stage 2 sampled residents. Resident #69 experienced a significant weight loss in one (1) month. There was no evidence the resident's physician was made aware of the resident's weight loss. Resident identifier: #69. Facility census: 53. Findings include: a) Resident #69 Review of the medical record revealed the following weights for Resident #69: -- 12/06/13 - 131.6 pounds (lbs) (this was the first weight since hospital readmission), -- 12/08/13 - 129.8 lbs, -- 12/16/13 - 127.4 lbs, -- 12/22/13 - 126.0 lbs, -- 12/30/13 - 120.7 lbs, and -- 01/05/14 - 120.7 lbs A review of the above weights revealed Resident #69 sustained a 10.9 pound weight loss over a thirty (30) day period; an 8.3 percent weight loss from 12/22/13 to 01/05/14. Further review of medical records found no evidence facility staff had notified the physician of this resident's weight loss. On 01/09/14 at 4:25 p.m., the director of nursing (DON) stated no evidence was available to verify the physician was notified of Resident #69's weight loss.",2017-08-01
7128,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2014-01-10,160,D,0,1,XBZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, financial record review, and staff interview, the facility failed to convey Resident #82's personal account funds to a legally qualified entity within thirty (30) days of the resident's death. This was found for one (1) of three (3) sampled residents reviewed for conveyance of funds upon death. Resident identifier: #83. Facility census: 53. Findings include: a) Resident #83 A review of the financial records and closed medical records [REDACTED]. He authorized the facility to manage the resident's personal funds at the time of admission. Further review of the financial and closed medical records [REDACTED]. A letter of administration for the estate of Resident #83 was completed on [DATE]. A check was not issued until [DATE], which was seventy-nine (79) days after the resident's death. During an interview with Employee #47, the business office supervisor (BOS), and Employee #89, vice-president of operations, at 1:45 p.m. on [DATE], it was stated that when the resident expired, the HCS had been having surgery so the facility thought they would hold it for him. They both verified the funds should have been released to the estate of the deceased resident within thirty (30) days of death as required by regulation.",2017-08-01
7129,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2014-01-10,161,E,0,1,XBZ111,"Based on facility record review and staff interview, the facility failed to obtain a surety bond of a sufficient amount to guarantee payment for any loss of residents' funds held, safeguarded, and/or managed by the facility. This had the potential to affect fifty-one (51) residents who had personal funds managed by the facility. Facility census: 53. Findings include: a) A review of the financial records of the facility revealed it had a surety bond in the amount of $28,000.00. A review of the fifty-one (51) residents' accounts (which were active on 01/09/14) revealed a cumulative total account balance of $27,063.75. At 1:45 p.m. on 01/09/14, this amount was verified by Employees #59 (Business office assistant) and #47 (Business office supervisor), the employees responsible for overseeing the accounts. A review of the bank statements, for the months ending on 10/31/13 and 11/30/13, revealed the residents' funds were deposited in a pooled account. The Daily Balance Summary revealed the following daily balance amounts: -- 10/31/13 - the amount was $41,418.54 -- 11/04/13 - the amount was $39,408.54 On these dates, the account balance exceeded the total coverage afforded by the surety bond. During an interview at 2:45 p.m. on 01/09/14, with Employees #47, business office supervisor, and #89, vice-president of operations (responsible for overseeing the accounts), and Employee #140 (assistant administrator), Employee #141, explained that all of the residents' incoming funds were deposited into this floating account and held there for up to several days before the facility withdrew the portion of funds required to pay the monthly bills. She stated this was done this way to ensure maximum interest accumulation. She verified these daily balances were typical for each month. Employees #140, and Employee #141 acknowledged that on these four (4) days, the total account balance exceeded the amount of the surety bond.",2017-08-01
7130,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2014-01-10,253,E,0,1,XBZ111,"Based on observation and staff interview, the facility failed to provide effective maintenance services in order to provide a sanitary, orderly and safe interior. Six (6) of thirty (30) resident rooms observed had maintenance issues. The rooms had issues such as peeling paint, holes in the walls, caulking coming off from around a sink, missing tile, and screws that were not covered. Room numbers: A4A, A5A, A5B A7A, B10B, and B11. Facility census: 53. Findings include: a) Room A4A, A5A, A5B, A7A, B10B, and B11 Observation and tour of room these rooms on 01/09/14 at 4:00 p.m., with Employee #12 (environmental services supervisor), revealed the following: 1) Room A4A - there were four (4) bare screws in the wall above the paper towel holder. 2) Room A5A - the wall behind the bed was rough in texture. Small pieces of paint had chipped off and there were small holes toward the top of the wall across from the bed. 3) Room A5B - the wall behind the bed had a rough texture. 4) Room A7A - the caulking around the sink was coming off and the wall behind the bed had a rough texture. 5) Room B10B - the wall was rough in texture behind the bed. 6) Room B11 - the bathroom floors had two (2) pieces of pieces of tile missing. One piece of tile measured two (2) centimeters (cm) x one (1) cm, and the other measured one (1) cm x one (1) cm. During the tour of these rooms, on 01/09/14 at 4:00 p.m., Employee #12 agreed with these findings. He stated they were in the progress of repairing these items. He stated the the facility had put wall protectors behind the beds to prevent further damage to the walls. Employee #12 indicated in room A4A, the screws above the paper towel holder were from where they had to lower the paper towel holder for the resident and had not repaired the wall. He stated he did not know about the tile in bathroom in Room B11.",2017-08-01
7131,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2014-01-10,272,D,0,1,XBZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately code an annual minimum data set (MDS) assessment for Resident #13 in the area of [MEDICAL TREATMENT]. The resident's MDS, with an assessment reference date (ARD) of 05/15/13, did not reflect the resident had received [MEDICAL TREATMENT] during the 14-day look back period. This was true for one (1) of fifteen (15) sampled Stage 2 residents. Resident Identifier: #13. Facility Census: 53. Findings Include: a) Resident #13 The medical record of Resident #13 was reviewed at 10:11 a.m. on 01/08/14. This review found the annual MDS, with an ARD of 05/15/13, was not coded in Item O0100J - [MEDICAL TREATMENT], to indicate the resident had received [MEDICAL TREATMENT] while a resident. The medical record also contained appointment/outing notes which indicated the resident went to [MEDICAL TREATMENT] on 04/22/13, 04/24/13, 04/26/13, 04/29/13, 05/01/13, and 05/03/13. Review of the Resident Assessment Instrument (RAI), Version 3.0 Manual, found the coding instructions for Column 2 of Section O were, Check all treatments, procedures and programs received or performed by the resident after admission/entry or reentry to the facility and within the 14-day look-back period. The RAI instructions for the area of O0100J - [MEDICAL TREATMENT], Code peritoneal or [MEDICAL TREATMENT] that occurs at the nursing home or at another facility in this item. Record treatments of hemofiltration, slow continuous ultrafiltration (SCUF), continuous arteriovenous hemofiltration (CAHV) and continuous ambulatory peritoneal [MEDICAL TREATMENT] (CAPD) in this item. Employee #79, Registered Nurse Assessment Coordinator (RNAC), was interviewed at 10:51 a.m. on 01/08/14. The RNAC reviewed this MDS assessment and confirmed she had failed to mark Item O0100J to indicate the resident had had this procedure completed while a resident. She confirmed this should have been coded according to the RAI manual and this item should have been marked but was not.",2017-08-01
7132,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2014-01-10,278,D,0,1,XBZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the accuracy in coding three (3) quarterly Minimum Data Set (MDS) assessments for Resident #13. A review of the MDSs revealed the assessments did not reflect the resident had received [MEDICAL TREATMENT] in the 14-day look back period from the assessment reference dates (ARD). This was true for one (1) of fifteen (15) sampled Stage 2 residents. Resident Identifier: #13. Facility Census: 53. Findings Include: a) Resident #13 The medical record of Resident #13 was reviewed at 10:11 a.m. on 01/08/14. Review of the Quarterly MDS assessment, with an ARD of 12/04/12, found item O0100J [MEDICAL TREATMENT] was not marked to indicate the resident had received [MEDICAL TREATMENT] while a resident. The medical record also contained Appointment/Outing Notes indicating the resident went to [MEDICAL TREATMENT] on 11/21/12, 11/23/12, 11/26/12, 11/28/12, 11/30/12, and 12/03/12. Further review revealed the Quarterly MDS assessment, with an ARD of 08/04/13, Item O0100J [MEDICAL TREATMENT] under column 2 was not marked to indicate the resident had received [MEDICAL TREATMENT] while a resident during the look back period. The medical record also contained Appointment/Outing Notes indicating the resident went to [MEDICAL TREATMENT] on 07/22/13, 07/24/13, 07/26/13, 07/29/13, 07/31/13, and 08/02/13. Additionally the medical record contained a Quarterly MDS assessment with an ARD of 10/24/13. This MDS under section O J [MEDICAL TREATMENT] under column 2 was not marked. The medical record also contained Appointment/Outing Notes indicating the resident went to [MEDICAL TREATMENT] on 10/11/13, 10/14/13,10/18/13, 10/21/13, and 10/23/13. The Resident Assessment Instrument (RAI) Version 3.0 Manual, was reviewed. The coding instructions for Column 2 of Section O are, Check all treatments, procedures and programs received or performed by the resident after admission/entry or reentry to the facility and within the 14-day look-back period. The RAI also gave the following coding instructions for the area of O0100J, Code peritoneal or [MEDICAL TREATMENT] that occurs at the nursing home or at another facility in this item. Record treatments of hemofiltration , Slow Continuous Ultrafiltration (SCUF), Continuous Arteriovenous Hemofiltration (CAHV) and Continuous Ambulatory Peritoneal [MEDICAL TREATMENT] (CAPD) in this item. Employee #79, Registered Nurse Assessment Coordinator (RNAC) was interviewed at 10:51 a.m. on 01/08/14. The RNAC reviewed the MDS assessments with the ARDs of 12/04/12, 08/04/13, and 10/24/13. She confirmed she had failed to mark Item O0100J correctly. She acknowledged that according to the RAI manual, this item should have been coded for all three (3) assessments and was not.",2017-08-01
7133,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2014-01-10,279,D,0,1,XBZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete a comprehensive care plan related to medication administration for one (1) of fifteen (15) residents reviewed during Stage 2 of the quality indicator survey. The resident used medications to treat and control hypertension. The care plan contained no established parameters for monitoring of the resident's blood pressure and pulse prior to administering the medication. Resident Identifier: #52. Facility Census: 53. Findings Include: a) Resident #52 Review of Resident #52's medical record, at 10:17 a.m. on 01/09/14, revealed a physician's orders [REDACTED]. This order had a start date of 04/10/13. Further review of the medical record revealed the order for [MEDICATION NAME] XL was changed on 12/02/13. The parameters for use were changed to hold if pulse is In addition, this resident received three (3) other medications to treat her [DIAGNOSES REDACTED]. The resident's Medication Administration Record (MAR) for the month of April 2013 was reviewed. The resident received a dose of [MEDICATION NAME] XL on two (2) separate occasions when her pulse was 55 or below: -- On 04/18/13 at 9:00 a.m. the resident's pulse was recorded on the MAR as 51. The MAR indicated the nurse administered the resident's 9:00 a.m. dose of [MEDICATION NAME] XL. -- On 04/27/13 at 9:00 a.m. the resident's pulse was recorded on the MAR as 55. The MAR indicated the nurse administered the resident's 9:00 a.m. dose of [MEDICATION NAME] XL. The MAR for the month of July 2013 was reviewed. The resident received the dose of [MEDICATION NAME] XL on two (2) separate occasions when her pulse was 55 or below. The resident also received her dose of [MEDICATION NAME] XL once (1) when her SBP was below 100 during this month: -- On 07/05/13 at 9:00 a.m. the resident's pulse was recorded on the MAR as 55. The MAR indicated the nurse administered the resident's 9:00 a.m. dose of [MEDICATION NAME] XL. -- On 07/06/13 at 9:00 a.m. the resident's pulse was recorded on the MAR as 51. The MAR indicated the nurse administered the resident's 9:00 a.m. dose of [MEDICATION NAME] XL. -- The MAR indicated on 07/22/13 at 9:00 p.m. the resident's blood pressure was 91/63. The MAR also indicated the 9:00 p.m. dose of [MEDICATION NAME] XL was administered, despite her blood pressure being outside the established parameters. The resident's MAR for the month of November 2013 was reviewed. The resident received a dose of [MEDICATION NAME] XL on two (2) separate occasions when her blood pressure was not obtained prior to administration of the medication. -- On 11/04/13 and 11/17/13 the resident's MAR had an X in the area where the resident's blood pressure should have been recorded. The MAR indicated the resident's 9:00 a.m. dose of [MEDICATION NAME] XL was administered on both of those days without prior monitoring of the blood pressure. Review of Resident #52's care plan found no mention of the the multiple treatments, monitoring, and/or management of this resident's hypertension. Employee #79, Registered Nurse Assessment Coordinator (RNAC), was interviewed at 1:36 p.m. on 01/09/14. She confirmed hypertension, the treatments, and the monitoring of the resident's blood pressure were not contained on Resident #52's care plan. She to her knowledge, it had never been on the resident's care plan.",2017-08-01
7134,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2014-01-10,329,D,0,1,XBZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the survey was free from unnecessary medications. The facility failed to monitor and/or hold a hypertensive medication according to the monitoring and other parameters established by the physician. Resident Identifier: #52. Facility Census: 53. Findings Include: a) Resident #52 Resident #52's medical record was reviewed at 10:17 a.m. on 01/09/14. This review revealed a physician's orders [REDACTED]. There was a nurse administration note to hold the medication if the resident's heart rate was 55 or below, or the systolic blood pressure (SBP) was below 100. This order had a start date of 04/10/13. 1) The resident's Medication Administration Record (MAR) for the month of April 2013 was reviewed. The resident received a dose of [MEDICATION NAME] XL on two (2) separate occasions when her pulse was 55 or below: -- On 04/18/13 at 9:00 a.m. the resident's pulse was recorded on the MAR as 51. The MAR indicated the nurse administered the resident's 9:00 a.m. dose of [MEDICATION NAME] XL. -- On 04/27/13 at 9:00 a.m. the resident's pulse was recorded on the MAR as 55. The MAR indicated the nurse administered the resident's 9:00 a.m. dose of [MEDICATION NAME] XL. 2) The MAR for the month of July 2013 was reviewed. The resident received the dose of [MEDICATION NAME] XL on two (2) separate occasions when her pulse was 55 or below. The resident also received her dose of [MEDICATION NAME] XL once (1) when her SBP was below 100 during this month: -- On 07/05/13 at 9:00 a.m. the resident's pulse was recorded on the MAR as 55. The MAR indicated the nurse administered the resident's 9:00 a.m. dose of [MEDICATION NAME] XL. -- On 07/06/13 at 9:00 a.m. the resident's pulse was recorded on the MAR as 51. The MAR indicated the nurse administered the resident's 9:00 a.m. dose of [MEDICATION NAME] XL. -- The MAR indicated on 07/22/13 at 9:00 p.m. the resident's blood pressure was 91/63. The MAR also indicated the 9:00 p.m. dose of [MEDICATION NAME] XL was administered, despite her blood pressure being outside the established parameters. 3) The resident's MAR for the month of November 2013 was reviewed. The resident received a dose of [MEDICATION NAME] XL on two (2) separate occasions when her blood pressure was not obtained prior to administration of the medication. -- On 11/04/13 and 11/17/13 the resident's MAR had an X in the area where the resident's blood pressure should have been recorded. The MAR indicated the resident's 9:00 a.m. dose of [MEDICATION NAME] XL was administered on both of those days without prior monitoring of the blood pressure. The Director or Nursing Services (DNS) was interviewed at 1:21 p.m. on 01/09/14. The DNS reviewed the MARs for April 2013, July 2013 and November 2013. She confirmed the physician's orders [REDACTED]. The DNS confirmed the medication was given on six (6) occasions without monitoring and/or being held according to established parameters. She agreed Resident #52 received unnecessary doses of [MEDICATION NAME] XL because her vital signs fell outside the established parameters. She also confirmed the resident was given the medication without adequate monitoring in November 2013, when the the resident's blood pressure was not obtained prior to the administration of the medication.",2017-08-01
7135,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2014-01-10,428,D,0,1,XBZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to act upon a recommendation made by the consulting pharmacist for one (1) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the survey. The resident had an order to hold Toprol XL 50 milligrams (mg) if the resident's heart rate was 55 or below or the systolic blood pressure (SBP) was below 100. On 04/29/13, the consulting pharmacist recommended the parameters be changed to monitor the pulse and hold the medication if the pulse was below 60. This change was not implemented until 12/02/13. Resident Identifier: #52. Facility Census: 53. Findings include: a) Resident #52 Resident #52's medical record was reviewed at 10:17 a.m. on 01/09/14. This review revealed a physician's orders [REDACTED]. There was a nurse administration note for the medication to be held if the resident's heart rate was 55 or below or the systolic blood pressure (SBP) was below 100. This order had a start date of 04/10/13. Further review of the medical record revealed a consultant pharmacist note dated 04/29/13. The pharmacist had recommended (typed as written), Toprol XL 50 mg oral (by mouth): One po (by mouth) twice daily. Start date: 04/10/13. needs to monitor pulse and hold if The director of nursing Services (DNS) was interviewed at 2:15 p.m. on 01/09/14. She reported when the consultant pharmacist made a recommendation, such as the one made on 04/29/13, the pharmacist sent a report which was printed and given to the physician. She said the physician reviewed the recommendations, accepted or declined them, and signed them. This report was then scanned back into the resident's electronic medical record. The DNS reviewed Resident #52's electronic medical record and reported this was not done for the recommendation made on 04/29/13. She stated she would check to see if she could locate this signed recommendation signed from the physician. An additional interview was conducted with the DNS at 4:27 p.m. on 01/09/14. She reported she could not find evidence this recommendation was ever acted upon by the facility or the physician. She stated she could not find evidence the report was ever given to the physician. The DNS confirmed the recommendation made by the pharmacist on 04/29/13 was not acted upon.",2017-08-01
7136,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2014-01-10,441,D,0,1,XBZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to implement measures to control, to the extent possible, the onset and spread of infection. A random observation during Stage 1 of the survey revealed signs were not placed on the outside of a room to alert staff and visitors of the need to use contact precautions when entering the room. Resident Identifier: #58. Facility Census: 53. Findings include: a) Resident #58 At 3:59 p.m. on 01/06/14, Resident #58's room was observed. Upon entering the room there was no signage visible to indicate this resident was on isolation, or to indicate the need to use special precautions while in the resident's room. At 4:30 p.m. on 01/06/14, review of the resident's medical record revealed [REDACTED]. An interview was conducted with Employee #49, a Licensed Practical Nurse (LPN) at 4:45 p.m. on 01/06/14. The LPN confirmed the resident was on contact precautions due to MRSA in her feeding tube site. When asked how a visitor would know the special precautions to use prior to entering this resident's room, she stated there should be a sign on the outside of the door with the protective equipment. Employee #49 went to Resident #58's room. She confirmed the sign and the protective equipment were not on the outside of the door. Further observation revealed the sign and protective equipment were hanging on the back side of the door and were not visible unless the door was closed. The facility's transmission based precautions policy was reviewed. The policy included, When transmission based precautions are assigned to a patient, a sign shall be placed on the outside of the patient's room door that identifies the expanded precautions that are required. Employee #76, nursing home administrator (NHA), and Employee #77, director of nursing services (DNS), were interviewed at 11:50 a.m., on 01/10/14. They both confirmed the policy stated the sign explaining the expanded precautions should be placed on the outside of the resident's door. The NHA stated the reason the sign was not on the outside of the door was because Resident #58's roommate had requested it not be made visible due to dignity. She said she did not know how to honor the resident's wishes in regards to this and still follow the policy of placing the sign on the outside of the door. She reported the staff all knew and could see the sign when they closed the door to provide care. No explanation was given as to how visitors entering the room would be aware of the expanded precautions needed, except that visitors should not be touching the resident's peg tub site or dressing and therefore they would not need to know. A discussion was held with the NHA regarding the potential of inanimate objects becoming contaminated if staff members who came in contact with the dressing and peg tub site touched other items in the room prior to removing their gloves, etc. The NHA, agreed this could create a risk for the visitor, even though the visitor would not come in contact with the infected area.",2017-08-01
7137,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2014-01-10,514,D,0,1,XBZ111,"**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 medical records for two (2) of nineteen (19) Stage 2 sampled residents. Resident #69's physician orders [REDACTED].#13's medical record contained two (2) weights for the same date that were over 100 pounds different from each other. Resident identifiers: #69 and #13. Facility Census: 53. Findings include: a) Resident #69 Review of medical records, on 01/09/14, revealed Resident #69 had a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. During an interview, on 01/09/14 at 2:35 p.m., the director of nursing (DON), stated the documentation on the physician order [REDACTED]. b) Resident #13 At 1:05 p.m. on 01/08/14, review of Resident #13's medical record found a weight of 126.8 pounds recorded in the resident's weight record for 07/21/13. The medical record indicated this weight was obtained at 2:25 p.m. on 07/21/13. The weight record also revealed a weight of 229.2 pounds which was obtained at 4:06 p.m. on 07/21/13. The resident's weight during this time frame had consistently been in the the 220 to 230 pound range. Employee #77, Director of Nursing Services (DNS), was interviewed at 1:20 p.m. on 01/08/14. She confirmed the weight of 126.8 pounds had to be inaccurate. She stated the weight should have been struck out of the electronic medical record and it was not.",2017-08-01
8161,"WYOMING NURSING AND REHABILITATION CENTER, LLC",515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2012-06-07,279,D,0,1,9E8C11,"**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 a resident who experienced bladder incontinence. Resident #40 was occasionally incontinent of bladder at the time of her admission. Her care plan did not describe services that were to be provided to prevent further decline in this resident's continence. It was subsequently identified, on her quarterly minimum data set (MDS) assessment, she had become frequently incontinent. The care plan did not address this resident's bladder needs to attempt to restore as much normal bladder function as possible. This practice affected one (1) of twenty-two (22) stage II sampled residents. Resident identifier: #40. Facility Census: 58 Findings Include: a) Resident #40 The initial MDS, with an assessment reference date (ARD) of 01/29/12, identified Resident #40 was occasionally incontinent of her bladder when she was admitted to the facility on [DATE]. Section H0300 was coded 1 to indicate she was occasionally incontinent. The instructions stated that this meant the resident had experienced less than seven (7) episodes of incontinence in the last seven (7) days. The quarterly MDS, with an ARD of 04/27/12, revealed in section H0200, that this resident was frequently incontinent of urine. This MDS was coded 2 in this section to indicate she had experienced more than seven (7) episodes of urinary incontinence, but had at least one (1) episode of continent voiding. A review of the care plan revealed there was no plan describing the services to be provided to try to restore the residents prior level of continence. Interview with the Care Conference Nurse (Employee # 75), on 06/06/12 at 3:00 p.m., verified the facility had not developed an individualized care plan based on the assessment and the increased frequency of urinary incontinence that was assessed.",2016-09-01
8162,"WYOMING NURSING AND REHABILITATION CENTER, LLC",515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2012-06-07,315,D,0,1,9E8C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement measures to address a decline in a resident's bladder function. Resident #40's initial assessment revealed she was occasionally incontinent of her bladder on admission. Her quarterly assessment identified she had experienced an increase in the frequency of her urinary incontinence. There was no evidence the facility had assessed the resident for possible reversible causes for the decline in bladder status and/or implemented interventions in an attempt to restore as much bladder function as possible. This was true for one (1) of twenty-two (22) stage II sampled residents. Resident identifier: #40. Census: 58. Findings Include: a) Resident #40 This resident was admitted on [DATE]. Her initial minimum data set (MDS), dated [DATE], revealed she was occasionally incontinent of her bladder at that time. Section H0300 was coded 1 to indicate that she was occasionally incontinent. According to the instructions for this MDS item, this meant the resident had experienced less than seven (7) episodes of urinary incontinence in the last seven (7) days. The quarterly MDS, with an ARD of 04/27/12, revealed section H0200 was coded 2 - the resident was frequently incontinent of urine. This meant the resident had experienced more than seven (7) episodes of urinary incontinence during the seven (7) day look back period, but had at least one (1) episode of continent voiding. The record was reviewed following this assessment that identified the resident was having increased urinary incontinence episodes. There was no evidence any interventions had been attempted to restore this resident's previous bladder functioning. A review of the care plan reviewed there was no plan to describe the services to be provided to try to restore the resident's prior level of continence. There was no evidence the facility had initiated any bladder program or further assessed the cause of the increased incontinence to determine what type of interventions needed to be initiated. Interview with the Care Conference Nurse (Employee # 75), on 06/06/12 at 3:00 p.m., revealed the facility did not provide individualized toileting plans, but they do provide toileting to all residents every two (2) hours. It was verified the facility had not developed an individualized plan of care based on the assessment and the increased frequency of incontinence that was assessed.",2016-09-01
8163,"WYOMING NURSING AND REHABILITATION CENTER, LLC",515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2012-06-07,329,D,0,1,9E8C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, and staff interview, the facility failed to: (1) identify the targeted behaviors for use of a psychoactive medication; and (2) monitor for potential adverse side effects of a psychoactive medication. This was true for one (1) of twenty-two (22) residents reviewed in Stage II of the quality indicator survey (QIS). Resident identifier: #66. Facility census: 58. Findings include: a) Resident #66 Medical record review found Resident #66 was admitted to the facility on [DATE]. Further review of the Medication Administration Record [REDACTED]. The dates the medications were prescribed and the dosages were: -- 01/21/12, [MEDICATION NAME] 100 mg (milligrams) QD (daily) at 7:00 p.m. -- 05/15/12, [MEDICATION NAME] 50 mg QD at 9:00 a.m. -- 04/06/12, [MEDICATION NAME] 0.5 mg BID (two times a day) -- 04/07/12, [MEDICATION NAME] 1 mg QD at 2:00 p.m. Review of the facility's policy entitled, General Guidelines for the Use of Chemical Restraints, found, Section 10. Designated facility staff will document episodes of behavior, the impact of the medication on behavior and the presence or absence of side effects. The clinical care coordinator (Employee #77) and the director of nursing (Employee #76) were interviewed, at approximately 9:30 a.m., on 06/07/12. Employee #77 verified the facility utilized the, psychoactive medication monthly flow record, to document the resident's specific behaviors and side effects of the medication. Employee #77 verified a flow record should have been completed for each of the medications, [MEDICATION NAME] and [MEDICATION NAME]. The flow records should have contained documentation of each episode of type of targeted behavior per shift, the number of episodes that occurred per shift, and any side effects exhibited by the resident as a result of taking [MEDICATION NAME] and [MEDICATION NAME]. Employee #77 stated the psychoactive medication monthly flow records had never been completed for any month during which the resident was receiving [MEDICATION NAME] or [MEDICATION NAME]. The facility was unable to provide documentation of the targeted behaviors for which the physician prescribed [MEDICATION NAME] and [MEDICATION NAME] and was unable to provide documentation of the monitoring of potential side effects associated with taking [MEDICATION NAME] and [MEDICATION NAME].",2016-09-01
8164,"WYOMING NURSING AND REHABILITATION CENTER, LLC",515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2012-06-07,428,D,0,1,9E8C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, and staff interview, the facility failed to ensure the pharmacist reported the following irregularities to the physician: (1) the facility was administering Ativan and Seroquel without adequate documentation of the targeted behaviors for which the medications were prescribed and (2) the facility was administering Ativan and Seroquel without monitoring for the presence of potential side effects associated with the use of the medications. This was true for one (1) of twenty-two (22) residents sampled in stage II of the quality indicator survey (QIS). Resident identifier: #66. Facility census: 58. Findings include: a) Resident #66 Medical record review found Resident #66 was admitted to the facility on [DATE]. Further review of the Medication Administration Record [REDACTED]. The following is a list of the dates the medications were prescribed and the dosages: 01/21/12, Seroquel 100 mg (milligrams) every day at 7:00 p.m. 05/15/12, Seroquel 50 mg at 9:00 a.m. 04/06/12, Ativan 0.5 mg BID (two times a day) 04/07/12, Ativan 1 mg at 2:00 p.m. Review of the facility's policy entitled, General Guidelines for the Use of Chemical Restraints, found, Section 12. The Pharmacy Consultant will review residents medication records on a monthly basis for documentation/justification for drug use and will recommend dosage reductions or modification. The clinical care coordinator (Employee #77) and the director of nursing (Employee #76), were interviewed, at approximately 9:30 a.m., on 06/07/12. Employee #77 verified the facility utilized the, psychoactive medication monthly flow record, to document the resident's specific behaviors and side effects of the medication. Employee #77 verified a flow record should have been completed for each of the medications, Ativan and Seroquel. The flow records should have contained documentation of each episode of type of targeted behavior per shift, the number of episodes that occurred per shift, and any side effects exhibited by the resident as a result of taking Ativan and Seroquel. Employee #77 stated the psychoactive medication monthly flow records had never been completed for any month during which the resident was receiving Seroquel or Ativan. The facility was unable to provide documentation of the targeted behaviors for which the physician prescribed Ativan and Seroquel and unable to provide documentation of the monitoring of side effects associated with taking Ativan and Seroquel. Review of the, Chronological Record of Drug Regimen Review, completed by the consultant pharmacist found the resident's drug regimen had been reviewed on 01/30/12, 02/28/12, 03/26/12, and 04/26/12. There was no evidence the absence of the required documentation regarding the targeted behaviors and monitoring of side effects had been identified as an irregularity. Employee #77 was interviewed on 06/07/12, at approximately 11:00 a.m. She was unable to provide any information to verify the pharmacist had notified the physician of the above irregularities associated with the use of Ativan and Seroquel.",2016-09-01
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
3230,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2019-02-07,578,E,0,1,5UYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure Resident #63's advance directives were completed in accordance and guidance with the State specific form used to communicate healthcare decisions. For Resident's #2, #30, and #67, the facility failed to ensure advance directives were followed according to the resident's wishes. Resident identifiers; #63, #2, #30, and #67. Facility census: 72. Findings included: a) Resident #63 Record review found the Resident was admitted to the facility on [DATE]. The resident's daughter was a court appointed guardian. On [DATE], the facility completed a physician's orders [REDACTED]. A POST form is a State specific form used as a document to help healthcare professionals know and honor the treatment wishes of their patients. The POST form contains resident's choices related to life sustaining treatment. The POST form was signed by the Resident's physician on [DATE], making the document a legal order. The POST form outlined the resident's following special directives and limitations: Do not resuscitate, Limited additional interventions. Use medical treatment, antibiotics, IV fluids and cardiac monitoring as indicated. Do not use incubation or mechanical ventilation. Transfer to hospital if indicated. Avoid intensive care unit. IV fluids for a trial period of no longer than 4 weeks. No feeding tube. The resident's care plan directed the resident was to have no CPR (Cardiopulmonary resuscitation), no feeding tube, IV fluids for a trial period of 4 weeks. The POST form did not contain the signature of the court appointed guardian. The form specifically directs signature as, mandatory. Review of the facility's policy statement for advance directives directs: .Upon admission, a resident's advance directives shall be translated into orders for treatment, using the physician's orders [REDACTED]. On [DATE] at 03:49 PM, the Director of Nursing (DON) said the POST form was signed by three (3) of the facility's licensed nursing staff members to indicate this was the wishes of the guardian. The DON confirmed the form had not been signed by the court appointed guardian, the resident's daughter, as directed by the instructions of the POST form. b) Resident #2 Record review found Resident #2 was admitted to the facility on [DATE]. On [DATE], the facility completed a physician's orders [REDACTED]. A POST form is a State specific form used as a document to help healthcare professionals know and honor the treatment wishes of their patients. The POST form contains resident's choices related to life sustaining treatment. The POST form was signed by the Resident's physician on [DATE], making the document a legal order. The POST form outlined the resident's following special directives and limitations: Do not resuscitate, Comfort measures. No IV fluids. No feeding tube. Additional orders: No weights. No Lab. No Hospice. Additional review of medical record review, found Resident #2 continued to have weights obtained and documented until (MONTH) (YEAR). Lab draws continued to be completed through ,[DATE]. On [DATE] at 03:00 PM, the Director of Nursing (DON) said the POST form was signed and dated [DATE]. The DON confirmed weights and labs had been continued after the POST form had been signed. She agreed the facility was not honoring the POST form, which was the wishes of the resident and/or responsible party. c) Resident #30 Record review found Resident #30 was admitted to the facility on [DATE]. On [DATE], the facility completed a physician's orders [REDACTED]. A POST form is a State specific form used as a document to help healthcare professionals know and honor the treatment wishes of their patients. The POST form contains resident's choices related to life sustaining treatment. The POST form was signed by the Resident's physician on [DATE], making the document a legal order. The POST form outlined the resident's following special directives and limitations: Do not resuscitate, Comfort measures. No IV fluids for no longer than two (2) days. No feeding tube. Additional orders: No weights. No Lab. Additional review of medical record review, found Resident #30 continued to have lab draws continued to be completed through ,[DATE]. On [DATE] at 01:00 PM, the Director of Nursing (DON) said the POST form was signed and dated [DATE]. The DON confirmed labs had been continued after the POST form had been signed. She agreed the facility was not honoring the POST form, which was the wishes of the resident and/or responsible party. d) Resident #67 Record review found Resident #67 was admitted to the facility on [DATE]. On [DATE], the facility completed a physician's orders [REDACTED]. A POST form is a State specific form used as a document to help healthcare professionals know and honor the treatment wishes of their patients. The POST form contains resident's choices related to life sustaining treatment. The POST form was signed by the Resident's physician on [DATE], making the document a legal order. The POST form outlined the resident's following special directives and limitations: Do not resuscitate, Comfort measures. No IV fluids for no longer than two (2) days. No feeding tube. Additional orders: No weights. No routine Lab Additional review of medical record review, found Resident #67 continued to have lab draws continued to be completed through ,[DATE]. On [DATE] at 10:00 AM, the Director of Nursing (DON) said the POST form was signed and dated [DATE]. The DON confirmed labs had been continued after the POST form had been signed. She agreed the facility was not honoring the POST form, which was the wishes of the resident and/or responsible party.",2020-09-01
3231,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2019-02-07,584,D,0,1,5UYC11,"Based on observation, policy review, family,resident, staff interview, and review of the State Operations Manual (SOM) Appendix PP - Guidance to Surveyors for Long Term Care Facilities, the facility failed to report a grievance/compliant of misappropriation of resident property for Resident #37 and Resident #6. This was true for two (2) of two (2) residents reviewed for personal property. Resident identifiers: #37 and #6. Facility census 72. Findings included: a) Resident #37 On 02/04/19 at 2:13 PM, in a family interview with Resident #37's daughter, she picked up a lacey pillow and said her mother (Resident #37) had lost a blanket that matched the lacey pillow. The daughter revealed the blanket had been missing for about a month, and she said one (1) time she went down to the laundry room to look for the blanket. The laundry employees were unable to find the blanket. Resident #37's daughter stated that, no one came to talked to her about her mother's blanket being missing. A review of Resident #37's inventory of personal effects finds the resident has three (3) blankets on the inventory of personal effects form. In an interview on 02/06/19 at 10:45 AM, with Environmental Assistant (EA) #97, revealed that Resident #37's daughter did come down and they did not find the blanket. EA #97 was asked, did you report the blanket missing to anyone. EA #97 said she did not do anything about it after she looked in the laundry and the closets of other residents. EA #97 did not know if any staff member here every went and reported the blanket missing. Social Service Supervisor (SSS) #9, on 02/06/19 at 11:08 AM, revealed that no employee informed her of Resident #37 missing a blanket. SSS #9, said her protocol is to fill out a grievance form, then she would then go and search the rooms to see if she could find the personal item, and if she cannot find the items the facility will replace the items. The SSS #9 stated that she did not fill out a grievance form for Resident #37's blanket, because she was not told about the blanket missing. SSS #9 stated, Wait I think I have a blanket that was brought up from the laundry room. Observed SSS #9 got up out of her chair and brought back a lacey blanket from the back of her office. SSS #9 revealed she did not know who the blanket belonged because it had no name on the blanket. SSS #9 agreed the staff was told by Resident #37's family, and they should have filled out a grievance /complaint form and brought it up to her. SSS #9 confirmed the staff did not follow the facilities policy on grievances and complaints. In an interview with Resident #37's daughter on 02/06/19 at 3:00 PM, she confirmed that SSS #9 brought her mothers missing blanket back to the room. A review of the facility's policy, shows this facility will conduct an educational in-service for its personnel during orientation, and at least annually thereafter, to familiarize them with the grievance procedure. Regulation from the SOM Appendix PP - Guidance to Surveyors for Long Term Care Facilities, 483.10 (ii) states that, the facility shall exercise reasonable care for the protection of the resident's property from loss or theft. b) Resident #6 (R#6) The facility failed to report a grievance/compliant of misappropriation of resident's hooded [NAME]et. An interview with R#6, on 02/04/19 at 01:33 PM, revealed the resident had a hooded [NAME]et missing for at least two (2) weeks. When asked if the facility was aware the [NAME]et was missing, R#6 said she had told the nurses aides and laundry staff two (2) weeks ago and several times since then. R#6 did not know the staff's names. R#6 was asked what the staff said they were doing about the missing [NAME]et . R#6 said they said they are looking for it but said they could not find it. When asked what else the facility planned to do about it, R#6 said the facility did not say they were going to do anything else about it. R#6 said she had not talked about the missing [NAME]et with the social worker but would the next time she saw the social worker. On 02/06/19 at 12:43 PM, an interview with the social worker (SW#9), revealed R# 6 Informed her of the missing [NAME]et after resident council meeting on Monday 02/04/19. The social worker said that was the first time she was made aware that R# 6's [NAME]et was missing for the past two (2) weeks. The social worker explained the process for dealing with resident's missing personal property is for staff to fill out a complaint form, then someone is assigned to look in to it, and if the item is not found then an offer to replace it is made. SW#9 said grievances and complaints are given to her. An interview with Laundry Environment Assistant EA#97, on 02/07/19 at 11:08 AM, revealed a log is kept in the laundry to track resident's missing items. Review of the log showed R# 6's hooded [NAME]et was missing. EA#97 said laundry staff had been looking for the [NAME]et but had not been able to find the [NAME]et. EA#97 stated the laundry should have reported the missing [NAME]et to the social worker, as they were supposed to do, but they did not report it. Review of facility operation policy grievances and complaints revealed the facility has designated the social worker (social services supervisor) as the grievance official. Under policy interpretation and implementation the following information was included: #1 The grievance official is responsible for accepting and ensuring a thorough investigation of any complaints voiced by #4 All complaints will be documented and promptly (generally within five (5) days) and thoroughly investigated. #5 A report of the findings and the actions taken if any will then be explained to the resident . to ensure satisfaction with the facility's handling of the complaint. The facility failed to follow their policy for grievances and complaints.",2020-09-01
3232,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2019-02-07,637,D,0,1,5UYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a significant change Minimum Data Set (MDS) on Resident #13 experienced a major decline in the resident's status that had an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both. This was true for one (1) of one (1) reviewed for the care area of death. Resident identifier: #13. Facility census: 72. Findings included: a) Resident #13 Review of Resident #13's medical records, found was admitted to the facility on [DATE]. On 12/05/18, the facility completed a physician's orders [REDACTED]. A POST form is a State specific form used as a document to help healthcare professionals know and honor the treatment wishes of their patients. The POST form contains resident's choices related to life sustaining treatment. The POST form was signed by the Resident's physician on 12/07/18, making the document a legal order. The POST form outlined the resident's following special directives and limitations: Do not resuscitate, Comfort measures. No IV fluids. No feeding tube. Additional orders: No weights. No Lab. No Hospice. Review of Resident #13's physician progress notes [REDACTED]. -- 12/07/18- Talked with family and patient discussed end of life. Patient refuses medication and doesn't want to eat patient is tired of living .POST form updated . -- 12/31/18- Facial drooping and slurred speech . possible [MEDICAL CONDITION] (TIA) . -- 01/07/19- Talked with patient and daughter, patient doesn't want to go to hospital and doesn't want test done. Continue comfort measures . -- 01/28/19- Patient weaker and eating less. Review of Resident #13's Minimum Data Set (MDS) found no significant change MDS after 12/07/18, when the resident experienced a major decline. Interview on 02/06/19 at 9:15 am, with the Director of Nursing (DON) and Nursing Home Administrator (NHA), they both agreed Resident #13 experienced a decline on 12/07/18 and did not improve. They both agreed a significant MDS should have been completed.",2020-09-01
3233,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2019-02-07,656,E,0,1,5UYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, and observations the facility failed to implement and/or develop each residents comprehensive care plan. Resident #46's care plan was not implemented in regards to a restricted limb. For Resident #73 the facility failed to develop a care plan that addressed the use of Liquids an anticoagulant medication. For Resident #8 the facility failed to implement the residents nutrition care plan and failed to fully develop a nutrition care plan that included all foods received with her meals. For Resident #27 the facility failed to implement his nutrition care plan. Finally, for Resident #27 the facility did not implement his care plan in regards to physical restraints. This was true for four (4) of 21 sampled residents. Resident Identifier: #46, #73, #8, and #27. Facility census: 72. Findings included: a) Resident #46 A review of Resident #46's medical record at 9:00 a.m. on 02/06/19 found Lab/Diagnostic progress note dated 01/28/19 which read as follows: . Drawn from left hand by (Name of Lab Company) phlebotomist. Tolerated well. Pending results. A review of Resident #46's care plan found the following focus statement, . (First name of Resident #46) has a new AV fistula implanted in his left arm for [MEDICAL TREATMENT] treatment. The goal associated with this focus statement read as follows, Will have no signs or symptoms of complications from [MEDICAL TREATMENT] through the review date. Interventions related to this focus statement and goals included, Do not draw blood or take B/p (blood pressure) in left arm. This intervention was added to the care plan on 01/15/19. An interview with the Director of Nursing (DON) at 3:27 p.m. on 02/07/19, confirmed the Lab Technician had taken the blood from the left arm which is a restricted limb for Resident #46. She stated, We have disposition sheets which this information should be wrote on. She stated, This is how we communicate this information to the Lab Technician. She agreed Resident #46's care plan was not implemented. b) Resident #73 Review of the Resident's medical record on 02/06/19 at 10:50 AM, found the resident was receiving Eliquis, 5 milligrams, two (2) times a day, for a [DIAGNOSES REDACTED]. Eliquis, is an anticoagulant used for the treatment of [REDACTED]. The manufactures warning label directs: Eliquis can cause serious, potentially fatal bleeding. Promptly evaluate signs and symptoms of blood loss. Review of the resident's current care plan, revised on 01/15/19, found the problem: [MEDICAL CONDITION] Fiburillation/[MEDICAL CONDITION] Flutter. The goal associated with the problem is: Will remain free of signs and symptoms of altered cardiac output through the next review date. Interventions included: Administer medications ([MEDICATION NAME], dilitiazem, eliquis) as ordered. On 02/06/19 at 11:00 AM, the care plan author, Registered Nurse Assessment Coordinator, (RNAC) #78 confirmed the care plan should have included an intervention to monitor for bleeding with the use of Eliquis. At 11:15 AM on 02/06/19, RNAC #78 provided an undated care plan which included: Problem: Anticoagulant therapy (Eliquis) related to [MEDICAL CONDITION]. The goal associated with the problem: Will be free from discomfort or adverse reactions related to anticoagulant use through next review. Interventions included: Monitor/document/report to physician as needed signs symptoms of anticoagulant complications: blood tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethergy, bruising. blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. c) Resident #8 A review of Resident #8's physician's orders [REDACTED]. A review of Resident #8's nutrition care plan during the survey revealed the following intervention, revised on 09/18/18: Provide and serve Regular texture regular consistency liquids as ordered, double portions for breakfast. Serving ice cream with lunch and dinner was not mentioned in this care plan intervention. During an interview on 02/06/19 at 1:06 PM, Registered Nurse Assessment Coordinator (RNAC) #78 stated that all specific dietary requirements should be present on the care plan. At 1:10 PM, RNAC #3 stated that since ice cream was ordered for Resident #8 at lunch and dinner, the ice cream should be reflected on the care plan for the care plan to be fully developed. After this issue was discussed with staff, Resident #8's diet order was altered in the electronic medical record to omit the ice cream entirely. On 02/06/19 at 3:59 PM, the facility's Administrator and Regional Director of Operations (RDO) #60 were informed of the issue with Resident #8's care plan not being fully developed. RDO #60 stated that Resident #8's ice cream order had been discontinued after a weight meeting, but that this discontinuation did not get properly updated in the electronic medical record. d) Resident #27 A review of Resident #27's electronic medical record on 02/05/19 at 1:58 PM revealed the following physician's diet order: No Concentrated Sweets diet Regular texture, Regular consistency, Gravy on his meats and chopped onions with every lunch and dinner meal. His nutritional care plan contained an intervention last revised on 04/02/18 that stated, in pertinent part, Provide and serve Regular NCS (No Concentrated Sweets) Diet. The care plan also listed Type 2 Diabetes Mellitus as one of Resident #27's diagnoses. On 02/05/19 at 4:19 PM, a review of Resident #27's laboratory results revealed four (4) occasions in which his hemoglobin A1c was elevated. Hemoglobin A1c is a measure of average blood glucose levels over 120 days. According to the American Diabetes Association (ADA), the appropriate Hemoglobin A1c level for individuals with diabetes is below seven (7) percent (%). According to Resident #27's laboratory reports, his hemoglobin A1c was 10.1% on 05/01/18, 11.3% on 07/31/18, 11.2% on 09/17/18, and 9.1% on 10/24/18. Hemoglobin A1c levels can often be lowered when residents receive the proper therapeutic diet in addition to their medications. On 02/06/19 at 8:53 AM, diet spreadsheets were requested from Dietary Services Supervisor (DSS) #66. At 9:38 AM, DSS #66 provided the dietary spreadsheets, saying that the facility was using a cycle menu. The spreadsheets had the following diets listed at the top of each page: Regular, Finger Food, Consistent CHO (carbohydrate), Puree, Mechanically Altered, and Advanced. The spreadsheets did not contain an NCS diet. On 02/06/19 at 10:46 AM, the Administrator and DSS #66 explained that the facility's diet manual had transitioned to a consistent carbohydrate diet, so Resident #27 was receiving a consistent carbohydrate diet instead of his ordered and care-planned NCS diet.",2020-09-01
3234,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2019-02-07,657,D,0,1,5UYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview; the facility failed to revise Resident (R) #20's care plan with current standing orders for bowel protocol for constipation. This was true for one (1) of three (3) residents reviewed for activities of daily living (ADL) care during the annual Long-Term Care Survey Process (LTCSP). This practice had the potential to affect more than a limited number of residents. Resident identifier: #20. Facility census: 72. Findings included: Review of the resident's quarterly minimum data set (MDS) with an assessment reference date (ARD) 12/01/18, on 02/05/19 at 01:54 PM, revealed the resident's Brief Interview for Mental Status (BIMS) score was ten (10) indicating cognitively the resident is moderately impaired. The resident needs extensive assistance for most activities of daily living, but needs supervision with eating, and is totally dependent for bathing. Resident is occasionally incontinent of bladder and always incontinent of bowel. Pertinent [DIAGNOSES REDACTED]. Review of records, on 02/05/19 at 02:42 PM, revealed an order for [REDACTED]. Review of care plan revealed under the focus area, Has [MEDICAL CONDITION] requiring management, included an intervention to monitor for constipation and implement bowel protocol if no bowel movement (BM) every three (3) days. Another focus area, At risk for constipation r/t (related to) medication side effects, impaired mobility. She c/o (complains of) gas with periodic episodes of abdominal pain. Revealed a goal Will pass soft, formed stool at least every three (3) days through the review date. Interventions under this focus area included; Record bowel movement pattern each day. Describe amount and consistency. Follow Standing Order for Constipation as needed: 1) Administer [MEDICATION NAME] 10mg 1 tab by mouth at bedtime on 3rd day. Document results. ([MEDICATION NAME] ([MEDICATION NAME]) is a laxative) 2) If no results, administer [MEDICATION NAME] 10mg suppository rectally at bedtime on 4th day. Document results. 3) If no results, administer sodium [MEDICATION NAME] enema 133ml rectally at bedtime on 5th day. Document results. Notify practitioner if no result after enema. On 02/06/19 at 02:25 PM, an interview with the Director of Nursing Services (DNS), revealed the bowel protocol described in the care plan was not correct. The DNS said the care plan was wrong, an should have reflected the facility's current standing order for bowel protocol for constipation. A request was made for a current copy of the correct standing order. Review of current standing order, on 02/06/19 at 03:45 PM, revealed Bowel Protocol for constipation (no bowl movement in three (3) days): - Administer [MEDICATION NAME] ([MEDICATION NAME]) 10 mg 1 tab by mouth on 4th day. Document results. ([MEDICATION NAME] ([MEDICATION NAME]) is a laxative) - If no results, within 12 hours, administer [MEDICATION NAME] ([MEDICATION NAME]) 10 mg suppository rectally. Document results. - If no results during night, administer Fleet enema (sodium [MEDICATION NAME] enema) 133 ml rectally at 0600 on 5th day. Document results. Notify physician if no result after enema. Review of records showed no evidence that any nurse intervened on 12/07/18 or 12/14/18, when the resident had no BM for more three (3) Days. The DNS was asked to provide evidence that the nurses intervened on 12/07/18 and 12/14/18. On 02/06/19 at 04:55 PM, the DNS confirmed the nurses did not intervene on 12/07/18 or 12/14/18 for R#20 and did not follow standing orders for bowel protocol for constipation as they should have.",2020-09-01
3235,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2019-02-07,684,E,0,1,5UYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, family interview, and observation, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was true for six (6) of twenty-one (21) sampled residents. For Resident's #75 and #20 the facility failed to consistently assess the resident after a change of condition. For Resident #63, the facility failed to notify the physician of the results of a laboratory value and failed to promptly start the Residents antibiotic. The facility failed to consistently notify the physician when Resident #27's blood sugar was over 400. For Resident #8, the facility failed to follow the physicians diet order. The facility failed to follow the physician order [REDACTED].#6. Resident identifiers: #75, #6, #63, #27, #8, and #20. Facility census: 72. Findings included: a) Resident #75 Record review found the resident was admitted to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. Review of the nursing notes found the resident expired at the facility on [DATE] at 7:40 AM. Nursing staff found the resident had no pulse or respirations when the room was entered during breakfast. The resident had do not resuscitate orders. From [DATE] through [DATE], the resident received the antibiotic, [MEDICATION NAME] for a respiratory infection The Resident's most recent Minimum Data Set (MDS), a quarterly, with an assessment reference date (ARD) of [DATE], found the resident scored a 14 on the brief interview for mental status (BIMS). A score of ,[DATE] on a BIMS indicates the resident is cognitively intact. A nursing note, dated [DATE] at 9:30 PM: Patient concern - Anxious and short of breath. Nursing assessment: Pale, Respirations 30, Pulse oxygen 84. Resident stated I have pain when I breathe. Diaphoretic, head of bed elevated, oxygen tubing shortened. The physician was contacted and ordered [MEDICATION NAME] every 6 hours, as needed. At 11:48 PM on [DATE], the nebulizer treatment was administered. At 12:31 AM on [DATE], the nurse documented the treatment was, effective. On [DATE] at 4:14 PM, the Director of Nursing (DON) reviewed the medical record. The DON found no evidence the resident was assessed again for the respiratory issues after the 12:31 AM, [DATE], nurses note indicating the breathing treatment was effective. The DON said the resident received medication at 6:00 AM on [DATE]; therefore, nursing staff would have been in the resident's room. She verified there was no nursing note indicating the resident's current condition was assessed. The DON said she would have expected some more documentation but that didn't mean the nurses were not checking on the resident. b) Resident #63 Record review found the resident was admitted to the facility on [DATE]. On [DATE], the resident's physician ordered a urinalysis with culture and sensitivity (UA with C&S) after the resident experienced a fall. The facility collected the UA on [DATE] as directed. On [DATE], the laboratory reported the results of the UA with C&S to the facility at 11:35 AM on [DATE]. The results of the culture confirmed the resident had VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]) and [NAME] ([MEDICATION NAME]) faecium. On [DATE], the resident's physician included a hand written notation, Not good. and circled VRE plus [NAME] faecium on the laboratory report. The physician prescribed [MEDICATION NAME] 600 milligrams, twice a day, for 10 days. Review of a nurses note, dated [DATE], at 4:02 PM: New orders obtained for [MEDICATION NAME] 600 mg. BID (twice a day) x 10 days, first dose now. Review of the Medication Administration Record [REDACTED]. The first dose of [MEDICATION NAME] was not administered until 9:00 PM on [DATE]. On [DATE] at 1:42 PM, the Director of Nursing (DON) confirmed she would have expected the physician to have been notified of the results of the US with C&S on [DATE]. In addition she would have expected the antibiotic to have been started in a more timely manner. At 3:49 PM on [DATE], the DON said she had educated the nurse involved for failure to notify the physician promptly of the laboratory results. c) Resident #27 Review of Resident #27's medical record at 9:45 a.m. on [DATE] found this resident most recently readmitted to the facility on [DATE] after a hospital stay. Review of Resident #27's [DIAGNOSES REDACTED]. Review of Resident #27's physician orders [REDACTED]. --Finger stick blood glucose two (2) hours past breakfast one time a day. Call physician if blood sugar is less than 60 or greater than 400. Review of Resident #27's MARs for [DATE] through [DATE] found the following occasions when Resident #27's blood sugars were greater than 400 and required notification of the physician as directed by the physician's orders [REDACTED]. -- [DATE] blood sugar was 446. -- [DATE] blood sugar was 504. -- [DATE] blood sugar was 486. -- [DATE] blood sugar was 503. -- [DATE] blood sugar was 436. -- [DATE] blood sugar was 401. -- [DATE] blood sugar was 431. -- [DATE] blood sugar was 416. -- [DATE] blood sugar was 410. -- [DATE] blood sugar was 435. -- [DATE] blood sugar was 403. -- [DATE] blood sugar was 465. -- [DATE] blood sugar was 458. -- [DATE] blood sugar was 466. -- [DATE] blood sugar was 465. -- [DATE] blood sugar was 454. -- [DATE] blood sugar was 434. At 1:09 p.m. on [DATE], the Director of Nursing (DON) confirmed the physician was not notified on the above mention dates in which the resident's blood glucose was greater than 400. d) Resident #20. The facility failed to follow the physician order [REDACTED]. Review of the resident's quarterly minimum data set (MDS) with an assessment reference date (ARD) [DATE], on [DATE] at 01:54 PM, revealed the resident's Brief Interview for Mental Status (BIMS) score was ten (10) indicating cognitively the resident is moderately impaired. The resident needs extensive assistance for most activities of daily living, but needs supervision with eating, and is totally dependent for bathing. Resident is occasionally incontinent of bladder and always incontinent of bowel. Pertinent [DIAGNOSES REDACTED]. Review of records, on [DATE] at 02:42 PM, revealed an order for [REDACTED]. Review of care plan revealed under the focus area, Has [MEDICAL CONDITION] requiring management, an intervention to monitor for constipation and implement bowel regimen if no bowel movement (BM) every three (3) days. Another focus area, At risk for constipation r/t (related to) medication side effects, impaired mobility. She c/o (complains of) gas with periodic episodes of abdominal pain. This focus area has a goal Will pass soft, formed stool at least every 3 days through the review date. Interventions under this focus area included; Record bowel movement pattern each day. Describe amount and consistency. Follow Standing Order for Constipation as needed: 1) Administer [MEDICATION NAME] 10mg 1 tab by mouth at bedtime on 3rd day. Document results. ([MEDICATION NAME] ([MEDICATION NAME]) is a laxative) 2) If no results, administer [MEDICATION NAME] 10mg suppository rectally at bedtime on 4th day. Document results. 3) If no results, administer sodium [MEDICATION NAME] enema 133ml rectally at bedtime on 5th day. Document results. Notify practitioner if no result after enema. On [DATE] at 02:25 PM, an interview with the Director of Nursing Services (DNS), revealed the bowel protocol described in the care plan was not correct. The DNS said the care plan was wrong, an should have reflected the facility's current standing order for bowel protocol for constipation. A request was made for a current copy of the correct standing order. Review of current standing order, on [DATE] at 03:45 PM, revealed Bowel Protocol for constipation (no bowl movement in three (3) days): - Administer [MEDICATION NAME] ([MEDICATION NAME]) 10 mg 1 tab by mouth on 4th day. Document results. - If no results, within 12 hours, administer [MEDICATION NAME] ([MEDICATION NAME]) 10 mg suppository rectally. Document results. - If no results during night, administer Fleet enema (sodium [MEDICATION NAME] enema) 133 ml rectally at 0600 on 5th day. Document results. Notify physician if no result after enema. Review of records showed no evidence that any nurse intervened on [DATE] or [DATE], when the resident had no BM for more three (3) Days. The DNS was asked to provide evidence that the nurses intervened on [DATE] and [DATE]. On [DATE] at 04:55 PM, the DNS confirmed the nurses did not intervene on [DATE] or [DATE] for R#20; the nurses did not follow the facility's standing orders Bowel Protocol for constipation as they should have. e) Resident #6 The facility failed to assess and treat Resident #6 timely when she had a change of condition. The facility failed to assess and treat Resident #6 timely when she had a change of condition concerning a persistent cough and complaints of sore ribs. Observations, on [DATE] at 12:25 PM, revealed R#6 coughing while eating her lunch at the table in the dining room. R#6 was heard complaining to staff and residents about coughing for several days. R#6 said the coughing made her ribs sore. An interview with R#6, on Monday [DATE] at 03:31 PM, revealed the resident has a persistent cough for several days, since the previous Thursday ([DATE]). The resident said the facility was not giving her medicine or anything for her cough. R#6 said she told the night nurses and the nurses over the weekend, about her cough and that her throat was scratchy and dry. R#6 said one of the nurses told her to drink plenty of water. R#6 said, The nurses thought it might be a sinus infection or a really bad cold. R#6 said she had told the therapy worker Thursday or Friday that her ribs were hurting and were sore and achy from coughing. R#6 said she told the therapy worker about her sore ribs because she was not sure how much she would be able to do in therapy because of the soreness. R#6 did not know if the physician knew about her coughing. Review of records revealed the first reference concerning the resident's cough was found in a nurse's progress note dated Monday [DATE]. The nurse's progress note read, Resident complains of cough. Nursing Assessment: Resident lungs sounds are clear at this time. Oxygen saturation is 97%. The Physician was notified and a new order for [MEDICATION NAME] 10mg daily for seasonal allergies [REDACTED]. f) Resident #8 A review of Resident #8's physician's orders [REDACTED]. On [DATE] at 12:33 PM, Resident #8 was observed eating her lunch. There was no ice cream present at her table. On [DATE] at 12:37 PM, Registered Nurse (RN) #10 was asked why Resident #8 did not receive ice cream with her lunch as outlined in her diet order. RN #10 replied that she did not know why the ice cream was not provided, but she agreed that ice cream with lunch and dinner was part of Resident #8's diet order. RN #10 then called the kitchen to alert them to the issue. After the phone call was completed, RN #10 said the kitchen was under the impression that Resident #8 was to receive ice cream only with dinner. RN #10 provided a copy of Resident #8's diet slip for review. The diet slip did not indicate to provide ice cream with lunch. RN #10 then said that she would provide Resident #8 with ice cream immediately. After this issue was discussed with staff, Resident #8's diet order was altered in the electronic medical record to omit the ice cream entirely. On [DATE] at 3:59 PM, the facility's Administrator and Regional Director of Operations (RDO) #60 were informed of the issue with Resident #8's physician's diet order not being followed. RDO #60 stated that Resident #8's ice cream order had been discontinued after a weight meeting, but that this discontinuation did not get properly updated in the electronic medical record until [DATE].",2020-09-01
3236,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2019-02-07,692,D,0,1,5UYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, observation, staff interview, and policy review, the facility failed to provide the appropriate physician-prescribed diet to meet the nutritional needs of Resident #27. This deficient practice affected one (1) of five (5) residents reviewed for the care area of nutrition. Resident identifier: #27. Facility census: 72. Findings included: a) Resident #27 Resident #27 was admitted to the facility on [DATE]. His list of [DIAGNOSES REDACTED]. A review of Resident #27's electronic medical record on 02/05/19 at 1:58 PM revealed the following physician's diet order, effective on 08/10/18: No Concentrated Sweets diet Regular texture, Regular consistency, Gravy on his meats and chopped onions with every lunch and dinner meal. On 02/05/19 at 4:19 PM, a review of Resident #27's laboratory results revealed four (4) occasions in which his hemoglobin A1c was elevated. Hemoglobin A1c is a measure of average blood glucose levels over 120 days. According to the American Diabetes Association (ADA), the appropriate Hemoglobin A1c level for individuals with diabetes is below seven (7) percent (%). Hemoglobin A1c levels can often be lowered when residents receive the proper therapeutic diet in addition to their medications. According to Resident #27's laboratory reports, his hemoglobin A1c was 10.1% on 05/01/18, 11.3% on 07/31/18, 11.2% on 09/17/18, and 9.1% on 10/24/18. On 02/06/19 at 8:53 AM, Dietary Services Supervisor (DSS) #66 was asked to provide dietary spreadsheets for all meals to be served during the week of the survey. At this time, DSS #66 stated that the facility used the Nutrition Care Manual (NCM), published by the Academy of Nutrition and Dietetics (AND) as their diet manual. According to the AND, A typical, no-concentrated-sweets diet differs from a regular diet in that the no-concentrated-sweets diet has no added sugar but uses a sugar substitute, diet syrup, or a diet dessert. On 02/06/19 at 9:38 AM, DSS #66 provided the requested dietary spreadsheets, saying that the facility was using a cycle menu, so the dates at the top of each spreadsheet would not match the dates of the week of the survey. The spreadsheets had the following diets listed at the top of each page: Regular, Finger Food, Consistent CHO (carbohydrate), Puree, Mechanically Altered, and Advanced. The spreadsheets did not contain a No Concentrated Sweets (NCS) diet. On 02/06/19 at 9:53 AM, Resident #27 said during an interview that he was receiving a special diet prescribed to help control his blood glucose levels. On 02/06/19 at 10:39 AM, the facility's Administrator was asked why the NCS diet was not on the dietary spreadsheets if it was prescribed to residents. He stated that he would need to check with DSS #66 on this matter. On 02/06/19 at 10:46 AM, the Administrator returned with DSS #66 and both of them explained that since the NCM had transitioned to a consistent carbohydrate diet, all residents with an order for [REDACTED]. [REDACTED]. According to the facility's Nutrition Services Operations Policy, last revised on 12/08/18, Therapeutic diets will be served as prescribed by the resident's attending physician. According to the NCM, No foods are omitted from the consistent carbohydrate meal plan unless a different medical condition necessitates the exclusion of certain foods or nutrients. However, per the spreadsheets for the week of the survey, a dinner roll was to be omitted from lunch one day. Also according to the NCM, Sugar-sweetened items are allowed as part of the carbohydrate source at meals or snacks. Regular desserts should be allowed on a consistent carbohydrate meal plan. However, according to the spreadsheets for the week of the survey, one half cup of peaches was to be substituted for a four (4) ounce serving of coconut cake, a half cup serving of sugar-free pudding was to be substituted for a four (4) ounce serving of banana pudding, no sugar added ice cream was to be substituted for a half cup serving of regular ice cream, and half a cup of sugar-free pudding was to be substituted for a brownie. On 02/06/19 at 12:35 PM, Resident #27 was observed eating his lunch. He had peaches on his tray instead of coconut cake. The NCM also stated that, With regard to the no concentrated sweets, no sugar added, low sugar, and liberal diabetic diets: None of these approaches to food and meal planning is appropriate because each unnecessarily restricts sucrose. On 02/06/19 at 3:59 PM, the facility's Administrator and Regional Director of Operations (RDO) #60 were informed of the discrepancies between the physician's orders [REDACTED]. The Administrator and RDO #60 stated that they would have Registered Dietitian (RD) #87 call and clarify the discrepancies. On 02/07/19 at 9:49 AM, RD #87 was interviewed via phone. RD #87 acknowledged that the dietary spreadsheets did not match the NCS diets prescribed by the physician. She stated that the company was working on an action plan to change the NCS diet orders to match the spreadsheets and move toward prescribing a consistent carbohydrate diet for all residents currently on the NCS diet. She said that she felt a grace period was needed for compliance, as the NCM had only recently recommended a consistent carbohydrate diet in place of the NCS diet. On 02/07/19 at 10:14 AM, the AND was contacted to confirm when the consistent carbohydrate diet had become the standard of practice outlined in the NCM. An official from the AND stated that the consistent carbohydrate diet became the standard of practice in (MONTH) of (YEAR). On 02/07/19 at 10:34 AM, an action plan related to changing the NCS diets to consistent carbohydrate diets was received and reviewed. According to the plan, the discrepancy between the NCS diet and the dietary spreadsheets was first addressed on 12/01/18, more than a year after the consistent carbohydrate diet became the standard of practice in the NCM. The goal date for fixing the problem was set as 02/22/19. No further information was provided prior to the end of the survey.",2020-09-01
3237,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2019-02-07,698,E,0,1,5UYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #46 who requires [MEDICAL TREATMENT] received services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences to ensure that he could attain and or maintain his highest practicable physical, mental and psychosocial well being. The [MEDICAL TREATMENT] Center recommended on 10/13/18 that Resident #46 be started on a phosphorus binder this medication was not started until 12/2018 only after [MEDICAL TREATMENT] sent another recommendation. Also the facility had a physician order [REDACTED]. However the facility was still obtaining Resident #46's weights in the facility. This was true for one (1) of one (1) residents reviewed for the care area of [MEDICAL TREATMENT] during the long term care survey process. Resident identifiers: #46. Facility census: 72. Findings included: a) Resident #46 1. Phosphorus Binder A review of Resident #46's medical record at 9:00 a.m. on 02/06/19 found a [MEDICAL TREATMENT] Communication form dated 10/13/18 found the following note written by the [MEDICAL TREATMENT] Center's Registered Dietician which read as follows, . Plus one (1) Auryxia (a phosphorus binder) with his largest meal (helps keeps his phosphorus within normal limits.) Further review of the record found no evidence this recommendation from the [MEDICAL TREATMENT] Center was ever addressed. However another recommendation from [MEDICAL TREATMENT] was received on 12/27/18 this was written on a physician order [REDACTED]. Start Auryxia one (1) tab with largest meal since SNF confirmed he is not currently on Auryxia. Additional review of the record found this medication was not ordered by the physician until 12/27/18. At this time the pharmacy sent a recommendation to not use this medication, but to instead increase Resident #46's dose of Iron Sulfate. The attending physician agreed with this recommendation and Resident #46's [MEDICATION NAME] sulfate was increased to two (2) tablets twice a day beginning on 12/28/18. An interview with the Director of Nursing (DON) at 11:17 a.m. on 02/07/19 confirmed the [MEDICAL TREATMENT] recommendation received on 10/13/18 was not acted on by the facility. She agreed the facility did not attempt to start the medication until the second recommendation was received on 12/27/18. 2. Weights A review of Resident #46's medical record at 9:00 a.m. on 02/06/19 found the following physician order [REDACTED]. Review of Resident #46's recorded weights in the electronic medical record found the following dates and weights which did not correspond with the weights which were recorded on the [MEDICAL TREATMENT] communication record, 08/16/18 facility weight of 414.6 pounds this was a Thursday and the post weight on the [MEDICAL TREATMENT] communication record was 411.4 pounds. 08/22/18 facility weight of 412.8 pounds this was a Wednesday and the weight from the [MEDICAL TREATMENT] communication record from the previous day was 407.66 pounds. 09/04/18 facility weight of 410.4 pounds this was a Tuesday but the post weight on the [MEDICAL TREATMENT] Communication Record was 399.52 pounds. An interview with Clinical Care Supervisor (CCS) #48 at 2:30 p.m. on 02/07/19 confirmed the weights entered into the medical record on 08/16/18, 08/22/18, and 09/04/18 were weights entered by a Nurse Aide. She stated, They do not have access to the [MEDICAL TREATMENT] Communication Record so they had to weigh him. She stated, It must be coming up in the system for them to get a weight. We will have to fix that. She indicated, this is the reason the weights on these dates do not match.",2020-09-01
3238,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2019-02-07,760,E,0,1,5UYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #46 drug regimen was free from significant medication errors. Resident #46 received the wrong dosage of [MEDICATION NAME] on 10/17/18, 10/18/18, and 01/30/19. Also the facility held Resident #46's [MEDICATION NAME] on 10/11/18, 10/16/18, and 10/23/18 because the resident was out of the facility to [MEDICAL TREATMENT]. The facility did not have in place a process to ensure Resident #46 received his [MEDICATION NAME] when arriving back to the facility late from [MEDICAL TREATMENT]. This was true for one (1) of one (1) residents reviewed for the care area of [MEDICAL TREATMENT] during the long term care survey process. Resident identifier: #46. Facility census: 72. Findings included: a) Resident #46 1. (MONTH) (YEAR) A review of Resident #46's medical record at 9:00 a.m. on 02/06/18, found a [MEDICATION NAME] time/international normalized ratio (PT/INR) dated 10/15/18 written on the results of the PT/INR was increase [MEDICATION NAME] to seven (7) milligrams (MG) on Monday, Wednesday, and Friday, and six (6) mg on Sunday, Tuesday, Thursday, and Saturday. This order was the active order until 10/19/18. Review of the Medication Administration Record [REDACTED]. Further Review of the MAR found that on Thursday 10/18/18 Resident #46 received seven (7) mg of [MEDICATION NAME] instead of the ordered dose of six (6) mg. Further review of the MAR found that on 10/11/18, 10/16/18, and 10/23/18 the facility held Resident #46's ordered [MEDICATION NAME]. The reason stated was because Resident #46 was out of the facility. Further review of the record found that Resident #46 did not return from [MEDICAL TREATMENT] on 10/11/18 until 6:19 p.m., on 10/16/18 until 6:08 p.m., and on 10/23/18 until 8:22 p.m. The residents [MEDICATION NAME] was scheduled to be given at 5:00 p.m. There was no evidence in the resident medical record to indicate the facility had in place a process to ensure resident #46 did not miss this significant medication on [MEDICAL TREATMENT] days. An interview with the Director of Nursing (DON) at 1:08 p.m. on 2/06/19 confirmed that according to the MAR indicated [REDACTED]. She also agreed that the medication was held on 10/11/18, 10/16/18 and 10/23/18 because Resident #46 was out to [MEDICAL TREATMENT]. She indicated, the facility will have to work with the physician to either change the time of the medication administration to avoid it being missed while he is out to [MEDICAL TREATMENT]. She indicated the nurse should have called the physician on these dates to obtain and order to administer the medication late. 2. (MONTH) (YEAR) A review of Resident #46's medical record at 9:00 a.m. on 02/06/19, found on the 01/2018 MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The residents physician orders [REDACTED]. An interview with the DON at 1:08 p.m. on 02/06/19 confirmed the MAR indicated [REDACTED]. She indicated she spoke with LPN #35 and she stated she did give Resident #46 his dose of [MEDICATION NAME] and did not ever give LPN #46 her medication cart keys so she could not have given the other dose. An interview with LPN #61 in the morning of 02/07/19 found that she did not recall administering Resident #46 any [MEDICATION NAME] on 01/30/19. She indicated that she must have signed the MAR indicated [REDACTED]. She did agree that the MAR indicated [REDACTED].",2020-09-01
3239,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2019-02-07,773,D,0,1,5UYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to promptly notify the attending physician of physician ordered laboratory testing for Resident #46 and Resident #63. Resident #46 had a [MEDICATION NAME] time/international normalized ratio (PT/INR) obtained on 02/01/19 in the early morning hours. The facility did not notify the attending physician of the results of this PT/INR until the next evening. For Resident #63 the facility did not promptly notify the attending physician of the results of their Urinalysis with Culture and Sensitivity. This was true for two (2) of 21 sampled residents. Resident identifiers: #46 and #63. Facility census: 72. Findings included: a) Resident #46 A review of Resident #46's medical record at 9:00 a.m. on 02/06/19 found a Lab Diagnostic note that indicated Resident #46 had a PT/INR drawn at 6:06 a.m. on 02/01/19. Further review of the record found a lab diagnostic result note which indicated the physician was notified of the results of this PT/INR drawn on 02/01/19 on 02/02/19 at 4:29 p.m. A review of the PT/INR result found the lab was obtained at 4:30 a.m. on 02/01/19. The fax confirmation line at the top of the result indicated it was faxed to the facility on [DATE] at 1:39 p.m. However the Physician was notified for over 24 hours of the results of this PT/INR. An interview with the DON at 1:08 p.m. on 02/08/19 confirmed the attending physician was not notified of the PT/INR results in a prompt manner. She stated that they should call with in the same day the results are received. b) Resident #63 Record review found the resident was admitted to the facility on [DATE]. On 12/30/18, the resident's physician ordered a urinalysis with culture and sensitivity (UA with C&S) after the resident experienced a fall. The facility collected the UA on 12/30/18 as directed. On 01/02/19, the laboratory reported the results of the UA with C&S to the facility at 11:35 AM on 01/02/18. The results of the culture confirmed the resident had VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]) and [NAME] ([MEDICATION NAME]) faecium. On 01/03/19, the resident's physician included a hand written notation, Not good. and circled VRE plus [NAME] faecium on the laboratory report. The physician prescribed [MEDICATION NAME] 600 milligrams, twice a day, for 10 days. On 02/06/19 at 1:42 PM, the Director of Nursing (DON) confirmed she would have expected the physician to have been notified of the results of the US with C&S on 01/03/19, when received by the facility. At 3:49 PM on 02/06/19, the DON said she had educated the nurse involved for failure to notify the physician promptly of the laboratory results.",2020-09-01
3240,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2019-02-07,808,E,0,1,5UYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to provide a No Concentrated Sweets diet as prescribed by the physician. This deficient practice had the potential to affect more than an isolated number of residents. Resident identifiers: #17, #73, #22, #41, #74, #52, #4, #55, #68, #33, #59, #10, #6, #67, #27, #5, #15, #34, #46, #44. Facility census: 72. Findings included: Resident #27 was admitted to the facility on [DATE]. His list of [DIAGNOSES REDACTED]. A review of Resident #27's electronic medical record on 02/05/19 at 1:58 PM revealed the following physician's diet order, active since 08/10/18: No Concentrated Sweets diet Regular texture, Regular consistency, Gravy on his meats and chopped onions with every lunch and dinner meal. On 02/05/19 at 4:19 PM, a review of Resident #27's laboratory results revealed four (4) occasions in which his hemoglobin A1c was elevated. Hemoglobin A1c is a measure of average blood glucose levels over 120 days. Hemoglobin A1c levels can often be lowered when residents receive the proper therapeutic diet in addition to their medications. On 02/06/19 at 8:53 AM, Dietary Services Supervisor (DSS) #66 was asked to provide dietary spreadsheets for all meals to be served during the week of the survey. At this time, DSS #66 stated that the facility used the Nutrition Care Manual (NCM), published by the Academy of Nutrition and Dietetics (AND) as their diet manual. According to the AND, A typical, no-concentrated-sweets diet differs from a regular diet in that the no-concentrated-sweets diet has no added sugar but uses a sugar substitute, diet syrup, or a diet dessert. On 02/06/19 at 9:38 AM, DSS #66 provided the requested dietary spreadsheets, saying that the facility was using a cycle menu, so the dates at the top of each spreadsheet would not match the dates of the week of the survey. The spreadsheets had the following diets listed at the top of each page: Regular, Finger Food, Consistent CHO (carbohydrate), Puree, Mechanically Altered, and Advanced. The spreadsheets did not contain a No Concentrated Sweets (NCS) diet. On 02/06/19 at 9:46 AM, a list of all residents in the facility who were ordered an NCS diet was requested. On 02/06/19 at 10:39 AM, the facility's Administrator was asked why the NCS diet was not on the dietary spreadsheets if it was prescribed to residents. He stated that he would need to check with DSS #66 on this matter. Also at this time, the list of all residents with a physician's orders [REDACTED]. The list showed that Residents #17, #73, #22, #41, #74, #52, #4, #55, #68, #33, #59, #10, #6, #67, #27, #5, #15, #34, #46, and #44 were all ordered an NCS diet. On 02/06/19 at 10:46 AM, the Administrator returned with DSS #66 and both of them explained that since the NCM had transitioned to a consistent carbohydrate diet, all residents with an order for [REDACTED]. [REDACTED]. According to the facility's Nutrition Services Operations Policy, last revised on 12/08/18, Therapeutic diets will be served as prescribed by the resident's attending physician. According to the NCM, No foods are omitted from the consistent carbohydrate meal plan unless a different medical condition necessitates the exclusion of certain foods or nutrients. However, per the spreadsheets for the week of the survey, a dinner roll was to be omitted from lunch one day. Also according to the NCM, Sugar-sweetened items are allowed as part of the carbohydrate source at meals or snacks. Regular desserts should be allowed on a consistent carbohydrate meal plan. However, according to the spreadsheets for the week of the survey, one half cup of peaches was to be substituted for a four (4) ounce serving of coconut cake, a half cup serving of sugar-free pudding was to be substituted for a four (4) ounce serving of banana pudding, no sugar added ice cream was to be substituted for a half cup serving of regular ice cream, and half a cup of sugar-free pudding was to be substituted for a brownie. On 02/06/19 at 12:35 PM, Resident #27 was observed eating his lunch. He had peaches on his tray instead of coconut cake. The NCM also stated that, With regard to the no concentrated sweets, no sugar added, low sugar, and liberal diabetic diets: None of these approaches to food and meal planning is appropriate because each unnecessarily restricts sucrose. On 02/06/19 at 3:59 PM, the facility's Administrator and Regional Director of Operations (RDO) #60 were informed of the discrepancies between the physician's orders [REDACTED]. The Administrator and RDO #60 stated that they would have Registered Dietitian (RD) #87 call and clarify the discrepancies. On 02/07/19 at 9:49 AM, RD #87 was interviewed via phone. RD #87 acknowledged that the dietary spreadsheets did not match the NCS diets prescribed by the physician. She stated that the company was working on an action plan to change the NCS diet orders to match the spreadsheets and move toward prescribing a consistent carbohydrate diet for all residents currently on the NCS diet. She said that she felt a grace period was needed for compliance, as the NCM had only recently recommended a consistent carbohydrate diet in place of the NCS diet. On 02/07/19 at 10:14 AM, the AND was contacted to confirm when the consistent carbohydrate diet had become the standard of practice outlined in the NCM. An official from the AND stated that the consistent carbohydrate diet became the standard of practice in (MONTH) of (YEAR). On 02/07/19 at 10:34 AM, an action plan related to changing the NCS diets to consistent carbohydrate diets was received and reviewed. According to the plan, the discrepancy between the NCS diet and the dietary spreadsheets was addressed on 12/01/18, more than a year after the consistent carbohydrate diet became the standard of practice in the NCM. The goal date for fixing the problem was set as 02/22/19. No further information was provided prior to the end of the survey.",2020-09-01
3241,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2018-02-08,550,D,0,1,T2JD11,"Based on observation and staff interview, the facility failed to ensure Resident #10 had a dignified dining experience during the dinner meal on 02/16/18. This was a random opportunity for discovery. Resident identifier: #10. Facility Census: 78. Findings include a) Resident #10 On 02/16/18 at 5:30 PM, observation found Resident #2 and Resident #10 shared a room together. At 5:38 PM Resident # 2 received her tray. At 5:50 PM on 02/16/18, Nurse Aide (NA) #37 delivered, opened and prepared the tray. NA#37, then left the room. At 6:00 PM on 02/16/18, NA #37, returned to the room and began to assist Resident #10 to eat her dinner. This was after this surveyor had asked Licensed Practical Nurse (LPN) #68 whether Resident #10 could feed herself and her response was, No. Review of Resident #10's medical records on 02/16/18 at 6:30 PM, found a Minimum Data Set (MDS) with a reference date (ARD) of 08/14/17, this assessment indicated Resident #10 required total assistance of one for eating. During an interview with the Director of Nursing (DON) at 11:10 AM on 02/17/18, it was confirmed it Resident #10 required total assistance of one for eating. Additionally, the DON confirmed the tray should not be taken into the room until the staff was ready to assist the residents with eating. No further information was provided.",2020-09-01
3242,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2018-02-08,641,D,0,1,T2JD11,"Based on record review and staff interview, the facility failed to accurately complete Resident #1's discharge tracking Minimum Data Set (MDS) on 09/26/17. Additionally, Resident #70's quarterly MDS with an assessment reference date (ARD) of 01/24/18 was inaccurate in the area of nutrition. This was true for two (2) of twenty-five (25) resident's MDS reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #1 and #70. Facility census: 78. Findings include: a) Resident #1 Review of Resident #1's medical records on 02/06/18 at 11:30 AM, revealed Resident #1 was discharged to home on 09/26/17. No discharge tracking MDS could be located in Resident #1's medical records. During an interview on 02/06/18 at 2:00 PM with the Director of Nursing (DON) confirmed Resident #1 had been discharged to home on 09/26/17 and the MDS discharge tracking had not been completed. It was immediately completed. b) Resident #70 A review of Resident #70's medical record, on 02/07/18 at 1:00 PM, found a quarterly MDS with an assessment reference date (ARD) of 01/24/18. Review of the MDS found Section K0310 (Weight Gain) was marked with a one (1) to indicate Resident #70 was on a physician -prescribed weight gain regimen. Review of Resident #70's physician orders did not indicate the resident was on a physician prescribed weight gain regimen. An interview with the Director of Nursing (DON) and the Dietary Manager (DM), at 2:45 PM on 02/07/18, confirmed the MDS with the ARD of 01/24/18 was inaccurate. Resident #70 is not on a physician prescribed weight gain regimen.",2020-09-01
3243,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2018-02-08,656,D,0,1,T2JD11,"**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 twenty-five (25) residents whose care plans were reviewed during the long term care survey process. Resident #25's care plan failed to identify the correct access site for [MEDICAL TREATMENT] treatment. Resident identifier: #25. Facility census: 78. Findings include: a) Resident #52 Record review found the resident was admitted to the facility on [DATE]. Review of the hospital discharge summary, dated 12/14/17, found the resident was receiving [MEDICAL TREATMENT] services for [MEDICAL CONDITION] and end stage [MEDICAL CONDITION]. A vas-cath (Catheter) was paced by the hospital on [DATE] for the initiation of [MEDICAL TREATMENT] services on Tuesday, Thursday and Saturday. A physician's orders [REDACTED]. The current care plan, dated 12/16/17, identified a problem: --Permanent catheter for [MEDICAL TREATMENT]. The goal associated with the problem was: --Patient will remain free of complications from the Venous Access Device Interventions included: --Monitor dressing and change per physician order [REDACTED]. --Monitor and report to physician any signs/symptoms of infection: such as chills, fever, confusion, change in cognition, lethargy and or redness/tenderness/swelling at site. Vas cath or Permacath are both temporary catheters used for [MEDICAL TREATMENT] until a more permanent access has time to mature (arteriovenous fistula or Arteriovenous (AV) Graft). Sometimes these catheters are used in more chronic [MEDICAL TREATMENT] situations, when fistula or graft access cannot be obtained. The vas cath is a specially-designed catheter with 2 or 3 lumens that is inserted into the [MEDICATION NAME], internal jugular, or femoral vein and can be used immediately (after x-ray confirmation). The vas cath is similar to a huge central venous line, and requires no tunneling. The Permacath is also used for short-term and immediate [MEDICAL TREATMENT] treatment. This procedure is more involved and requires tunneling under the skin. At 10:17 a.m. on 02/06/18, the Registered Nurse, Clinical Care Supervisor, RN #38 said the resident has a Vas cath in his left chest area. We checked it daily but the staff at the [MEDICAL TREATMENT] center maintains the cath. RN #38 verified the admission documentation from the hospital noted the resident had a vas cath. RN #38 added the resident has a new access site in the left forearm, which was just inserted last week. She stated the [MEDICAL TREATMENT] center is still using the vas cath for his access for [MEDICAL TREATMENT] until the new area heals. She verified the resident does not have a Permacath as identified in the care plan. At 2:36 p.m. on 02/16/18, the Director of Nursing said she was aware of the documentation in the resident's medical record. She said RN #38 had already told her about the confusion.",2020-09-01
3244,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2018-02-08,657,E,0,1,T2JD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise five (5) of twenty-five (25) care plans, reviewed during Long Term Care Survey Process (LTCSP), when the residents experienced a change in condition. The facility did not revise Residents #31's care plan after the resident experienced an accident with major injury requiring hospitalization . Resident #36's care plan was not revised after she experienced a decline in activities of daily (ADL). Resident #40 and #12's care plans had not been revised when a new pressure ulcer developed and/or when the pressure ulcers had healed. Additionally, Resident #38's care plan was not revised after an [MEDICAL CONDITION] medication had been discontinued. Resident identifiers: #31, #36, #40, #12 and 38. Facility census 78. Findings include: a) Resident #31 Review of the Resident #31 care plan found the following problem: --(Name of Resident) has experienced an actual fall with minor injury related to unsteady gait. The care plan was dated 06/12/17. The goal associated with the problem is: --Patient will have no major/serious injuries related to falls through review date (02/13/18). Interventions included: --Anti roll back to wheel chair. --Ensure that patient wears appropriate footwear when ambulating or mobilizing in wheelchair. --Contact physician as necessary. At 1:30 p.m. on 02/07/18, Registered Nurse Assessment Coordinator, RN #79, verified the resident had experienced a fall on 12/23/17 with major injury requiring hospitalization . RN #79 said the care plan should have been updated to reflect the fall with major injury. b) Resident #36 Review of the resident's care plan found the following problem: --(Name of Resident) has an ADL (Activities of Daily Living) self care performance deficit related to (r/t) Alzheimer's. The care plan was dated 04/01/17. The goal associated with the problem is: --(Name of resident) will maintain current level of function in participation of ADLs through the review date. (04/08/18). Interventions included: --Activity level: Up in wheelchair daily as tolerated. --Weight bearing status: as tolerated. --Bed mobility self performance: requires physical assist of one. --Transfers performance: requires physical assist of one. --Dressing: requires physical help of one. --Eating: requires supervision with set up by staff. --Toilet use: requires physical assist of one. --Oral care: Oral hygiene every shift and as needed. Assist as needed. --Personal hygiene: requires physical assist of one. --Bathing: requires the physical assist of one. Review of Resident #36's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/18/17. This MDS reveals the resident requires extensive assistance of two or more with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Additionally, the resident requires limited assistance of one with eating. At 1:30 PM on 02/07/18, Registered Nurse Assessment Coordinator, RN #79, verified the resident had experienced a decline in ADLs. RN #79 said the care plan should have been updated to reflect the decline in ADL status after the MDS with ARD of 12/18/17. c) Resident #40 Review of Resident #40s care plan found the following problem: --(Resident's Name) has the potential for pressure ulcer development r/t impaired mobility secondary to bilateral [MEDICAL CONDITION]. This care plan was dated 06/28/17. The goal associated with the problem is: --Patient will have intact skin, free of redness, blisters or discoloration by/through next review date. (03/27/18). Interventions included: --Pressure relieving/reducing air mattress on bed at all times. --Pressure relieving/reducing cushion to chair while in use. --Provide prompt, thorough pericare using moisture barrier product if an incontinence episode should occur. Do not massage over bony prominence's. At 1:30 PM on 02/07/18, Registered Nurse Assessment Coordinator, RN #79, verified the resident had developed a pressure ulcer on his right stump from a new prosthetic leg on 12/28/17. RN #79 said the care plan should have been updated to reflect the pressure ulcer on the residents right stump. d) Resident #12 Review of Resident #12s care plan found the following problem: --(Resident's Name) is at risk for pressure ulcer development r/t immobility and incontinence and history of pressure ulcer. This care plan was dated 06/14/17 with a revision on 10/04/17. The goal associated with the problem is: --Patient will have intact skin, free of additional redness, blisters or discoloration by/through next review date. (03/27/18). Interventions included: --Pressure relieving/reducing air mattress on bed at all times. --Pressure relieving/reducing cushion to chair while in use. --Provide prompt, thorough pericare using moisture barrier product if an incontinence episode should occur. Do not massage over bony prominence's. --Obtain and monitor lab/diagnostic work as ordered. --Observe/document/report to physician whenever changes in skin status: appearance, color, wound healing. signs/symptoms of infection, wound size (length x width x depth) and stage. --Assess/record/monitor wound healing per facility protocol --Administer treatments as ordered and monitor for effectiveness. At 1:30 PM on 02/07/18, Registered Nurse Assessment Coordinator, RN #79, reviewed Resident #12's medical records. This review revealed on 10/04/17 a pressure ulcer developed on the residents left buttocks and resolved/healed on 12/12/17. Additionally, on 11/15/17 Resident #12 developed two (2) new pressure ulcers on the right buttocks and coccyx. The right buttocks pressure ulcer resolved/healed on 12/12/18 and the coccyx pressure ulcer healed/resolved on 01/30/18. RN #79 said the care plan should have been updated to reflect the pressure ulcers development as well as the healed/resolve of the pressure ulcers/injuries. e) Resident #38 Review of the resident's care plan found the following problem: --(Name of Resident) receives antipsychotic medication ([MEDICATION NAME]) related to behavior management. The care plan was dated 11/30/17. The goal associated with the problem is: --(Name of resident) will be free from adverse effects related to attempted titration of antipsychotic/hypnotic/mood stabilized medication. Interventions included: --Administer medications as ordered. Monitor/document for side effects and effectiveness. --Attempt gradual dose reduction of ([MEDICATION NAME]) in accordance with physician orders [REDACTED]. --Contact physician as necessary. At 3:30 PM on 02/07/18, Registered Nurse Assessment Coordinator, RN #79, verified the resident antipsychotic medication, [MEDICATION NAME] was discontinued on 12/19/17. RN #79 said the care plan should have been updated to reflect the changes.",2020-09-01
3245,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2018-02-08,677,D,1,1,T2JD11,"> Based on observation and staff interview, the facility failed to ensure, Resident #10, whom was unable to carry out her activities of daily living (ADL) of eating, assistance with her dinner meal on 02/16/18. This was a random opportunity for discovery. Resident identifier: #10. Facility Census: 78. Findings include a) Resident #10 On 02/16/18 at 5:30 PM, observation found Resident #2 and Resident #10 shared a room together. At 5:38 PM Resident # 2 received her tray. At 5:50 PM on 02/16/18, Nurse Aide (NA) #37 delivered and opened and prepared the tray. NA #37, then left the room. At 6:00 PM on 02/16/18, NA #37, returned to the room to begin to assist Resident #10 to eat her dinner. This was after this surveyor had asked Licensed Practical Nurse (LPN) #68, licensed whether Resident #10 could feed herself and her response was, No. Review of Resident #10's medical records on 02/16/18 at 6:30 PM, found a Minimum Data Set (MDS) with a reference date (ARD) of 08/14/17, this assessment indicated Resident #10 required total assistance of one for eating. During an interview with the Director of Nursing (DON) at 11:10 AM on 02/17/18, it was confirmed it Resident #10 required total assistance of one for eating. Additionally, the DON confirmed the tray should not be taken into the room until the staff was ready to assist the residents with eating. No further information was provided.",2020-09-01
3246,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2018-02-08,686,E,0,1,T2JD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure services were provided to promote healing of pressure ulcers. This was true for two (2) of four (4) reviewed in the care area of pressure ulcer during the Long Term Survey Process (LTCSP). Resident identifiers: #12 and #52. Facility census: 78. Findings include: a) Resident #12 Review of Resident #12's medical records found a progress note written by the attending physician dated 11/15/17 which noted the Resident had three (3) pressure ulcers on the left and right buttocks and coccyx. The physician's progress noted detailed the measurements of the three pressure ulcers as follows: --Area on the right buttock measured 1 centimeter (cm) in length, 0.5 cm in width and 0.1 cm in depth --Area on the coccyx measured 2.5 cm in length, 1 cm in width and less than 0.1 cm in depth. --Area on the left buttock measured 2 cm in length, 1 cm in width and less then 0.1 cm in depth. The physician's noted classifed all pressure ulcers as Stage 2, and inclued the following ordered interventions: --Turn left to right side only; --Multi-vitamin with minerals daily; --Protein supplement twice daily; --Leave in bed except up in wheelchair three times a day for meals; and --Booties worn while in bed. Further review of the medical records found the licensed nurses failed to follow the physician orders [REDACTED].>--Turn left to right side only; and --Leave in bed except up in wheelchair three times a day for meals. Additionally, the medical record did not contain initial pressure ulcer documenattion by licensed staff for the area to the left buttock. Assessments for the pressure ulcer to the left buttock was not initiated until 11/23/17. This was eight days after the physician's progress note concerning the three pressure ulcers. At 12:30 PM on 02/08/18,the Director of Nursing (DON) reviewed Resident #12's medical records. She confirmed the licensed nurses failed to initiate and follow the physician's orders [REDACTED]. No further information provided through the exit of the survey. b) Resident #52 Record review found this resident was admitted to the facility on [DATE] with a Stage 2 pressure to the coccyx. Review of the weekly wound assessments found the pressure ulcer remained a Stage 2 until 01/15/18. On 01/15/18, the wound was an unstageable pressure ulcer. On 01/22/18, the wound was staged as a Stage 3 pressure ulcer. On 02/01/18 the wound was staged as a Stage 4 pressure area. On 01/18/18, the resident went out of the facility for an appointment to see a physician regarding the pressure ulcer. The physician noted the area was a Stage 3 pressure ulcer. Debridement was scheduled for 01/30/18. The report of consult, dated 01/30/18, noted the wound was a Stage 4 pressure area. The wound was debrided and a wound vac was ordered on [DATE]. The resident returned to the facility after the procedure. On 01/19/18 the physician ordered a culture of the wound due to drainage/odor. The culture was obtained on 01/19/18, The laboratory report, with the culture and sensitivity, was reported to the facility on [DATE]. The culture report noted the resident had heavy growth of Escherichia coli. The values of the wound culture were not reported to the physician until 01/29/18, as which time the physician ordered [MEDICATION NAME] 1 gram by intramuscular injection for 7 days. At 11:10 AM on 02/06/18, Register Nurse, Clinical Care Coordinator #38 confirmed she could find no evidence the physician was notified of the laboratory report on 01/25/18. RN #38 further confirmed, after reading the Medication Administration Record, [REDACTED]. The failure to notify the physician timely of the laboratory report, reported to the facility on [DATE], resulted in a five (5) day delay in treatment of [REDACTED]. At 2:58 PM on 02/06/18, the Director of Nursing (DON) was informed of the findings. No further evidence was provided by the facility. On 02/08/18 at 11:54 AM, the DON was unable to provide any information to contradict the above findings.",2020-09-01
3247,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2018-02-08,698,E,1,1,T2JD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure an accurate assessment for one (1) of one (1) resident receiving [MEDICAL TREATMENT]. The facility failed to correctly identify the access site used for [MEDICAL TREATMENT]. Resident identifier: #52. Facility census: 78. Findings include: a) Resident #52 Record review found the resident was admitted to the facility on [DATE]. Review of the hospital discharge summary, dated 12/14/17, found the resident was receiving [MEDICAL TREATMENT] services for [MEDICAL CONDITION] and end stage [MEDICAL CONDITION]. A vas-cath (catheter) was paced by the hospital on [DATE] for the initiation of [MEDICAL TREATMENT] services on Tuesday, Thursday and Saturday. A physician's orders [REDACTED]. The current care plan, dated 12/16/17, identified a problem: --Perm [MEDICATION NAME] for [MEDICAL TREATMENT]. --Interventions included: --Monitor dressing and change per physician order [REDACTED]. --Monitor and report to physician any signs/symptoms of infection: such as chills, fever, confusion, change in cognition, lethargy and or redness/tenderness/swelling at site. Vas cath or Permacath are both temporary catheters used for [MEDICAL TREATMENT] until a more permanent access has time to mature (arteriovenous fistula or Arteriovenous (AV) Graft). Sometimes these catheters are used in more chronic [MEDICAL TREATMENT] situations, when fistula or graft access cannot be obtained. The vas cath is a specially-designed catheter with 2 or 3 lumens that is inserted into the [MEDICATION NAME], internal jugular, or femoral vein and can be used immediately (after x-ray confirmation). The vas cath is similar to a huge central venous line, and requires no tunneling. The Permacath is also used for short-term and immediate [MEDICAL TREATMENT] treatment. This procedure is a little more involved and requires tunneling under the skin. At 10:17 a.m. on 02/06/18, the Registered Nurse Clinical Care Supervisor, RN #38 said the resident has a Vas cath in his left chest area. We checked it daily but the staff at the [MEDICAL TREATMENT] center maintains the cath. RN #38 verified the admission documentation from the hospital noted the resident had a vas cath. RN #38 added the resident has a new access site in the left forearm, which was just inserted last week. She stated the [MEDICAL TREATMENT] center is still using the vas cath for his access for [MEDICAL TREATMENT]. At 2:36 p.m. on 02/16/18, the Director of Nursing said she was aware of the documentation in the resident's medical record. She said RN #38 already told her about the confusion.",2020-09-01
3248,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2018-02-08,758,E,0,1,T2JD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure as needed (or PRN) [MEDICATION NAME] was limited to fourteen (14) days, or the length of duration and the rationale for a longer duration was documented. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #46. Facility census: 78. Findings include: a) Resident #46 On 01/17/18, an order was written for Resident #46 for [MEDICATION NAME] ([MEDICATION NAME]) 1 milligram (mg), one (1) tablet by mouth every six (6) hours as needed for anxiousness. Review of Resident #46's medication administration records (MARs) demonstrated the resident had not received any as needed [MEDICATION NAME] since the order was written on 01/17/18. During an interview on 02/06/18 at 3:17 PM, the Director of Nursing (DON) was notified Resident #46's PRN [MEDICATION NAME] order was not limited to fourteen (14) days, nor was the length of duration along with the rational for a longer duration documented. The DON was also informed Resident #46 had not required PRN [MEDICATION NAME] since the order was written on 01/17/18. The DON stated the [MEDICATION NAME] order would be discontinued.",2020-09-01
3249,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2018-02-08,773,D,0,1,T2JD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the physician was promptly notified of the results of a laboratory value, resulting in a delay in treatment for [REDACTED]. This was true for one (1) of four (4) residents reviewed for pressure ulcers during the long term care survey process. Resident identifier: #52. Facility census: 78. Findings include: a) Resident #52 Record review on 02/06/18 found this resident was admitted to the facility with a Stage 3 pressure to the coccyx. Review of the weekly wound assessments found the pressure ulcer remained a Stage 2 until 01/15/18. On 01/15/18, the wound was an unstageable pressure ulcer. On 01/22/18, the wound was staged as a Stage 3 pressure ulcer. On 02/01/18 the wound was staged as a Stage 4 pressure area. On 01/19/18 the physician ordered a culture of the pressure ulcer due to drainage/odor. The culture was obtained on 01/19/18, The laboratory report, with the culture and sensitivity, was reported to the facility on [DATE]. The culture report noted the resident had heavy growth of Escherichia coli. The values of the wound culture were not reported to the physician until 01/29/18, as which time the physician ordered [MEDICATION NAME] 1 gram intramuscular injection for 7 days. At 11:10 a.m. on 02/06/18, Register Nurse, Clinical Care Coordinator #38 confirmed she could find no evidence the physician was notified of the laboratory report on 01/25/18. RN #38 further confirmed, after reading the Medication Administration Record, [REDACTED]. The failure to notify the physician timely of the laboratory report, reported to the facility on [DATE], resulted in a five (5) day delay in treatment of [REDACTED]. At 2:58 PM on 02/06/18, the Director of Nursing (DON) was informed of the findings. No further evidence was provided by the facility. On 02/08/18 at 11:54 AM, the DON was unable to provide any information to contradict the above findings.",2020-09-01
3250,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2018-02-08,804,E,0,1,T2JD11,"Based on observation, staff interview and resident interview, the facility failed to ensure food was served at the proper temperatures to prevent the outbreak of food born illness, and at a temperature acceptable to the residents. This practice had the potential to effect more than an isolated number of residents. Facility census: 78. Findings include: a) Resident interviews Anonymous interviews with the residents on 02/05/18, found several complaints of cold food. b) Food temperatures on first floor At 8:55 AM on 02/07/18, the following temperatures, of the last breakfast tray served, was obtained on the first floor with the Dietary Manager (DM): --Gravy: 97.9 degrees --Boiled egg: 93.5 degrees --Orange Juice: 47.3 degrees --Milk: 45 degrees --Oatmeal: 105.5 degrees The DM said the food cart arrived on the first floor at 7:30 AM. The DM said the food temperatures, at the time of service, were not acceptable. The DM provided evidence food temperatures were within acceptable standards when the food left the kitchen: --Oatmeal: 191 degrees --Eggs: 186 degrees --Gravy: 176 degrees On the morning of 02/08/18 the administrator was asked to provide the facility's policy for the food temperatures at the time of service. A copy of Food Safety Guidelines was provided with the following temperatures: --Cold food: less than 41 degrees --Hot foods: 135 degrees or higher.",2020-09-01
3251,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2018-02-08,806,D,0,1,T2JD11,"Based on observation, resident interview and staff interview, the facility failed to honor the resident's food preferences. Resident identifier: #53. Facility census: 78. Findinds include: a) Resident #53 During a random opportunity for discovery, on 02/06/18 at 6:58 PM, dinner was served to Resident #53 in her room. Dinner consisted of baked steak with gravy, mashed potatoes, mixed vegetables. The gravy was covering the meat and on the potatoes, and had a lot of visible pepper in the gravy. Resident #53 said she has instructions for food likes/dislikes, and she does not like food with a lot of pepper or spices or spicy foods. At the time of the random observation, DON #35 was helping with dinner, I asked if she thought there was a lot of pepper in her gravy and she agreed. On 02/08/18 at 09:43 AM during an interview with the the Dietary Services Supervisor (DSS) #8 she was asked to provide a copy of Resident's food likes and dislikes. DSS #8 responded that staff were well aware of Resident #53's dislike of pepper or spicy foods, tea or kool-aid. The written likes and dislikes confirmed the Resident's dislikes. DSS #8 agreed Resident # 53 should have been give an alternative meal that did not have so much pepper in it.",2020-09-01
3252,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2018-02-08,842,E,0,1,T2JD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to document in the medical record the length of time Resident #32's posey palm guard was applied daily. This was true for one (1) of one (1) resident reviewed for the care area of Range of Motion. Resident identifier: Resident #32. Facility census: 78. Findings include: a) Resident #32 Resident #32 had a [DIAGNOSES REDACTED]. She had contractures of her right wrist and hand. On 12/10/17, an order was written to apply a right upper extremity posey palm guard up to six (6) hours daily as tolerated. A care plan intervention was written on 12/07/17 to apply right upper extremity protective sleeve and posey palm guard for up to six (6) hours as tolerated, from midnight to 6:00 AM. On 01/19/17, the care plan was revised for the right upper extremity protective sleeve and posey palm guard to be applied on day shift for up to six (6) hours a day. The Point of Care Response History for the posey palm guard device was reviewed for 01/14/18 through 02/08/18. The Point of Care Response History answered the question, Was device in place as ordered this shift? On 01/14/18, the column indicating yes was marked at 2:59 AM and 10:58 AM. On 01/15/18, the column indicating yes was marked at 2:52 AM and 8:37 AM. On 01/16/18, the column indicating yes was marked at 12:57 AM and 11:10 AM. For the dates 01/17/18, through 02/08/18, the column indicating yes was marked one (1) time during day shift, at varying times. During an interview on 02/08/18 at 11:22 AM, Registered Nurse Assessment Coordinator (RNAC) #79 agreed the Point of Care Response History for the posey palm guard device did not document the precise time the device was applied and the precise time the device was removed, or the total amount of time the device was in use. During an interview on 02/08/18 at 1:50 PM, the Director of Nursing (DON) was informed the Point of Care Response History for the posey palm guard device did not document the precise time the device was applied and the precise time the device was removed. Therefore, it could not be determined how long the device was in use each day. It could not be determined how well Resident #32 tolerated the posey palm guard or whether the facility was in compliance with the physician's orders [REDACTED]. The DON had no additional documentation this matter.",2020-09-01
3253,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2018-02-08,880,D,0,1,T2JD11,"Based on observation and staff interview, the facility failed to maintain effective infection control practices during incontinence care. This was a random opportunity for discovery. Resident identifier: #65. Facility census: 78. Findings include: a) Resident #65 On 02/07/18 at 10:57 AM, Nurse Aide (NA) #16 was observed performing incontinence care for Resident #65. NA #16 donned gloves before beginning the task. After removing and discarding Resident #65's soiled incontinence brief, NA #16 washed the resident's vaginal area with soapy water, rinsed the area with water, and dried the area. The NA then washed, rinsed, and dried Resident #65's rectal area. NA #16 changed her gloves before applying a clean incontinence brief and pulling up the resident's hipsters and pants. The NA did not perform hand hygiene after removing her potentially contaminated gloves and before donning clean gloves. The NA was informed of her failure to perform hand hygiene after removing her potentially contaminated gloves and before donning clean gloves. During an interview on 02/07/18 at11:09 AM, the Director of Nursing was notified about NA #16's failure to maintain effective infection control practices during incontinence care.",2020-09-01
3254,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2016-12-14,157,E,0,1,467L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the attending physician when a change of condition occurred for two (2) of three (3) residents reviewed for the care area of notification of changes during Stage 2 of the Quality Indicator Survey (QIS). Resident #88's international normalized ratio (INR) results on six (6) of nine (9) occasions from 09/16/16 through 09/24/16. Newly developed pressure ulcers for Resident #20 ' s were not reported to the attending physician on two (2) separate occasions. Resident identifiers: #88 and #20. Facility Census: 75. Findings include: a) Resident #88 A review of Resident #88's medical record, at 2:03 p.m. on 12/12/16, found a physician ' s order dated 09/15/16 which read as follows, Daily INR, then call physician for dosing. A review of Resident #88's medication administration record (MAR) found the nurses initials daily, beginning on 09/16/16 through 09/24/16, to indicate they checked the residents INR. However, the INR results for 09/16/16 through 09/23/16 were not documented on the MAR. A review of the nursing progress notes found a note on 09/16/16 which indicated the residents attending physician was notified of the INR result and gave an order to start [MEDICATION NAME] 10 milligrams (mg). On 09/18/16 the attending physician changed Resident #88's [MEDICATION NAME] dose to 9 mg daily. The INR result was not noted in the medical record. Finally, on 09/24/16, a nursing note indicated Resident #88's INR was 1.9 and the attending physician was notified and gave new orders to continue the 9 mg daily and to check INR on Monday and Thursday. There was no other indication in the medical record to show Resident #88's physician was notified of his INR results on 09/17/16, 09/19/16, 09/20/16, 09/21/16, 09/22/16, and 09/23/16. Which is six (6) of the nine (9) occasions in which the attending physician should have been notified. An interview with the director of nursing (DON) at 1:16 p.m. on 12/13/16, confirmed the medical record contained no evidence the attending physician was notified of Resident #88's INR results on 09/17/16, 09/19/16, 09/20/16, 09/21/16, 09/22/16, and 09/23/16. She stated if they notified the attending physician this should be indicated in a nursing note. She indicated, there was no way to know if they notified the attending physician or not because it is not documented. b) Resident #20 A review of Resident #20's medical record, at 12:35 p.m. on 12/11/16, found she was originally admitted to the facility on [DATE], returned from an acute care hospital on [DATE] after receiving treatment for [REDACTED]. Review of Resident #20's progress notes revealed, on 02/24/16 at 12:40 p.m., a Stage II pressure ulcer noted to right upper inner buttocks. The medical record contained no indication the physician was notified of this new pressure ulcer until 02/29/16 during the physician's visit. Further review of Resident #20's progress notes indicated on 05/17/16 a deep tissue injury (DTI) was noted on the right buttocks measuring 4 cm in length and 2.5 cm in width with a deep purple center with redness surrounding the area. No indication the physician was notified until 05/23/16. An interview with the DON, at 12:16 p.m. on 12/12/16, confirmed the medical record contained no evidence the attending physician was notified of Resident #20's new pressure ulcers on 02/24/16 and 05/17/16. She stated if they notified the attending physician this should be indicated in a nursing note. She indicated, there was no way to know if they notified the attending physician or not because it is not documented.",2020-09-01
3255,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2016-12-14,224,D,0,1,467L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and policy review, the facility failed to ensure Resident #56 was transferred in accordance with her care plan and facility policy by staff [MEDICATION NAME] within the scope of their practice. The nurse aide acted out of her scope of practice by stopping and re-starting a continuous feeding for a resident with a gastrostomy tube (a gastrostomy tube is a tube inserted through the abdomen that delivers nutrition directly to the stomach.) This failure by the facility to keep residents free from neglect was discovered during a random opportunity for discovery. Resident identifier: #56. Facility census: 75. Findings include: a) Resident #56 At 9:40 a.m. on 12/07/16, nurse aide (NA) #38 was observed opening the door of Resident #56 ' s room pushing a mechanical lift into the hallway. Resident #56 was observed to be up in her geri-chair. No other staff member were present in the room or with NA #38. Further observation found a private sitter was in the room with Resident #56. NA #38 was asked if she had assistance when using the mechanical lift for Resident #56. NA #38 replied, No, the sitter helped me. At 9:49 a.m. on 12/07/16, the resident's private sitter verified NA #38 had transferred the resident to her geri-chair without any staff assistance. The sitter said she assisted NA #38 by holding the resident's chair for her while NA #38 operated the lift. The sitter said she was a nurse aide at one time but she was no longer certified. The sitter said, That happens a lot, sometimes they have two (2) (referring to staff) sometimes they don't. On 12/07/16, at 10:00 a.m., the director of nursing (DON), confirmed Resident #56 is a full body lift with the assistance of two (2) staff members for transfers. The DON said nurse aides are to look at the care plan to see how the resident should be transferred. The electronic care plan was reviewed with the DON at this time and revealed the following: --The care plan problem was: (Name of resident) requires extensive to total assist with ADL's (activities of daily living) related [MEDICAL CONDITION](cerebral vascular incident) dysphagia, [MEDICAL CONDITION], memory loss, contractures, and muscle weakness. --The goal associated with this problem was: Resident will have daily ADL needs met with extensive to total assist as evidenced by being well groomed, neat and appropriately dressed daily through review. --Approaches included: Transfers dependent of 2. Full body lift for all transfers. The DON confirmed the resident is transferred with a full body lift and the assistance of two (2) staff members is required. The DON said she would immediately investigate this issue. While reviewing the medical record for the issue related to the lift, it was discovered the resident also had a gastrostomy tube with continuous feeding for the following: --Review of the resident's care plan found an additional problem: (Name of resident) is dependent on tube feeding for nutritional support and hydration, with potential for complications, side effects. --The goal associated with this problem is: Will maintain adequate nutritional and hydration statue as evidence by: no signs/symptoms of malnutrition or dehydration through review. An approach associated with this goal was: Prior to toileting resident, stop feeding 30 minutes prior to position changes. At 11:06 a.m. on 12/07/16, licensed practical nurse (LPN), #67 was asked if she had stopped Resident #56's feeding at any time this morning. She replied, No, I will put it on hold at noon when I give her medicine at noon. At 11:30 a.m. on 12/07/16, NA #38, was asked how she managed the Resident's tube feeding during the transfer. NA #38 said, I tied a knot in it and corked it so it wouldn't leak. When asked to explain this procedure, NA #38 said there is a yellow plug you put in the tube which stops the feeding. She said that after the transfer, she started the feeding again. At 11:32 a.m. on 12/07/16, the sitter confirmed the NA stopped the resident's feeding during the transfer to the geri-chair. On 12/07/2016 at 2:30 p.m., the resident's care plan for the feeding tube was reviewed with the DON. The DON confirmed the resident's gastrostomy tube feeding is to be stopped prior to transferring the resident from the bed to a geri-chair. The DON said this would be a position change referred to in the care plan. The DON was made aware of NA #38's statement that she, tied a knot in the tubing and corked it off ., during the Resident's transfer. The DON said NA #38 should have asked the nurse on duty to stop the feeding before transferring the resident. She said she would also investigate this situation because the NA was acting out of her scope of practice. The DON confirmed only a licensed nurse can stop and start a resident's tube feeding. The DON provided a copy of the facility's policy, entitled, Lifting Machine, at 2:30 p.m. on 112/07/16. The policy directs, .The full body requires two staff members to perform the procedure. At 2:00 p.m. on 12/12/16, the DON provided a copy of the facility's completed investigation of the care provided to Resident #56 by NA #38 on 12/07/16. The facility's investigation began on 12/07/16. The facility reported the incident, involving NA #38 to the proper state authorities as directed by State Law. NA #38 was suspended pending investigation. Review of the facility's five (5) day follow up report, completed on 12/10/16, found the facility substantiated NA #38 transferred Resident #56, . by herself which was against facility policy and care plan which calls for assistance of 2. It was substantiated that CNA (certified nursing assistant) did disconnect fed tube which is outside her scope of practice and a violation of facility policy. Attached to the investigation was a hand written statement by NA #38, dated 12/09/16 that read: On Wednesday the 7th, I went into (resident ' s room number) room to do care when I pulled the covers back I seen she had stuff on her. So I got her up with the full body lift by myself which I should have waited for the other aides to get back but I didn't. I know I did wrong by having (name of sitter) help me but I just didn't have the heart to walk away from her and get her later and let her lay there in it. I did ask the nurse to come in (resident ' s room number) to look and was gonna have her help transfer but the nurse didn't hear me. All (name of sitter) did was lower her down while I held the chair and pulled (resident ' s room number) up in it. LPN #67 provided a had written statement, dated 12/09/16, stating NA #38 did not ask for help getting the resident up and the NA did not tell her the feeding machine needed to be unhooked.",2020-09-01
3256,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2016-12-14,241,D,0,1,467L11,"Based on observation and staff interview the facility failed to ensure Resident #99 and Resident #100 had a dignified dining experience during the noon time meal on 12/06/16. Resident #99 and Resident #100 were served their meal 20 minutes after all other residents, including their tablemates, dining in the first (1st) floor dining area. This was discovered randomly during the noon meal observation on the first day of the Quality Indicator Survey (QIS). This practice affected two (2) of fifteen (15) residents dining in the first floor dining area. Resident Identifiers: #100 and #99. Facility Census: 75. Findings include: a) Resident #99 and #100 Observations of the noon time meal in the first floor dining area began at 12:00 p.m. on 12/06/16. There were fifteen (15) residents, including Resident #99 and Resident #100, dining in this dining area. At 12:23 p.m. on 12/06/16 the staff completed serving the meals to 13 of the 15 residents and began to assist residents who needed assistance with eating. At this time Resident #99 and Resident #100 were not served their noon time meal. They were seated at a table with Resident #95 and Resident #92 who were eating their meal. At 12:29 p.m. on 12/06/16, Resident #95 looked at Resident #99 and stated, I think they forgot your meal (name of resident #99), to which Resident #99 replied, I don't know. I hope not. At 12:32 p.m. licensed practical nurse (LPN) #67 stood up and stated I am going to call them and remind them that we did not get their trays. During this time Resident #95 again said to Resident #99, I think they forgot you. Resident #99 again replied, I hope not. Resident #99 and Resident #100 were not served their meal until 12:43 p.m. on 12/06/16, which was a full 20 minutes after all other residents in the dining room had received their meal. While waiting for her tray Resident #99 kept looking around the room as if she was looking to see if anyone was going to bring her lunch to her. During the 20 minute wait Resident #100 left the dining room and went to the bathroom and came back and still did not have his meal. An interview with the Infection Control Nurse at 12:50 p.m. on 12/06/16, confirmed Resident #99 and Resident #100 did not receive their noontime meal with all the other residents. She stated the kitchen did not send up their meals with everyone else's for some reason. She was then asked how many times staff had to call to get the meals, she stated, I think they called twice. I went into the hallway to call a third time and saw the kitchen staff bringing the meals. At 3:37 p.m. on 12/06/16, the Certified Dietary Manager (CDM) was interviewed. She stated a new person was printing off the tray tickets (paper with the residents name, diet, and likes and dislikes) and she laid them on a shelf in the kitchen and did not incorporate them in with the existing resident tray tickets and they were missed. She stated, That is why they did not get their tray with everyone else. An additional interview with the CDM, at 4:22 p.m. on 12/06/16, confirmed she had spoken with the evening shift tray aide who took the first phone call from first floor nursing requesting Resident #99 and Resident #100's tray. The CDM indicated the first call came to the kitchen about 12:15 p.m. The evening shift aide indicated she told the morning shift cook and morning shift tray aide who assured her they knew the trays were sent and to give nursing a couple minutes and they would find them. It was not until the second call came from LPN #67 at 12:32 p.m. that they realized nursing had not found the trays and they fixed them and sent them to the floor.",2020-09-01
3257,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2016-12-14,272,E,0,1,467L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected Resident #15 terminal prognosis. The MDS assessment did not accurately reflect pressure ulcers for Resident #20 and #77. The MDS assessment for Resident #67 did not accurately reflect her functional status. This was true for four (4) of seventeen (17) residents reviewed for accuracy of comprehensive assessments during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #15, #20, #77 and #67. Facility Census: 75. Findings include: a) Resident #15 Resident #15 was readmitted on [DATE] after a stay in an acute care hospital for the treatment of [REDACTED]. Hospice services were approved and initiated on 07/13/16 for the treatment of [REDACTED]. The significant change MDS with an assessment review date (ARD) of 07/22/16 did not indicate the resident had a condition or terminal illness which would result in a life expectancy of less than six (6) months. The MDS did indicate she was on hospice services.Orders showed the resident had Hospice services, which began on 07/13/16. During an interview on 12/08/16 at 10:00 a.m., the MDS Coordinator register nurse (RN) #65, verified the MDS with ARD date 07/22/16 was inaccurate. She confirmed the resident had a chronic disease that may result in a life expectancy of less than six (6) months. b) Resident #20 A review of Resident #20's medical record at 12:35 p.m. on 12/11/16, found she was originally admitted to the facility on [DATE], returned from an acute care hospital on [DATE] after receiving treatment for [REDACTED]. The Body Assessment form completed upon her readmission on 03/05/16, identified Resident #20 had a Stage II pressure ulcer on coccyx, which measured 0.7 centimeters (cm) in length by 0.5 cm in width and less than 0.1 cm in depth upon her readmission. 1. The significant change MDS with ARD of 03/19/16 indicated the date of the oldest Stage II pressure ulcer was 02/24/16 instead of 03/05/16. During an interview on 12/11/16 at 4:00 p.m., RN #65 verified the MDS with an ARD date of 03/19/16 was inaccurate. She further verified the date of the oldest Stage II pressure ulcer should have been 03/05/16. 2. The significant MDS with ARD of 06/14/16 indicated Resident #20 had a stage IV pressure ulcer on the right upper buttocks. Review of the Body Assessment completed on 06/14/16 (this assessment is completed on a weekly basis), indicated Resident #20 had an unstageable pressure ulcer on the right upper buttocks that measured 4 cm in length and 1.5 cm in width with a gray colored center with yellow slough edges. Center of wound is loose at edges and spongy with a foul odor to the wound. During an interview on 12/11/16 at 4:00 p.m., RN #65 verified the MDS with an ARD of 06/14/16 was inaccurate. She confirmed Resident #20 had an unstageable pressure ulcer not a stage IV as indicated. c) Resident #77 A review of the medical record for Resident #77, at 11:35 a.m. on 12/12/16, found she was admitted to the facility on [DATE] after receiving treatment for [REDACTED]. Review of the significant change MDS with an assessment review date (ARD) of 07/15/16 indicated Resident #77 had two (2) Stage II pressure ulcers and one (1) unstageable pressure. Review of the Wound Assessment and Progress Review dated 07/14/16 revealed the following: --A deep tissue injury (DTI) on Resident #77's right heel measured 3.1 cm in length and 5.1 cm in width with a brown blister like area. The attending physician notified and new orders given for Moon boots at all times, Multivitamin one tablet daily, Vitamin C 500 milligrams (mg) daily, Prostat 30 milliliters (ml) twice daily, and air mattress to bed. --A Stage II pressure ulcer noted to right buttocks measuring 0.5 cm in length by 0.3 cm in width by 0.1 cm in depth. Interview with RN #65, on 12/12/16 at 2:00 p.m., confirmed the MDS with ARD of 07/15/16 was inaccurate. She verified Resident #77 had one (1) DTI on right heel and one (1) stage II pressure ulcer on the right buttocks. d) Resident #67 A review of the medical record for Resident #67, on 12/13/16, revealed the Minimum Data Set (MDS) comprehensive assessment with an Assessment Reference Date (ARD) of 10/01/16 had functional status for walking in room coded as the activity did not occur. Further review of the Point of Care Activity of Daily Living (ADL) Category Report used to code the MDS, indicated this resident required limited assistance of one (1) staff for walking in room. An interview with the MDS Coordinator on 12/13/16 at 9:20 a.m., verified the MDS comprehensive assessment for Section G, Functional Status was not coded accurately to reflect Resident #67 required limited assistance of one (1) staff to walk in room.",2020-09-01
3258,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2016-12-14,282,E,0,1,467L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, observation, and policy review, the facility failed to implement the comprehensive care plans, for four (4) of seventeen (17) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #56's was not transferred with the assistance of two (2) staff members, as directed by the care plan, during a transfer with a mechanical lift. Resident #35's care plan was not implemented in the care area of hydration. The resident's intake and output was to be recorded every shift. (Intake and output refers to how much liquid was consumed and how much was eliminated as urine.) Staff failed to properly record the resident's output as directed by the care plan. Resident #20 did not receive pain medication prior to the treatment of [REDACTED]. In addition, the facility failed to turn and reposition the resident as directed by the care plan. The care plan for Resident #77 was not implemented for turning and repositioning and providing a chair pad for a resident with a pressure ulcer. Resident identifiers: #56, #35, #20, and #77. Facility census: 75. Findings include: a) Resident #56 At 9:40 a.m. on 12/07/16, nurse aide (NA) #38 was observed opening the door of Resident #56's room pushing a mechanical lift into the hallway. Resident #56 is the only resident who resides in the room. Resident #56 was observed to be up in her geri-chair. No other staff member were present in the room or with NA #38. Further observation found a private sitter was in the room with Resident #56. NA #38 was asked if she had assistance when using the mechanical lift for Resident #56. NA #38 replied, No, the sitter helped me. At 9:49 a.m. on 12/07/16, the resident's private sitter verified NA #38 had transferred the resident to her geri-chair without any staff assistance. The sitter said she assisted NA #38 by holding the resident's chair for her while NA #38 operated the lift. The sitter said she was a nurse aide at one time but she was no longer certified. The sitter said, That happens a lot, sometimes they have two (referring to staff members) sometimes they don't. On 12/07/16, at 10:00 a.m., the director of nursing (DON), confirmed Resident #56 is a full body lift with the assistance of two (2) staff members for transfers. The DON said nurse aides are to look at the care plan to see how the resident should be transferred. The electronic care plan was reviewed with the DON. The care plan problem was: (Name of resident) requires extensive to total assist with ADL's (activities of daily living) related [MEDICAL CONDITION](cerebral vascular incident) dysphagia, [MEDICAL CONDITION], memory loss, contractures, and muscle weakness. The goal associated with this problem was: Resident will have daily ADL needs met with extensive to total assist as evidenced by being well groomed, neat and appropriately dressed daily through review. Approaches included: Transfers dependent of 2. Full body lift for all transfers. The DON confirmed the resident is to be transferred with a full body lift and the assistance of two (2) staff members. The DON provided a copy of the facility's policy, entitled Lifting Machine, at 2:30 p.m. on 12/07/16. The policy directs, . The full body requires two staff members to perform the procedure. At 2:00 p.m. on 12/12/16, the DON provided a copy of the facility's completed investigation of the care provided to Resident #56 by NA #38 on 12/07/16. The DON confirmed NA #38 did not follow the care plan or the facility policy when transferring Resident #56. Attached to the investigation was a hand written statement, completed by NA #38, dated 12/09/16: On Wednesday the 7th, I went into (resident's room number) room to do care when I pulled the covers back I seen she had stuff on her. So I got her up with the full body lift by myself which I should have waited for the other aides to get back but I didn't. I know I did wrong by having (name of sitter) help me but I just didn't have the heart to walk away from her and get her later and let her lay there in it. I did ask the nurse to come in (resident's room number) to look and was gonna have her help transfer but the nurse didn't hear me. All (name of sitter) did was lower her down while I held the chair and pulled (resident's room number) up in it. b) Resident #35 Review of the resident's care plan on 12/12/16 at 1:30 p.m., found the following problem: (Name of resident) is on a diuretic which puts her at risk for dehydration. The goal associated with the problem: Resident will not exhibit signs/symptoms of dehydration through review. Approaches included: Record intake and output every shift. Review of the facility's Vitals Report, found documentation of the residents daily fluids (intake) for each shift. The resident's urine output was recorded as being; small, medium or large. At 2:01 p.m. on 12/12/16, the DON was asked where the facility records the resident's output as outlined on the care plan. The DON reviewed the vitals report and verified the urine output could not be recorded as small, medium or large. She stated this was incorrect and staff would need to use a specimen collection container for urine which measures the exact volume of urine output. The DON confirmed the facility was not measuring the resident's output correctly as directed by the care plan. On 12/13/16 at 12:01, the registered nurse (RN), Minimum Data Set (MDS) coordinator, #65 said she had removed the approach to record the output from the care plan because she did not have a physician's orders [REDACTED]. At 3:01 p.m. on 12/12/16, the resident's physician, #116, confirmed she did not expect the facility to record the resident's output. c) Resident #20 Observation of Surgeon #117 ' s examination and wound care by LPN #67, on 12/13/16 at 3:35 p.m., found the resident lying on her right side; upon palpitation of the wound and surrounding area on right upper buttocks by the surgeon, Resident #20 began to attempt to pull away from him and repeatedly said, OH, OH (First name of Resident's daughter) don't do that, OH, OH. LPN #67 completed the wound care at this time and during the packing of the wound with a wet gauze, Resident #20 again started attempting to pull away from the LPN and said, OH, don't do that that's home, no, no. Interview, on 12/13/16 at 3:50 p.m., with LPN #67 concerning the resident's resistance and expression of pain and discomfort and she replied, Yes, she does resist and expresses discomfort during wound assessments and treatments. This is normal for her. That is why we pre-medicate her for pain thirty (30) minutes prior to the treatment. She further explained the resident had been medicated at 1:30 p.m. due to the doctor had called and said he would be here in thirty (30) minutes and had run late. During an interview with nurse aide (NA) #38, on 12/14/16 at 9:45 a.m., confirmed she was present for the assessment and wound care for Resident #20 on 12/13/16. When asked if the resident resisted or expressed discomfort/pain during treatments/care, she replied, Yes she always try to pull away and yells out when they are touching and or cleaning/dressing the wound. It is not as bad as it was when she had the [DEVICE]. The care plan problem was: The resident is at risk for pain secondary to limited mobility, history of [MEDICAL CONDITION], and a stage IV pressure ulcer. The goal associated with this problem was: Resident will have pain controlled through next review. Approaches included: Administer pain medication as ordered by the physician. [MEDICATION NAME] routine, and [MEDICATION NAME] before dressing changes as ordered. Observe the resident for non-verbal signs/symptoms of pain such as grimacing, crying, increased anxiety/behaviors, guarding/holding area, wincing, or verbal complaints of pain. Review of the medication administration record (MAR) for the period of 07/19/16 through 12/13/16 found Resident #20 did not receive [MEDICATION NAME] (pain medication) thirty (30) minutes prior to dressing change twenty-three (23) times out of thirty-five (35) treatments completed. During interview with the DON, on 12/14/16 at 9:30 a.m., Resident #20's MAR and Individual Controlled Substance Record for [MEDICATION NAME] were reviewed. She confirmed Resident #20 had not received her [MEDICATION NAME] as ordered on twenty-three (23) of thirty-five (35) treatments. d) Resident #77 Observation revealed a deep tissue injury (DTI) to coccyx that measured 4.5 centimeters (cm) in length, 1.5 cm in width and unable to determine depth due to slough covering the wound bed. A moderate amount of drainage and no odor were noted. Observation, on 12/13/16 at 10:48 a.m., by this surveyor at the time of measurements and dressing change revealed no indications of pain and/or discomfort during the dressing change, and no pressure reducing cushion noted in chair. Observations of Resident #77, on 12/08/16 at 1:00 p.m. and 12/13/16 at 8:30 a.m., revealed no pressure reducing cushion in the chair. The care plan problem was: (Resident's name) has a stage II pressure ulcer to coccyx and history of DTI to right heel and requires assist with bed mobility, transfers, toileting, and is occasionally incontinent which puts her at risk for additional skin breakdown. The goal associated with this problem was: Resident will show no signs/symptoms of skin breakdown through next review. Approaches included: Use pressure reducing device for pressure reduction when resident is in chair. At 11:00 a.m. on 12/13/16 the DON was informed of my observations of Resident #77 not having a cushion to her chair on the previous mentioned dates. On 12/14/16 at 9:45 a.m. an observation of Resident #77 was noted to have a cushion in her chair. She further verified she had obtained the cushion on 12/13/16 after observations by this surveyor.",2020-09-01
3259,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2016-12-14,309,G,0,1,467L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and staff interview, the facility failed to provide care and services to in accordance with the comprehensive assessments and plan of care for one (1) of three (3) reviewed for pressure ulcers and one (1) of five (5) reviewed for unnecessary medication. The facility failed to follow the physician's orders [REDACTED]. This failed practice resulted in actual harm for Resident #20. For Resident #93, the facility failed to administer a pain medication ([MEDICATION NAME]) as directed by the physician's orders [REDACTED].>Resident identifiers: #20 and #93. Facility Census: 75. Findings include: a) Resident #20 Observation of Surgeon #117's examination and wound care by Licensed Practical Nurse (LPN) #67 on 12/13/16 at 3:35 p.m., found the resident lying on her right side. When the surgeon palpated the wound and surrounding area on the resident's right upper buttocks, Resident #20 began to attempt to pull away from him and repeatedly said, OH, OH (First name of Resident's daughter) don't do that, OH, OH. LPN #67 completed the wound care at that time and during the packing of the wound with a wet gauze, Resident #20 again started attempting to pull away from the LPN and said, OH, don't do that that's home, no, no. Review of physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. During an interview on 12/13/16 at 3:50 p.m. concerning the resident's resistance and expression of pain and discomfort LPN #67 said, Yes, she does resist and expresses discomfort during wound assessments and treatments. This is normal for her. That is why we pre-medicate her for pain thirty (30) minutes prior to the treatment. She further explained the resident had been medicated at 1:30 p.m. due to the doctor had called and said he would be there in thirty (30) minutes, but had run late. During an interview on 12/14/16 at 9:45 a.m., Nurse Aide (NA) #38 confirmed she was present for the assessment and wound care for Resident #20 on 12/13/16. When asked if the resident resisted or expressed discomfort/pain during treatments/care, she replied, Yes she always try to pull away and yells out when they are touching and or cleaning/dressing the wound. It is not as bad as it was when she had the [DEVICE]. Further review of Resident #20's MAR, treatment administration record (TAR), and the individual control substance record for 07/18/16 through 12/13/16, found the [MEDICATION NAME] was not administered twenty- three (23) of thirty-five (35) times prior to the dressing change. Review of physician's orders [REDACTED]. On 09/17/16 the order for the dressing was changed to twice weekly on Tuesday and Friday. On 10/10/16 the order for the dressing was changed to twice weekly on Monday and Friday. On 12/01/16 the treatment for [REDACTED]. [MEDICATION NAME] was not administered to Resident #20 on the following occasions prior to dressing changes: 07/26/16, 08/16/16, 08/30/16, 09/20/16, 09/23/16, 09/27/16, 09/30/16, 10/14/16, 10/17/16, 10/21/16, 10/24/16, 10/28/16, 11/04/16, 11/07/16, 11/11/16, 11/14/16, 11/18/16, 11/21/16, 11/28/16, 12/02/16, 12/05/16, 12/09/16 and 12/12/16. An interview with the director of nursing (DON), at 1:30 p.m. on 12/13/16, confirmed Resident #20 was to receive [MEDICATION NAME] thirty (30) minutes prior to her dressing changes. She reviewed the MARs and confirmed the medication was not given on the twenty-three (23) dates which were days her dressings were scheduled to be changed. b) Resident #93 A review of Resident #93's medical record beginning at 7:46 a.m. on 12/08/16, found an order dated 11/20/16 for [MEDICATION NAME] 5/325 milligrams (mg) every 4 hours for pain. Review of the Medication Administration Record [REDACTED]#3 documented the medication was not administered because the drug was not available. In interviews with the Director of Nursing (DON) on 12/08/16 at 1:50 p.m. and again at 3:30 p.m. she confirmed Resident #93 missed three (3) doses of her scheduled pain medication on 12/06/16. She indicated the problem was the pharmacy was waiting to get a new prescription from the attending physician and they had not sent the medication to the facility. When asked if the narcotic emergency box contained [MEDICATION NAME] 5/325 mg, she stated that it did and provided the list of medications contained in the Emergency box. This list indicated the box contained 5 tablets of [MEDICATION NAME] 5/325 mg. The DON stated the nurse should have gotten the medication from the Emergency Narcotic Box and administered it to Resident #93.",2020-09-01
3260,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2016-12-14,314,D,0,1,467L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, policy review and staff interview the facility failed to ensure Resident #77 and Resident #20 did not develop pressure sores unless the wounds were unavoidable. The facility failed to implement preventative measures for Residents #20 and #77, who were assessed as at risk to develop pressure sores. This was true for two (2) of three (3) residents reviewed for the care area of pressure ulcers during Stage 2 of the Quality Indicator Survey. Resident Identifiers: #20 and #77. Facility Census: 75. Findings Include: a) Resident #20 A review of Resident #20's medical record at 12:35 p.m. on 12/11/16, found she was originally admitted to the facility on [DATE], from an acute care hospital on [DATE] after receiving treatment for [REDACTED]. The Body Assessment form completed upon her readmission on 03/05/16 identified she had a Stage II pressure ulcer on her coccyx measuring 0.7 centimeters (cm) in length by 0.5 cm in width and less than 0.1 cm in depth. Further review of the record found the Stage II pressure ulcer on the coccyx healed on 03/23/16. A Braden Scale used to predict the resident's risk for development of pressure ulcers completed on readmission revealed a score of 12. This score indicated high risk for the development of pressure ulcers. Review of physician orders [REDACTED]. -- 03/05/16 through 03/31/16, apply [MEDICATION NAME] to buttocks every shift for protection. -- 03/05/16 through 04/19/16, assess skin at least daily. -- 03/05/16 through 03/23/16, cleanse Stage II pressure ulcer to coccyx area with normal saline and apply [MEDICATION NAME] border daily until healed. -- 03/05/16 through open ended, turn and position according to facility protocol, and avoid pressure to affected area. -- 03/05/16 - ongoing, when up in Geri chair with tray, release and reposition every two (2) hours, and check every thirty (30) minutes. -- 03/23/16 through 05/17/16, cleanse coccyx daily with normal saline and apply [MEDICATION NAME] border for protection. -- 03/05/16 through 09/28/16, use Dycem (to prevent sliding) in chair while up at all times. -- 03/05/16 through 04/25/16, daily multivitamin, Vitamin C (500 mg) by mouth daily for wound healing. -- 03/07/16 and ongoing, use sheep skin on Geri chair and cover with sheet to be in place at all times while resident is up in Geri chair. On 05/02/16 at 4:01 p.m., a nurse noted, Resident alert and awake at this time. No signs/symptoms of distress. Nursing assistant (NA) reported redness to right buttock. This nurse observed several small areas of scattered blanchable redness. This nurse also observed a horizontal line of blanchable redness with a quarter sized area of redness surrounding it. Resident denies any pain or discomfort on palpitation. Area appears to be from previous incident. A documented incident on 04/30/16 at 4:00 p.m., found the resident sitting in front of her Geri chair with the tray intact while in the dining room. No injuries documented. Another documented incident on 05/07/16 at 6:25 p.m., noted the resident experienced a witnessed fall from her Geri chair with no injuries. Review of Weekly Body Assessment revealed the following: -- On 05/12/16, no pressure ulcers noted or observed by Licensed Practical Nurse (LPN) #67, and body assessment completed on 05/14/16 by Registered Nurse (RN) #118. -- 05/19/16, no pressure ulcers noted, observed and completed by LPN #33. -- 05/26/16, deep tissue injury (DTI) noted on right buttocks observed and completed by LPN #119. Further review of nursing notes from 05/11/16 through 05/19/16 found the following: -- 05/11/16 at 12:37 a.m., Resident refused evening medications. Slapped nurse in the face. Has been screaming and crying all night. Unable to identify the cause. Left up in chair due to being high risk for falls. Placed in dining room for nurse to observe behaviors. -- 05/12/16 at 5:06 p.m., Weekly body audit completed. -- 05/13/16 at 12:09 p.m., Complained of pain during restorative therapy. Physician standing order entered for 500 mg PRN (as needed) Tylenol and administered. -- 05/18/16 at 5:58 a.m. (recorded as late entry on 05/19/16 at 12:00 a.m.), Resident has been up all night in Geri chair in the dining room. Bouts of crying and angry shouting occurred frequently. Resident has repositioned herself in the Geri chair with no resistance and has denied help from staff. -- 05/18/16 at 4:48 p.m., Meplilex dressing changed to DTI on right buttocks. Review of Wound Assessment and Progress Review found on 05/17/16 a DTI was noted on the right buttocks measuring 4 centimeters (cm) in length and 2.5 cm in width and no depth, deep purple in center with redness around. Start pressure ulcer protocol. Daughter notified. Completed by LPN #67. On 05/23/16 a physician progress notes [REDACTED].#20's attending physician noted, .has a new pressure ulcer (DTI) to right buttocks with increased pain noted. New orders . [MEDICATION NAME] 25 micrograms (mcg) change every 72 hours, turn every 2 hours and consult surgeon for wound care On 05/31/16, a weekly wound assessment noted the area was identified as a black/necrotic area measuring 4 cm x 5 cm, unable to determine depth, and moderate amount of brown drainage noted. The center of wound was a black necrotic area with yellow edges. The attending physician was notified of area being black and necrotic. On 06/07/16, the weekly wound assessment conducted by LPN #67 and Surgeon #117, wound specialist revealed the area on the right buttocks was unstageable and measured 4 cm x 6.5 cm and black in color. Yellow-green drainage noted coming from around outer edges of wound. Foul odor noted from the wound. Resident will be scheduled for debridement of wound on Tuesday (06/14/16). On 06/14/16, Wound on right upper buttocks pressure ulcer debrided by Surgeon #117 and [DEVICE] was ordered and Foley catheter inserted due to stage IV pressure ulcer debridement to prevent further infection. Observations of Resident #20 on 12/06/16 at 12:30 p.m., 12/07/16 at 9:00 a.m., 12/08/16 at 1:00 p.m., and 12/13/16 at 8:30 a.m., found her sitting up in a Geri chair with no pressure reducing cushion in her chair. Observation of Surgeon 117's examination and wound care by LPN #67 on 12/13/16 at 3:35 p.m., found the resident lying on her right side. Upon palpitation of the wound and surrounding area on the resident's right upper buttocks by the surgeon, Resident #20 began to attempt to pull away from him and repeatedly said, OH, OH (First name of Resident's daughter) don't do that OH,OH. LPN #67 completed the wound care at that time and during the packing of the wound with a wet gauze, Resident #20 again started attempting to pull away from the LPN and said, OH, don't do that that's home, no, no. In an interview on 12/13/16 at 3:50 p.m. concerning the resident's resistance and expression of pain and discomfort, LPN #67 replied, Yes, she does resist and expresses discomfort during wound assessments and treatments. This is normal for her. That is why we pre-medicate her for pain thirty (30) minutes prior to the treatment. She further explained the resident was medicated at 1:30 p.m. due to the doctor had called and said he would be there in thirty (30) minutes and had run late. During an interview on 12/14/16 at 9:45 a.m., Nurse Aide (NA) #38 verified she was present and assisted with Resident #20 on 12/13/16 during the assessment and wound care. When asked if the resident resisted or expressed discomfort/pain during treatments/care, she replied, Yes she always tries to pull away and yells out when they are touching and or cleaning/dressing the wound. It is not as bad as it was when she had the [DEVICE]. The National Pressure Ulcer Advisory Panel (NPUAP) defines a Suspected Deep Tissue Injury (SDTI), depth unknown as a, purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, and warmer or cooler as compared to adjacent tissue . Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment. NPUAP definitions also include, Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknown - Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV A review of Resident #20's care plan found a goal of, Stage IV pressure ulcer to right buttocks will have no signs/symptoms of complications prior to next review. The goal was initiated on 05/17/16 with a revision date of 09/27/16 and a target date of 12/27/16. The care plan contained no interventions for the prevention of pressure ulcers to the buttocks. The rest of the medical record also contained no indication any interventions were ever put in place to prevent the resident from developing pressure ulcers to her buttocks. She was readmitted to the facility on [DATE] after a fall resulting in a [MEDICAL CONDITION] requiring surgical repair. She experienced a decline in mobility and the staff failed to recognize interventions were necessary to prevent the development of pressure ulcers to the buttocks due to the use of a Geri chair with a tray to prevent resident from standing and/or repositioning. The facility identified the resident was at high risk by using a Braden Scale as the care plan instructed, but failed to follow up with interventions to prevent the development of avoidable pressure ulcers. An interview with the director of nursing (DON) at 9:32 a.m. on 12/14/16, confirmed the facility identified the wounds to the right buttocks on 05/17/16. She confirmed the physician was not notified of the pressure ulcer on the resident's right buttocks until 05/23/16. When asked how they evaluated for risk of pressure ulcers, the DON stated that upon admission, quarterly, or if there was a change of condition, they would complete an assessment which included a Braden scale. She stated if the Braden Scale indicated the resident was at risk, they would implement preventative measures to ensure the resident did not develop a pressure ulcer. When asked what preventative measures were in place for Resident #20, the DON reviewed the record and stated, Air mattress to bed, sheepskin to Geri chair and turn every two (2) hours. Review of the facility's policy, General Preventative Measures, found for a person in a chair staff are to change position at least every hour and use foam, gel, or air cushion as indicated to relieve pressure. During an interview with the DON, at 11:00 a.m. on 12/14/16, these findings were reviewed. She was asked to provide any information the facility might have to indicate they attempted interventions and/or treatments to prevent the development of Resident #20's SDTIs to her right buttocks as the facility's policy directed. She stated, We have initiated a cushion to Resident #20's Geri chair as of 12/13/16. She was unable to provide any further information to show the wound was unavoidable. b) Resident #77 A review of Resident #77's medical record at 11:35 a.m. on 12/12/16, found this resident was admitted to the facility on [DATE] after receiving treatment for [REDACTED]. The Body Assessment form completed upon her admission on 04/14/16, identified Resident #77 had no pressure ulcers noted. The Braden Scale used to predict the resident's risks for development of pressure ulcers completed on admission revealed a score of 12 indicating a high risk for the development of pressure ulcers. Review of physician orders [REDACTED]. -- 11/07/16 and ongoing, Turn every two (2) hours. -- 04/14/16 and ongoing, Pressure reducing device when up in wheelchair. -- 07/15/16 through 09/22/16, Air mattress on bed. --07/14/16 and ongoing, Moon boots to bilateral feet at all times. --07/21/16 and ongoing, Float heels when in bed. --12/12/16 and ongoing, Air mattress to bed. Review of Wound Assessment and Progress Review revealed: -- 07/14/16, DTI (deep tissue injury) noted to (Resident #77's name) right heel measuring 3.1 cm in length and 5.1 cm in width. Brown blister like area. Attending physician notified and new orders given for Moon boots at all times, Multivitamin one tablet daily, Vitamin C (500mg) daily, Prostat 30 milliliters (ml) twice daily, and air mattress to bed. Additionally, Stage II pressure ulcer noted to right buttocks measuring 0.5 cm in length, 0.3 cm in width and 0.1 cm in depth. -- 07/19/16, A second Stage II pressure ulcer noted to the right buttocks that measures 0.5 cm in length and 1 cm in width and 0.1 cm in depth. -- 12/13/16, DTI noted to coccyx and measures 4.5 cm in length, 1.5 cm in width and unable to determine depth due to slough covering the wound bed. Moderate amount of drainage. No odor noted. Surveyor observations on 12/13/16 at 10:48 a.m., at the time of the measurements and dressing change, noted there was no pressure-reducing cushion in the resident ' s chair. Observations of Resident #77 on 12/08/16 at 1:00 p.m. and 12/13/16 at 8:30 a.m., found no pressure reducing cushion in the resident's chair. A review of Resident #77's care plan found a goal of Resident will show no signs/symptoms of skin breakdown through next review. The goal was initiated on 04/27/16 with a revision date of 10/25/16 and a target date of 01/24/16. The resident's care plan contained no interventions for the prevention of pressure ulcers to the resident's right heel and coccyx prior to the development of pressure ulcers. During an interview with the DON, at 9:32 a.m. on 12/14/16, she stated residents are evaluated for risk of pressure ulcers upon admission, quarterly, or if there was a change of condition, they would complete an assessment which included a Braden scale. She stated if the Braden Scale indicated the resident was at risk, they would implement preventative measures to ensure the resident did not develop a pressure ulcer. When asked what preventative measures were in place for Resident #77 prior to the development of the pressure ulcers on coccyx and right heel, the DON reviewed the record and stated, Pressure reducing cushion to chair and turn every two (2) hours. Review of the facility's policy, General Preventative Measures, found for a person in a chair staff are required to re-position at least every hour and use foam, gel, or air cushion as indicated to relieve pressure and for a person in bed change position at least every two (2) hours or more frequently if needed, determine if the resident needs a special mattress. During an interview with the DON, at 11:00 a.m. on 12/14/16, these findings were reviewed. She was asked to provide any information the facility might have to indicate they attempted interventions and/or treatments to prevent the development of Resident #77's SDTIs to her right heel and two (2) Stage II pressure ulcers to coccyx as the facility's policy directs. She stated, We initiated a cushion to Resident #77's chair and turn every two (2) hours prior to the development of the pressure ulcers. When she was informed Resident #77 did not have a cushion in her chair on any of my observations, she stated, I will look in to that immediately. She was unable to provide any further information to show the wound was unavoidable.",2020-09-01
3261,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2016-12-14,323,D,0,1,467L11,"Based on observation, record review, staff interview and policy review, the facility failed to ensure two (2) of four (4) residents reviewed for the care area of accidents were free from accident hazards. Resident #56 was not transferred with two (2) staff members during a transfer with a mechanically lift as directed by the resident's care plan and facility policy. The facility identified Resident #31 had a new bruise. However, the facility failed to investigate, evaluate and analyze the cause of the injury, and implement interventions to reduce further injuries. Resident identifiers: #56 and #31. Facility census: 75. Findings include: a) Resident #56 At 9:40 a.m. on 12/07/16, nurse aide (NA) #38 was observed opening the door of Resident #56's room pushing a mechanical lift into the hallway. Resident #56 was observed to be up in her geri-chair. No other staff member were present in the room or with NA #38. Further observation found a private sitter was in the room with Resident #56. NA #38 was asked if she had assistance when using the mechanical lift for Resident #56. NA #38 replied, No, the sitter helped me. At 9:49 a.m. on 12/07/16, the resident's private sitter verified NA #38 had transferred the resident to her geri-chair without any staff assistance. The sitter said she assisted NA #38 by holding the resident's chair for her while NA #38 operated the lift. The sitter said she was a nurse aide at one time but she was no longer certified. The sitter said, That happens a lot, sometimes they have two (2) (referring to staff) sometimes they don't. On 12/07/16, at 10:00 a.m., the director of nursing (DON), confirmed Resident #56 is a full body lift with the assistance of two (2) staff members for transfers. The DON said nurse aides are to look at the care plan to see how the resident should be transferred. The electronic care plan was reviewed with the DON at this time and revealed the following: --The care plan problem was: (Name of resident) requires extensive to total assist with ADL's (activities of daily living) related to CVA (cerebral vascular incident) dysphagia, osteoarthritis, memory loss, contractures, and muscle weakness. --The goal associated with this problem was: Resident will have daily ADL needs met with extensive to total assist as evidenced by being well groomed, neat and appropriately dressed daily through review. --Approaches included: Transfers dependent of 2. Full body lift for all transfers. The DON confirmed the resident is transferred with a full body lift and the assistance of two (2) staff members is required. The DON said she would immediately investigate this issue. The DON provided a copy of the facility's policy, entitled, Lifting Machine, at 2:30 p.m. on 12/07/16. The policy directs, .The full body requires two staff members to perform the procedure. At 2:00 p.m. on 12/12/16, the DON provided a copy of the facility's completed investigation of the care provided to Resident #56 by NA #38 on 12/07/16. Review of the facility's five (5) day follow up report, completed on 12/10/16, found the facility substantiated NA #38 transferred Resident #56, . by herself which was against facility policy and care plan which calls for assistance of 2. It was substantiated that CNA (certified nursing assistant) did disconnect fed tube which is outside her scope of practice and a violation of facility policy. Attached to the investigation was a hand written statement by NA #38, dated 12/09/16 that read: On Wednesday the 7th, I went into (resident's room number) room to do care when I pulled the covers back I seen she had stuff on her. So I got her up with the full body lift by myself which I should have waited for the other aides to get back but I didn't. I know I did wrong by having (name of sitter) help me but I just didn't have the heart to walk away from her and get her later and let her lay there in it. I did ask the nurse to come in (resident's room number) to look and was gonna have her help transfer but the nurse didn't hear me. All (name of sitter) did was lower her down while I held the chair and pulled (resident's room number) up in it. LPN #67 provided a had written statement, dated 12/09/16, stating NA #38 did not ask for help getting the resident up and the NA did not tell her the feeding machine needed to be unhooked. b) Resident #31 Review of the resident's medical record, on 12/08/16 at 10:00 a.m., found the following nursing note, dated 11/29/16, at 11:14 p.m., Resident has a circular bruise to left shin about mid way. States a CNA (certified nursing assistant) hit her leg earlier today. States there is no pain from bruise. There was no further documentation regarding the bruise in the medical record. Review of the facility's incident/accident logs for bruises occurring during (MONTH) of (YEAR), found no information related to Resident #31's bruise. During an interview with the director of nursing (DON), at 1:38 p.m. on 12/08/2016, she confirmed she was unable to find any documentation regarding any investigation of Resident #31's bruise. The DON said, We should have completed an incident report so we can track bruises to make sure that the area is not suspicious in nature. We also track any bruises to prevent further injuries. Further review of the resident's medical record found the resident's last full annual minimum data set (MDS) was completed on 12/16/15. The MDS documentation noted the resident had contractures of both ankles and both knees. At 10:02 a.m. on 12/12/16, the DON said she had called the nurse who wrote the nursing note on 11/29/16. The DON said the nurse was unaware she should complete an incident/accident report. The DON assisted this nurse with completing a report. The nurse said the resident told her a CNA had bumped the resident's leg against the bed rail. At 10:10 a.m. on 12/12/16, the DON provided the facility policy, entitled, Incident/Accident Reports. The policy directs, . In case of an incident/accident, the nurse in charge will check the patient using all skills of observation including basic diagnostic signs to determine the seriousness of the situation . Each incident will be monitored by the RN (registered nurse) for appropriate action, completion of the Incident Report, and measures taken to prevent a reoccurrence. The DON confirmed the nurse on duty did not assess the resident after discovery of the bruise. At the time of discovery, no measures were taken to determine how the injury occurred, and no measures were taken to prevent a reoccurrence.",2020-09-01
3262,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2016-12-14,328,D,0,1,467L11,"Based on observation, staff interview, and record review, the facility failed to ensure Resident #56 received the appropriate treatment and services to prevent complications of enteral feeding. The resident's nurse aide, acting outside of her scope and practice, stopped and started the resident's continuous enteral feeding. This was found during a random opportunity for discovery. Resident identifier: #56. Facility census: 75. Findings include: a) Resident #56 While investigating the inappropriate transfer of Resident #56, which began at 9:40 a.m. on 12/07/16, it was discovered the resident receives continuous enteral feedings by way of a gastrostomy tube. (A gastrostomy tube is inserted through the abdomen and delivers nutrition directly to the stomach.) Review of the resident's care plan found the following problem: (Name of resident) is dependent on tube feeding for nutritional support and hydration, with potential for complications, side effects. The goal associated with this problem is: Will maintain adequate nutritional and hydration statue as evidence by: no signs/symptoms of malnutrition or dehydration through review. An approach associated with this goal was: Prior to toileting resident, stop feeding 30 minutes prior to position changes. ' At 11:06 a.m. on 12/07/16, the resident's licensed practical nurse (LPN) #67 was asked if she had stopped Resident #56's feeding at any time this morning. She replied, No, I will put it on hold at noon when I give her medicine at noon. At 11:30 a.m. on 12/07/16, NA #38, was asked how she managed the Resident's tube feeding during the transfer. NA #38 said, I tied a knot in it and corked it so it wouldn't leak. When asked to explain this procedure, NA #38 said there is a yellow plug you put in the tube which stops the feeding. NA #38 confirmed she stopped the feeding during the transfer. After the transfer was completed, she started the feeding. A private sitter, who was present in the room during the transfer, confirmed at 11:32 a.m. on 12/07/16, the NA stopped the resident's feeding during the transfer to the geri-chair. On 12/07/2016 at 2:30 p.m., the resident's care plan for the feeding tube was reviewed with the DON. The DON confirmed the resident's gastrostomy tube feeding is to be stopped prior to transferring the resident from the bed to a geri-chair. The DON said this would be a position change referred to in the care plan. The DON was made aware of NA #38's statement that she tied a knot in the tubing and corked it off during the Resident's transfer. The DON said NA #38 should have asked the nurse on duty to stop the feeding before transferring the resident. She said she would also investigate this situation because the NA was acting outside of her scope of practice. The DON confirmed only a licensed nurse can stop and start a resident's tube feeding. At 2:00 p.m. on 12/12/16, the DON provided a copy of the facility's completed investigation of the care provided to Resident #56 by NA #38 on 12/07/16. The facility's investigation began on 12/07/16. The facility reported the incident, involving NA #38 to the proper state authorities as directed by State Law. NA #38 was suspended pending investigation. Review of the facility's five (5) day follow up report found the facility substantiated the NA transferred Resident #56, . by herself which was against facility policy and care plan which calls for assistance of 2. It was substantiated that CNA (certified nursing assistant) did disconnect fed tube which is outside her scope of practice and a violation of facility policy. Attached to the investigation was a hand written statement from LPN #67, 12/09/16, stating NA #38 did not ask for help getting the resident up and the NA did not tell her the feeding machine needed to be unhooked.",2020-09-01
3263,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2016-12-14,329,E,0,1,467L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #78 and Resident #20's drug regimens were free of unnecessary medications. Resident #78 continued to receive doses of [MEDICATION NAME] (a medication used to treat pain) even after the attending physician discontinued the order. Resident #20 received nine (9) doses of [MEDICATION NAME] (a medication used to treat pain) on days that it was not ordered. This practice affected two (2) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifiers: #78 and #20. Facility Census: 75. Findings include: a) Resident #78 A review of Resident #78's medical record beginning at 2:31 p.m. on 12/08/16, found a physician's orders [REDACTED]. This order had a start date of 10/21/15 and an end date of 09/15/16. Further review of the medical record found a written recommendation to the attending physician/prescriber by the consulting pharmacist on 05/02/16. The pharmacist recommendation read as follows, This resident has prn (as needed) orders for APAP (acetamiophen) 650 mg (milligrams), [MEDICATION NAME], and [MEDICATION NAME]. A review of the 14 day MAR (medication administration record) shows that these medications have not been given. If appropriate, consider discontinuing the orders. The attending physician responded to this recommendation on 05/05/16. The attending physician agreed with the recommendation and ordered all three (3) medications be discontinued. Review of the (MONTH) (YEAR) MAR found that the APAP and [MEDICATION NAME] were discontinued on 05/09/16, however the [MEDICATION NAME] was not discontinued. Further review of the MARs from 06/01/16 through 09/15/16 found this medication was administered to Resident #78 on the following occasions: --06/26/16 at 4:26 p.m. --07/05/16 at 3:43 p.m. --07/07/16 at 5:58 p.m. --07/15/16 at 3:24 p.m. --07/16/16 at 6:01 p.m. --07/20/16 at 1:43 p.m. --07/28//16 at 6:54 p.m. --08/07/16 at 3:27 p.m. --08/12/16 at 3:12 p.m. --08/19/16 at 1:12 p.m. An interview with the Director of Nursing (DON) at 1:58 p.m. on 12/12/16, confirmed Resident #78's [MEDICATION NAME] should have been discontinued on 05/09/16 along with the APAP and [MEDICATION NAME]. She reviewed the MARs and confirmed the medication was given on the above mentioned dates which were after the medication should have been discontinued. She stated, I would have thought the pharmacist would have caught that. b) Resident #20 Review of Resident #20's medical records found a physician's orders [REDACTED]. This order had a start date of 07/18/16. Review of the Medication Administration Record [REDACTED]. [MEDICATION NAME] was administered to Resident #20 on the following occasions: --07/29/16 at 9:50 a.m. --07/30/16 at 12:00 p.m. --08/06/16 at 10:00 a.m. --08/07/16 at 8:00 p.m. --09/16/16 at 5:00 p.m. --09/26/16 at 2:00 p.m. --09/29/16 at 1:25 p.m. --10/13/16 at 5:30 a.m. --11/29/16 at 9:30 a.m. An interview with the director of nursing (DON) at 1:30 p.m. on 12/13/16 confirmed Resident #20 received [MEDICATION NAME] thirty (30) minutes prior to her dressing changes. She reviewed the MARs and confirmed the medication was given on the above mentioned dates which were days her dressings were not scheduled to be changed.",2020-09-01
3264,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2016-12-14,332,D,0,1,467L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of medication administration, reconciliation of the observed medication administrations with medical records, staff interviews, and review of the Centers for Medicare and Medicaid Services (CMS) guidance to surveyors, the facility failed to ensure it was free of a medication error rate of five (5) percent or greater. Two (2) errors were identified during twenty-seven (27) observed opportunities, making the facility's medication error rate 7.41%. This affected one (1) of four (4) residents observed during medication administration observations. Resident identifier: #40. Facility census: 75. Findings include: a) Resident #40 During the medication pass observation on 12/13/16 at 8:50 a.m., Licensed Practical Nurse (LPN) #81, was observed administering medications to Resident #40. Reconciliation of the observed medications administered with the resident's medical record revealed two (2) medication errors. Error #1: --[MEDICATION NAME] 20 milligrams (mg), one (1) tablet by mouth every morning (a medication given for [MEDICAL CONDITION] reflux disease), scheduled at 9:00 a.m., was omitted. Error #2: --[MEDICATION NAME] by mouth twice daily (bid) scheduled at 9:00 a.m., was omitted. On 12/13/16 at 10:20 a.m., upon inquiry as to the omission of [MEDICATION NAME] and [MEDICATION NAME], LPN #81 said, I cannot find either medication in the cart, they are both unavailable and I have ordered both. She further verified neither medication are new orders, the [MEDICATION NAME] was ordered on [DATE] and the [MEDICATION NAME] was ordered on [DATE]. At 10:30 a.m. on 12/13/16, the director of nursing (DON) was made aware of the medication errors identified for Resident #40 during the medication administration observation. The DON verified neither medication could be located on the medication cart.",2020-09-01
3265,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2016-12-14,425,D,0,1,467L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure the pharmacy provided pharmaceutical services to meet the needs of each resident. This was true for Resident #40, the pharmacy had not provided the facility with Pepcid and Miralax for the administration scheduled at 9:00 a.m. on 12/13/16. Resident identifier: #40. Facility Census: 75. Findings include: On 12/13/16 at 8:50 a.m., Licensed Practical Nurse (LPN) #81, was observed administering medications to Resident #40. Reconciliation of the observed medications administered with the resident's medical record revealed two (2) medication errors. Error #1: --Pepcid 20 milligrams (mg), one (1) tablet by mouth every morning (a medication given for gastroesophageal reflux disease), scheduled at 9:00 a.m., was omitted. Error #2: --Miralax by mouth twice daily (bid) scheduled at 9:00 a.m., was omitted. On 12/13/16 at 10:20 a.m., upon inquiry as to the omission of Pepcid and Miralax, LPN #81 said, I cannot find either medication in the cart, they are both unavailable and I have ordered both from the pharmacy. She further verified neither medication are new orders, the Pepcid was ordered on [DATE] and the Miralax was ordered on [DATE]. At 10:30 a.m. on 12/13/16, the Director of Nursing (DON) was made aware of the medication errors identified for Resident #40 during the medication administration observation. The DON verified neither medication could be located on the medication cart.",2020-09-01
3266,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2016-12-14,428,E,0,1,467L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the consulting pharmacist failed to identify Resident #78 continued to receive Tramadol after a recommendation made by her was accepted by the physician to discontinue this medication. The facility also failed to act timely on recommendations made by the consulting pharmacist for Resident #88. This was due to the pharmacist failure to forward the recommendation to the facility in a timely manner. For Resident #40, the consulting pharmacist failed to recognize an incomplete order for Miralax which contained no dosage amount or route of administration. These failures affected two (2) of six (6) residents reviewed for the care area of unnecessary medications. Resident #40 was identified while completing the medication administration mandatory task and was one (1) of four (4) residents whose medication administration was observed. Resident identifiers: #78, #88 and #40. Facility census: 75. Findings include: a) Resident #78 A review of Resident #78's medical record beginning at 2:31 p.m. on 12/08/16, found a physician's orders [REDACTED]. This order had a start date of 10/21/15 and an end date of 09/15/16. Further review of the medical record found the following, Note to attending physician/prescriber. Issued to the facility on [DATE] by the consulting pharmacist. The pharmacist recommendation read as follows, This resident has prn (as needed) orders for APAP (acetaminophen) 650 mg (milligrams), Tramadol, and bisacodyl. A review of the 14 day MAR (medication administration record) shows that these medications have not been given. If appropriate, consider discontinuing the orders. The attending physician responded to this recommendation on 05/05/16, and agreed to discontinue all three (3) medications. Review of the (MONTH) (YEAR) MAR found that the APAP and Bisacodyl were discontinued on 05/09/16, however the Tramadol was not discontinued. Further review of the MARs from 06/01/16 through 09/15/16 found this medication was administered to Resident #78 on the following occasions: --06/26/16 at 4:26 p.m. --07/05/16 at 3:43 p.m. --07/07/16 at 5:58 p.m. --07/15/16 at 3:24 p.m. --07/16/16 at 6:01 p.m. --07/20/16 at 1:43 p.m. --07/28//16 at 6:54 p.m. --08/07/16 at 3:27 p.m. --08/12/16 at 3:12 p.m. --08/19/16 at 1:12 p.m. Further review of the record found the consulting pharmacist completed additional drug regimen reviews on 06/02/16, 07/05/16, 08/03/16, and 09/06/16. On none these reviews did the consulting pharmacist identify that Resident #78 continued to receive Tramadol despite the physician agreeing to discontinue it on 05/09/16. An interview with the Director of Nursing (DON) at 1:58 p.m. on 12/12/16, confirmed Resident #78's Tramadol should have been discontinued on 05/09/16 along with the APAP and Bisacodyl. She reviewed the MARs and confirmed the medication was given on the above mentioned dates which were after the medication should have been discontinued. She stated, I would have thought the pharmacist would have caught that. b) Resident #88 A review of Resident #88's medical record beginning at 2:03 p.m. on 12/12/16 found Resident #88 was admitted to the facility on [DATE]. Review of the pharmacist's drug regimen reviews for Resident #88 found she reviewed his drug regimen on 09/06/16, 10/04/16, 11/03/16, and 12/01/16. On all occasions she made no recommendations to the attending physician except on 09/06/16. On 09/06/16, the consulting pharmacist recommended the following, A review of the medication regimen prompted a request for the following regularly scheduled labs: TSH: Synthroid and LIPIDS/LFTs: pravastatin. This reported had a printed date of 09/09/16. The recommendation was not accepted and signed by the physician until 10/05/16 which was almost 30 days after the review of drug regimen which prompted the recommendation. During an interview with the Director of Nursing (DON) at 1:16 p.m. on 12/13/16 she indicated the reason this recommendation was not acted upon promptly was because the pharmacist forgot to send the recommendation to the facility. She stated we did not get it until 10/05/16 and that is why the attending physician did not review it and act upon it more timely. c) Resident 40 During the medication pass observation on 12/13/16 at 8:50 a.m., Licensed Practical Nurse (LPN) #81, was observed administering medications to Resident #40. Reconciliation of the observed medications administered with the resident's medical record revealed an order for [REDACTED]. Further review of the record found the consulting pharmacist completed drug regimen reviews on 11/03/16 and 12/01/16. On none of these reviews did the consulting pharmacist identify that Resident #40 had a physician order [REDACTED]. At 10:30 a.m. on 12/13/16, the Director of Nursing (DON) was made aware of the medication order for Resident #40 did not contain the dosage to be administered or route. The DON verified the order was incomplete and she would immediately call the physician and get the order clarified.",2020-09-01
3267,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2016-12-14,502,D,0,1,467L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to obtain laboratory tests which were ordered by Resident #93's attending physician. The attending physician ordered a urinalysis (UA) on 09/13/16 as a follow up to the hospitals discharge summary. This UA was never obtained. On 10/05/16 the attending physician ordered a Glycated Hemoglobin (HGA1C) laboratory test, and this was never obtained. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #93. Facility census: 75. Findings include: a) Resident #93 1. Urinalysis A review of Resident #93's medical record beginning at 7:56 a.m. on 12/08/16 found Resident #93 was admitted to the facility on [DATE] after a stay at an acute care hospital. A review of Resident #93's physician orders [REDACTED]. The discharge summary dated 09/13/16 from the acute care hospital contained the following under the heading special instructions, UA not obtained, it will need to be ordered and followed up at nursing facility. The results of the UA could not be located in the medical record and were requested from facility staff. At 12:04 p.m. on 12/08/16, the Minimum Data Set Coordinator/Registered Nurse (MDS-RN) #65 stated the nursing facility did not obtain the UA or the results. She stated, When the hospital called they told us that they had obtained the UA but the results were not back yet. When asked if the facility had followed up with the acute care hospital to get the results she stated, I don't think so. I could not find the results. The Director of Nursing (DON) in an interview at 3:31 p.m. on 12/08/16, confirmed the facility did not have the results for the ordered U[NAME] She indicated she had called the acute care hospital to try to get the results, but was told that they did not obtain the UA there and therefore did not have any results to send to the facility. She stated, We did not obtain the UA and neither did the hospital. She confirmed the discharge summary from the hospital clearly stated it was not obtained at the hospital and that the nursing facility should obtain it. She stated, We should have obtained it but we didn't. 2. HGA1C laboratory test A review of Resident #93's medical record beginning at 7:56 a.m. on 12/08/16 found a physician order [REDACTED]. This order had a start date of 10/10/16 and had no end date. Further review of the record found no results for a HGA1C. The facility was asked to provide the results of the HGA1C which was ordered on [DATE]. At 12:04 p.m. on 12/08/16, MDS-RN #65 reported that she could not find where the HGA1C ordered on [DATE] was ever obtained. She stated, it looks like the order was put into the computer after the labs had all ready been drawn for the day and it was missed. She confirmed the order had a start date of 10/10/16 and should have been drawn on the next lab day and then every 12 weeks thereafter. She stated, It looks like (Name of Physician) noticed there was no results on 11/23/16 and that is why she ordered a one time HGA1C for 11/23/16. She referred to an order dated 11/23/16 which read, HGA1C with a start and end date of 11/23/16. An interview with the DON at 3:31 p.m. on 12/08/16 confirmed the HGA1C ordered on [DATE] was not obtained by the facility as directed in the physician's orders [REDACTED].>",2020-09-01
3268,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2016-12-14,505,D,0,1,467L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to promptly notify Resident #93's attending physician of the results of a physician ordered Glycated Hemoglobin (HGA1C) ordered for 11/23/16. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #93. Facility census: 75. Findings include: a) Resident #93 A review of Resident #93's medical record beginning at 7:56 a.m. on 12/08/16 found an order for [REDACTED].#93's medical record found no indication the attending physician was ever notified of these results. In fact the results of the test could not be located in the medical record either. The results were requested from facility staff at approximately 10:00 a.m. on 12/08/16. At 12:04 p.m. on 12/08/16, the Minimum Data Set Coordinator/Registered Nurse (MDS-RN) # 65 presented the results of the HGA1C that was obtained on 11/23/16. The print date at the top of the lab result page was 12/08/16 at 10:50 a.m., MDS-RN #65 stated she was not sure when it was printed because Infection Control RN (IC-RN) #88 had given it to her to bring to the surveyor. The results were not signed by the attending physician. MDS-RN #65 stated if the results are not critical then they are printed and placed in the physician sick call book which is reviewed by the physician at least weekly, but often more than once weekly depending on how often the physician comes to the facility during the week. An interview with IC-RN #88 at 1:06 p.m. on 12/08/16, confirmed she had just printed the lab off from the hospitals lab system today after the surveyor requested the results. She stated, that it was just easier to print it off, but she would look to see if she could find the results in the residents record. She indicated they should have the results in the record which would be signed by the physician. During an interview with the DON, at 3:31 p.m. on 12/08/16, she confirmed they could not find the results of the HGA1C that was ordered on [DATE] for Resident #93 in her medical record. She confirmed it looked like the results were never printed off the hospitals lab system until after the surveyor asked for them. She confirmed the residents attending physician was not notified of the results of the HGA1C until today after they realized they had not pulled this lab from the system and had not notified the physician.",2020-09-01
3269,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2016-12-14,507,D,0,1,467L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to maintain the results of a physician ordered labotory test in Resident #93's medical record. The results for the Glycated Hemoglobin (HGA1C) ordered for 11/23/16 could not be found in the resident medical record. This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #93. Facility census: 75. Findings include: a) Resident #93 A review of Resident #93's medical record beginning at 7:56 a.m. on 12/08/16 found, an order for [REDACTED].#93's medical record found no results for this test and they were requested from facility staff at approximately 10:00 a.m. on 12/08/16. At 12:04 p.m. on 12/08/16 the Minimum Data Set Coordinator/Registered Nurse (MDS-RN) #65 presented the results of the HGA1C that was obtained on 11/23/16. The print date at the top of the lab result page was 12/08/16 at 10:50 a.m. MDS-RN #65 stated that she was not sure when it was printed because Infection Control RN (IC-RN) #88 had given it to her to bring to the surveyor. An interview with IC-RN #88 at 1:06 p.m. on 12/08/16 confirmed she had just printed the lab off from the hospitals lab system today after the surveyor requested the results. She stated, that it was just easier to print it off, but she would look to see if she could find the results in the residents record. An interview with the DON at 3:31 p.m. on 12/08/16 confirmed they could not find the results of the HGA1C that was ordered on [DATE] for Resident #93 in her medical record. She confirmed it looked like the results were never printed off the hospitals lab system until after the surveyor asked for them.",2020-09-01
3270,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2016-12-14,514,E,0,1,467L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the medical record for for three (3) of 17 Stage 2 sampled residents was complete and accurate. Resident #78's weights were not recorded in her medical record. Resident #88's record did not contain the results of his international normalized ratio (INR) for several days. Resident # 66's death certificate was incomplete. Resident identifiers: #78, #88, and #66. Facility census: 75. Findings include: a) Resident #78 A review of Resident #78's medical record beginning at 2:31 p.m. on [DATE], found the resident had one recorded weight in the medical record since [DATE]. This weight was recorded on [DATE] and was 131 pounds (lbs) Further review of the record found a note to attending physician/prescriber from the consulting pharmacist on [DATE]. This recommendation was for the attending physician to consider a gradual dose reduction of Resident #78's [MEDICATION NAME] which was given due to abnormal weight loss ([MEDICATION NAME] is an antidepressant medication which is often used to stimulate the appetite). The physician responded to this recommendation by disagreeing stating, :wt. (weight) improved cont. (continue) [MEDICATION NAME]. During an interview with the Director of Nursing (DON) at 3:41 p.m. on [DATE], she was asked why Resident #78 had only one recorded weight in the record since [DATE], she replied, Because she is on comfort measures and the physician don't want to monitor her weight. The DON was again interviewed on [DATE] at 12:58 p.m. She was asked to review the pharmacy recommendation dated [DATE]. She was asked how the physician determined the residents weight improved if she is not weighed. The DON indicated the facility does weigh her, but does not document it in the record because of her comfort measure status. She was then asked to provide the residents weight since [DATE]. She provided a weight list for every month from ,[DATE] through present. Each list contained the name and weight of each resident. Review of the weight list found the following weights for Resident #78: --[DATE] - 131 lbs --[DATE] - 135 lbs --[DATE] - 134 lbs --[DATE] - 134 lbs --[DATE] - 135 lbs --[DATE] - 132 lbs --[DATE] - 135 lbs The DON agreed these weights were not recorded in Resident #78's medical record. b) Resident #88 A review of Resident #88's medical record at 2:03 p.m. on [DATE], found a physicians order dated [DATE] which read as follows, Daily INR, then call physician for dosing. A review of Resident #88's medication administration record (MAR) found the nurses initialed daily beginning on [DATE] through [DATE] that they checked the residents INR. However the INR results for [DATE] through [DATE] were not documented on the MAR. A review of the nursing progress notes found a note on [DATE] which documented the INR result was 1.7 and a nursing note dated [DATE] indicated the INR was 2.6. The INR result for [DATE] was documented on the MAR. The medical record for Resident #88 did not contain the INR result which was obtained on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. An interview with the Director of Nursing (DON), at 1:16 p.m. on [DATE], confirmed the medical record did not contain the INR results for [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. She stated that it should have been documented in the box below the nurses initials on the MAR just like the one for [DATE] was documented. c) Resident #66 A review of the medical record on [DATE] revealed Resident #66 had died on [DATE] at 9:42 a.m. The Death certificate did not include the date and time of death for this resident. An interview, on [DATE] at 12:20 p.m., with the Medical Records Coordinator verified the date and time of death for Resident #66 was not recorded on the Death Certificate.",2020-09-01
5035,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2015-09-18,159,D,0,1,IPN311,"Based on staff interviews and review of personal funds, the facility failed to obtain consents to manage personal funds for two (2) of five (5) residents whose funds were reviewed (Resident #46 and #68) In addition, the facility failed to deposit personal funds into Resident #46's account on two (2) separate occasions. Resident identifiers: #46 and #68. Facility census: 72. Findings include: a) Resident #46 and Resident #68 On 9/16/15 at 11:24 a.m., the personal funds for these residents were requested from Administrative Assistant (AA) #100. AA #100 stated she would locate the consent forms. On 09/17/2015 at 11:18 a.m., AA #100 provided the consents to manage personal funds from the admission packets of Residents #46 and #68. The forms completed at the time of admission for each of these residents indicated they did not want the facility to manage their personal funds. AA #100 verified the facility managed the personal funds for both residents, and confirmed the facility did not have a current consent form that authorized the facility to manage the residents' personal funds An interview with Administrator #97, on 09/17/15 at 10:22 a.m., revealed the social workers obtained permission to manage funds at the time of admission, from the resident or the responsible party. This documentation was included in the admission packet. If a resident or responsible party later decided they wanted the facility to manage the resident's personal funds, the social worker did not always obtain consent. Administrator #97 verified consents were not obtained from Resident #46 and #68 to manage their personal funds. b) Resident #46 A review of the personal funds for five (5) residents, with AA #100 on 09/16/15 at 11:24 a.m., revealed the personal fund account for Resident #46 did not show deposits of $50.00 for the months of (MONTH) (YEAR) and (MONTH) (YEAR). Interview with Billing Clerk #101, on 09/17/15 at 10:22 a.m., revealed Resident #46 changed payor sources from Medicare to private pay to Medicaid over the course of her stay at the facility. Resident #46's family handled her personal funds, then changed to the have the facility handle the resident's personal funds. Billing Clerk #101 stated the resident became eligible to receive $50.00 each month once she became eligible for Medicaid. Billing Clerk #101 stated the resident's billing was confusing with the different changes in payor sources. She verified the failure to deposit $50.00 into the resident's personal funds in (MONTH) (YEAR) and (MONTH) (YEAR).",2019-04-01
5036,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2015-09-18,225,D,0,1,IPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, staff interview and review of the abuse policy and procedure, the facility failed to immediately report and investigate injuries of unknown origin regarding two (2) of three (3) sampled residents reviewed for non-pressure skin conditions. Resident identifiers #33 and #99. Facility census: 72. Findings include: a) Resident #33 On 09/17/15 at approximately 3:30 p.m., the electronic medical record of Resident #33 was reviewed. The physician progress notes [REDACTED].#33 had severe cognitive impairment. Observation on 09/16/15 at 2:33 p.m. revealed Resident #33 was in the dining room by herself, seated in a ger-ichair/Broda chair. The middle finger of the resident's left hand was slightly swollen and had a purple bruise. On 09/17/15 at 9:38 a.m., the middle finger of the left hand remained bruised, but was not swollen. Observation on 09/18/15 at 8:13 a.m. revealed the middle finger on the left hand. was still bruised. At the time of the observation on 09/18/15, an interview was conducted with Licensed Practical Nurse (LPN) #18. She stated she did not know what happened or where the bruise came from. She stated Resident #33 was known to throw her hands around. LPN #18 reviewed the nursing progress notes and indicated there was nothing documented regarding the bruised middle finger on the resident's left hand. The skin audit, dated 09/14/15, did not have any bruising documented. LPN #18 checked for events in the electronic charting system, and found nothing was documented regarding the bruised finger. LPN #18 stated she would notify LPN #19 regarding the bruise. An interview with the Director of Nursing (DON), on 09/18/15 at 8:46 a.m., revealed once a bruise was found, an investigation should begin. At that time, an event was started in the electronic charting system (Matrix). The DON discussed the procedure staff should follow when an injury of unknown origin was discovered. She verified staff did not follow the policy and procedure when they failed to notify leadership staff, including the DON and Administrator, of the bruised finger, and failed to start an investigation. An interview with Nursing Assistant (NA), #49 on 09/18/15 at 10:00 a.m., revealed she notified LPN #9 (night nurse) of the bruise on 09/17/15. NA #49 stated she saw the bruised middle finger on the left hand on first rounds and notified the nurse. She stated she did not know how Resident #33 obtained the bruise. b) Resident #99 This resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. Observations on 09/15/15 at 1:12 p.m., revealed a dressing on the left lower leg. On 09/17/15 at 4:19 p.m. the medical record was reviewed. The nurse's notes indicated the resident acquired a skin tear on 08/17/15 to the left lower leg. The skin tear measured 2.0 centimeters (cm) by 2.0 cm. The nurse's note indicated the skin tear was of unknown origin. According to the note, the area was cleansed and Seri strips were applied. The family and the physician were notified. The event in the electronic medical records indicated the event was closed on 09/11/15 and the skin tear was healed. Observation, on 09/17/15 at 4:00 p.m., found the resident sitting in the dining room with a dressing covering her left lower leg. Registered Nurse (RN) #7 took the resident to her room and removed the dressing on the left lower leg. A skin tear was observed underneath the dressing. There was also a healed skin tear above the wound. RN #7 was not aware of the injury, and indicated the skin tear may have been caused by the wheelchair leg rests. At 5:00 p.m., LPN #18 was interviewed. The LPN stated she identified the skin tear on 08/17/15. LPN #18 removed the dressing to the left lower leg. When she looked at the wound, she stated the skin tear that was there at that time looked like a new skin tear. As she observed the skin tear, she indicated there was a healed skin tear above the area on the left lower leg. She identified the healed skin tear was what she originally observed on 08/17/15. LPN #18 indicated the skin tears may have been caused by the resident's wheelchair leg rests. On 09/17/15 nurses' notes indicated a skin tear was identified, the physician was notified, and a treatment was ordered. On 09/18/15, the skin tear was assessed. It measured one (1) cm by one (1) centimeter and was V-shaped. On 09/18/15 at 8:30 a.m., Social Worker (SW) #65 was interviewed. The SW stated when injuries of unknown origin were identified by staff, they were to report it to her, the DON, or the Administrator. She said they were to start an investigation at that time. The SW indicated she was not aware of the skin tear to Resident #99's left lower leg. At 8:40 a.m., NA #48 was interviewed. The NA stated she was told approximately one (1) and half (1/2) to two (2) weeks ago, by a nurse, that the resident had a skin tear on her left lower leg. She could not remember who the nurse was. The NA stated if she identified a skin tear, she would report it to the nurse and the nurse follows through with reporting. At 9:00 a.m., the DON was interviewed. The DON stated it was the responsibility of nursing staff, injuries of unknown origin were identified, to report the incident to herself, social services, or the administrator. She verified there was a injury of unknown origin to the left lower leg on 08/17/15, and the nurse failed to start an investigation. She was not aware of the new skin tear to the left lower leg. She verified nobody investigated the new skin tear to the left lower leg. The DON stated she was not aware staff were aware of the injury from approximately 1-1/2 to 2 weeks ago. She stated the process begins once the nurse is aware and creates an event in the computer. The DON said she expected the nurse to start an investigation of the injury of unknown origin. At 10:15 a.m., LPN #18 was interviewed. She stated on 08/17/15, when she identified the skin tear, she did not have any red flags go up. She stated she was aware of how to begin an investigation on an injury of unknown origin, but she did not feel this was an suspicious event that needed an investigation. c) On 09/18/15 at 10:19 a.m., the policy on accidents and incidents was reviewed. The policy indicated the nurse shall promptly initiate and document an investigation of the accident or incident. The investigative documentation was to include the nature of the injury, circumstances, where the incident took place, account of injury, and notification. The facility's policy on Abuse stated the facility must ensure that all alleged violations of injuries of unknown source will be reported to the administrator of the facility as soon as possible. The facility failed to report injuries of unknown origin for Residents #33 and #99.",2019-04-01
5037,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2015-09-18,226,D,0,1,IPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and review of the facility's abuse policy and procedure, the facility failed to operationalize its policies and procedures related to reporting and investigating injuries of unknown origin. This affected two (2) of three (3) sampled residents reviewed for non-pressure skin conditions. Resident identifiers #33 and #99. Facility census: 72. Findings include: a) Resident #33 On 09/17/15 at approximately 3:30 p.m., the electronic medical record of Resident #33 was reviewed. The physician progress notes [REDACTED].#33 had severe cognitive impairment. Observation on 09/16/15 at 2:33 p.m. revealed Resident #33 was in the dining room by herself, seated in a ger-ichair/Broda chair. The middle finger of the resident's left hand was slightly swollen and had a purple bruise. On 09/17/15 at 9:38 a.m., the middle finger of the left hand remained bruised, but was not swollen. Observation on 09/18/15 at 8:13 a.m. revealed the middle finger on the left hand. was still bruised. At the time of the observation on 09/18/15, an interview was conducted with Licensed Practical Nurse (LPN) #18. She stated she did not know what happened or where the bruise came from. She stated Resident #33 was known to throw her hands around. LPN #18 reviewed the nursing progress notes and indicated there was nothing documented regarding the bruised middle finger on the resident's left hand. The skin audit, dated 09/14/15, did not have any bruising documented. LPN #18 checked for events in the electronic charting system, and found nothing was documented regarding the bruised finger. LPN #18 stated she would notify LPN #19 regarding the bruise. An interview with the Director of Nursing (DON), on 09/18/15 at 8:46 a.m., revealed once a bruise was found, an investigation should begin. At that time, an event was started in the electronic charting system (Matrix). The DON discussed the procedure staff should follow when an injury of unknown origin was discovered. She verified staff did not follow the policy and procedure when they failed to notify leadership staff, including the DON and Administrator, of the bruised finger, and failed to start an investigation. An interview with Nursing Assistant (NA), #49 on 09/18/15 at 10:00 a.m., revealed she notified LPN #9 (night nurse) of the bruise on 09/17/15. NA #49 stated she saw the bruised middle finger on the left hand on first rounds and notified the nurse. She stated she did not know how Resident #33 obtained the bruise. The facility did not operationalize its policies and procedures to report and investigate this injury of unknown origin. b) Resident #99 This resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. Observations on 09/15/15 at 1:12 p.m., revealed a dressing on the left lower leg. On 09/17/15 at 4:19 p.m. the medical record was reviewed. The nurse's notes indicated the resident acquired a skin tear on 08/17/15 to the left lower leg. The skin tear measured 2.0 centimeters (cm) by 2.0 cm. The nurse's note indicated the skin tear was of unknown origin. According to the note, the area was cleansed and Seri strips were applied. The family and the physician were notified. The event in the electronic medical records indicated the event was closed on 09/11/15 and the skin tear was healed. Observation, on 09/17/15 at 4:00 p.m., found the resident sitting in the dining room with a dressing covering her left lower leg. Registered Nurse (RN) #7 took the resident to her room and removed the dressing on the left lower leg. A skin tear was observed underneath the dressing. There was also a healed skin tear above the wound. RN #7 was not aware of the injury, and indicated the skin tear may have been caused by the wheelchair leg rests. At 5:00 p.m., LPN #18 was interviewed. The LPN stated she identified the skin tear on 08/17/15. LPN #18 removed the dressing to the left lower leg. When she looked at the wound, she stated the skin tear that was there at that time looked like a new skin tear. As she observed the skin tear, she indicated there was a healed skin tear above the area on the left lower leg. She identified the healed skin tear was what she originally observed on 08/17/15. LPN #18 indicated the skin tears may have been caused by the resident's wheelchair leg rests. On 09/17/15 nurses' notes indicated a skin tear was identified, the physician was notified, and a treatment was ordered. On 09/18/15, the skin tear was assessed. It measured one (1) cm by one (1) centimeter and was V-shaped. On 09/18/15 at 8:30 a.m., Social Worker (SW) #65 was interviewed. The SW stated when injuries of unknown origin were identified by staff, they were to report it to her, the DON, or the Administrator. She said they were to start an investigation at that time. The SW indicated she was not aware of the skin tear to Resident #99's left lower leg. At 8:40 a.m., NA #48 was interviewed. The NA stated she was told approximately one (1) and half (1/2) to two (2) weeks ago, by a nurse, that the resident had a skin tear on her left lower leg. She could not remember who the nurse was. The NA stated if she identified a skin tear, she would report it to the nurse and the nurse follows through with reporting. At 9:00 a.m., the DON was interviewed. The DON stated it was the responsibility of nursing staff, injuries of unknown origin were identified, to report the incident to herself, social services, or the administrator. She verified there was a injury of unknown origin to the left lower leg on 08/17/15, and the nurse failed to start an investigation. She was not aware of the new skin tear to the left lower leg. She verified nobody investigated the new skin tear to the left lower leg. The DON stated she was not aware staff were aware of the injury from approximately 1-1/2 to 2 weeks ago. She stated the process begins once the nurse is aware and creates an event in the computer. The DON said she expected the nurse to start an investigation of the injury of unknown origin. At 10:15 a.m., LPN #18 was interviewed. She stated on 08/17/15, when she identified the skin tear, she did not have any red flags go up. She stated she was aware of how to begin an investigation on an injury of unknown origin, but she did not feel this was an suspicious event that needed an investigation. The facility did not operationalize its policies and procedures to report and investigate these injuries of unknown origin. c) On 09/18/15 at 10:19 a.m., the policy on accidents and incidents was reviewed. The policy indicated the nurse shall promptly initiate and document an investigation of the accident or incident. The investigative documentation was to include the nature of the injury, circumstances, where the incident took place, account of injury, and notification. The facility's policy on Abuse stated the facility must ensure that all alleged violations of injuries of unknown source will be reported to the administrator of the facility as soon as possible. These policies and procedures were not implemented for the injuries of unknown origin experienced by Residents #33 and #99.",2019-04-01
5038,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2015-09-18,241,D,0,1,IPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of resident council meeting minutes, the facility failed to provide care and services, for three (3) of 36 sample residents, in a manner and in an environment that promoted each resident's dignity and respect. A sign which contained personal information was posted above Resident #46's bed, and was visible to visiting family and friends. In addition, staff entered the rooms of Residents #10 and #62 without first knocking or otherwise asking permission to enter. Resident identifiers: #46, #62, and #20. Facility census Findings include: a) Resident #46 On 09/14/15 at 1:08 p.m. observation revealed a sign posted above the resident's bed, which directed no blood draws or blood pressure checks be done using the resident's right arm. An interview with the resident at that time revealed she was bothered by the sign, because when she had visitors they asked her why she had a sign like that over her bed. The resident stated she did not like to share the reason for the sign with her visiting friends. She considered the reason was too private. Review of the medical record revealed the resident had orders for blood draws on a recurring basis two (2) times each month, and sometimes more frequently. Personnel from the hospital came to the facility to draw the blood, and blood pressure checks were conducted on a recurring basis by facility staff. During a follow-up interview with the resident, on 09/17/15 at 4:30 p.m., she stated if the sign was removed, she could tell staff about her need that the left arm be used for the blood pressure monitoring. She said she tires of having to tell staff each time, and believed it should be their responsibility to know about her need. A review of the physician's orders [REDACTED]. The record did not reveal the underlying reason for Resident #46's preference that the left arm be used for monitoring. Staff Nurse #7 confirmed, during an interview and record review on 09/17/15 at 5:15 p.m., there were no orders specifying which arm to use, or the rationale for the resident's preference. On 09/18/15, Staff Nurse #1 provided information that an order was written early in the morning on 9/18/15 for Resident #46 stating, No blood pressure or blood drawn in right arm. b) Resident #62 During an interview Resident #62, on 09/14/15 at 11:48 a.m., Resident Service Personnel (RSP) #105 entered the room without knocking or otherwise asking permission to enter. When she observed a surveyor and the resident seated just inside the door, she commented she had not expected there to be anyone in the room, and that was why she had come in without knocking. c) Resident #20 RSP #104 entered Resident #20's room on 09/15/15 at 7:09 a.m. without knocking or otherwise asking permission to enter. The resident and a surveyor were conversing in the resident's room at that time. The RSP entered to exchange water pitchers - removing one water pitcher and replacing it with another one filled with fresh ice water. c) Review of Resident Council minutes, from the meeting on 09/01/15, revealed an issue was raised regarding staff's failure to knock and gain permission to enter resident rooms. The minutes stated, Second floor resident identified that staff are not knocking and gaining permission to enter the room while she is in a state of undress. She also had issues with male nurse not entering to give her evening medications while she is undressing for bed.",2019-04-01
5039,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2015-09-18,282,G,0,1,IPN311,"**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 in accordance with the written care plan for one (1) of three (3) residents reviewed for accidents. The resident's care plan for assistance of two (2) persons was not followed, resulting in actual harm to the resident. The resident experienced an avoidable fall resulting in a right shoulder fracture and a fractured pelvis. In addition, the care plan for oral health care was not implemented for Resident #5. Resident identifier #5. Facility census 72. Findings include; a) Resident #5 1. Review of the electronic record, in the afternoon of 09/16/15, revealed Resident #5 had medical [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set (MDS) assessment, with an assessment reference date of 05/21/15, indicated the resident required extensive assistance of two (2) staff members for bed mobility and toileting. The activity of daily living (ADL) care plan, with a problem start date of 11/22/13, stated Resident #5 required extensive to total assistance with all ADLs except eating. The approach, dated 02/03/15, noted Resident #5 required extensive assistance of two (2) staff members for toileting. On 09/16/15, review of a nursing progress note, dated 06/04/15, revealed at 1:40 p.m., a nurse was called to Resident #5's room by the nursing assistants (NAs). Upon entering the room, Resident #5 was found lying on the floor on her right side. A nursing evaluation revealed abnormal alignment of the right shoulder, and the resident was complaining of increased pain to the area. The resident was transported to the hospital for emergent treatment. On 06/04/15 at 4:18 p.m., the hospital was called and revealed Resident #5 had a right shoulder fracture and a fractured pelvis. The fall investigation documents were reviewed in the afternoon of 09/16/15. The documentation of the incident, dated 06/04/15 by NA #52 revealed while drying the resident, he found bowel movement (BM) all the way up her back. All of the wipes had been used. NA #33 came in the room and NA #52 requested her to get more wipes. When NA #33 returned to the room, the resident was already on the floor. A telephone interview regarding the fall was conducted with NA #52 on 09/17/15 at 2:57 p.m. NA #52 confirmed he was the only NA providing care at the time of the fall on 06/04/15. He said he started incontinence care without any other staff member present. NA #52 stated he read the resident profile on the electronic charting system and knew the toileting needs of Resident #5. 2. Review of the electronic medical record, on 09/17/15, revealed Resident #5 had medical [DIAGNOSES REDACTED]. The most recent annual MDS, with an ARD of 05/21/15 indicated Resident #5 had obvious or likely cavities or broken natural teeth. The ADL care plan noted Resident #5 had some teeth with cavities. An intervention, dated 11/22/13, was to use saline mouth wash after meals and at bedtime to help remove debris. On 09/16/15 at 11:30 a.m., an observation of the resident in the dining room revealed she had visible missing teeth, and the teeth present were yellow with darkened spots. On 09/16/15 at 4:02 p.m., Resident #5 was observed seated in a geri/Broda chair. She smiled when spoken to, and her teeth were yellow with darkened spots. An interview was conducted with NA #59 on 09/17/15 at 5:50 a.m. She stated she used pink swabs to cleanse the mouth of Resident #5. She stated she had already provided mouth care. At 10:38 a.m., an interview was conducted with NA #49. She stated she used mouth swabs at night. Upon inquiry, the NA stated she did not use saline mouth wash for the resident. She stated the resident care needs were documented under the Resident Profile in the electronic charting system. On 09/17/15 at 2:25 p.m., NA #49 was interviewed regarding the use of saline mouth wash for the resident after lunch. She stated she did not do a saline mouth wash after lunch, that she only brushed the resident's teeth. The ADL care plan referencing the saline mouth wash was shared with NA #49. She stated saline was a medication, and nursing should be doing the saline mouth wash after meals. LPN #22 was present at the time of the interview with NA #49. She stated the saline wash should be on the nursing sheet. Review of the nursing sheet and Medication Administration Record [REDACTED]. LPN #22 called MDS Nurse #7 regarding the saline mouth wash. MDS Nurse #7 stated since the saline wash was on the care plan, and the discipline was the NA, the NAs should be providing the care. On 09/17/15 at 5:15 p.m., an interview was conducted with the Director of Nursing (DON). She stated nurses should be doing the saline mouth wash. Upon review of the care plan, the DON verified the care plan had NAs as responsible for doing the saline mouth rinse. The DON said the nurses, not the NAs, should have been providing the saline wash mouth care.",2019-04-01
5040,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2015-09-18,318,D,0,1,IPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure two (2) of three (3) residents reviewed for range of motion (ROM) received services to increase ROM and/or to prevent further decline in ROM. Resident #5 was not provided passive range of motion (PROM) as indicated by the care plan, and the physician's orders [REDACTED].#66. Resident identifiers: #5 and #66. Facility census: 72. Findings include: a) Resident #5 Review of the clinical record, in the afternoon of 09/16/15, revealed the resident had [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/15, indicated the resident had functional limitations of the upper extremity on one (1) side of the body. The activities of daily living (ADL) care plan identified a problem of limited physical mobility related to joint contractures. The intervention was bilateral upper extremity passive range of motion (PROM) with staff during bathing and dressing. Observations on 09/15/2015 at 3:11 p.m. revealed Resident #5 was lying in bed on her back. The right hand was contracted. On 09/15/15 at 4:09 p.m., observation revealed Resident #5 remained in a low bed on her back with her right hand contracted. On 09/16/15 at 8:15 a.m., the resident was seated in a geri/Broda chair in the dining room hallway. Her right hand was contracted. On 09/17/15 at 5:33 a.m., Nursing Assistant (NA) #59 was interviewed regarding the resident's morning bath and the provision of PROM. She stated she provided morning care between 5:00 a.m. and 5:30 a.m. The NA said she did not provide PROM, as physical therapy provided PROM. On 09/17/15 at 8:46 a.m., NAs #32 and #49 were observed transferring Resident #5 to the bed. At the time of the observation, the NAs were interviewed regarding PROM. NA #32 straightened each finger on the right hand once. No PROM of the bilateral wrist, left hand, or upper extremities was observed. During an interview at the time of the observation, NA #32 stated she opened the resident's fingers during care, but provided no other PROM. On 09/17/2015 at 4:15 p.m. the Director of Nursing (DON) was interviewed regarding the observations of the PROM for Resident #5. She stated the NAs should be doing formal PROM on the resident's hands and bilateral upper extremities in accordance with the care plan. . b) Resident #66 This resident was readmitted to the facility readmitted on [DATE]. The resident was non ambulatory and spent his time either in bed or in his specialized wheelchair. The resident was non interviewable. During an interview on 09/14/15 at 11:54 a.m., Licensed Practical Nurse (LPN) #24 stated Resident #66 had contractures. The LPN said the resident did not receive restorative care and did not use any splint devices. Resident #66 was observed during the survey on 09/14/15 and 09/15/15. He had contractures to both legs and to his left hand. Record review revealed that the resident had physician's orders [REDACTED]. Moon boots were ordered to be worn whenever the resident was in bed, and a splint was ordered to be worn continuously on his left hand Observations of the resident in bed on 09/14/15 at 9:45 a.m. and at 2:30 p.m. revealed neither the boots nor the splint were in place. Observations on 09/15/15 at 8:00 a.m. revealed no boots nor hand splint were in place while the resident was in bed. Observations on 09/16/15 at 10:00 a.m., revealed no boots were in place while the resident was in bed, just before staff got him up for his weekly shower. At 2:20 p.m. on 09/16/15, the resident was observed in bed without the boots. Nursing Assistant (NA) #57, who confirmed she cared for the resident, was interviewed on 09/17/15 regarding how she was made aware of whether a resident had orders for any special devices. The NA showed how she accessed the orders on the wall Kiosk (the NA care plan information) and showed the orders for the boots and hand splint. She stated she would receive word of a new order or change in a device via her report at the beginning of a shift. The wall Kiosk served as a reference, but was too lengthy to review for each resident each day. The Kiosk provided a reference for the NA regarding the orders for the devices; however, there was no requirement for documentation to the Kiosk record regarding whether the resident had worn the devices during that shift.",2019-04-01
5041,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2015-09-18,323,G,0,1,IPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for accidents was provided the identified required supervision to prevent an avoidable accident. The resident required the assistance of two (2) persons for bed mobility and toileting. This level of assistance was not provided, resulting in actual harm to the resident. The resident experienced an avoidable fall resulting in a right shoulder fracture and a fractured pelvis. Resident identifier #5. Facility census: 72 Findings include: a) Resident #5 On 09/16/15, at approximately 2:35 p.m., record review revealed Resident #5 had medical [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/21/15, indicated the resident required extensive assistance of two (2) plus staff members for bed mobility and toileting. Toileting is defined as the manner a resident changes him/herself after elimination or changing a pad. The activity of daily living (ADL) care plan, with a problem start date of 11/22/13, noted Resident #5 required extensive to total assistance with all ADLs except eating. The approach, dated 02/03/15, noted Resident #5 required extensive assistance of two (2) staff members for toileting. A review of the nursing progress notes, on 09/16/15, revealed a progress note dated 06/04/15 at 1:40 p.m. The note stated a nurse was called to Resident #5's room by nursing assistants (NAs). Upon entering the room, Resident #5 was found lying on the floor on her right side. The note indicated NA #52 stated the resident was incontinent of stool, so she was turned over onto her left side so she could be cleaned. The NA stated he turned around to get some wipes and Resident #5 slipped out of the bed and landed on her right side. The nursing evaluation revealed abnormal alignment of the right shoulder, and the resident complained of increased pain to the area. The note further indicated at 2:00 p.m. on 06/04/15, the hospital emergency room (ER) was called, made aware of transport of the resident, and was given a report on the resident. Emergency Services were called and made aware of the need to transport Resident #5 to the ER. On 06/04/15 at 4:18 p.m., the hospital was called. Hospital personnel informed the nursing home that Resident #5 had a right shoulder fracture and a fractured pelvis. The documentation, dated 06/04/15 at 4:56 p.m., noted staff received a call from the hospital indicating Resident #5 would return to the facility with a [DIAGNOSES REDACTED]. During an observation of incontinence care, on 09/17/15 at 8:46 a.m., Resident #5 was totally dependent upon two (2) NAs for turning and repositioning, as well as incontinence care. The right hand was contracted and there was no use of the right arm. The fall investigation documents were reviewed on the morning of 09/17/15. The documentation of the 06/04/15 incident by NA #52 revealed while drying the resident, he found bowel movement (BM) all the way up her back. All of the wipes had been used. NA #52 said NA #33 came in the room, and NA #52 requested her to get more wipes. NA #52 looked around to find something. The resident reached for the curtain and when he looked back, the resident was rolling off the bed. Review of the incident documentation, dated 06/04/15, from NA #33 revealed at 1:40 p.m., NA #52 asked her to get a box of wipes for him to use for the resident. When she (NA #33) returned to the room, the resident was already on the floor. NA #33 further documented that NA #52 stated Resident #5 was rolling down the bed when he was cleaning her. A telephone interview regarding the fall was conducted with NA #52 on 09/17/15 at 2:57 p.m NA #52 stated he was turning Resident #5 over and drying her. He looked around and the resident grabbed something. Resident #5 was on her left side at the time of fall. NA #52 confirmed NA #33 was not in room at the time he started incontinence care, or at the time of the fall. NA #52 said NA #33 came into the room and he (NA #52) requested she get more wipes. NA #52 stated he reviewed the resident profile in the electronic charting system to know the care needs of each resident The electronic resident profile was observed, on 09/17/15 in the afternoon. It revealed Resident #52 was a two (2) person assist for toileting. This was consistent with the MDS and the care plan. An interview regarding the fall was conducted, on 09/17/15 at 3:55 p.m., with NA #33 in the presence of the Administrator and Social Worker #63. NA #33 stated she went with NA #52 to assist with incontinence care because Resident #5 was a two (2) person assist. NA #33 said while cleaning the resident, Resident #5 had a blow out. NA #33 said she left the room to get wipes, and the resident was on her side facing the wall when she returned. She said NA #52 was alone in the room and Resident #5 was on the floor. The interview with NA #33 on 09/17/15 at 3:55 p.m., regarding who was in the room providing incontinence care for Resident #5, did not completely correlate with the information obtained during the telephone interview with NA #52 on 09/17/15 at 2:57 p.m. During the interview with NA #52, he stated NA #33 was not in the room at the time he started incontinence care. On 09/17/15 at 4:30 p.m., the most recent quarterly MDS, with an ARD of 08/15/15, was reviewed for changes in functional ability since the fall on 06/04/15. The functional status, including bed mobility and toileting, remained unchanged. There were no documented changes in functional ability, nor was there a significant change assessment completed since the fall.",2019-04-01
5042,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2015-09-18,364,F,0,1,IPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident remarks, and review of resident council meeting minutes, the facility failed to ensure foods were prepared and served in a manner which did not compromise nutritive value, flavor, palatability, and appearance. The facility failed to coordinate meal preparation and meal service times to assure foods were served at their optimal quality. This practice had the potential to affect all residents who consumed oral nutrition. Facility census: 72. Findings include: a) Posted meal times for the facility were: breakfast at 7:30 a.m., lunch at noon, and the evening meal at 5:30 p.m Meals for the first and second floors were plated in the kitchen and delivered to the floors in closed food carts. Residents who ate in the Social Dining Room were served directly from the kitchen steam table. b) During observation of meal preparation and service on 09/14/15 at 7:00 a.m., kitchen personnel were observed plating the food and placing resident meal trays in enclosed carts. The carts were then transported to the first and second floors, where the meals were served by Resident Service Personnel (RSP) and Nursing Assistants (NAs). At the time of the observation, Dietary Manager (DM) #72 explained that tray line service had begun at 6:45 a.m. that morning. All tray line menu items were prepared prior to the start of the tray line. This interview revealed the eggs were prepared in a skillet on the grill beginning shortly after 6:00 a.m. Observation revealed at 7:00 a.m., all eggs were prepared, and the skillet and grill used for the egg preparation were already clean. The trays for residents dining in the Social Dining Room were assembled following the first and second floor trays. Carts for both the first and second floors were due on the floors at the posted meal times. c) Observations were made of the breakfast meal service on the first floor on 09/14/15. The cart, with the plated meals inside, arrived on time at 7:30 a.m. RSPs distributed the trays beginning with the approximately 22 room trays, followed by the meals for 11 residents in the first floor dining room. The last tray was served at 8:11 a.m. to a resident in the dining room. The tray distribution process took 40 minutes from the time the cart arrived on the floor at 7:30 a.m. until the last tray was served. Resident comments were heard in the dining room commenting on the color of the eggs. Observation revealed the scrambled eggs, for which preparation began at 6:00 a.m., were distinctly greenish gray in appearance. Toast served on the heated plates was tough and moist, rather than crisp as it had been when first toasted. Food held for a lengthy period of time on a heated plate begins to dry out or get too moist, depending on the food product. These foods also have a potential to lose its fresh appearance, flavor, and/or temperature. d) A review of the 4 week cycle menu revealed eggs were on the breakfast menu for each of the 28 days in the cycle. e) Another breakfast meal observation was made on 09/15/15. Observation revealed the scrambled eggs again were green. Observations of green eggs were made in each of the three (3) dining rooms, as well as on room trays. Resident comments regarding the green eggs were overheard in the first floor dining room and Social Dining Room. f) DM #72 was interviewed on 09/15/15 at 3:45 p.m. She explained the scrambled eggs were prepared in a skillet on the grill beginning at approximately 6:15 a.m. on both 09/14/15 and 09/15/15. She explained that usually the facility purchased eggs which were already cracked/broken, and came refrigerated in bags. DM #72 said the supplier was out of that product, so dietary staff had cracked fresh shell eggs for the scrambled eggs on both days. She attributed the green color of the eggs to the fresh eggs used in lieu of the usual purchased bulk eggs. g) Scrambled eggs can turn green if they are prepared in aluminum or cast iron cookware, or if aluminum spatulas or utensils are used, or if they are held for lengthy periods of time. The hydrogen [MEDICATION NAME] in egg whites reacts with the iron in the yolks to form iron [MEDICATION NAME]. h) The DM was asked whether batch cooking was used to ensure residents received fresh food with optimum flavor and an appetizing appearance. The DM was unfamiliar with the term batch cooking. (Batch cooking means preparing menu items in smaller quantities throughout the meal service, so foods will be at their peak quality when served.) When asked whether an adjustment to serving times (within the 14 hour limitation between the evening meal and breakfast the following morning) had been considered to allow food preparation to more closely match the meal service schedule, the DM said no schedule variations had been considered. i) A third observation of breakfast meal service was made on 09/18/15. The scrambled eggs were not green. The facility had received a delivery of the usual bagged eggs on 09/17/15; however, the meal preparation was on the same schedule as the previous two (2) days, allowing food to be prepared up to two (2) hours in advance of service. j) Review of Resident Council minutes for (MONTH) 2, (YEAR) revealed an issue was raised regarding the Pork chops are consistently too tough to cut or eat. Extended holding times for menu items contributes negatively to their palatability. The same schedule, as outlined for the breakfast meal observed on 9/14/15, was followed for each of the three (3) meals observed. All foods were prepared prior to the start of tray line service, and tray line service began 45 minutes before the posted meal service time.",2019-04-01
5043,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2015-09-18,441,E,0,1,IPN311,"Based on observation, staff interview, and review of manufacturer's recommendations, the facility failed to maintain an infection control program which controlled, to the extent possible, the onset and spread of infection within the facility. The facility did not ensure glucometers were cleaned and disinfected between resident use. This practice affected two (2) residents randomly observed during medication administration observation. The facility had ten (10) residents who received blood sugar monitoring using glucometers. Residents #76 and #32 were affected; however, the practice had the potential to affect more than an isolated number of residents. Facility census: 72. Findings include: a) Residents # 76 and #32 On 09/17/15 at 6:04 a.m., Licensed Practical Nurse (LPN) #14 was observed performing a fingerstick blood sugar using a communal glucometer (Evencare G2 meter) on Resident #76. After administering medications, LPN #14 returned to the medication cart with the glucometer. Without cleaning and disinfecting the glucometer; she returned it to the cart. The LPN then went to the room of Resident #32 to perform a fingerstick blood sugar. After having all supplies ready and entering the room; the nurse was queried regarding cleaning and disinfecting the glucometer after each resident. LPN #14 stated there were no policies or procedures in place regarding cleaning the glucometer between residents. She stated she could clean the glucometer with rubbing alcohol. She further stated she would have to read the policy and procedure. Prior to reading the policy and procedure, she returned to the medication cart and cleaned the glucometer with an alcohol prep. After performing the fingerstick blood sugar; LPN #14 returned to the cart and cleansed the glucometer with an alcohol prep. During an interview with LPN #18 at 9:50 a.m. on 09/17/15, she stated she was not aware of a policy and procedure for cleaning and disinfecting the glucometer. At 11:12 a.m. on 09/17/15, during another interview with LPN #18, she stated she was provided a container of Clorox wipes by housekeeping. She stated the director (DON) instructed her to use the Clorox wipes on the glucometer between resident use. She stated prior to today, no Clorox wipes were on the cart. Observation of the medication cart on the 2 Short Hall revealed no Clorox wipes. LPN #11 confirmed the observation. Interviews with LPN #18 and RN #5 confirmed prior to 09/17/15, they were never told to use Clorox wipes to cleanse and disinfect glucometers, nor were they aware of a policy and procedure. At 11:40 a.m. on 09/17/15, an interview was conducted with the Infection Control Nurse (#6) regarding manufacturer recommendations for cleaning and disinfecting the glucometer. She stated staff should use Clorox wipes on all resident equipment. She stated Clorox wipes were on all medication carts. Additionally, during the interview, she stated staff had been in-serviced on infection control including cleansing of equipment on 08/17/15. The in-service agenda, dated 08/17/15 was reviewed at the time of the interview. It included isolation precautions, hand washing, and donning and removing personal protective equipment. The agenda focused on residents with clostridium difficile and did not specifically mention glucometers. During the interview, a request was made for a policy and procedure for cleansing and disinfecting the glucometer. An undated policy entitled, Policy for General Cleaning and Maintenance of Equipment, was received from Infection Control Nurse #6. The policy did not specifically address cleaning and disinfecting the glucometer. On 09/17/15 at approximately 4:40 p.m., the manufacturer recommendations were provided by Infection Control Nurse #6. The manufacturer recommendations for the EvenCare G2 meter revealed cleaning and disinfecting the meter device was very important in the prevention of infectious disease. The recommendation further stated to disinfect the meter, clean the meter with one (1) of the validated disinfecting wipes which included Clorox Healthcare Bleach Germicidal and Disinfectant wipes. The manufacturer recommendations directed staff to wipe all external areas of the meter, including both front and back surfaces, until visibly clean. It indicated staff should allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use.",2019-04-01
5780,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2015-08-05,225,D,1,0,5S9P11,Deficiency Text Not Available,2018-08-01
5781,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2015-08-05,282,D,1,0,5S9P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure services were provided by qualified persons in accordance with the resident's written plan of care for the treatment of [REDACTED]. Resident identifier: #23. Facility census: 74. Findings include: a) Resident #23 Record review, on 08/04/15 at 11:00 a.m., found the resident was admitted to the facility, from her home, on 05/26/15. Resident #23's primary [DIAGNOSES REDACTED]. The resident was admitted to the facility with pressure ulcers. Since her admission to the facility, the resident had two (2) discharges and two (2) readmissions to the facility at the time of her care plan review on 08/03/15: discharged on [DATE], readmitted on [DATE], discharged on [DATE], readmitted on [DATE]. Review of the resident's current plan of care, on 08/03/15 at 8:30 a.m., found the following problem, created on 06/19/15, addressing pressure ulcers: Resident has a unstageable pressure ulcer to her coccyx related to bowel incontinence, a history of previously healed pressure ulcers and MS ([MEDICAL CONDITION]). The long-term goal was, Resident's ulcer will show signs of healing without complications by next review. Approaches included: Assess the pressure ulcer for location, stage, size, (length, width, and depth), presence/absence of granulation tissue and epithelization with dressing changes and chart on area weekly. Treatments as per physician's orders [REDACTED]. An admission body audit was completed by Licensed Practical Nurse (LPN) #17, on 06/06/15. LPN #17 noted the resident had a Stage II pressure ulcer upon admission on the coccyx. The coccyx was red and excoriation was noted on the buttocks. Registered Nurse (RN), #2, completed a pressure ulcer assessment, on 06/09/15. This nurse determined the resident had an unstageable pressure area to the coccyx, measuring 2 x 6.5 x 0. The pressure area was described as pink or red tissue with shiny, moist, granular appearance with a scant amount of exudate. There was no mention of any Stage II pressure area to the coccyx. The treatments ordered for the pressure areas on 06/06/15 were: Anti-Monkey Butt ( a baby's diaper rash cream), twice a day (BID), apply to buttock with every toileting change with [MEDICATION NAME] cream every shift. [MEDICATION NAME] cream to be applied to the buttock with every toilet change, every shift. Cleanse area to the left lower lateral leg with Normal Saline, pat dry then apply skip prep QD (daily). The [DIAGNOSES REDACTED]. [MEDICATION NAME] border was ordered for the unstageable pressure ulcer on coccyx. Change daily and as needed. Measure weekly. The area to the left ankle was never assessed or discussed again; although, the facility had a physician's orders [REDACTED]. According to documentation on the treatment administration record (TAR), the treatment continued to the left ankle from 06/06/15 through 07/07/15. On 07/07/15, the resident was discharged to the hospital. The resident's care plan never addressed the pressure area to the ankle. The care plan only addressed an unstageable pressure area to her coccyx. On 06/24/15, the resident's physician observed the pressure area and documented the following: An unstageable pressure area to the coccyx, measuring (2 x 6.2 x .1 centimeters). The plan for treatment was to continue the Calazine and [MEDICATION NAME] dressing. On 06/26/15, a RN (no longer employed at the facility), discontinued the [MEDICATION NAME], which was ordered to treat the unstageable pressure area to the coccyx. There was no evidence in the medical record to confirm the physician was contacted regarding the discontinuation of the order and no documentation the resident's responsible party was notified of any medication/treatment changes. On 07/17/15, an admission body audit was completed. The nurse noted a Stage II pressure area to the coccyx, measuring 0.5 x 0.5 x 0.1. (Measured in centimeters) On 07/19/15, Employee #6, completed a body audit and noted the resident had a Stage II pressure area to the coccyx. The care plan never addressed a Stage II pressure area to the coccyx. Review of the physician's orders [REDACTED]. The area was never mentioned again in the medical record and was never assessed after 07/19/15. There were no weekly wound assessments completed. On 08/04/15, during the complaint investigation, the resident was sent to the hospital. The author of the care plan was unable to be interviewed as this employee no longer works at the facility. At 1:50 p.m. on 08/04/15 the director of nursing (DON) and the medical records clerk, Employee #52 were interviewed regarding the care provided for treatment for [REDACTED]. The DON stated she could not explain the confusion, and the discrepancies related to the number of pressure ulcers present and the treatment of [REDACTED]. At 4:00 p.m. on 08/04/15, the residents care was discussed with the administrator and Registered Nurse #3. The physician was contacted by telephone on 08/05/15 at 11:45 a.m. The physician stated she did not remember discontinuing the treatment ([MEDICATION NAME]) to the coccyx on 06/26/15. She said it would be unlikely she would discontinue a treatment when the resident continued to have the pressure area. She said if she would have discontinued the [MEDICATION NAME], she would have ordered another treatment to the area. At the close of the survey, no further information was provided regarding the care and treatment of [REDACTED]. Facility staff failed to follow the care plan interventions of assessing the area weekly as directed by the care plan. The facility documentation was not consistent as to how many pressure areas the resident had. After the re-admission to the facility on [DATE], the care plan did not include the Stage II pressure ulcer noted to the coccyx. The facility failed to follow the physician's orders [REDACTED]. An alternative treatment was not provided for the area on the coccyx.",2018-08-01
5782,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2015-08-05,309,D,1,0,5S9P11,"**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 to attain or maintain the highest practicable physical well-being for two (2) of six (6) sampled residents. Resident #72's sliding scale insulin was not administered as directed by the physician's orders [REDACTED]. Resident identifiers: #72, and #23. Facility census: 73.Findings include: a) Resident #72A review of Resident #72's medical records, on 08/04/15 at 3:15 p.m., found a physician's orders [REDACTED]. If blood sugar is 200-300 give 4 units subcutaneously. If blood sugar is 300-400 give 6 units subcutaneously. Review of (MONTH) and (MONTH) (YEAR) Medication Administration Record [REDACTED] 06/15/15 at 12 noon blood sugar recorded as 234 and no insulin given. 07/18/15 at 12 noon blood sugar recorded as 233 and 6 units of insulin given. 07/24/15 at 12 noon blood sugar recorded as 259 and 6 units of insulin given. 07/25/15 at 5:00 p.m. blood sugar recorded as 262 and no insulin given. During an interview with Registered Nurse #3, on 08/05/15 at 11:00 a.m., it was confirmed the insulin had not been administered as directed by the physician's orders [REDACTED]. b) Resident #23 The medical record review, on 08/04/15 at 11:00 a.m., revealed Resident #23 was readmitted to the facility on [DATE]. On 06/06/15 the physician ordered [MEDICATION NAME] border to an unstageable pressure ulcer to the coccyx and [MEDICATION NAME] cream to be applied to the buttocks with every toilet change on every shift. On 06/24/15 the physician saw the resident for a wound assessment and evaluation. The physician's documentation on the wound assessment directed staff to continue the current treatment of [REDACTED]. On 06/26/15, a registered nurse, discontinued the [MEDICATION NAME], which was ordered to treat the unstageable pressure area to the coccyx. There was no evidence in the medical record to confirm the physician was contacted regarding the discontinuation of the order and no documentation the resident's responsible party was notified of any medication/treatment changes. The wound did not heal and no alternative treatment was ordered. At 1:48 p.m. on 08/04/15 the Director of Nursing (DON), #1, and Medical Records Clerk #52 were interviewed regarding the discontinuation of the residents treatment on 06/26/15. The DON said she did not know why the treatment was discontinued. She said the nurse should have written a nursing note. The DON and Medical Records Clerk #52 were unable to find any notes from this nurse on 06/26/15 in the electronic medical record. The DON stated the physician should be contacted regarding the order. The resident's physician was contacted by telephone on 08/05/15 at 11:45 a.m. The physician stated she did not remember discontinuing the treatment ([MEDICATION NAME]) to the coccyx on 06/26/15. She said it would be unlikely she would discontinue a treatment when the resident continued to have a pressure area. She said if she would have discontinued the [MEDICATION NAME], she would have ordered another treatment to the area.",2018-08-01
5783,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2015-08-05,314,D,1,0,5S9P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy review, the facility failed to ensure a resident, admitted with pressure ulcers, received necessary treatment and services to promote healing of the pressure areas. The facility failed to complete consistent assessments identifying the pressure ulcers present; implement the treatment ordered by the physician; monitor and evaluate the effectiveness of the interventions as appropriate; and implement the comprehensive care plan regarding pressure ulcer treatment. This was true for one (1) of two (2) residents reviewed for the care area of pressure ulcers. Resident identifier: #23. Facility census: 74. Findings include: 1) First admission to facility a) Resident #23 The medical record review for Resident #23, on 08/04/15 at 11:00 a.m., found the resident was admitted to the facility, from her home, on 05/26/15. Her primary [DIAGNOSES REDACTED]. b) Upon admission, a licensed practical nurse, (no longer employed at the facility) documented the resident had, . areas of [MEDICATION NAME] scarring to coccyx and sacrum from previous pressure ulcers. Unstageable 0.1 cm (centimeter) x 0.1 cm x unknown tunneling to open area noted to scarring on coccyx. This entry was made at 3:14 p.m. on 05/26/15. c) On 05/27/15, Licensed Practical Nurse #14 (LPN), completed three (3) pressure ulcer assessments. -Resident was admitted with an unstageable pressure ulcer on lower right posterior leg measuring 2 x 1.5 x 0 cm-dry black scab [MEDICATION NAME] was applied. -Unstageable pressure ulcer noted on coccyx measuring 0.1 x 0.1? Unable to measure depth due to size. [MEDICATION NAME] border applied. -Resident was admitted with a Stage II pressure ulcer on left buttock measuring 7 x 4 x 0.1 cm-red and excoriated with a scant amount of bloody drainage noted .Turn per facility protocol. Multivitamin, Vitamin C 500 mg and Prostat x 6 weeks. Moon boots when in bed. Air mattress. d) On 05/27/15, the physician saw the resident to complete a history and physical. Under the category, entitled skin, the physician documented the following pressure areas: -A scab to the right ankle, measuring 2 x 1.5 -A pressure area to the coccyx, measuring 4.5.5 x 4 (typed as written). The physician did not stage or describe the pressure areas. e) A body audit, completed on 05/27/15 by Employee #6, the minimum data set (MDS) coordinator, found the resident had a Stage II pressure ulcer to the left buttock measuring 7 (centimeters) cm x 4 cm x 0.1. f) Three (3) licensed nurses and the facility physician all saw the resident within 24 hours of admission to the facility, and all four (4) staff members had a different opinion of the number and description of the pressure areas. g) Review of the treatment administration record (TAR) found the following treatments ordered by the physician: -[MEDICATION NAME] cream to buttock and bilateral upper thighs over [MEDICATION NAME] for protectant BID (twice daily). -[MEDICATION NAME] border to Stage II pressure ulcer on right buttock. Change daily and as needed. Measure weekly. -[MEDICATION NAME] border to unstageable pressure ulcer on coccyx. Change daily and PRN (an needed). Measure weekly. The treatments ordered for the pressure ulcers did not match the pressure area's documented by the physician. 2. Second admission to the facility a) On 05/29/15, the resident was discharged to a local hospital. She returned to the facility on [DATE]. b) An admission body audit was completed by LPN #17, on 06/06/15. LPN #17 noted the resident had a Stage II pressure ulcer upon admission on the coccyx. The coccyx was red and excoriation was noted on the buttocks. c) A pressure ulcer assessment was completed by Registered Nurse (RN) #2 on 06/09/15 This nurse determined the resident had an unstageable pressure area to the coccyx, measuring 2 x 6.5 x 0. The pressure area was described as pink or red tissue with shiny, moist, granular appearance with a scant amount of exudate. There was no mention of any Stage II pressure area to the coccyx. d) The treatments ordered for the pressure areas on 06/06/15 were: -Anti-Monkey Butt ( a diaper rash cream for babies), twice a day (BID), apply to buttock with every toileting change with [MEDICATION NAME] cream every shift. -[MEDICATION NAME] cream to be applied to buttock with every toilet change, every shift. -Cleanse area to left lower lateral leg with Normal Saline, pat dry then apply skip prep QD (daily). The [DIAGNOSES REDACTED]. -[MEDICATION NAME] border to unstageable pressure ulcer on coccyx. Change daily and as needed. Measure weekly. e) The area to the left ankle was never assessed upon admission; although, the facility had a physician's orders [REDACTED]. According to documentation on the treatment assessment record (TAR), the treatment continued to the left ankle from 06/06/15 through 07/07/15. On 07/07/15 the resident was discharged to the hospital. The medical record contained no further documentation relating to the left ankle. f) When the resident was discharged from the facility on 05/29/15, a Stage II pressure area was noted to be on the right leg, not the left leg. g) Again two licensed nurses had discrepancies in the pressure ulcer observations upon re-admission on 06/06/15. h) Review of the medical record found no evidence the physician observed the residents skin until 06/24/15 when she completed, Wound Rounds. On 06/24/15, the physician documented the resident had an unstageable pressure area to the coccyx and she stated the plan for treatment was to continue the Calazine and [MEDICATION NAME] dressing. i) On 06/26/15, a registered nurse (no longer employed at the facility), discontinued the [MEDICATION NAME], which was ordered to treat the unstageable pressure area to the coccyx. There was no evidence in the medical record to confirm the physician was contacted regarding the discontinuation of the order and no documentation the resident's responsible party was notified of any medication/treatment changes. The nurse did not write any orders for treatment although the area was unhealed. j) Record review found two (2) skin assessments, one completed prior to the discontinuation of the [MEDICATION NAME], and one after the discontinuation of the [MEDICATION NAME]. - A pressure ulcer assessment, completed by a registered nurse (no longer working at the facility), on 06/23/15 found a Stage II pressure area to the coccyx, measuring 2 cm x 6.2 cm x 0.1 cm. - On 06/30/15, the same registered nurse completing the 06/23/15 assessment, completed a second pressure ulcer assessment which documented the Stage II pressure ulcer to the coccyx was now 3 cm x 7 cm x 0.1 cm. -An increase in size since the [MEDICATION NAME] was discontinued without a physician's orders [REDACTED]. 3. Third admission to the hospital a) On 07/07/15 the resident was again discharged to the hospital. The resident returned to the facility on [DATE]. b) On 07/17/15, an admission body audit was completed. The RN, no longer employed at the facility, noted a Stage II pressure area to the coccyx, measuring 0.5 x 0.5 x 0.1 cm. c) On 07/19/15, RN #6/ minimum data set coordinator, completed a body audit and noted the resident had a Stage II pressure area to the coccyx. There were no measurements of the pressure area on the assessment. d) Review of the physician's orders [REDACTED]. e) The pressure area was never mentioned again in the medical record. There were no weekly assessments completed. It was unknown if the area was healing. 4. Fourth admission to the hospital a) On 08/04/15, during the complaint investigation, the resident was sent to the hospital. The resident had not returned to the facility at the conclusion of the survey on 08/05/15. Review of the residents current plan of care on 08/03/15 at 8:30 a.m. found the following problem addressing pressure ulcers: Resident has a unstageable pressure ulcer to her coccyx related to bowel incontinence, a history of previously healed pressure ulcers and MS ([MEDICAL CONDITION]). The problem was updated on 06/19/15. The long term goal was, Resident's ulcer will show signs of healing without complications by next review. Approaches included: Assess the pressure ulcer for location, stage, size, (length, width, and depth), presence/absence of granulation tissue and epithelization with dressing changes and chart on area weekly. Treatments as per physician's orders [REDACTED]. 5) Staff Interviews a) At 1:48 p.m. on 08/04/15 the medical record of Resident #23 was reviewed with Director of Nursing #1, and Medical Records Clerk #52. The following issues were discussed with these employees: The discrepancy in the measuring, description and staging of the pressure ulcers upon each admission. The Stage II pressure area noted during the first admission to the right lower leg, documented by nursing staff but not the physician. The discrepancy of the area to the right lower leg that was documented as being the left lower leg upon the residents re-admission on 06/06/15. The fact the facility documented a treatment as being provided on the left lower leg from 06/06/15 until the residents discharge on 07/07/15 but the area was never re-assessed. The left lower leg was never mentioned in the facility's weekly assessments after 06/06/15. The treatment that was discontinued by the nurse on 06/26/15, to the pressure area to the coccyx, with no documentation the physician was contacted and ordered the discontinuation of the treatment. The fact the resident was readmitted with a Stage II pressure area to the coccyx on 07/17/15 and the area was never assessed before the residents discharge from the facility on 08/04/15. There were no orders for any treatment to this area. The DON was asked if the care plan interventions to provide treatment as ordered and to measure the areas weekly had been provided. The DON stated she did not know what to say about the areas. b) At 4:00 p.m. on 08/04/15 the residents care was discussed with the administrator and Registered Nurse (RN) #3. These employees could not explain all the confusion surrounding the treatment of [REDACTED]. c) The physician was contacted by telephone on 08/05/15 at 11:45 a.m. The physician stated she did not remember discontinuing the treatment ([MEDICATION NAME]) to the coccyx on 06/26/15. She said it would be unlikely she would discontinue a treatment when the resident continued to have the pressure area. She said if she would have discontinued the [MEDICATION NAME], she would have ordered another treatment to the area. d) At the close of the survey on 08/05/15, no further evidence was provided regarding the pressure area treatments and documentation. 6. Facility Policy for Pressure Ulcer Treatment a) Review of the facility's policy for Pressure Ulcer Treatment provided by the administrator on 08/05/15 at 2:00 p.m. found the following: Documentation required by staff: .The type of treatment and resident response. The date and time the wound care was given. The position in which the resident was placed. The name and title of the individual performing the care. Any change in the resident's condition. All assessment data (i.e., color size, pain, drainage, etc) when inspecting the wound . .Review the resident's care plan to assess for any special needs of the resident",2018-08-01
5784,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2015-08-05,441,D,1,0,5S9P11,Deficiency Text Not Available,2018-08-01
6377,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,152,E,0,1,35BV11,"Based on staff interview, observation, review of facility policy, family interview, and resident interview, the facility failed to ensure four (4) of four (4) residents reviewed for rights were afforded the opportunity to exercise their rights. Residents were not free to exercise their rights regarding the use of side rails. Resident identifiers: # 98, #71, #29, and #2. Facility census: 77. Findings include: a) During the survey, residents and family members expressed serious concerns regarding the facility's decision to discontinue the use of side rails. The residents who expressed concern were those who used the side rails for turning and repositioning. An interview with Employee #1 (director of nursing), on 06/24/14 at 9:30 a.m., revealed the side rails were discontinued on 06/11/14 at the request of the medical director. Review of a new policy regarding side rails, which the facility implemented on 06/11/14, revealed the statement, No Resident will have side rails, unless the resident has capacity. Capacity to make health care decisions and the right to use side rails are not one and the same. The decision to discontinue the side rails was not discussed with the resident to judge how well the resident understood the facility's concerns with the use of side rails and/or how the resident used the side rails. Each of the residents for whom concerns were raised were deemed to not have capacity to make health care decisions. The facility also did not allow the person appointed under State law to act on the resident's behalf regarding the use of the side rails. 1) Resident #98 On 06/23/14 at 1:47 p.m., during an interview with Resident #98 and his wife, who acts as the resident's medical power of attorney (MPOA), the MPOA said a couple of weeks ago a facility staff member informed them the resident could no longer use his side rails. The MPOA became visibly upset when discussing the matter. The MPOA stated the facility staff member said, State says we can't use side rails because someone may get their head caught in them. The two (2) 1/4 side rails on the resident's bed were secured in the lowered position with two (2) zip ties on each side rail. The MPOA said Resident #98 could turn and reposition himself independently when the side rails were in the up position. Without the side rails, the resident had to call staff to assist him to turn and reposition. The MPOA said recently the resident had an itch on his back, and they had to use the call light to get staff to help him turn so he could scratch his back. She said the resident was upset by this and told her he did not want to have to push his button every time he had an itch. During the interview, the resident asked if he would again be able to use his side rails. The resident and his wife/MPOA said they were not consulted in the decision regarding discontinuation of the use of the side rails. 2) Resident #71 On 06/25/14 at 3:30 p.m., Resident #71 was observed in her bed. Her side rails were in the down position secured with two (2) zip ties on each side rail. The resident said she wished she still had her side rails because she used them to position herself in the bed. She asked if she would ever get them back. During a telephone conversation, on 06/25/14 at 5:00 p.m., with the MPOA for Resident #71, the Resident's MPOA said she received a letter stating the side rails would no longer be allowed to be used by the residents. She thought the letter came from the State. She said her mother was very upset about losing her side rails, as she was able to turn and reposition independently while in bed. She said her mother no longer feels safe in bed, and now requires assistance to turn and reposition. The MPOA said it was her opinion, as well as her Mother's opinion that she (the resident )could do more and felt safer with the side rails. She said she wanted her mother to once again be able to utilize her side rails. 3) Resident #29 During an interview on 06/17/14 at 4:20 p.m., Resident #29 said her side rails were removed about a week ago. She said she was informed by staff that she could no longer use them. On 06/25/14 at 11:20 a.m., Resident #29 said she almost fell getting out of bed that morning because she did not have her side rail to assist her. Several times during the conversation, she expressed a fear of falling. The resident said she used to be able to get out of bed herself using the side rail and the arm of her recliner. She said she no longer attempts to get out of bed, without staff, due to a fear of falling. The resident said when she had her side rails, she was not fearful of falling. She said her anxiety was higher now because she cannot have her side rails. During a telephone interview with the resident's MPOA, on 06/25/14 at 11:31 a.m., the MPOA said she really believed Resident #29 needed her side rails. She voiced fear for the risk of injury to the resident was greater without the side rails than with the side rails. The MPOA said when she talked with the administrator and expressed her desire for the resident to have side rails, the administrator told her, State says side rails cannot be used, and I just can't go against State rules. The MPOA said the facility made a decision to discontnue the use of side rails regardless of the resident's or the MPOA's wishes. She said she thought the decision made the resident require staff assistance in areas in which she did not previously need assistance. The MPOA also said the entire situation had made the resident's anxiety worse. 4) Resident #2 On 06/11/14 the facility implemented a policy which stated No Resident will have side rails, unless the resident has capacity. An interview with Resident #2, on 06/20/14 at 9:10 a.m., she demonstrated she could raise the bed, but was not able to reposition in bed or raise the head of the bed due to the controls being on the lowered secured side rail. Observation of the resident's side rails revealed the side rails were secured in the lowered position. An interview on 06/24/14 at 9:30 a.m. with the director of nursing revealed there was no assessment completed for Resident #2 prior to implementing the policy and discontinuing the resident's side rails. She stated she had ordered two (2) devices to assist with bed mobility, but they had not yet arrived. She verified the side rails were discontinued prior to the alternative devices being in place. An interview with the medical director on 06/25/14 at 8:00 a.m. revealed residents were to be assessed by physical therapy and alternate bed control and positioning devices were to be in place prior to the discontinuation of the bed rails. She confirmed the facility had not completed the physical therapy evaluations. She also said the facility had not received the positioning devices they ordered.",2018-04-01
6378,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,221,E,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for physical restraints was free from a restraint used for staff convenience not for an assessed medical need. A pelvic restraint was used without an assessment or a plan to systematically and gradually reduce the use of the restraint. Resident identifier: #64. Facility census: 77. Findings include: a) Resident #64 Observation of the resident during Stage 1 of the Quality Indicator Survey, on 06/17/14 at 2:22 p.m., found the resident was seated in a reclining Broda chair (a tilting and reclining positioning chair) with a pelvic sling applied. The sling was tied behind and under the seat of the Broda chair. The pelvic restraint was in use during numerous daily observations, including but not limited to: -- 06/16/14 at 12:15 p.m. -- 06/17/14 at 2:22 p.m. -- 06/18/14 at 12:30 p.m. -- 06/19/14 at 9:00 a.m. -- 06/20/14 at 10:17 a.m. -- 06/23/14 at 1:26 p.m. -- On 06/24/14 the resident was observed with the sling in place continuously from 8:15 a.m. until 9:51 a.m. -- On 06/25/14 the resident was observed from 9:00 a.m. to 9:33 a.m., and at 5:13 p.m. with the sling in place. -- On 06/26/14 at 11:46 a.m. Medical record review, on 06/24/14 at 9:45 a.m., found a physician's orders [REDACTED]. Further review of the medical record, on 06/24/14, found the resident's last annual minimum data set (MDS) had an assessment reference date (ARD) of 03/06/14. Section P of the MDS was not coded to reflect the resident had a physical restraint. The care plan in use at the time of the survey was reviewed on 06/24/14 at 10:30 a.m. It did not address the pelvic sling as a restraint. On 06/24/14 at 1:06 p.m., Employee #2, the registered nurse MDS coordinator, stated the physician told her the pelvic sling was not a restraint, it was a positioning device, so she did not code a restraint on the MDS. Employee #2 verified the care plan did not address the use of a restraint. She stated the resident was unable to remove the pelvic sling and/or reposition herself. The director of nursing was interviewed at 12:37 p.m. on 06/25/14. She was unable to provide evidence the facility assessed the resident for the medical necessity of a pelvic restraint.",2018-04-01
6379,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,223,D,0,1,35BV11,"Based on review of allegations reported to the State, family interview, resident interview, staff interview, and medical record review, the facility failed to ensure (2) of three (3) residents, reviewed for the care area of abuse during Stage 2 of the Quality Indicator Survey (QIS), were afforded the right to be free from physical abuse. Residents #100 and #95 both alleged staff had treated them rough during care. The facility failed to recognize the abuse and failed to address the allegations of physical abuse. Resident identifiers: #100 and #95. Facility census: 77. Findings include: a) Resident #100 On 06/16/14 at 6:32 p.m., the family member of Resident #100 stated staff had been rough with the resident during care. The family member said the incident was reported to the facility staff during a care plan meeting about two (2) weeks ago. The facility assured them the incident would be investigated, but the family member did not know the outcome of the investigation. Review of the medical record found the resident's last care plan meeting was held on 06/03/14. The care plan note identified the family member attended the conference, but there was no discussion of any concerns reported by the family. Review of the allegations of abuse and neglect the facility had reported to the State, found no evidence of a report or investigation of any concerns related to Resident #100. This was further evidence the facility did not recognize alleged abuse. Employee #3, a registered nurse, who attended the care plan meeting on 06/03/14, was interviewed on 06/19/14 at 11:06 a.m. Employee #3 stated she remembered the meeting when the resident's family told the care plan team a staff member had been rough with the resident during care. Employee #3 said she believed the social worker investigated the situation. The social worker, Employee #63, who attended the care plan meeting on 06/03/14, was interviewed at 12:58 p.m. on 06/19/14. She stated the resident's wife told her, Someone had been rough with him. At the same time, the resident told her it was One of those girls. The social worker did not report the incident because she said she was not able to Confirm the who, what, where and when. I took this upon myself not to report it because some people are just rougher than others. She explained she normally discussed all accusations of abuse and neglect with the administrator, but this time she did not because she did not think it was abuse. b) Resident #95 During an interview with Resident #95, at 3:55 p.m. on 06/17/14, she reported a CNA (certified nursing assistant) was rough with her when taking her to the commode, bruising her wrist and making her ribs sore. She reported that she thought it was about one year ago and said, The CNA was mad. During an interview with the son of Resident #95, on 06/19/14 at 1:45 p.m., he reported his mom told him someone had been rough with her. He reported this to Employee #61 (social worker). When interviewed on 06/19/14 at 2:20 p.m., Employee #61 stated she was not notified of the resident's allegations for a long time. Employee #61 provided a copy of a facility In House Concern dated 01/14/14. Review of the document revealed Employee #61 was made aware of the alleged incident, and interviewed the resident, but failed to report the allegation to the required agencies. She reported she did not feel the allegations were substantiated. Review of the facility's reportable allegations, on 06/19/14 at 3:00 p.m., revealed no record the allegations were reported to the required agencies. This was further evidence the facility did not recognize alleged abuse. The review also revealed no internal investigation was completed, nor were staff interviews conducted.",2018-04-01
6380,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,224,G,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for accidents was free from neglect. The resident was assisted with toileting by one (1) nurse aide; however, the resident's care plan indicated he required the assistance of two (2) for toileting. The resident fell while transferring to the toilet, resulting in a head injury and was subsequently sent to the emergency room . Resident Identifier: #59. Facility Census: 77. Findings Include: a) Resident #59 On 06/24/14 at 8:35 a.m., review of the resident's nurses' notes, revealed an entry dated 03/11/14 at 3:11 p.m., stating, Resident pulled call bell out of wall and tipped over nightstand with drawers. Resident came out of room stating he had to piss. Aide called to room to take resident to bathroom. Aide had resident holding onto bar which she moved wheelchair out of way and resident fell in bathroom onto floor hitting back of head and bottom . Resident complained of pain in the back of head . Resident in bed lethargic, resting with eyes closed at times, not wanting to get up to use the bathroom. Resident pulled penis out of brief three times and urinated on self and in bed . Resident noted to have cough and congestion in throat and this nurse questioned the need for chest x-ray . Talked with physician at 11:45 AM and orders given to send resident to ER (emergency room ) . Sent out regarding changes in status, lung sounds and bump on head. (The time of the fall and the time the resident was sent to the emergency room was not indicated in the nurse's note.) Further review of the resident's medical record found the most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of 03/03/14, found the Brief Interview for Mental Status (BIMS) was not attempted. The resident was noted to have short term memory problems, disorganized thinking was coded as continuously present and did not fluctuate, and he had trouble concentrating on things. According to the assessment, walking in his room only occurred once or twice in the look back period and walking in the corridor did not occur. For toilet use, he was coded as the extensive assist of one person and for balance, all areas were coded as Not steady, only able to stabilize with staff assistance. The assessment also identified the resident had active [DIAGNOSES REDACTED]. (No additional assessments were conducted. The next record was a Death in Facility record dated 03/13/14.) Upon inquiry, at 10:00 a.m. on 06/24/14, as to the time Resident #59 was transported to the ER for evaluation, Employee #66, medical records personnel, provided the resident's transfer form. The transfer form contained a nurse's note, written by Employee #11, a licensed practical nurse on 03/11/14 at 12:24 p.m. The form included, Resident lost balance due to weakness and fell in bathroom this morning. Hit head and had neck at abnormal angle upon observation of scene . Resident lethargic and unresponsive to voice stimuli . Dr. notified with order to send to emergency room for evaluation and treatment. CT scan of head and chest x-ray if needed. On 06/19/14 at 1:21 p.m., Employee #2, a registered nurse (RN), was asked how many staff members were assisting the resident at the time of his fall. She stated Employee #32, a nurse aide (NA), was the only staff member assisting Resident #59 at the time of the fall. The care plan was reviewed on 06/20/14 at 9:20 a.m. The ADL (Activities of Daily Living) function / Rehabilitation Potential portion of the care plan indicated the resident required the extensive assistance of two (2) with transfers and total assist of two (2) with toileting. This problem was dated 01/20/14, three (3) days after the resident was admitted . It was reviewed by the facility on 02/28/14, and remained the same.",2018-04-01
6381,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,225,F,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, family interview, review of reportable allegations and review of personnel records, the facility failed to ensure allegations of mistreatment, neglect, and/or abuse were reported and/or thoroughly investigated for two (2) of five (5) residents reviewed for abuse and neglect. In addition, the facility failed to complete a thorough background investigation for one (1) of ten (10) employees (#103) whose personnel records were reviewed. This practice had the potential to affect all residents. Resident identifiers: #59 and #110. Employee identifier: #103. Facility census: 77. Findings include: a) Resident #59 Review of the resident's medical record, on [DATE] at 9:00 a.m., revealed the resident had a fall resulting in a head injury on [DATE]. On [DATE] at 2:30 p.m., the event summary report related to the resident's accident was reviewed. The summary indicated the resident fell on [DATE] at 8:20 a.m., hitting his head, resulting in a lump. He was sent to the hospital for an evaluation where a frontal lobe bleed was identified. Review of the nurse's notes, on [DATE] at 3:00 p.m., revealed a note dated [DATE] at 3:11 p.m. It indicated a nursing assistant (NA) was called to the resident's room to take the resident to the bathroom. The note described the NA had the resident holding onto a bar while she moved the wheelchair out of the way. The resident fell on to the bathroom floor, hitting the back of his head and his bottom. The resident complained of pain in the back of his head and the physician was notified. After the fall, it was noted the resident was in bed and was lethargic. He was also noted with a cough and congestion in his throat. At 11:45 a.m., the physician gave an order to send the resident to the emergency room (ER). The resident was sent to the ER for an evaluation regarding his changes in status, lung sounds, and bump on head. Further review of the resident's medical record found the most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], found the Brief Interview for Mental Status (BIMS) was not attempted. The resident was noted to have short term memory problems, disorganized thinking was coded as continuously present and did not fluctuate, and he had trouble concentrating on things. According to the assessment, walking in his room only occurred once or twice in the look back period and walking in the corridor did not occur. For toilet use, he was coded as the extensive assist of one person and for balance, all areas were coded as Not steady, only able to stabilize with staff assistance. The assessment also identified the resident had active [DIAGNOSES REDACTED]. (No additional assessments were completed for this resident as he expired in the facility on [DATE].) During an interview with Employee #2, a registered nurse (RN), on [DATE] at 1:21 p.m., an inquiry was made regarding how many staff members were assisting the resident when he fell . She confirmed Employee #32, a NA, was the only staff member assisting Resident #59 at the time of the fall. Review of the resident's care plan on [DATE] at 9:20 a.m., found the ADL (activities of daily living) function / Rehabilitation Potential portion of the care plan indicated the resident required extensive assist of two (2) with transfers and total assist of two (2) with toileting. This problem was dated [DATE], three (3) days after the resident was admitted . It was reviewed by the facility on [DATE], and remained the same. Upon inquiry, on [DATE] at 1:48 p.m., Employee #1, the director of nursing (DON) said, The facility most always investigates occurrences such as this. She said Social Services kept the investigations and she would provide the investigation reports if they were completed. At 2:47 p.m. on [DATE], the DON reported, Social services reminded me we did not investigate the matter because the physician wrote a note that the resident was having a stroke prior to or during the fall. On [DATE] at 2:56 p.m., a review of the physician's note, dated [DATE], written two (2) days after the resident fell , stated (typed as written): pt (patient) has a cerebral hemorrhage dx (diagnosis) at (name of hospital). i talked to son and told pt may not survive this illness. talked to daughter and she also feels the bleed may have occurred before Tuesday and the fall. This did not negate the fact the resident was transferred by one (1) person instead of two (2). That part of the incident, neglect, required reporting and investigation. b) Resident #110 The resident's medical record was reviewed on [DATE] at 12:30 p.m. A nurse's note, written by Employee #8, a licensed practical nurse (LPN), on [DATE] at 3:39 p.m. noted (typed as written): Resident was sent to (name of hospital) at 1:45 p.m. to have a Rape kit done as she had stated that a male CNA (certified nursing assistant) had raped her. Review of the resident's quarterly MDS, with an ARD of [DATE], (the last assessment prior to her death in the facility on [DATE]) found this resident had severe cognitive impairment. According to her assessment, her speech was clear, she usually could be understood, and sometimes understood others. Her [DIAGNOSES REDACTED]. She also received scheduled pain medication for moderate pain that limited her activities. Review of the facility's reportable allegations of abuse/neglect revealed the incident was reported to the required State agencies; however, there was no evidence the allegation was investigated by the facility. On [DATE] at 1:20 p.m., during an interview with Employee #1, the Director of Nurses (DON), she stated she could not remember any details regarding the allegation of the rape, but she stated she knew the resident had not been raped. When asked how she knew this, she stated the Medical Director received a phone call from the hospital informing the medical director and herself the resident was not raped. When the DON was asked if the incident was reported or investigated, she stated she did not know. The DON said, Perhaps the social worker has that information. An interview with Employee #63, a Social Worker (SW), on [DATE] at 1:35 p.m., revealed the facility did not do an investigation of the allegation because the hospital report showed no evidence the resident was raped and the resident had no memory of the allegation. Upon inquiry, the SW confirmed she had not considered the possibility that something happened to the resident which required an investigation, even though it was not rape. The SW stated she did not think she had to investigate the incident since she had reported it. She could not remember any details concerning the alleged rape, such as how she found out about the allegation, what happened, how it happened, or who was involved. Employee #63 provided evidence that faxes were sent on [DATE] to the Office Health Facility Licensure and Certification and Adult Protective Services. The incident date on these faxes indicated the allegation of rape occurred on [DATE]; however, the resident was not sent to the hospital for the rape testing until 1:45 p.m. on [DATE]. c) Employee #103 On [DATE] at 1:20 p.m., the personnel file review revealed one (1) of ten (10) employees did not have a thorough criminal background check completed. Employee #103 (resident service provider) came to work at the facility on [DATE]. This employee listed on her application she had worked in a neighboring state until 2007. The facility had completed a criminal background check for the state of West Virginia at the time the employee was hired. The personnel file contained no evidence showing the facility had conducted a criminal background check outside of West Virginia. On [DATE] at 1:30 p.m. Employee #99 (bookkeeper) said the facility had not conducted a criminal background check in the neighboring state for Employee #103.",2018-04-01
6382,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,226,F,0,1,35BV11,"Based on record review, family interview, staff interview, and policy review, the facility failed to develop and operationalize abuse policies and procedures (P & P) to prevent, identify, investigate, and report abuse and mistreatment. In addition, the policy referred to a Federal requirement which does not exist, and to an outdated State Licensure rule regarding abuse. The facility also failed to operationalize their policies and procedures for three (3) residents. They failed to investigate all alleged abuse and neglect; failed to obtain statements from all witnesses, employees, residents; and failed to document all interviews with witnesses. These practices had the potential to affect all residents. Resident identifier: #95, #100, and #59. Facility census: 77. Findings include: a) Review of the facility's abuse policies and procedures found all aspects of the seven (7) required components were not accurate and/or developed: 1. The procedures for reporting did not include the requirement to immediately (within 24 hours) report all allegations of abuse or neglect to the appropriate State agencies. 2. The policy refers to F228, a regulation which does not exist. 3. The policy refers to the Nursing Home rule dated June 18, 2001; however, this is not the most current rule. b) Resident #95 The facility failed to operationalize their P & P to report and investigate an allegation of abuse regarding Resident #95. During an interview with Resident #95, at 3:55 p.m. on 06/17/14, she reported, A CNA (certified nursing assistant) was rough with me when she took me to the commode. The resident said the nurse aide bruised her wrist and made her ribs sore. She reported she thought it was about a year ago and said, The CNA was mad. The resident's family was interviewed on 06/19/14 at 1:45 p.m. The family member said Resident #95 told him someone had been rough with her. According to the family, this allegation was reported to Employee #61 (social worker). Upon inquiry on 06/19/14 at 2:20 p.m., Employee #61 stated she was not notified of the resident's allegation for a long time. The social worker provided a copy of the resident's allegation, written on a form called In House Concern which was dated 01/14/14. Review of the document revealed Employee #61 was made aware of the alleged incident and interviewed the resident, but failed to conduct a thorough investigation. During the interview, on 06/19/14, the social worker said she did nothing further because she did not feel the allegation was substantiated. Review of the facility's reportable allegations, on 06/19/14 at 3:00 p.m., revealed no record the allegation was reported to the required agencies. The review also revealed no evidence of a thorough investigation. c) Resident #100 The facility failed to operationalize their P &P to report and investigate an allegation of abuse regarding Resident #100. On 06/16/14 at 6:32 p.m., the family member of Resident #100 stated staff had been rough with the resident during care. The family member said the incident was reported to facility staff during a care plan meeting about two (2) weeks ago. The facility assured them the incident would be investigated, but the family member did not know the outcome of the investigation. Review of the medical record found the resident's last care plan meeting was held on 06/03/14. The care plan note identified the family member attended the conference, but there was no discussion of any concerns reported by the family. The facility's reported allegations of abuse and neglect, which had been reported to the State, contained no reporting or investigation of any concerns related to Resident #100. Employee #3, a registered nurse, who attended the care plan meeting on 06/03/14, was interviewed on 06/19/2014 at 11:06 a.m. Employee #3 stated she remembered the meeting when the resident's family told the care plan team a staff member had been rough with the resident during care. Employee #3 said she believed the social worker investigated the situation. The social worker, Employee #63, who attended the care plan meeting on 06/03/14, was interviewed at 12:58 p.m. on 06/19/14. She stated the resident's wife told her, Someone had been rough with him. At the same time, the resident told her it was one of those girls. The social worker did not report the incident because she said she was not able to Confirm the who, what, where and when. I took this upon myself not to report it because some people are just rougher than others. She explained she normally discussed all accusations of abuse and neglect with the administrator, but this time she did not because she did not think it was abuse. d) The facility's policy entitled, Procedure for Patient Abuse Investigation was reviewed on 06/25/14 at 3:00 p.m. It included: The facility shall investigate and report alleged abuse as follows: a. Report incident to Administrator, Director of Nursing and Social Services Director. The Social Services Director, upon preliminary investigation, shall notify the Office of Health Facility Licensure and Certification and the Department of Health and Human Resources, Adult Protective Services about the alleged abuse. b. The facility will investigate reports of alleged abuse and neglect to determine if the conduct of the employee is in violation of any standard of care 5. As part of the investigation process the following will be done: c. Obtain statement from all witnesses, employees, residents or visitors. d. The facility will document all interviews with witnesses e) Resident #59 This resident was reviewed for falls during the survey. Record review revealed the resident fell , on 03/11/14 (the time was not identified), while being assisted with toileting. Review of the resident's care plan revealed the ADL function/Rehabilitation Potential portion of the care plan indicated the resident required extensive assistance of two (2) with transfers and total assistance of two (2) with toileting. This problem originated on 01/20/14, three (3) days after the resident was admitted . It was reviewed by the facility, on 02/28/14, and remained the same. At 1:21 p.m. on 06/19/14, Employee #2, a registered nurse (RN), was asked how many staff members were assisting the resident at the time of his fall on 03/11/13. She stated Employee #32, a NA, was the only staff member assisting Resident #59 at the time of the fall. Upon inquiry, on 06/19/14 1:48 p.m., Employee #1, the director of nursing (DON) said ,The facility most always investigates occurrences such as this. She said Social Services kept those investigations, and could provide the investigation reports if they were completed. At 2:47 p.m. on 06/19/2014, the DON reported the the facility did not investigate the matter. The facility failed to operationalize their P & P to report and investigate this alleged neglect of Resident #56.",2018-04-01
6383,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,241,E,0,1,35BV11,"Based on observation and staff interview, the facility failed to ensure a dignified dining experience for residents who had their meals in the main dining room. Several residents were still eating when a staff member removed their plates without asking if they were finished. In addition, the staff member scraped unconsumed food and beverages into a bucket in view of the residents. This had the potential to affect more than an isolated number of residents. Resident Identifier #100. Facility Census: 77 Findings Include: a) Resident #100 On 06/16/14 at 12:30 p.m., Resident #100 was observed eating pizza in the main dining room. Employee #60, an activities assistant and resident service provider (RSP), was clearing tables at that time. She asked Resident #100 if he was finished; however she did not wait for his reply before removing his plate. Resident #100 grabbed and held his bowl of ice cream, so Employee #60 did not take it from him. b) Other Residents in the Dining Room During the observation in the dining room, at 12:30 p.m. on 06/16/14, Employee #60 pushed a cart, with a green bucket on top. Observation revealed she dumped liquids and scraped unconsumed foods into the bucket, at she maneuver around, and in view of residents who were still eating their meals. As Employee #60 cleared the plates from the tables, she did not not ask each resident if they were finished before removing their plates. c) On 06/23/14 at 2:40 p.m., Employee #74, the director of food services (DFS), was interviewed. She confirmed the removal of plates without asking residents if they were finished with their meals, as well as scraping plate scraps into a bucket in view of residents as they finished their meals, did not maintain residents' dignity. d) At 3:10 p.m. on 06/23/14, Employee #60 was interviewed regarding the practices observed in the dining room at 12:30 p.m. on 06/16/14. She stated she did not always ask residents if they were finished eating before removing their plates. Employee #60 said she just knew when someone was finished. Upon inquiry, she stated, I do ask a few times a week. .",2018-04-01
6384,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,242,E,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, observation, family interview, and resident interview, the facility failed to ensure six (6) of six (6) residents reviewed for choices were free to exercise autonomy regarding what the residents considered important aspects of their lives. Residents #2, #98, #71, and #29 were not free to exercise autonomy regarding the use of side rails. Residents #21 and #100 did not have a choice regarding the number of showers they received each week. Resident identifiers: #2, #98, #71, #9, #21, #100. Facility census: 77. Findings include: a) Resident #2 Resident #2 reported, on 06/17/14 at 4:25 p.m., she was upset the facility discontinued her side rails because she felt safer with them. An observation and interview with Resident #2, on 06/20/14 at 9:10 a.m., revealed the resident could only raise the height of her bed. She was not able to reposition herself in bed or raise the head of the bed because the controls were located on the lowered side rail. Observation revealed the lowered side rail was secured in place with two (2) plastic zip ties. Review of the side rail assessment, completed on 05/04/14, revealed the resident required side rails for turning and repositioning, as well as to transfer herself in and out of the bed. Review of the resident care plan revealed an intervention, dated 11/07/13, which stated: May have 1/4 to 1/2 side rails to head of bed for mobility. b) Resident #98 On 06/23/14 at 1:47 p.m., an interview with Resident #98 and his wife, whom acts as the medical power of attorney (MPOA) occurred. The MPOA said a couple of weeks ago a facility staff member informed them the resident could no longer use his side rails. The MPOA became visibly upset when discussing the matter. She said the staff member said, State says we can't use side rails because someone may get their head caught in them. The resident was observed with two (2) 1/4 side rails that were secured in the lowered position with two (2) zip ties on each side rail . The MPOA said Resident #98 could turn and reposition himself independently when the side rails were in the up position. Without the side rails, the resident had to call staff to assist him to turn and reposition. The MPOA said recently the resident had an itch on his back, and they had to use the call light to get staff to help him turn so he could scratch his back. She said the resident was upset by this and told her he did not want to have to push his button every time he had an itch. During the interview, the resident asked if he would again be able to use his side rails. The resident and his wife/MPOA said they were not consulted in the decision regarding discontinuation of the use of the side rails. c) Resident #71 On 06/25/14 at 3:30 p.m., Resident # 71 was observed in her bed. Her side rails were in the down position. They were secured with two (2) zip ties on each side rail . The resident said she wished she still had her side rails, because she used them to position herself in the bed. She asked if she would ever get them back. During a telephone conversation, on 06/25/14 at 5:00 p.m., with the MPOA for Resident #71, the resident's MPOA said, she received a letter stating the side rails would no longer be allowed to be used by the residents. She thought the letter came from the state. She said the resident was very upset about losing her side rails, as she was able to turn and reposition independently while in bed. She said the resident longer feels safe in bed, and now requires assistance to turn and reposition. The MPOA said it was her opinion, the resident could do more and felt safer with the side rails. She said she wanted the resident to once again be able to utilize her side rails. d) Resident #29 During an interview, on 6/17/14 at 4:20 p.m., Resident #29 said her side rails were removed about a week ago. She said she was informed by staff that she could no longer use them. On 06/25/14 at 11:20 a.m., Resident #29 said she almost fell getting out of bed that morning because she did not have her side rail to assist her. Several times during the conversation, she expressed a fear of falling. The resident said she used to be able to get out of bed herself using the side rail and the arm of her recliner. She said she now no longer attempted to get out of bed, without staff, due to a fear of falling. The resident said when she had her side rails, she was not fearful of falling. She said her anxiety was higher now because she cannot have her side rails. During a telephone interview with the resident's MPOA, on 06/25/14 at 11:31 a.m., the MPOA said she really believed Resident #29 needed her side rails. She voiced fear the risk of injury to the resident was greater without the side rails than with the side rails. The MPOA said when she talked with the administrator and expressed her desire for the resident to have side rails, the administrator told her, State says side rails cannot be used, and she just can't go against state rules. The MPOA said the facility made a decision regardless of the resident's or the MPOA's wishes. She said she thought the decision made the resident require staff assistance in areas in which she did not previously need assistance. The MPOA also said the entire situation has made the resident's anxiety worse. e) During an interview with Employee #1 (director of nursing), on 06/24/14 at 9:30 a.m., she reported the side rails were discontinued on 06/11/14 at the request of the medical director. When asked what alternatives were offered the residents, she said the side rails were discontinued prior to the alternative devices being in place. An interview with the medical director, on 06/25/14 at 8:00 a.m., revealed residents were to be assessed by physical therapy and alternate bed control and positioning devices were to be in place prior to the discontinuation of the bed rails. She confirmed the facility had not completed the physical therapy evaluations, and did not have alternate positioning devices prior to the discontinuation of the side rails. f) Resident #21 During a Stage 1 interview with the resident on 06/16/14 at 1:06 p.m., this alert and oriented resident expressed a desire to have two (2) showers a week. He stated the facility's current policy was to give one (1) shower a week. His was scheduled for Mondays. Upon inquiry, he said the facility had not consulted him regarding his shower preference. Review of the shower schedule, on 06/18/14, revealed the resident was scheduled for a shower every Monday on day shift. The resident's day shift nursing assistant, Employee #33, was interviewed, at 1:35 p.m. on 06/18/14, to determine if she was aware of the resident's preference for showers. She confirmed the resident was scheduled for his shower on Mondays. Employee #33 said the resident had asked her for an extra shower, but she was not sure when he had asked. She said she was not able to give the shower. She reported it to her charge nurse, whom she believed would inform the oncoming shift. At 1:50 p.m. on 06/18/14, Employee #9, the resident's licensed practical nurse, was asked how staff determined a resident's preference for bathing. Employee #9 said the preference for bathing should be on the resident's interim plan of care. Another interview was held with Resident #21, on 06/18/14 at 2:55 p.m. He again stated he was not given a choice regarding the number of showers he received. He acknowledged he had received an extra shower on occasion if he had a doctors appointment, but he consistently did not receive his preference of two (2) showers each week. On 06/18/14 at 3:15 p.m., Employee #3, a registered nurse stated the resident's shower preference was discussed during the individualized interim plan of care. She provided a copy of the resident's Individualized Interim Plan of Care, which was completed on 04/07/14. The section entitled Bathing indicated the resident preferred only showers. Employee #3 stated the resident's preference for the number of weekly showers should have been included in the plan of care. She verified the plan of care was incomplete regarding the resident's preference for the number of showers he wished to receive. She stated, I should not have signed off on that without verifying the plan was complete. Review of the resident's activities of daily living (ADL) reports found the resident had not consistently been provided two (2) showers each week since his admission on 04/02/14. On 06/24/14 at 8:05 a.m. interview with the director of nursing (DON) revealed she was unable to provide verification the resident received his preference of two (2) showers each week. g) Resident #100 A Stage 1 interview was conducted with the resident and his wife, at 6:24 p.m. on 06/16/14. The resident said he would like more showers. He stated he was supposed to receive one (1) shower every week, but sometimes he did not receive a weekly shower. Review of the resident's medical record found the resident was admitted to the facility on [DATE]. Review of the bathing schedule on 06/24/14 found the resident was to receive showers on Tuesdays. The ADL report revealed the resident did not receive his scheduled shower on 06/10/14 or 06/17/14. The DON reviewed the ADL report on 6/24/14 at 8:05 a.m. She was unable to provide verification the resident had a shower on 06/10/14 and 06/17/14.",2018-04-01
6385,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,246,E,0,1,35BV11,"Based on record review, staff interview, observation, and resident interview, the facility failed to ensure five (5) residents were provided reasonable accommodations of individual needs and preferences. The environment and staff behaviors were not directed toward assisting each resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible. The facility did not evaluate each resident's unique needs and preferences, to ensure each resident was reasonably accommodated, when the side rails for Residents #2, #29, #71, and #98 were removed from use. In addition, Resident #56 did not have access to her call light on three (3) occasions. Resident identifiers: #2, #29, #56, # 71, #98 Facility census: 77 Findings include: a) Resident #2 Resident #2 reported on 06/17/14 at 4:25 p.m., she was upset the facility had discontinued the side rails because she felt safer with them. An observation and interview with Resident #2 on 06/20/14 at 9:10 a.m. revealed the resident demonstrated she could raise the bed but was not able to reposition in bed or raise the head of the bed due to the controls being on the lowered secured side rail. Review of the side rail assessment completed 05/04/14 revealed the resident required side rails for turning and repositioning in bed and to transfer. Review of the resident care plan revealed an intervention dated 11/07/13 which stated May have 1/4 to 1/2 side rails to head of bed for mobility. b) Resident #98 On 06/23/14 at 1:47 p.m., an interview with Resident #98 and his wife, whom acts as the medical power of attorney (MPOA) occurred. The MPOA said a couple of weeks ago a facility staff member informed them the resident could no longer use his side rails. The MPOA became visibly upset when discussing the matter. She said the staff member said, State says we can't use side rails because someone may get their head caught in them. The resident was observed with two (2) 1/4 side rails that were secured in the lowered position with two (2) zip ties on each side rail . The MPOA said Resident #98 could turn and reposition himself independently when the side rails were in the up position. Without the side rails, the resident had to call staff to assist him to turn and reposition. The MPOA said recently the resident had an itch on his back, and they had to use the call light to get staff to help him turn so he could scratch his back. She said the resident was upset by this and told her he did not want to have to push his button every time he had an itch. During the interview, the resident asked if he would again be able to use his side rails. The resident and his wife/MPOA said they were not consulted in the decision regarding discontinuation of the use of the side rails. c) Resident #71 On 06/25/14 at 3:30 p.m., Resident # 71 was observed in her bed. Her side rails were in the down position. They were secured with two (2) zip ties on each side rail . The resident said she wished she still had her side rails, because she used them to position herself in the bed. She asked if she would ever get them back. During a telephone conversation, on 06/25/14 at 5:00 p.m., with the MPOA for Resident #71, the Resident's MPOA said, she received a letter stating the side rails would no longer be allowed to be used by the residents. She thought the letter came from the state. She said her mother was very upset about losing her side rails, as she was able to turn and reposition independently while in bed. She said her mother no longer feels safe in bed, and now requires assistance to turn and reposition. The MPOA said it was her opinion, as well as her Mother's, the resident could do more and felt safer with the side rails. She said she wanted her mother to once again be able to utilize her side rails. d) Resident #29 During an interview, on 6/17/14 at 4:20 p.m., Resident #29 said her side rails were removed about a week ago. She said she was informed by staff that she could no longer use them. On 06/25/14 at 11:20 a.m., Resident #29 said she almost fell getting out of bed that morning because she did not have her side rail to assist her. Several times during the conversation, she expressed a fear of falling. The resident said she used to be able to get out of bed herself using the side rail and the arm of her recliner. She said she now no longer attempted to get out of bed, without staff, due to a fear of falling. The resident said when she had her side rails, she was not fearful of falling. She said her anxiety was higher now because she cannot have her side rails. During a telephone interview with the resident's MPOA, on 06/25/14 at 11:31 a.m., the MPOA said she really believed Resident #29 needed her side rails. She voiced fear the risk of injury to the resident was greater without the side rails than with the side rails. The MPOA said when she talked with the administrator and expressed her desire for the resident to have side rails, the administrator told her, State says side rails cannot be used, and she just can't go against state rules. The MPOA said the facility made a decision regardless of the resident's or the MPOA's wishes. She said she thought the decision made the resident require staff assistance in areas in which she did not previously need assistance. The MPOA also said the entire situation has made the resident's anxiety worse. e) An interview with Employee #1 (director of nursing) on 06/24/14 at 9:30 a.m., revealed the side rails were discontinued at the request of the medical director. On 06/11/14, the facility implemented a policy which stated No Resident will have side rails unless the resident has capacity. She stated she had ordered two (2) devices (to evaluate) to assist with bed mobility but they had not yet arrived. The director of nursing confirmed there was no assessment completed for any of the residents prior to implementing the policy and discontinuing the residents' side rails. She also verified the side rails were discontinued prior to alternative devices being determined and put into place for each resident. An interview with the medical director, on 06/25/14 at 8:00 a.m., revealed the plan was for residents to be assessed by physical therapy and alternate bed control and positioning devices were to be in place prior to the discontinuation of the bed rails. She confirmed the facility had not done the physical therapy evaluations and had not provided alternatives to the side rails prior to discontinuing them. e) Resident #56 On 06/17/14 at 1:40 p.m., observation revealed Resident #56 was sitting in her recliner with her walker in front of her. The resident's call light was not within her reach. The resident had a small hand bell, which was also not within her reach. On 06/20/14 at 10:55 a.m., an observation of Resident #56's room revealed the resident did not have access to her call light. The call light was behind the bed. The resident had a small hand bell on her over-the-bed table which was in front of her. The resident said she used the bell sometimes to get the nurses. Employee # 94 (maintenance) reached behind the resident's bed, got her call light, and placed it on the resident's bed. The resident then pushed the call light. Resident #56 said, This would be easier than ringing the bell. On 06/25/14 at 4:30 p.m., the resident again did not have her call light or small hand bell within reach. On 06/62/14 at 4:41 p.m., Employee #2 (registered nurse) said the resident sometimes used the call light and at other times she used the bell. At that time, Employee #2 asked a nurse aide to go into the resident's room and make sure she had access to her small hand bell and call light.",2018-04-01
6386,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,247,D,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, policy review, and staff interview, the facility failed to notify one (1) of one (1) resident, reviewed for the care area of admission, transfer and discharge, before a room change occurred. Resident identifier: #21. Facility census: 77. Findings include: a) Resident #21 During Stage 1 of the Quality Indicator Survey, at 1:16 p.m. on 06/17/14, the resident stated he was moved from the first floor to the second floor without explanation. After he was moved to the second floor, he said a nurse finally explained he was moved because he had an infection. He said all his friends were on the first floor and he wanted to get back to his old room. Review of the nurse's note, dated 06/06/14, found the resident was moved from room [ROOM NUMBER] to room [ROOM NUMBER] on 06/06/14. According to the note, the medical power of attorney was called about the room move. There was no evidence the resident was notified of the room move. Medical record review found the resident was deemed to have capacity to make medical decisions on 04/04/14. Employees #61 and #63 (the social service directors) were interviewed, on 06/23/14 at 3:55 p.m., regarding the resident's room change. Employee #61 stated it was facility policy to notify both the resident and the responsible party before a room move occurred. She stated Resident #21 was moved after hours, and she had not participated in the decision to move the resident. The facility's policy for, Room to Room Transfers, was provided by the administrator on 06/23/14 at 3:55 p.m. The policy directed, .Prior to the room transfer, the resident, his or her roommate (if any), and the resident's representative (sponsor) will be provided with information concerning the decision to make the room transfer The director of nursing (DON) was interviewed at 12:52 p.m. on 06/25/14. She was unable to provide evidence the room move was discussed with Resident #21 before he was moved.",2018-04-01
6387,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,253,E,0,1,35BV11,"Based on observations and staff interview, the facility failed to provide effective maintenance services in 20 of 39 resident rooms/bathrooms and a resident common area. The ceramic tiles around the sink area in resident rooms were cracked. Bathroom doors had deep scratches in the wood surfaces. Door facings going into bathrooms had chipped paint. Exhaust fans in the bathrooms were rusted. The ceiling in one (1) resident room had peeling plaster/paint. Doorknob plates were loose. Chairs in the dining area on first floor had scratched arms and legs. The hand rail across from the nursing station on second floor was loose. In addition, effective housekeeping and/or maintenance services were not provided for two (2) of 77 residents, observed through random observations, who had dirty wheelchairs. Four (4) of 35 census sample residents and one (1) resident observed through random observations had cracked wheelchair and/or Broda chair coverings. These cracks in the coverings rendered the equipment unable to be effectively cleaned. These practices affected more than an isolated number of residents. Room numbers: #106, #107, #108, #110, #111, #113, #115, #117, #118, #120, #202, #207, #208, #209, #211, #212, #216, #217, #219, and #220. Resident identifiers: #69, #42, #92, #46, #50, and #12. Facility census: 77. Findings include: a) On 06/20/14 at 9:00 a.m., a maintenance employee (Employee #94) was present for a tour of the facility. Observations revealed the following maintenance concerns: 1. At 9:40 a.m. on 06/20/14 Room #106 was observed with cracked ceramic tile and rough edges to the left of the sink area. The finish on the bathroom door was worn off, leaving the wood exposed. 2. Room #107's bathroom door, observed at 10:02 a.m. on 06/20/14, had worn finish. 3. Room 108's bathroom door was worn with scratches to the underlying wood. The bathroom door facing also had chipped paint. The maintenance director said, It is scratched up pretty bad. 4. Room #110, observed at 9:50 a.m. on 06/20/14, had a worn bathroom door with deep scratches. The ceramic tiles in the bathroom floor were cracked. 5. Room #111, observed on 06/20/14 at 9:45 a.m., had cracked tiles with sharp edges on the right side of the wall near the sink. The bathroom door had scratches and gouges on the inside and outside. The door facing was rusted. 6. Room #113, observed at 10:00 a.m. on 06/20/14, had scratches to the inside and outside of the bathroom door. The door facing had peeling paint. The yellow ceramic tiles to the left of the sink area were cracked. 7. Room #115 had a bathroom door with gouges. Observation revealed rust on the lower half of the bathroom door facing. The doorknob plate was loose. The maintenance employee said he could easily tighten up the doorknob plate. 8. Room #117 had gouges to the lower half of the bathroom door. The heating/air conditioning unit had rust on the front of the covering. The sprinkler head in the ceiling of the bathroom was rusted. The over-the-bed table in the resident's room had a black piece of material which covered the outer area around the table. A large piece of this black material was missing, leaving the wood exposed. 9. Room #118's bathroom door, observed at 10:26 a.m. on 06/20/14, had gouges on the inside and outside of the door. 10. Room #120, observed at 10:05 a.m. on 06/20/14, revealed a bathroom door with gouges along the bottom as well as a loose doorknob plate. 11. Room #202's bathroom door, observed on 06/20/14 at 10:50 a.m., had paint chipped off the door facing. 12. Room #207 had a bathroom door with grooves to the inside of the door. The exhaust fan in the bathroom was rusted. 13. Room #208, observed at 11:00 a.m. on 06/20/14, had chipped paint on the door frame going into the bathroom. The bathroom door had chips and gouges on the inside of the bathroom door. There were tiles sticking up on the bathroom floor, creating a potential trip hazard. 14. Room #209's door-facing going into the bathroom had chipped paint. The tiles on the bathroom floor were cracked. The doorknob plate on the bathroom door was loose. 15. Room #211's bathroom door had scratches with deep groves on the front and back of the door. Observation revealed chipped paint on the bottom of the door facing. The ceramic tiles near the sink in the resident's room were cracked. 16. The door facing in Room #212 had chipped paint. There were also scratches on the inside and outside of the bathroom door. The doorknob plate was loose. 17. Room #216 had a chipped and broken baseboard near the sink. The bathroom door had deep scratches inside and outside. The bathroom door facing had rust at the bottom. 18. Room #217 had paint peeling off the plaster on the ceiling. The maintenance employee said, The paint is coming off the plaster. I can use a putty knife to smooth that down and then paint. Cracked ceramic tiles were around the right side of the sink near the floor. The doorknob plate on the bathroom door was loose. 19. Room #219, observed at 10:45 a.m. on 06/20/14, had unfinished repair work to the wall under the window in the resident's room. The lower half of the bathroom door had gouges. 20. Room #220, observed at 10:50 a.m., had a bathroom door facing with chipped paint. There were deep scratches that created rough edges on the inside of the bathroom door. The exhaust fan in the resident's bathroom was rusted. b) At 11:00 a.m. on 06/2014, Employee #94 said he would begin working on the maintenance issues identified in the rooms on first and second floor. c) On 06/20/14, at 10:00 a.m., observations on the first and second floor revealed five (5) residents had cracked wheelchairs and/or Broda chair coverings. 1) The right arm of Resident #69's wheelchair was taped because the surface covering was cracked. 2) Resident #42's wheelchair had cracks in the surface on both arms. 3) Resident #92's Broda chair covering was torn and frayed. 4) Resident #46's right wheelchair arm was cracked. 5) An observation of Resident #50's wheelchair arms on 06/20/14 at 10:30 a.m. revealed they were cracked. d) Observations on 06/20/14 revealed two (2) residents were sitting in dirty wheelchairs. 1. At 10:15 a.m., on 06/20/14, an observation of Resident #12's wheelchair revealed it was dirty. The wheels contained a large amount of dust, dirt and debris. Employee #83 (housekeeping) observed Resident #12's dirty wheelchair on 06/20/14 at 10:20 a.m. She pointed out a sticker on the resident's wheelchair, which indicated the facility last cleaned the wheelchair on 12/18/13. 2. On 06/20/14 at 10:30 a.m., an observation of Resident #50's wheelchair revealed the wheelchair had dirty wheels. Employee #108 (resident service provider) said resident service providers cleaned wheelchairs at night. She confirmed Resident #50's wheelchair needed cleaned. e) On 06/23/14 at 3:10 p.m., an observation of the hand rail across from the nursing station on second floor revealed the hand rail for resident use was loose. At 3:15 p.m. on 06/23/14, Employee #2, a nurse, said she would have maintenance look at the hand rail. f) On 06/26/14 at 3:00 p.m., observation in the first floor dining room revealed six (6) chairs for resident use with scratches on the arms and legs. Employee #93 (maintenance supervisor) was made aware of the scratched chairs. He said the facility had replaced some of the chairs in the first floor dining room but not all of them.",2018-04-01
6388,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,279,D,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a comprehensive care plan was developed to address the needs of two (2) of 23 residents whose care plans were reviewed during Stage 2 of the survey. Resident #56 did not have a care plan to address [MEDICAL CONDITION]. Resident #64 did not have a care plan to address positioning. Resident identifiers: #56, #64. Facility census: 77. Findings include: a) Resident #56 On 06/20/14 at 8:56 a.m., medical record review showed Resident #56 was taking [MEDICATION NAME] 40 milligram (mg) 1 tablet every day for [MEDICAL CONDITION]. Review of medical records, on 6/24/14 at 8:50 a.m., revealed pertinent [DIAGNOSES REDACTED]. The resident's care plan did not identify [MEDICAL CONDITION] as a problem. The only mention of [MEDICAL CONDITION] was in a problem statement under dehydration, created on 1/14/14, which stated . on a diuretic for [MEDICAL CONDITION] which puts her at risk for dehydration. Employee #18, a Licensed Practical Nurse (LPN), was interviewed, on 6/24/14 at 10:45 a.m. The LPN was knowledgeable about Resident #56's care. She reported the resident had bilateral lower extremity [MEDICAL CONDITION] that comes and goes, and the resident was encouraged to keep her legs elevated The resident's care plan did not discuss elevating the resident's legs, or directives to monitor the resident's [MEDICAL CONDITION]. On 6/25/14 at 5:50 p.m., Employee #2, a minimum data set (MDS) nurse, was interviewed regarding care plans and the care needed Resident #56 needed related to [MEDICAL CONDITION]. The MDS nurse stated staff followed the care plans for the resident's care. The MDS nurse reviewed Resident's #56's care plan and confirmed the only care plan concerning [MEDICAL CONDITION] was under dehydration. When asked how staff knew what care the resident required to address the [MEDICAL CONDITION] (such as elevating the resident's legs and monitoring), Employee #2 replied: . they wouldn't, because it wasn't in the care plan . b) Resident #64 Observation, on 06/16/14 at 12:45 p.m., revealed this resident was reclined in a Broda chair. The resident also had a pelvic sling tied under the Broda chair, and out of reach of the resident. Her legs were elevated with the foot rest of the chair. The pelvic sling, which was between the resident's legs and tied to the chair, rendered the resident incapable of turning and repositioning herself. The care plan was reviewed on 06/20/14 at 10:33 a.m. There were no interventions for position changes while the resident was in the Broda chair and using a pelvic sling. On 06/25/14 at 2:15 p.m., an interview was held with Employee #2, a minimum data set (MDS) coordinator, regarding the lack of a care plan which addressed repositioning of the resident while she was in a Broda chair and using a pelvic sling. Employee #2 reviewed the care plan and confirmed there was no care plan regarding how and when the resident should be repositioned.",2018-04-01
6389,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,280,D,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure two (2) of a forty-three residents, whose care plans were reviewed, were revised to meet individualized needs. The care plan for Resident #59 was not revised related to falls or to reflect the number of staff needed for assistance. In addition, the care plan for Resident #92 was not revised related to side rails. Facility Census: 77. Resident Identifiers: #59, and #2. Findings Include: a) Resident #59 The care plan, with a start date of 01/20/14, was reviewed on 06/20/14 at 9:20 a.m. The category of ADL function / Rehabilitation Potential stated: extensive assist of two (2) with transfers and total assist of two (2) with toileting. It had an edited date of 02/28/14. The category of Falls, listed five (5) falls from 02/10/14 - 03/11/14. The fall that occurred on 03/09/14 was not identified on the care plan which was updated on 03/12/14. The approach / intervention, dated for 03/12/14, was for the resident to have assist of two (2) for all transfers. This was the first time this intervention was listed under the falls category; however, this approach had been an active intervention since 01/20/14, under the ADL function / Rehabilitation Potential category. The Minimum Data Set (MDS), with an assessment reference date (ARD) of 02/24/14, was reviewed on 06/19/14 at 10:32 a.m. It indicated a change/or correction in the resident's level of functioning was needed. The previous MDS, with an ARD of 02/03/14, indicated the resident was extensive assist of two (2) for transferring and toileting (weight bearing). The correction/or change, on the MDS with an ARD of 02/24/14, stated he was extensive assist of one (1) staff member for transferring and toileting. On 06/19/14 at 4:06 p.m., Employee #1, the director of nursing (DON) provided the MDS dated [DATE] that indicated the resident was extensive assist of one (1) for toileting. She stated that the MDS was correct and the care plan was incorrect. The care plan was not revised to reflect the resident's current assessed needs. b) Resident #2 review of the resident's medical record revealed [REDACTED]. This assessment indicated the resident was ordered to have side rails to assist with transfers and bed mobility. It also indicated the risks and benefits were explained to the family of Resident #2. It said the MPOA (medical power of attorney) gave consent for the use of side rails for the resident. Review of the care plan for Resident #2 revealed it included an intervention, dated 11/07/13, which stated May have 1/4 to 1/2 side rails to head of bed for mobility. The care plan indicated the last review was done on 05/13/14. Review of the facility's side rail policy revealed it was implemented on 06/11/14 resulting in the resident's side rails being discontinued. No evidence was found in the care plan to indicate it was revised to reflect the discontinuation of the resident's side rails and the need for an alternative device for bed mobility.",2018-04-01
6390,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,282,G,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, and staff interview, the facility failed to ensure services for two (2) of forty-three residents, whose care plans were reviewed, were provided according to the residents' care plans. Resident #59 was not provided assistance as required by his care plan. This resulted in harm to Resident #59 when he fell and injured his head. In addition, the care plan for positioning and support for Resident #40 was not implemented. Resident identifiers: #59 and #40. Facility Census: 77. Findings include: a) Resident #59 Review of the Nurses notes,on 06/24/14 at 8:35 a.m., revealed an entry dated 03/11/14 at 3:11 p.m It indicated the resident came out of his room and stated he needed to toilet. According to the nurse's note, .Aide called to room to take resident to bathroom. Aide had resident holding onto bar which she moved wheelchair out of way and resident fell in bathroom onto floor hitting back of head and bottom. Resident complained of pain in the back of head. Physician notified Resident in bed lethargic, resting with eyes closed at times, not wanting to get up to use the bathroom Talked with physician at 11:45 AM and orders given to send resident to ER Sent out regarding changes in status, lung sounds and bump on head. Upon request, Employee #66, medical records personnel, provided the resident's transfer to the hospital form at 10:00 a.m. on 06/24/14. It contained the following nurse's note, written by Employee #11 (nurse) on 03/11/14 at 12:24 p.m., .Resident lost balance due to weakness and fell in bathroom this morning. Hit head and had neck at abnormal angle upon observation of scene Resident lethargic and unresponsive to voice stimuli. Confused conversation with staff Dr. notified with order to send to emergency room for evaluation and treatment . Upon inquiry, at 10:00 a.m. on 06/24/14, as to the time Resident #59 was transported to the ER for evaluation, Employee #66, medical records personnel, provided the resident's transfer form. The transfer form contained a nurse's note, written by Employee #11, a licensed practical nurse on 03/11/14 at 12:24 p.m. The form included, Resident lost balance due to weakness and fell in bathroom this morning. Hit head and had neck at abnormal angle upon observation of scene . Resident lethargic and unresponsive to voice stimuli . Dr. notified with order to send to emergency room for evaluation and treatment. CT scan of head and chest x-ray if needed. On 06/18/14 at 2:30 p.m., the event summary report related to the resident's accident was reviewed. The summary indicated the resident fell on [DATE] at 8:20 a.m., hitting his head, resulting in a lump. He was sent to the hospital for an evaluation where a frontal lobe bleed was identified. An interview with Employee #2, a registered nurse (RN), on 06/19/14 at 1:21 p.m., confirmed Employee #32, a nurse aide (NA) was the only staff member assisting Resident #59 at the time of the fall. On 06/20/14 at 9:20 a.m., the resident's care plan at the time of the fall, with a start date of 01/20/14 (edited on 02/28/14 and updated on 03/12/14) was reviewed. The care plan contained an intervention requiring the assistance of two (2) for toileting. The category of ADL function / Rehabilitation Potential stated the resident required extensive assistance of two (2) with transfers and total assistance of two (2) with toileting. The category related to falls identified the resident had five (5) falls from 02/10/14 - 03/11/14. Medical record review revealed the resident had a sixth fall, on 03/09/14, which was not identified on his care plan. The approach / intervention, dated 03/12/14, was for the resident to have assistance of two (2) for all transfers. This was the first time this intervention was listed under the falls category; however, this approach had been an active intervention since 01/20/14, under the ADL function / Rehabilitation Potential category. Upon inquiry, on 06/19/14 at 4:06 p.m., Employee #1, the director of nursing (DON) said the nurse aides (NAs) identified how much assistance was needed for each resident's individual needs by looking at the the resident profiles. She explained the resident profiles were based on the residents' care plans, and were accessible to the NAs on the computers located on each hall. On 06/24/2014 at 9:37 a.m., the resident profile which was to have been used by the NA to provide care for Resident #59 on 03/11/14 was reviewed. It indicated Resident #59 was to have extensive assist of two (2) with bed mobility, transfers, hygiene, and total assist of two (2) with toileting. b) Resident #40 On 06/16/14 at 12:00 p.m., Resident #40 was observed sitting in her wheelchair with her lower extremities unsupported. The resident's feet did not reach the floor and no foot rests were observed on the wheelchair. The resident was observed in the same circumstances on 06/16/14 at 2:00 p.m., and again on 06/17/14 at 1:00 p.m. During an interview with Employee #2 (registered nurse), on 06/19/14 at 3:15 p.m., she stated the resident had diabetes and developed sores from the foot rests so they were removed. She said they had tried sheep skin protectors and the resident kicked them off. Review of the resident's care plan, on 06/19/14, revealed an intervention, dated 12/23/13, to position for comfort with physical support as necessary. An interview with Employee #3 (registered nurse), on 06/23/14 at 3:25 p.m., revealed the facility had no evidence to show they provided the resident with support to the lower extremities after they tried the sheep skin protectors which the resident kicked off. On 06/24/14 at 9:00 a.m., an observation revealed Resident #40 was up in her wheelchair in the dining room with her legs elevated on a padded footrest. The resident was interviewed on 06/24/14 at 10:10 a.m. She stated this is a lot better when asked about her feet being elevated on the padded footrest.",2018-04-01
6391,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,309,D,0,1,35BV11,"Based on observation, staff interview, resident interview, and record review, the facility failed to ensure one (1) of three (3) residents reviewed for positioning was properly positioned to promote comfort and prevent potential complications. Resident #40 was not provided with support for her feet and legs when up in her wheelchair. Resident identifier: #40. Facility census: 77 Findings include: a) Resident #40 On 06/16/14 at 12:00 p.m., Resident #40 was observed sitting in her wheelchair with her lower extremities unsupported. The resident's feet did not reach the floor and no foot rests were observed on the wheelchair. The resident was observed in the same circumstances on 06/16/14 at 2:00 p.m. and again on 06/17/14 at 1:00 p.m. During an interview with Employee #2 (registered nurse), on 06/19/14 at 3:15 p.m., she stated the resident had diabetes and developed sores from the foot rests so they were removed. She said they had tried sheep skin protectors and the resident kicked them off. Review of the resident's care plan on 06/19/14 revealed an intervention, dated 12/23/13, to Position for comfort with physical support as necessary. An interview with Employee #3 (registered nurse) on 06/23/14 at 3:25 p.m., revealed the facility had no further evidence to show they provided the resident with support to the lower extremities after they had tried the sheep skin protectors which the resident kicked off. On 06/24/14 at 9:00 a.m., an observation revealed Resident #40 was up in her wheelchair in the dining room with her legs elevated on a padded footrest. The resident was interviewed on 06/24/14 at 10:10 a.m. She stated this is a lot better when asked about her feet being elevated on the padded footrest.",2018-04-01
6392,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,311,G,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interviews, staff interviews, and record review, the facility failed to ensure three (3) of three (3) residents reviewed for activities of daily living (ADLs) were provided services to maintain and maximize each resident's functional abilities. Resident #2 demonstrated she was able to use the bed controls to which she had access, but was unable to reach the one that allowed her to raise and lower the head of the bed. Resident #98's responsible party stated the resident could turn and reposition himself independently with the side rails, but was unable to do this without the side rails. Resident #29 said she had used the side rails to get out of bed. Without the side rail, she feared she would fall and no longer was able to get out of bed and into her recliner independently. Residents #98, #2, and #29 were independent, or more independent, in transfers and/or positioning prior to the discontinuation of their side rails. The side rails for each of these residents were discontinued without assessment or implementation of alternatives to prevent an avoidable decline and/or to assist each resident in maintaining and maximizing his/her current independent functioning. The facility did not identify or address each resident's unique functional needs prior to the discontinuation of the devices these residents used for independent functioning. These residents and/or their families experienced psychological harm as the result of the facility's failure to provide an acceptable means to maintain each resident's independent functioning. Resident identifiers: #98, #2, #29. Facility census: 77. Findings include: a) Resident #2 During an interview with Resident #2, on 06/20/14 at 9:10 a.m., she demonstrated she could raise her bed, but was not able to reposition herself in bed or raise the head of the bed. She said this was because the controls for the bed were located on a lowered secured side rail. Observation revealed the side rails were still attached to the bed, but they were secured in a lowered position, rendering them unusable/inaccessible to the resident. The resident said she was able to independently reposition herself and raise the head of her bed, when the side rails were up. She said she could no longer do this herself, and now had to ask for help with repositioning and raising the head of the bed. The resident voiced discontentment with the decision by the facility to discontinue her side rail use. She stated facility staff told her The State said we couldn't have them anymore. Review of the resident's most recent minimum data set (MDS) assessment, a quarterly assessment with an assessment reference date of 05/01/14, found this resident had no functional limitations in range of motion, and required limited assistance with bed mobility and transfers. An interview was conducted, on 06/24/14 at 9:30 a.m., with Employee #31 (nurse aide). She reported several residents, including Resident #2, were requiring more assistance with mobility and ADLs since the side rails were discontinued. b) Resident #98 On 06/23/14 at 1:47 p.m., during an interview with Resident #98 and his medical power of attorney (MPOA), the MPOA said a facility staff member informed them the resident could no longer use his side rails. The MPOA became visibly upset when discussing the matter. She said the staff member said, State says we can't use side rails because someone may get their head caught in them. The MPOA said when the resident had his side rails in the up position, he could independently turn and reposition himself with them. She said now he had to call staff to assist him to turn and reposition. The MPOA said they now had to use the call light to get staff assistance to do things the resident was once capable of doing for himself. During the interview, the resident concurred with the MPOA and asked if he would again be able to use his side rails. Observation revealed the resident had 1/4 side rails on each side of the bed. Each was lowered and tied down with two (2) zip ties. Review of the resident's most recent MDS, a quarterly assessment with an ARD of 06/13/14, found the resident had a Brief Interview of Mental Status of 14 - indicating he was cognitively intact. His assessment indicated he needed extensive assistance of two (2) for bed mobility and transfers, which meant he was able to participate to some degree in these activities. On 06/23/14 at 4:20 p.m. Employee #44, NA, said prior to the removal of the side rails, Resident #98 was independent with turning and repositioning in the bed, and needed the assistance of only one (1) person for transfers into and out of the bed. Now, without the ability to utilize the side rails, the NA said the resident required the assistance of a NA to turn and reposition, and the assistance of two (2) persons to transfer in and out of bed. c) Resident #29 On 06/25/14 at 11:20 a.m. Resident #29 said she almost fell getting out of bed that morning because she did not have her side rail to assist her in getting up. She said she experiences a fear of falling when she attempts to get up without her side rail. The resident said she used to be able to get out of bed independently by using the side rail and the arm of her recliner. Resident #29 said she could no longer attempt to get out of bed without staff assistance, due to her fear of falling; however, she stated she was afraid of falling even with staff assistance. The resident said she felt safer and more secure when she independently transferred herself using her side rail and the arm of her recliner to balance herself. She said a staff member was with her that morning when she almost fell . The resident said her anxiety was higher now because she could not have her side rail to assist her. Review of this resident's quarterly MDS, with an ARD of 04/02/14, found her BIMS score of 14 indicated she was cognitively intact. She had functional limitation in range of motion to both lower extremities. According to the assessment, she had required the limited assistance of one (1) for bed mobility and transfers during the look back period of the assessment. During a telephone interview with Resident #29's MPOA, on 06/25/14 at 11:31 a.m., she said she really believed the resident needed her side rails. The MPOA feared the resident's risk of injury was greater without the side rails than with the side rails. She said she spoke with the administrator and expressed her desire for the resident to have side rails. The MPOA said the administrator told her, State says side rails cannot be used, and she just can't go against state rules. The MPOA said she thought this decision had made the resident more dependent on staff assistance in areas in which she did not need assistance before. She also said this entire situation had made the resident's anxiety worse. On 06/25/14 at 3:08 p.m., Employee #51, NA, stated she had noticed a big difference in the functional ability of Resident #29 since the discontinuation of the side rails. The NA said the resident was not as dependent on staff for transferring prior to the discontinuation of the side rails. d) An interview was conducted, at 9:30 a.m. on 06/24/14, with the director of nursing (DON). When asked if an assessment was completed for each resident prior to the discontinuation of their side rails on 06/11/14, the DON said, No. She stated the side rails were discontinued, at the request of the Medical Director (MEDIR), for safety purposes. The DON stated she ordered two (2) devices to assist with bed mobility, but they had not yet been received. During an interview with the administrator (NHA), on 06/24/14 at 10:55 a.m., she confirmed the side rails in the facility were discontinued on 06/11/14. She said the medical director (MEDIR), had spoken to facility staff and was very [MEDICATION NAME] about the reduction of side rail usage. The NHA said the MEDIR spoke of statistics related to entanglement. When asked about resident functioning levels declining while in bed because a resident could no longer turn or reposition independently, the NHA said she would defer that to the physician. The NHA said the facility planned to try two (2) different types of bed canes for the residents to use instead of the side rails. At that time, the residents had not been assessed for a device, the two (2) devices had not been ordered specifically for any particular resident, the devices had not arrived, and had not been tried for any resident. On 06/25/2014 at 8:00 a.m., the MEDIR was interviewed about the discontinuation of the side rails. She said she had been working on this for several months, since December 2013. She stated a solution for the bed control was being explored, but a viable solution had not yet been determined. The MEDIR also stated residents were to have been assessed by physical therapy (PT) for an alternative means for repositioning and/or transferring. She said the assessment by PT had not occurred. The MEDIR agreed there was a need for alternatives to the side rails to assist residents in attaining and/or maintaining independent functioning. She confirmed the side rails were discontinued without individual assessments and without the availability of an alternative for residents who had previously used their side rails for positioning and assistance in transferring themselves.",2018-04-01
6393,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,314,D,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of Lippincott Nursing Procedures, the facility failed to provide care and services to promote the healing of a pressure ulcer and to prevent infection, to the extent possible, for one (1) of three (3) residents reviewed for pressure ulcers. Staff failed to follow physician's treatment orders for application of an enzymatic wound debridement agent (product for removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue). In addition, staff failed to ensure effective infection control techniques during wound care, potentially transferring bacteria and /or infection into the wound. Resident identifier: #88. Facility census: 77 Findings include: a) Resident #88 On 06/25/14 at 2:30 p.m., Employee #13, a Licensed Practical Nurse (LPN), was observed providing wound care to the resident. The wound was a stage III pressure ulcer on the right inner heel. The LPN cleansed the wound bed and the surrounding area, using a saline solution and a 4 x 4 gauze pad. She used a back and forth scrubbing motion to cleanse the area. According to Lippincott Nursing Procedures (WOUND WISE: Basic wound cleaning step by step Nursing Made Incredibly Easy! September/October 2008 Volume 6 Number 5, Pages 30 - 31, found at www.nursingcenter.com/lnc/static?pageid= 4), to prevent contamination and potential infection when cleaning an open wound, such as a pressure ulcer, the area should be gently wiped in a circular motion starting directly over the wound and moving outward. The LPN then applied Santyl ointment (gel), a wound [MEDICATION NAME] agent, from a disposable medicine cup. The nurse dipped the index finger of her right gloved hand into the product, and scooped up a very large portion of the ointment. She applied a thick portion of the Santyl across the wound bed. Instead of keeping the ointment (gel) within the wound bed, as ordered by the physician and in accordance with the product's instructions, the LPN spread a thick layer of [MEDICATION NAME] ointment around a large area (about three (3) to four (4) inches) of skin beyond the wound bed. Review of the resident's most recent minimum data set (MDS) assessment, a quarterly with an assessment reference date of 05/23/14, found to Item M0800B, the resident had a Stage III that had worsened since the prior assessment. The assessment indicate the resident required the extensive assistance of two (2) staff members for bed mobility and transfers. The Director of Nurses (DON) was interviewed, on 06/25/14 at 2:55 p.m., regarding the procedure for pressure ulcer care. She described that care was given based on what the physician ordered. The DON stated, A debridement agent is to be placed only in the wound bed, not on good tissue surrounding the wound. Review of the resident's physician's orders [REDACTED]. On 6/25/14 at 3:48 p.m., Employee #5, the Infection Control Nurse, was interviewed regarding cleansing of a wound. She confirmed . the nurse should clean the wound with sterile water or whatever was ordered, using a circular motion from the inside of the wound to the outside and pat dry . When asked how a [MEDICATION NAME] agent should be applied to a wound, she stated the debridement agent should be applied to the wound bed. When asked if it should be applied anywhere else, she replied no, it only goes in the wound bed.",2018-04-01
6394,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,323,K,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to ensure the resident environment, over which the facility had control, was as free of accident hazards as possible. Free standing floor fans, with grills which allowed access to the blades were in use. In addition, it was not possible to immediately determine if each fan was UL (Underwriters Laboratories - an independent, not-for-profit product safety testing and certification organization) listed. This was determined an immediate jeopardy to resident safety. A random observation revealed a resident attempting to place her fingers inside of the grill of a free-standing floor fan, which was located in the dining room on the second floor. Observation revealed the grill of the fan was wide enough to insert a finger and touch the revolving fan blades. It was not known whether or not the fan would shut down if someone touched the blades, so a maintenance employee inserted a tongue depressor into the fan grill and touched the blades. The fan did not shut down. Further observations found free-standing floor fans in the dining areas in the basement and the first floor. Observation revealed the gaps in the grill of the fan would allow residents to insert a finger and touch the revolving fan blades. On 06/25/14 at 10:21 a.m., the administrator was notified of the unsafe conditions related to the use of the fans. She was informed it was an immediate jeopardy (IJ) which had the potential to affect more than an isolated number of residents. Additionally, the facility failed to ensure one (1) of three (3) residents reviewed for the care area of accidents was provided adequate supervision. The resident required the assistance of two (2) staff members for transfers. He was transferred by only one (1) staff member and fell sustaining a head injury for which he was sent to the emergency room . Resident identifiers: #72 and #59. Facility census: 77. Findings include: a) Resident #72 On 06/25/14 at 9:15 a.m., Resident #72 was observed attempting to place her fingers inside the grill of an operating, free-standing floor fan, located in the second story dining room. At the time of this observation, no staff were present to redirect the resident away from the fan. Subsequent review of the resident's medical record found this resident's minimum data set (MDS) assessment, with an assessment reference date of 04/16/14, identified the resident could sometimes understand what was said to her and sometimes could be understood. The Brief Interview of Mental Status was not attempted. According to the assessment, the resident had inattention, disorganized thinking continuously and fluctuating psychomotor retardation. She also was coded as having hallucinations and delusions, wandering that significantly intruded on the privacy of activities of others. She was independent for walking in her room and in the corridors. Her [DIAGNOSES REDACTED]. At 9:44 a.m. on 06/25/14, upon inquiry, Employee #93, the maintenance director, stated he did not know if the fan would shut down if someone touched the blades. Observation revealed he inserted a tongue depressor into the fan grill and touched the blades. The fan did not shut down. Employee #93 confirmed the gaps in the grill of the fan would allow residents to insert a finger and touch the revolving fan blades. When asked if the fan was UL (Underwriters Laboratory - an independent, not-for-profit product safety testing and certification organization) listed, Employee #93 stated he was not sure. He looked at the tag and the fan, and said, If it is, I can't find it. b) Between 9:44 a.m. and 10:10 a.m., observations of the dining areas on the first floor and the basement revealed the presence of additional free-standing floor fans with grills. Residents frequented these areas for meals and activities. At times, residents were observed in the areas without direct supervision by staff. c) The administrator was notified of the unsafe conditions related to the use of the fams on 06/25/14 at 10:21 a.m. She was informed it was an immediate jeopardy (IJ) which had the potential to affect more than an isolated number of residents. An accepatable plan of correction was provided and accepted on 06/25/14 at 11:10 a.m. The facility's plan involved the removal of all free standing fans until they could determine if the fans were safe and the UL listed. Observation on 06/25/14 at 1:00 p.m. revealed the fans were no longer in the building. At 1:20 p.m. on 06/25/14, the administrator was informed the IJ was abated. The citation was decreased from a K to an E. b) Resident #59 Review of the resident's medical record, on 06/18/14 at 9:00 a.m. revealed the resident had a fall on 03/11/14. The event summary report, reviewed on 06/18/14 at 2:30 p.m., indicated the resident fell on [DATE] at 8:20 a.m. Review of the nurses' notes, on 06/18/14 at 3:00 p.m., revealed a nursing assistant (NA) was called to the resident's room to take the resident to the bathroom. The note described the NA had the resident holding onto a bar while she moved the wheelchair out of the way. The resident fell on to the bathroom floor. The care plan was reviewed on 06/19/14 at 9:20 a.m. The ADL function / Rehabilitation Potential portion of the care plan, dated 01/20/14 indicated the resident required extensive assist of two (2) with transfers and total assist of two (2) with toileting. During an interview with Employee #2, a registered nurse (RN), on 06/19/14 at 1:21 p.m., an inquiry was made regarding how many staff members were assisting the resident when he fell . She confirmed Employee #32, a NA, was the only staff member assisting Resident #59 at the time of the fall. On 06/24/14 at 8:35 a.m., review of the resident's nurses' notes, revealed an entry dated 03/11/14 at 3:11 p.m., stating, Resident pulled call bell out of wall and tipped over nightstand with drawers. Resident came out of room stating he had to piss. Aide called to room to take resident to bathroom. Aide had resident holding onto bar which she moved wheelchair out of way and resident fell in bathroom onto floor hitting back of head and bottom . Resident complained of pain in the back of head . Resident in bed lethargic, resting with eyes closed at times, not wanting to get up to use the bathroom. Resident pulled penis out of brief three times and urinated on self and in bed . Resident noted to have cough and congestion in throat and this nurse questioned the need for chest x-ray . Talked with physician at 11:45 AM and orders given to send resident to ER (emergency room ) . Sent out regarding changes in status, lung sounds and bump on head. (The time of the fall and the time the resident was sent to the emergency room was not indicated in the nurse's note.) Upon inquiry, at 10:00 a.m. on 06/24/14, as to the time Resident #59 was transported to the ER for evaluation, Employee #66, medical records personnel, provided the resident's transfer form. The transfer form contained a nurse's note, written by Employee #11, a licensed practical nurse on 03/11/14 at 12:24 p.m. The form included, Resident lost balance due to weakness and fell in bathroom this morning. Hit head and had neck at abnormal angle upon observation of scene . Resident lethargic and unresponsive to voice stimuli . Dr. notified with order to send to emergency room for evaluation and treatment. CT scan of head and chest x-ray if needed. On 06/18/14 at 2:30 p.m., the event summary report related to the resident's accident was reviewed. The summary indicated the resident fell on [DATE] at 8:20 a.m., hitting his head, resulting in a lump. He was sent to the hospital for an evaluation where a frontal lobe bleed was identified. A review of the point of care history (information the nurse aides entered into the computer system related to staff support for toileting) on 06/24/14 at 1:10 p.m., identified NA entries dated from 02/28/14 - 03/10/14 consistently stated only one (1) person assisted the resident with toileting and transfers.",2018-04-01
6395,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,334,C,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to develop and/or implement policies and procedures which ensured residents were educated on the risks of refusing influenza and/or pneumococcal immunizations. The facility also failed to ensure the reason for not receiving either immunization, whether due to contraindication or refusal, was documented in each resident's medical record. In addition, the facility failed to ensure Resident #40 was offered the pneumococcal vaccine after a refusal several years ago. This practice affected two (2) of five (5) residents reviewed; however, it had the potential to affect more than a limited number of residents. Resident identifiers: #40 and #95. Facility census: 77. Findings include: a) Review of the facility's policies for influenza and pneumococcal immunizations revealed the facility's policies did not specify educating residents/legal representatives on the risk of refusing the vaccines. The policy did state that the resident's medical record must include, at a minimum, the following: 1. Documentation that the resident or resident's legal representative was provided education regarding the benefits and potential side effects of the influenza and/or pneumococcal immunizations; and 2. Documentation that the resident either received the influenza and/or pneumococcal immunizations or did not receive the influenza and/or pneumococcal immunization due to medical contraindications or refusal. b) The facility's influenza policy did not indicate the resident had the right to refuse the immunization, or that this refusal must be documented as described. c) Employee #5, the infection control nurse verified, at 4:00 p.m. on 06/26/14, the facility's policy did not include educating residents on the risk of refusing influenza and pneumococcal vaccines, or the need to document this information. d) When the director of nursing (DON) was asked what information was provided residents and families regarding the influenza vaccine, on 06/24/14 at 10:45 a.m., she provided a general information sheet. It was an excerpt from the Centers for Disease Control (CDC) titled: What You Need to Know. The DON was unable to provide evidence this sheet, or any other information, was provided each resident and/or family. e) Resident #40 review of the resident's medical record revealed [REDACTED]. As of 06/26/14 there was no evidence the resident was ever offered the pneumococcal immunization after the refusal on 04/23/10. In addition, there was no documented evidence the benefits and potential side effects of the vaccine were discussed with the resident. Upon inquiry, Employee #5, the infection control nurse, reported at 4:00 p.m. on 06/24/14, she was unable to find evidence the resident was again offered the pneumococcal immunization. f) Resident #95 review of the resident's medical record revealed [REDACTED]. There was no documented evidence the risks and benefits of the refusal were explained to the resident and/or responsible party. At 4:00 p.m. on 06/25/14, the infection control nurse confirmed there was no evidence the resident was provided the required education regarding the benefits and risks of the immunizations.",2018-04-01
6396,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,356,C,0,1,35BV11,". Based on observation and staff interview, the facility failed to ensure the daily staff posting was posted on a daily basis at the beginning of each shift. This had the potential to affect all residents, their families, and/or visitors. Facility census: 77. Findings include: a) On 06/17/14, at 4:00 p.m., observation revealed the facility staff posting was the posting information for 06/16/14, and not for 06/17/14 as required. At that time, this was brought to the attention of Employee #5 (registered nurse). She said she would have staff correct the issue.",2018-04-01
6397,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,371,F,0,1,35BV11,"Based on observations and staff interview, the facility failed to ensure foods were stored, prepared, and served under conditions which reduced the potential for foodborne illnesses. Food service and preparation items were not stored in a manner to prevent contamination. Equipment was not clean and/or rust free. Foods were served with contaminated gloves. Foods in the nourishment pantry were unlabeled and undated. These practices had the potential to affect all residents who received nourishment from the dietary department. Facility census: 77 Findings include: a) An initial tour of the kitchen was conducted, on 06/16/14 at 10:45 a.m., with Employee #74, the director of food services (DFS). The following observations were made: 1. Bowls and saucers were stacked with eating surfaces exposed. A large piece of food debris was observed on the shelf on which these items were stored. The DFS scraped the debris into her hand and threw it away. 2. A steam table pan was stored with the food side up. 3. Skillets and pots were stored with the food surfaces upward. 4. A rusted air conditioning vent was noted in an area in which staff would pass underneath with food and food preparation items. 5. A large oscillating fan was observed with a build up of grease and grime, to which dust had adhered, giving a dark, fuzzy appearance. 6. An exhaust vent, located directly above the dishwashing area, also was observed with a build up of grease and grime, having the same dark, fuzzy appearance. 7. The DFS said she would notify maintenance and have the fan and the exhaust vent cleaned. b) On 06/16/14 at 12:00 p.m., Employee #59, activities/resident service provider (RSP), was observed serving pizza to the residents. While wearing the same pair of gloves, she touched the cart which held the pizza boxes, opened and closed the pizza boxes, and served the residents slices of pizza with her contaminated gloved hand. c) Ice cream was being served on 06/16/14 at 12:40 p.m. A used #10 food can, filled with water, was observed on a cart which contained the ice cream. The water in the can was used to rinse the scoop. Upon inquiry, at 2:00 p.m. on 06/17/14, the DFS agreed the can should not have been used to rinse the ice cream scoop. She said the dietary department had bowls that could be used. On 6/19/14 at 2:30 p.m., activity staff was observed having an ice cream social. The ice cream scoop was again observed being rinsed in a used #10 food can filled with water. When the DFS was notified of this observation, she stated she had forgotten to tell activity staff that using the used food cans was not a sanitary practice. d) During the initial tour of the facility, at 10:54 a.m. on 06/16/14, with Employee #22, a licensed practical nurse, observation of the second floor pantry refrigerator revealed an unidentifiable, unlabeled, and undated product in a used plastic grocery store bag. Employee #22 identified the product as ramps (a wild leak). e) A partially eaten chocolate cake was observed on the counter of the second floor pantry on 06/16/14 at 10:54 a.m. It was not labeled or dated.",2018-04-01
6398,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,411,D,0,1,35BV11,"Based on observation, resident interview, staff interview, and review of facility contracts, the facility failed to ensure they assisted one (1) of two (2) residents reviewed was provided in obtaining needed dental services. Resident #14 had missing bottom molars and a cracked upper left tooth. Resident #14. Facility census: 77. Findings include: a) Resident #14 During an interview with the resident, on 06/16/14 at 2:00 p.m., she stated, The dentist pulled some teeth a long time ago. When asked if her teeth hurt her, she replied sometimes. At that time, it was revealed one (1) of the resident's teeth had broken since she was admitted to the facility. Observation revealed several bottom molars missing and an upper left tooth that was cracked. Her teeth were also discolored. Employee #12 (licensed practical nurse) performed an assessment and confirmed the observation. Employee #12 (licensed practical nurse) was asked to assess the resident's mouth on 06/16/14 at 2:20 p.m. She confirmed several of the resident's bottom molars were missing, her teeth were discolored, and an upper left tooth next to the front tooth was cracked. Employee #2 (registered nurse) was interviewed on 06/19/14 at 3:00 p.m. When asked about dental care for the resident, she confirmed the resident's tooth had broken after she was admitted to the facility. Employee #2 stated, We have tried to get dental appointments, but no dentist will come to the facility. She said she had made several attempts to arrange for a dentist to see the residents, but had no evidence to support these attempts. When Employee # 2 was asked about taking residents to a dentist, her only reply was, It would be difficult for large residents to fit in a dental chair. No evidence was provided to support the facility had made any attempts to obtain dental services for Resident #14. b) Review of facility contracts revealed the facility did not have a contract or other arrangements with a dentist to provide routine and 24-hour emergency dental care.",2018-04-01
6399,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,412,D,0,1,35BV11,"Based on observation, resident interview, staff interview, and review of facility contracts, the facility failed to ensure they obtained from an outside resource routine and/or emergency dental services to meet the need of one (1) of two (2) residents. Resident #95 had problems with broken/missing teeth and dentures. reviewed was provided assistance in obtaining needed dental services. Resident #95. Facility census: 77. Findings include: a) Resident #95 On 06/19/14 at 3:00 p.m., Resident #95's teeth were observed, with a registered nurse, Employee #2. Observation revealed the resident had a broken lower tooth on the left side, and several missing teeth on the lower jaw. The resident stated she had to be careful regarding what she ate, due to chewing difficulties. She said she was unable to use her upper dentures because they would fall out even with the use of denture adhesive. At that time, Employee #2 reported the facility was in the process of trying to obtain a dentist to make visits to the residents in the facility; however, Employee #2 was unable to provide evidence to support these attempts. During review of contracts and other arrangements with outside entities, no contract or arrangement for emergency dental services and/or routine dental care was found. At 3:15 p.m., on 06/19/14, Employee #2 confirmed the facility had no contract with a dentist to provide services to the residents. No evidence was provided to support the facility had made any attempts to obtain dental services for Resident #95.",2018-04-01
6400,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,425,E,0,1,35BV11,"Based on observation and staff interview, the facility, in collaboration with the consultant pharmacist, failed to coordinate the provision of pharmacy services. There was not an effective process for the disposition of outdated stock medications from the medication refrigerator on the 2nd floor. This practice had the potential to affect more than an isolated number of residents. Facility census: 77 Findings include: a) Observation of the 2nd floor medication refrigerator, on 06/25/14 at 9:30 a.m., revealed it contained outdated stock medications: [REDACTED] 1. Acephan Tylenol 650 mg suppositories, with a discard date 06/17/14 2. Promethegan 25 mg suppositories, with a discard date of 06/11/14 Employee #11, a licensed practical nurse, was present when the expired medications were identified. She said the medications should have been discarded. Employee #11 removed them from the refrigerator.",2018-04-01
6401,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,441,L,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to implement an infection control program to prevent, recognize, and control, to the extent possible, the onset and spread of infections within the facility. The facility failed to ensure infection control procedures were in accordance with the Centers for Disease and Control and Prevention (CDC) guidelines. Isolation rooms were not effectively cleaned and sanitized and staff did not effectively use personal protective equipment (PPE). Wound care for Resident #88 was not performed by methods which eliminated the potential for cross contamination. The chairs used for Residents #69, #42, #92, #46, and #50 had areas which could not be effectively sanitized. These deficits were determined an Immediate Jeopardy (IJ) to the health and well-being of all facility residents. The IJ was first called at 4:50 p.m. on 06/16/14. The facility had continued non-compliance with infection control practices until 06/25/14 at 5:48 p.m. At that time the facility was informed the IJ was abated. The scope and severity was reduced from a scope and severity of an L to an F. The practices affected Residents #88, #69, #42, #92, #46, and #50, but had the potential to affect all residents. Facility census: 77. Findings include: a) On 06/16/14 at 12:45 p.m. observations were conducted on the long hall on second floor. A housekeeping staff member (Employee #87) entered room [ROOM NUMBER], an isolation room. At 12:50 p.m. on 06/16/14, the housekeeper exited room [ROOM NUMBER] wearing booties over her shoes. The booties were a part of the isolation personal protective equipment (PPE) required for room [ROOM NUMBER]. As she left the room, Employee #87 swept the debris (dust and debris, such as a napkin and paper products) with a dust mop, from the floor of room [ROOM NUMBER] down the middle of the hallway. She passed by six (6) resident rooms while pushing the dust mop and debris. The housekeeper went into a closet which was located between rooms [ROOM NUMBERS]. She came out without the dust mop and debris, but was still wearing the booties. On 06/16/14 at 12:54 p.m., the housekeeper was asked if the resident in room [ROOM NUMBER] was in isolation. She replied, Yes. When asked what type of PPE was needed when she cleaned the isolation room, she stated she wore gloves and booties when cleaning the room. When asked why she was still wearing the booties, she said she should have removed her booties but she forgot. Employee #87 then walked from the closet, past the six (6) rooms again, to room [ROOM NUMBER] still wearing the booties. She removed the booties with an un-gloved hand, placed them in a trash can in room [ROOM NUMBER], and exited the room without sanitizing her hands. Employee #9, a licensed practical nurse (LPN), on the resident's unit (Second floor long hall) was interviewed at 12:57 p.m. on 06/16/14. She was asked what PPE should be worn when entering room [ROOM NUMBER]. She stated all staff should wear gowns, gloves, and booties when entering the room. She added the PPE should be discarded before leaving the room and placed in the red trash can in the room. Employee #9 verified the housekeeper should have removed the booties and should not have pushed the debris from room [ROOM NUMBER] down the hallway. At 3:55 p.m. on 06/16/14, Employee #19, a LPN, on unit two (2) long hall verified a resident in room [ROOM NUMBER] was positive for Clostridium difficile (c-diff). The nurse located the last culture, obtained on 05/21/14, which verified the resident was positive for[DIAGNOSES REDACTED]. The nurse also stated any staff member entering the resident's room should wear gloves, gown, and booties. Employee #83,the housekeeping supervisor (HKS) was interviewed at 4:35 p.m. on 06/16/14. When asked to describe the procedures used by her staff to clean an isolation room, she stated PPE including gloves, gowns, booties, and possibly a mask, should be worn. When the situation involving Employee #87 was described, Employee #83 stated the housekeeper should have removed the booties and left them in the room. She said the dust mop head should have been placed in a bag, tied, and removed from the resident's room. Employee #83 also confirmed the housekeeper should have washed her hands and should not have pushed the debris from any room down the hall. An immediate jeopardy (IJ) was called at 4:50 p.m. on 06/16/14. Employee #83, Employee #5, the infection control nurse, and the administrator were present to hear the discussion regarding breaches in infection control which resulted in the IJ. At 5:45 p.m. on 06/16/14, the facility provided an action plan for abatement of the IJ. The infection control nurse had already begun providing inservice to all staff regarding effective infection control regarding residents requiring isolation and the rooms in which they resided. Housekeeping personnel was the first group provided in-servicing. An area was set up in the facility's main lobby, and every employee had to give a return demonstration as part of the in-service. The in-services were going to be provided on each shift, before staff members went to work on that shift. Any employee who was scheduled off was going to be provided the in-service before they began work on their first day back. Observations were made of the information provided and the return demonstrations. On 06/16/14 at 7:45 p.m., the IJ was abated when the action plan was observed being implemented. b) The following day, at 2:34 p.m. on 06/17/14, Employee #92, a housekeeper, was observed mopping the floor in room [ROOM NUMBER], another isolation room. The resident in this room had a methicillin resistant Staphylococcus aureus (MRSA) infection. When asked what cleaning solution he was using to clean the floor, he stated he had put some bleach in his mop water. When asked how he cleaned room [ROOM NUMBER], the isolation room for a resident with confirmed[DIAGNOSES REDACTED]., he stated he also used bleach in his mop water to clean room [ROOM NUMBER]. He said he knew there was a formula, but he did not have a measuring device so he had to guess at the amount of bleach he added to the water. He said he just put bleach in the water. At 2:45 p.m. on 06/17/14, the HKS was interviewed along with Employee #92, regarding how to prepare the bleach solution to clean a room where a resident had[DIAGNOSES REDACTED]. The HKS noted the directions on the housecleaning cart, which contained instructions on how to prepare the bleach solution for cleaning the isolation rooms. The administrator joined the interview and was made aware of the current situation. The directions, provided by the HKS, instructed staff to, Mix 1 1/2 gallons and 1 cup water to 1/2 cup of Clorox. She stated this was the solution used to clean all isolation rooms. The HKS verified this was the solution used to clean room [ROOM NUMBER], which housed a resident with[DIAGNOSES REDACTED]. She confirmed there was no measuring equipment, on second floor, to mix the solution. According to CDC, a 10:1 (ten parts water to 1 part bleach), solution is required to eradicate Clostridium difficile (c-diff) spores. The directions provided to staff by the facility, to mix the bleach solution, was a 50:1 (50 parts water to one (1) part bleach). A 50:1 mixture would not be of sufficient strength to ensure disinfection. At 3:30 p.m. on 06/17/14, the administrator, the housekeeping supervisor, and the infection control nurse, were informed the IJ was continued due to continuing non-compliance with infection control standards. The administrator stated the HKS would immediately purchase buckets and measuring devices to enable staff to clean with a 10:1 bleach solution. On 06/17/14 at 5:45 p.m. the continuation of non-compliance was abated when observations revealed staff had the necessary supplies and were correctly mixing the bleach solution. c) At 1:30 p.m. on 06/19/14, the facility was again found in a situation of non-compliance with infection control practices. Employee #41 came out of room [ROOM NUMBER], an isolation room where the resident had an infection with methicillin resistant staphylococcus aures (MRSA), with a mechanical lift, and went directly into room [ROOM NUMBER] with the mechanical lift. Observation revealed Employee #41 did not clean the lift, which had been in an isolation room, prior to taking it to another resident's room. When this was brought to the attention of Employee #2, a registered nurse (RN), she confirmed the lift should have been cleaned prior to being taken to another room. She approached Employee #41, who admitted she did not clean the lift. The RN instructed Employee #41 to immediately clean the lift. On 06/19/14 at 2:00 p.m., the administrator was informed the facility remained in non-compliance with infection control practices. d) Residents #69, #42, #92, #46, and #50 On 06/20/14, at 10:00 a.m., observations on the first and second floors revealed these residents had cracked wheelchair and/or Broda chair coverings, rendering them unable to be effectively sanitized to prevent the spread of infection. 1. The right arm of Resident #69's wheelchair was taped because the surface covering was cracked. 2. Resident #42's wheelchair had cracks in the surface on both arms. 3. Resident #92's Broda chair covering was torn and frayed. 4. Resident #46's right wheelchair arm was cracked. 5. An observation of Resident #50's wheelchair arms on 06/20/14 at 10:30 a.m. revealed they were cracked. At 11:45 a.m. on 06/20/14, the administrator was informed the Centers for Medicaid and Medicare concurred the facility remained in non-compliance with infection control practices. She was informed to do whatever was necessary to ensure all employees were retrained and implemented effective infection control procedures. On 06/23/14 at 4:30 p.m., the facility provided evidence all employees were educated on effective infection control procedures. Continuing observations were made for infection control deficits. Throughout the day, on 06/23/14, observations revealed no breaches of infection control. At that time, it was thought the facility had abated the infection control continuing non-compliance at an IJ level. The facility was informed the IJ, which was called at 4:50 p.m. on 06/16/14, was abated at 4:30 p.m. on 06/23/14. d) Resident #88 On 06/25/14 at 2:30 p.m., continuing non-compliance regarding infection control was again observed. Employee #13, a Licensed Practical Nurse (LPN) was observed providing wound care to Resident #88. During the treatment, the LPN cleaned the wound and skin surrounding the wound with a 4 x 4 wet gauze, using a back and forth scrubbing motion, potentially transferring bacteria and /or infection into the wound. This provided an opportunity for the transfer of microorganisms from the skin, where they are less likely to do harm, to an open area where the microorganisms can proliferate. On 6/25/14 at 3:48 p.m., Employee #5, the Infection Control Nurse, was interviewed regarding cleansing of a wound. She confirmed . the nurse should clean the wound with sterile water or whatever was ordered, using a circular motion from the inside of the wound to the outside and pat dry . After the facility was informed, in-service training was provided for all nurses regarding infection control related to wound care. According to Lippincott Nursing Procedures (WOUND WISE: Basic wound cleaning step by step Nursing Made Incredibly Easy! September/October 2008 Volume 6 Number 5, Pages 30 - 31, found at www.nursingcenter.com/lnc/static?pageid= 4), to prevent contamination and potential infection when cleaning an open wound, such as a pressure ulcer, the area should be gently wiped in a circular motion starting directly over the wound and moving outward. e) Continuing observations for infection control deficits were made throughout the remainder of the day on 06/25/14. At 5:48 p.m. on 06/25/14, it was determined the IJ which was originally called at 4:50 p.m. on 06/16/14 was abated. The scope and severity was reduced from an L to an F.",2018-04-01
6402,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,490,F,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, policy reviews, review of incident reports, review of reportable abuse allegations, review of personnel records, resident interviews, family interviews, and staff interviews, the administration failed to ensure the facility was administered in an efficient and effective manner to maintain the highest practicable physical, mental and psychosocial well-being of each resident. This administrative failure had the potential to affect all residents. Rights: The facility failed to ensure residents were afforded the opportunity to exercise their rights. Resident Behavior and Facility Practices: The facility failed to ensure a resident was free from a restraint used for staff convenience. The facility also failed to implement their abuse and neglect policies, and failed to identify, report, investigate, and address resident abuse and neglect. These failures resulted in substandard quality of care. Quality of Life: The facility failed to ensure residents were treated with dignity and respect, failed to allow residents to make choices regarding important aspects of their lives, failed to ensure accommodation of individual resident needs, and failed to ensure adequate housekeeping and maintenance services necessary to maintain an orderly, sanitary, and comfortable environment. Resident Assessment: The facility failed to ensure the accuracy of assessments, failed to ensure care plans were developed and/or revised as needed, and failed to ensure care plans were implemented. Quality of Care: The facility failed to provide services to promote a resident's highest level of well-being and failed to provide adequate care and services for a pressure ulcer The facility failed to ensure an effective program for influenza and pneumococcal immunizations. The facility also failed to ensure the resident environment remained as free of accident hazards as possible. The facility also failed to ensure the resident environment remained as free of accident hazards as possible, resulting in an immediate jeopardy. Dental Services: The facility failed to provide emergency and routine dental services to residents and failed to maintain a contract or agreement with a dentist to provide these services. Infection Control: The facility failed to implement an effective infection control program to prevent, recognize, and control, to the extent possible, the onset and spread of infections within the facility. This failure resulted in an immediate jeopardy. Medical Records: The facility failed to ensure medical records were readily accessible to facility staff and the survey team. Staff were not knowledgeable of how to access the pharmacist's monthly medication reviews. This lack of knowledge resulted in an inability for staff to use and/or provide essential information which was only available in the facility's computer program. These practices which had the potential to affect all residents, were identified during the survey from June 16, 2014 through June 27, 2014. Resident identifiers: #2, #14, #21, #29, 40, #42, #46, #50, #56, #59, #64, #69, #71, #72, #88, #92, #95, #98, #100, and #110. Facility census: 77 Findings include: a) Residents #98, #71, #29, and #2 were not afforded the opportunity to exercise their rights regarding the use of side rails. These residents and families expressed serious concerns regarding the facility's decision to discontinue the use of side rails because the used the side rails for turning and repositioning. The side rails were discontinued without discussion with the residents and/or families, and without the provision of alternative assistive devices to maintain each resident's independence. b) Resident #64 was not free from a restraint used for staff convenience, and not used for an assessed medical need. The facility maintained the resident in a reclining Broda chair (a tilting and reclining positioning chair) with a pelvic sling applied. The sling was tied behind and under the seat of the Broda chair. There was no assessment for the restraint, and no plan to systematically and gradually reduce the use of the restraint. Neither the resident's current minimum data set (MDS) nor the current care plan reflected the resident had a physical restraint. c) The facility failed to ensure Residents #100 and #95 were afforded the right to be free from physical abuse. Each resident alleged staff treated them rough during care. The facility failed to recognize the abuse and failed to address the allegations of physical abuse. 1. Resident #100's family reported abuse to facility staff during a care plan meeting. Review of reported allegations of abuse and neglect found no evidence of a report or an investigation of any concerns related to the resident. This was further evidence the facility did not recognize alleged abuse. Employee #3, a registered nurse, was interviewed on 06/19/14 at 11:06 a.m. She stated she remembered the resident's family told the care plan team a staff member had been rough with the resident during care. Employee #3 said she believed the social worker investigated the situation. The social worker, Employee #63, was interviewed at 12:58 p.m. on 06/19/14. She confirmed the resident's wife told her, Someone had been rough with him. The social worker did not report the incident because she said she was not able to Confirm the who, what, where and when. I took this upon myself not to report it because some people are just rougher than others. She stated she did not think it was abuse, 2. Resident #95 was interviewed at 3:55 p.m. on 06/17/14. She reported a nursing assistant was rough with her when taking her to the commode, bruising her wrist and making her ribs sore. An interview with the resident's son, on 06/19/14 at 1:45 p.m., revealed his mom told him someone had been rough with her, and he reported this to Employee #61 (social worker). When interviewed on 06/19/14 at 2:20 p.m., Employee #61 confirmed she was notified of the resident's allegation. The social worker provided information that indicated she interviewed the resident, but there was no evidence of a thorough investigation. She did not report the allegation to the required agencies because she did not feel the allegation was substantiated. d) The facility failed to ensure allegations of mistreatment, neglect, and/or abuse were reported and/or thoroughly investigated for Residents #59 and #110. In addition, the facility failed to complete a thorough background investigation for one Employee, #103. 1. Resident #59 had a fall resulting in a head injury on 03/11/14. Review of the nurse's notes, on 06/18/14 at 3:00 p.m., revealed a note dated, 03/11/14 at 3:11 p.m., which described the resident fell on to the bathroom floor while being assisted in toileting. An interview with Employee #2, a registered nurse (RN), on 06/19/14 at 1:21 p.m., revealed only one (1) nursing assistant was assisting the resident when he fell . Review of the resident's care plan, on 06/19/14 at 9:20 a.m., found it indicated the resident required extensive assist of two (2) with transfers and total assist of two (2) with toileting. There was no evidence this incident was thoroughly investigated. At 2:47 p.m. on 06/19/14, the director of nursing said, Social services reminded me we did not investigate the matter because the physician wrote a note that the resident was having a stroke prior to or during the fall. This did not negate the fact the resident was transferred by one (1) person instead of two (2). That part of the incident, neglect, required reporting and investigation. 2. Resident #110's medical record indicated she was sent to the hospital on [DATE] to have a Rape kit done. She had stated a male nursing assistant had raped her. There was no evidence the allegation was investigated by the facility. An interview with Employee #63, a Social Worker (SW), on 06/26/14 at 1:35 p.m., revealed the facility did not do an investigation of the allegation because the hospital report showed no evidence the resident was raped and the resident had no memory of the allegation. Upon inquiry, the SW confirmed she had not considered the possibility that something happened to the resident which required an investigation, even though it was not rape. 3. On 06/17/14 at 1:20 p.m., the personnel file review revealed Employee #103 (resident service provider) came to work at the facility on 06/01/10. This employee listed on her application she had worked in a neighboring state until 2007. The facility had completed a criminal background check for the state of West Virginia at the time the employee was hired. The personnel file contained no evidence showing the facility had conducted a criminal background check outside of West Virginia. On 06/23/14 at 1:30 p.m. Employee #99 (bookkeeper) said the facility had not conducted a criminal background check in the neighboring state for Employee #103. e) The facility failed to develop and operationalize abuse policies and procedures (P & P) to prevent, identify, investigate, and report abuse and mistreatment. In addition, the policy referred to a Federal requirement which does not exist, and to an outdated State Licensure rule regarding abuse. The facility also failed to operationalize their policies and procedures for Residents #95, #100, and #59, when they failed to investigate all alleged abuse and neglect; failed to obtain statements from all witnesses, employees, residents; and failed to document all interviews with witnesses. 1. Review of the facility's abuse policies and procedures found all aspects of the seven (7) required components were not accurate and/or developed: -- The procedures for reporting did not include the requirement to immediately (within 24 hours) report all allegations of abuse or neglect to the appropriate State agencies. -- The policy refers to F228, a regulation which does not exist. -- The policy refers to the Nursing Home rule dated June 18, 2001; however, this is not the most current rule. 2. Resident #95: The facility failed to operationalize their P & P to report and investigate an allegation of abuse regarding Resident #95. During an interview with Resident #95, at 3:55 p.m. on 06/17/14, she reported, a nursing assistant was rough with her, bruising her wrist and made her ribs sore, when she took her to the commode. The resident's family was interviewed on 06/19/14 at 1:45 p.m. The family member said Resident #95 told him someone had been rough with her. According to the family, this allegation was reported to Employee #61 (social worker). Upon inquiry on 06/19/14 at 2:20 p.m., Employee #61, social worker, provided a copy of the resident's allegation dated 01/14/14. Review of the document revealed Employee #61 was made aware of the alleged incident and interviewed the resident, but failed to conduct a thorough investigation. The social worker said she did nothing further because she did not feel the allegation was substantiated. Review of the facility's reportable allegations, on 06/19/14 at 3:00 p.m., revealed no record the allegation was reported to the required agencies. The review also revealed no evidence of a thorough investigation. 3. Resident #100: The facility failed to operationalize their P &P to report and investigate an allegation of abuse regarding Resident #100. On 06/16/14 at 6:32 p.m., the family member of Resident #100 stated staff had been rough with the resident during care. The family member said the incident was reported to facility staff during a care plan meeting, and the facility assured them the incident would be investigated. The facility's reported allegations of abuse and neglect, which had been reported to the State, contained no reporting or investigation of any concerns related to Resident #100. Employee #3, a registered nurse, was interviewed on 06/19/2014 at 11:06 a.m. Employee #3 stated she remembered the meeting when the resident's family told the care plan team a staff member had been rough with the resident during care. Employee #3 said she believed the social worker investigated the situation. The social worker, Employee #63, was interviewed at 12:58 p.m. on 06/19/14. She stated the resident's wife told her, Someone had been rough with him. The social worker said she did not report the incident because she said she was not able to confirm the who, what, where and when. She said she took it upon herself to not report it because some people are just rougher than others. 4. The facility's policy entitled, Procedure for Patient Abuse Investigation was reviewed on 06/25/14 at 3:00 p.m. It included: The facility shall investigate and report alleged abuse as follows: -- Report incident to Administrator, Director of Nursing and Social Services Director. The Social Services Director, upon preliminary investigation, shall notify the Office of Health Facility Licensure and Certification and the Department of Health and Human Resources, Adult Protective Services about the alleged abuse. -- The facility will investigate reports of alleged abuse and neglect to determine if the conduct of the employee is in violation of any standard of care -- As part of the investigation process the following will be done: -- Obtain statement from all witnesses, employees, residents or visitors. -- The facility will document all interviews with witnesses 5. Resident #59 fell , on 03/11/14 (the time was not identified), while being assisted with toileting. Review of the resident's care plan revealed the resident required extensive assistance of two (2) with transfers and total assistance of two (2) with toileting. At 1:21 p.m. on 06/19/14, Employee #2, a registered nurse (RN), was asked how many staff members were assisting the resident at the time of his fall on 03/11/13. She stated only one (1) staff member was assisting Resident #59 at the time of the fall. At 2:47 p.m. on 06/19/2014, the DON reported the the facility did not investigate the matter. The facility failed to operationalize their P & P to report and investigate this alleged neglect of Resident #56. f) The facility failed to ensure a dignified dining experience for residents who had their meals in the main dining room. Several residents were still eating when a staff member removed their plates without asking if they were finished. In addition, the staff member scraped unconsumed food and beverages into a bucket in view of the residents. g) The facility failed to ensure residents were free to exercise autonomy regarding what the residents considered important aspects of their lives. Residents #2, #98, #71, and #29 were not free to exercise autonomy regarding the use of side rails. Residents #21 and #100 did not have a choice regarding the number of showers they received each week. 1. Resident #2 said she was upset on 06/17/14 at 4:25 p.m., because the facility discontinued her side rails. she said she felt safer with them. An observation and interview with Resident #2, on 06/20/14 at 9:10 a.m., revealed she could only raise the height of her bed. She was not able to reposition herself in bed or raise the head of the bed because the controls were located on the lowered side rail., which was secured in the lower position with two (2) plastic zip ties. Review of the side rail assessment, completed on 05/04/14, revealed the resident required side rails for turning and repositioning, as well as to transfer herself in and out of the bed. Review of the resident care plan revealed an intervention, dated 11/07/13, which stated: May have 1/4 to 1/2 side rails to head of bed for mobility. 2. Resident #98 was interviewed, along with his wife, on 06/23/14 at 1:47 p.m. They were concerned because the facility informed them the resident could no longer use his side rails. Observation revealed the resident's two (2) 1/4 side rails were secured in the lowered position with two (2) zip ties on each side rail . The resident could not turn and reposition himself independently when the side rails were down. Without the side rails, the resident had to call staff to assist him to turn and reposition. During the interview, the resident asked if he would again be able to use his side rails. The resident and his wife said they were not consulted in the decision regarding discontinuation of the use of the side rails. 3) Resident #71 was observed in her bed on 06/25/14 at 3:30 p.m Her side rails were in the down position, and were secured with two (2) zip ties on each side rail . The resident said she wished she still had her side rails, because she used them to position herself in the bed. She asked if she would ever get them back. During a telephone conversation, on 06/25/14 at 5:00 p.m., with the MPOA for Resident #71, the resident's MPOA said the resident was very upset about losing her side rails, as she was able to turn and reposition independently while in bed. She said the resident longer feels safe in bed, and now requires assistance to turn and reposition. The MPOA said it was her opinion, the resident could do more and felt safer with the side rails. She said she wanted the resident to once again be able to utilize her side rails. 4. Resident #29, when interviewed on 6/17/14 at 4:20 p.m., said her side rails were removed about a week ago. She said she was informed by staff that she could no longer use them. On 06/25/14 at 11:20 a.m., during another interview, Resident #29 said she almost fell getting out of bed that morning because she did not have her side rail to assist her. Several times during the conversation, she expressed a fear of falling. The resident said she used to be able to get out of bed herself using the side rail and the arm of her recliner. She said she now no longer attempted to get out of bed, without staff, due to a fear of falling. The resident said when she had her side rails, she was not fearful of falling. She said her anxiety was higher now because she cannot have her side rails. During a telephone interview with the resident's MPOA, on 06/25/14 at 11:31 a.m., the MPOA said she really believed Resident #29 needed her side rails. She voiced fear the risk of injury to the resident was greater without the side rails than with the side rails. The MPOA said she thought the decision made the resident require staff assistance in areas in which she did not previously need assistance. The MPOA also said the entire situation has made the resident's anxiety worse. 5. During an interview with Employee #1 (director of nursing), on 06/24/14 at 9:30 a.m., she reported the side rails were discontinued on 06/11/14 at the request of the medical director. When asked what alternatives were offered the residents, she said the side rails were discontinued prior to the alternative devices being in place. An interview with the medical director, on 06/25/14 at 8:00 a.m., revealed residents were to be assessed by physical therapy and alternate bed control and positioning devices were to be in place prior to the discontinuation of the bed rails. She confirmed the facility had not completed the physical therapy evaluations, and did not have alternate positioning devices prior to the discontinuation of the side rails. h) The facility failed to ensure Residents #2, #29, #71, #98, and #56 were provided reasonable accommodations of individual needs and preferences. The environment and staff behaviors were not directed toward assisting each resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible. For residents #2, #29, #71, #98, and #56, the facility did not evaluate each resident's unique needs and preferences, to ensure each resident was reasonably accommodated, when their side rails were removed from use. The plan was for residents to be assessed by physical therapy and alternate bed control and positioning devices were to be in place prior to the discontinuation of the bed rails. The facility had not done the physical therapy evaluations and had not provided alternatives to the side rails prior to discontinuing them. i) Resident #21 was not notified before a room change occurred. During an interview, at 1:16 p.m. on 06/17/14, the resident stated he was moved from the first floor to the second floor without explanation. Review of the nurse's note, dated 06/06/14, confirmed the resident was moved from room [ROOM NUMBER] to room [ROOM NUMBER] on 06/06/14. According to the note, the medical power of attorney was called about the room move; however, there was no evidence the resident was notified of the room move. The director of nursing was interviewed at 12:52 p.m. on 06/25/14. She was unable to provide evidence the room move was discussed with Resident #21 before he was moved. j) The facility failed to provide effective maintenance services in 20 of 39 resident rooms/bathrooms and a resident common area. The ceramic tiles around the sink area in resident rooms were cracked. Bathroom doors had deep scratches in the wood surfaces. Door facings going into bathrooms had chipped paint. Exhaust fans in the bathrooms were rusted. The ceiling in one (1) resident room had peeling plaster/paint. Doorknob plates were loose. Chairs in the dining area on first floor had scratched arms and legs. The hand rail across from the nursing station on second floor was loose. In addition, effective housekeeping and/or maintenance services were not provided for two (2) of 77 residents, observed through random observations, who had dirty wheelchairs. Five (5) of 35 census sample residents and one (1) resident observed through random observations had cracked wheelchair and/or Broda chair coverings. These cracks in the coverings rendered the equipment unable to be effectively cleaned. k) The facility failed to use the Resident Assessment Instrument (RAI) to accurately assess residents using the Minimum Data Set (MDS), to develop care plans, to revise care plans as needed, and/or to implement care plans. 1. Resident #64's MDS was not accurate. The MDS did not indicate the resident used a restraint or that the resident had a fall. The resident was observed restrained with a pelvic sling in a reclining Broda chair (a tilting and reclining positioning chair). The sling was tied behind and under the seat of the Broda chair. The pelvic restraint was observed in use on 06/17/14 at 2:22 p.m., 06/18/14 at 12:30 p.m.,06/19/14 at 9:00 a.m., 06/20/14 at 10:17 a.m., and 06/23/14 at 1:26 p.m. On 06/24/14 the resident was observed with the sling in place continuously from 8:15 a.m. until 9:51 a.m. On 06/25/14 the resident was observed from 9:00 a.m. to 9:33 a.m., and at 5:13 p.m. with the sling in place. The resident was also observed seated in this manner on 06/26/14 at 11:46 a.m. Review of the medical record, on 06/24/14, found the resident's last annual MDS had an assessment reference date (ARD) of 03/06/14. Section P of the MDS was not coded to reflect the resident had a physical restraint. Medical record review, on 06/25/14, found the resident fell from her bed on 12/13/13. Review of the resident's annual MDS with an ARD of 03/06/14, Section J (Health Conditions), indicated the resident had no falls since her last assessment, which was a quarterly MDS with an ARD of 12/06/13. 2. Resident #14's MDS was not accurate. During an interview with the resident, on 06/16/14 at 2:00 p.m., she stated, The dentist pulled some teeth a long time ago. When asked if her teeth hurt her, she replied sometimes. review of the resident's medical record revealed [REDACTED]. Section (L) Oral Dental Status indicated the resident had no dental problems. Employee #12 (licensed practical nurse) was asked to assess the resident's mouth on 06/16/14 at 2:20 p.m. She confirmed several of the resident's bottom molars were missing, her teeth were discolored, an upper left tooth next to the front tooth was cracked, and food particles were on the resident's teeth. 3. Resident #56 did not have a comprehensive care plan to address the resident's [MEDICAL CONDITION]. On 06/20/14 at 8:56 a.m., medical record review showed Resident #56 was taking [MEDICATION NAME] 40 milligram (mg) 1 tablet every day for [MEDICAL CONDITION]. Review of medical records, on 6/24/14 at 8:50 a.m., revealed pertinent [DIAGNOSES REDACTED]. The resident's care plan did not identify [MEDICAL CONDITION] as a problem. The only mention of [MEDICAL CONDITION] was in a problem statement under dehydration, created on 1/14/14, which stated . on a diuretic for [MEDICAL CONDITION] which puts her at risk for dehydration. Employee #18, a Licensed Practical Nurse (LPN), was interviewed, on 6/24/14 at 10:45 a.m. She reported the resident had bilateral lower extremity [MEDICAL CONDITION] that comes and goes, and the resident was encouraged to keep her legs elevated The resident's care plan did not discuss elevating the resident's legs, or directives to monitor the resident's [MEDICAL CONDITION]. On 6/25/14 at 5:50 p.m., Employee #2, a MDS nurse, was interviewed. She reviewed Resident's #56's care plan and confirmed the only care plan concerning [MEDICAL CONDITION] was under dehydration. When asked how staff knew what care the resident required to address the [MEDICAL CONDITION] (such as elevating the resident's legs and monitoring), Employee #2 replied: . they wouldn't, because it wasn't in the care plan . 4. Resident #64 did not have a care plan related to the use of a restraint. Observation, on 06/16/14 at 12:45 p.m., revealed this resident was reclined in a Broda chair. The resident also had a pelvic sling tied under the Broda chair, and out of reach of the resident. Her legs were elevated with the foot rest of the chair. The pelvic sling, which was between the resident's legs and tied to the chair, rendered the resident incapable of turning and repositioning herself. The care plan was reviewed on 06/20/14 at 10:33 a.m. There were no interventions for position changes while the resident was in the Broda chair and using a pelvic sling. On 06/25/14 at 2:15 p.m., an interview was held with Employee #2, a MDS nurse. She reviewed the care plan and confirmed there was no care plan regarding how and when the resident should be repositioned. 5. Resident #59's care plan was not revised related to falls or to reflect the number of staff needed for assistance. The care plan, with a start date of 01/20/14, was reviewed on 06/20/14 at 9:20 a.m. The category of ADL function / Rehabilitation Potential stated: extensive assist of two (2) with transfers and total assist of two (2) with toileting. It had an edited date of 02/28/14. The category of Falls, listed five (5) falls from 02/10/14 - 03/11/14. A fall that occurred on 03/09/14 was not identified on the care plan which was updated on 03/12/14. The approach / intervention, dated for 03/12/14, was for the resident to have assist of two (2) for all transfers. The MDS, with an assessment reference date (ARD) of 02/24/14, was reviewed on 06/19/14 at 10:32 a.m. It indicated a change/or correction in the resident's level of functioning was needed. The previous MDS, with an ARD of 02/03/14, indicated the resident was extensive assist of two (2) for transferring and toileting (weight bearing). The correction/or change, on the MDS with an ARD of 02/24/14, stated he was extensive assist of one (1) staff member for transferring and toileting. On 06/19/14 at 4:06 p.m., Employee #1, the director of nursing (DON) provided the MDS dated [DATE] that indicated the resident was extensive assist of one (1) for toileting. She stated that the MDS was correct and the care plan was incorrect. The care plan was not revised to reflect the resident's current assessed needs. 6. Resident #2's care plan revealed an intervention, dated 11/07/13, which stated May have 1/4 to 1/2 side rails to head of bed for mobility. The care plan indicated the last review was done on 05/13/14. The facility discontinued this resident's side rails on 06/11/14. The care plan was not revised regarding the side rails and/or the need for an alternative device for bed mobility. 7. Resident #59's care plan was not implemented regarding the amount of assistance he needed, resulting in harm when he fell and injured his head. Review of the Nurses notes,on 06/24/14 at 8:35 a.m., revealed an entry dated 03/11/14 at 3:11 p.m. indicating the resident fell while being assisted in the bathroom. An interview with Employee #2, a registered nurse (RN), on 06/19/14 at 1:21 p.m., revealed Employee #32, a nurse aide (NA) was the only staff member assisting Resident #59 at the time of the fall. On 06/20/14 at 9:20 a.m., the resident's care plan at the time of the fall, with a start date of 01/20/14 (edited on 02/28/14 and updated on 03/12/14) was reviewed. The care plan contained an intervention requiring the assistance of two (2) for toileting. The category of ADL function / Rehabilitation Potential stated the resident required extensive assistance of two (2) with transfers and total assistance of two (2) with toileting. Upon inquiry, on 06/19/14 at 4:06 p.m., Employee #1, the director of nursing (DON), said the nurse aides (NAs) identified how much assistance was needed for each resident's individual needs by looking at the the resident profiles. She explained the resident profiles were based on the residents' care plans, and were accessible to the NAs on the computers located on each hall. On 06/24/2014 at 9:37 a.m., the resident profile which was to have been used by the NA to provide care for Resident #59 on 03/11/14 was reviewed. It indicated Resident #59 was to have extensive assist of two (2) with bed mobility, transfers, hygiene, and total assist of two (2) with toileting. 8. Resident #40's care plan for positioning and support was not implemented. On 06/16/14 at 12:00 p.m., Resident #40 was observed sitting in her wheelchair with her lower extremities unsupported. The resident's feet did not reach the floor and no foot rests were observed on the wheelchair. The resident was observed in the same circumstances on 06/16/14 at 2:00 p.m., and again on 06/17/14 at 1:00 p.m. During an interview with Employee #2 (registered nurse), on 06/19/14 at 3:15 p.m., she stated the resident had diabetes and developed sores from the foot rests so they were removed. She said they had tried sheep skin protectors and the resident kicked them off. Review of the resident's care plan, on 06/19/14, revealed an intervention, dated 12/23/13, to position for comfort with physical support as necessary. An interview with Employee #3 (registered nurse), on 06/23/14 at 3:25 p.m., revealed the facility had no evidence to show they provided the resident with support to the lower extremities after they tried the sheep skin protectors which the resident kicked off. l) Residents were not provided services to maintain and maximize each resident's functional abilities related to activities of daily living (ADLs). These residents were independent, or more independent, in transfers and/or positioning prior to the discontinuation of their side rails. The side rails for each of these residents were discontinued without assessment or implementation of alternatives to prevent an avoidable decline and/or to assist each resident in maintaining and maximizing his/her current independent functioning. The facility did not identify or address each resident's unique functional needs prior to the discontinuation of the devices these residents used for independent functioning. These residents and/or their families experienced psychological harm as the result of the facility's failure to provide an acceptable means to maintain each resident's independent functioning. 1. Resident #2 was interviewed and observed on 06/20/14 at 9:10 a.m., She demonstrated she could raise her bed, but was not able to reposition herself in bed or raise the head of t (TRUNCATED)",2018-04-01
6403,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,493,C,0,1,35BV11,"Based on record review and staff interview, the governing body failed to establish policies which reflected current regulations. The admission contract contained two (2) clauses which were in direct conflict with Federal and State regulations. This had the potential to affect all residents. Facility census: 77 Findings include: a) Review of the facility's admission contract, on 06/24/14, revealed it contained clauses which were in conflict with regulation and/or the facility's actual practices. During an interview with Employee #63 (social worker) on 06/24/14 at 2:00 p.m., she confirmed this admission contract was used for all new residents. The inaccurate information included: 1. The contract stated Residents' personal laundry is not covered in the basic room charge. Should the facility be requested to do the laundry, the expense must be paid by the resident. Basic personal laundry is a covered service for Medicare/Medicaid eligible residents. An interview with the administrator, at 2:00 p.m. on 06/24/14 revealed the facility does not charge for personal laundry. She stated this clause needed removed from the contract. 2. The contract also stated if a physician ordered a special nurse or nurse aide to sit with the resident, the resident was responsible for the cost incurred. Residents eligible for Medicare/Medicaid services may not be charged for items and services that are not requested by the resident or representative. Any item or service ordered by a physician. The item or service ordered by the physician should fit in with the resident's care plan. At 3:00 p.m. on 06/24/14, the administrator said the facility had never charged a resident for physician ordered nursing services. She said the clause would be removed.",2018-04-01
6404,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,497,F,0,1,35BV11,"Based on a review of performance evaluations for nurse aides and staff interview, the facility failed to ensure 20 of 20 nurse aides had a performance evaluation completed at least once every 12 months. The facility had not completed performance evaluations for nurse aides since 2012. Employee identifiers: #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, and #41. Facility census: 77. Findings include: a) A review of the facility's nurse aide evaluations, on 06/19/14 9:20 a.m., revealed the facility did not have up to date performance evaluations for the nurse aides. Employees #22, #23, #24, #25, #26, #27, #28, #29, #30. #31. #32. #33. #34. #35. #36, #37, #38, #39, #40, and #41 had all worked at the facility for more than one (1) year and had not had an annual performance evaluation completed. The director of nursing (Employee #1) said they had not completed performance evaluations on nurse aides since 2012. She indicated the facility had not given raises to employees since 2012; therefore, they had not completed performance evaluations.",2018-04-01
6405,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,502,D,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to obtain a laboratory specimen as ordered by the physician in a timely manner for one (1) of five (5) medical records reviewed for laboratory services. Resident identifier: #92. Facility census: 77 Findings include: a) Resident #92 Observation of Resident #92, on 06/16/14 at 11:17 a.m., revealed the resident was in isolation due to a [DIAGNOSES REDACTED]. Review of the medical record, on 06/18/14 at 2:00 p.m., revealed an order, dated 06/02/14, for the collection of a repeat stool culture. The medical record contained no evidence the repeat stool culture was obtained. An interview with the administrator and Employee # 5, the infection control nurse, on 06/18/14 at 2:30 p.m. found the sample had not been collected. Upon inquiry, it was also found the physician had not been notified the sample had not been obtained. Review of resident's bowel records revealed bowel movements were documented on 06/02/14, 06/06/14 (twice), 06/08/14, 06/09/14, 06/11/14, 06/15/14, and 06/16/14. There were eight (8) opportunities, after the order was given, to collect the stool specimen. The specimen was not collected until 06/18/14, after surveyor intervention.",2018-04-01
6406,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,514,F,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of pharmacy reports, the facility failed to maintain complete and accurate clinical records for three (3) of forty-three Stage 2 sample residents. The medical records did not contain enough information to show the facility knew the status of each resident. Contradictory and inaccurate information was identified for Resident #59. Nurses' notes for Resident #100 indicated he was receiving skilled services, which he was not receiving. The Medication Administration Record [REDACTED]. In addition, the pharmacist's computerized monthly medication regimen reviews were not readily accessible to nursing staff. This practice had the potential to affect all residents. Resident identifiers: #59, #100, and #112. facility Census: 77. a) Resident #59 1. Review of the resident's nurses' notes, on 06/18/14 at 3:00 p.m., revealed a note, dated 03/09/14 at 2:58 p.m., which stated: Resident had a fall at 9:25 a.m. unwitnessed. Resident vitals 96.8, 95%, 62, 20, 130/72. Resident was attempting to take himself to toilet. The first documentation related to the fall was more than five (5) and 1/2 hours after the occurrence. In addition, the medical record contained no follow-up information or assessments after the resident fell . 2. The medical record indicated the resident fell again, on 03/11/14. The time of the fall was not identified in the note. 3. The resident's current care plan, last reviewed by the facility on 02/28/14, was reviewed on 06/19/14 at 9:20 a.m. The ADL function / Rehabilitation Potential portion of the care plan indicated the resident required extensive assist of two (2) with transfers and total assist of two (2) with toileting. On 06/19/14 at 4:06 p.m., Employee #1, the director of nursing (DON), provided the resident's MDS, dated [DATE]. It indicated the resident required extensive assist of one (1) for toileting. This was in conflict with the care plan, which indicated the resident required total assist of two (2) with toileting. 4. The Fall portion of the care plan identified five (5) falls occurring on 02/10/14, 02/14/14, two (2) falls on 02/18/14, and 03/11/14. A 6th fall, which occurred on 03/09/14, was not identified on the care plan. b) Resident #100 Review of the nurse's notes for Resident #100, on 06/24/14 at 2:30 p.m., indicated the resident was receiving skilled services under Medicare Part A. Interview with Employee #206, a physical therapy employee, revealed this resident was not receiving skilled services. Nurses' notes dated 06/04/14, 06/05/14, 06/06/14, 06/08/14, and 06/10/14 all noted Resident #100 was Skilled under Part A . The DON, on 06/24/14 at 2:55 p.m., verified the resident was not skilled and was not receiving any skilled services. c) Resident #112 The MAR (medication administration record) and the controlled medication sheet for Resident #112 were reviewed. The period of 08/07/14 through 08/09/14 did not clearly indicate what dosage of the controlled medication was administered, at what time it was administered, or by whom it was administered. An interview was conducted with the DON, during the afternoon of 06/25/14. She confirmed the records were not accurate and complete. d) The monthly pharmacist medication reviews were not accessible to facility nursing personnel. An interview with the DON, on 06/24/14 at 3:20 p.m., revealed she was unable to access the monthly medication regimen reviews for residents and was unable to verify if the reviews had been done. At 3:30 p.m., the DON called the consulting pharmacist to inquire if the reviews had been done. The consulting pharmacist told the DON they were done. She asked the pharmacist how she could access the monthly pharmacy reviews in the facility's electronic system. The consulting pharmacist tried to talk her through accessing the reports; however, the DON was unable to access the monthly medication regimen reviews. The monthly reviews were found in the facility's electronic system by the consulting pharmacist, who had remote access to the facility's system. For the purpose of review, the DON had to request the pharmacist fax the reports to the facility. The DON acknowledged the monthly medication regimen reviews were not readily accessible to facility nursing personnel.",2018-04-01
6407,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,520,G,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, policy reviews, review of incident reports, review of reportable abuse allegations, review of personnel records, resident interviews, family interviews, and staff interviews, the quality assessment and assurance (QA & A) committee failed to identify and address quality deficiencies of which they were aware or should have been aware. These practices had the potential to affect all residents. Rights: The QA & A committee failed to identify the need to develop and implement processes to ensure residents were afforded the opportunity to exercise their rights. Resident Behavior and Facility Practices: The QA & A committee failed to identify the need to develop and implement processes to ensure a resident was free from a restraint used for staff convenience. The QA & A committee also failed to identify the need to develop and implement processes to implement their abuse and neglect policies, and failed to identify the need to develop and implement processes to ensure allegations of abuse and neglect were identified, reported and investigated. These failures resulted in substandard quality of care. Quality of Life: The QA & A committee failed to identify the need to develop and implement processes to ensure residents were treated with dignity and respect, failed to identify the need to develop and implement processes to allow residents to make choices regarding important aspects of their lives, failed to identify the need to develop and implement processes to ensure accommodation of individual resident needs, and failed to identify the need to develop and implement processes to ensure adequate housekeeping and maintenance services necessary to maintain an orderly, sanitary, and comfortable environment. Resident Assessment: The QA & A committee failed to identify the need to develop and implement processes to ensure the accuracy of assessments, failed to identify the need to develop and implement processes to ensure care plans were developed and/or revised as needed, and failed to identify the need to develop and implement processes to ensure care plans were implemented. Quality of Care: The QA & A committee failed to identify the need to develop and implement processes to provide services to promote each resident's highest level of well-being, such as care and services for a pressure ulcer and an effective program for influenza and pneumococcal immunizations. The QA & A committee also failed to identify the need to develop and implement processes to ensure the resident environment remained as free of accident hazards as possible, resulting in an immediate jeopardy. Dental Services: The QA & A committee failed to identify the need to develop and implement processes to provide emergency and routine dental services to residents and failed to identify the need to maintain a contract or agreement with a dentist to provide these services. Infection Control: The QA & A committee failed to identify the need to develop and implement processes to implement an effective infection control program to prevent, recognize, and control, to the extent possible, the onset and spread of infections within the facility. This failure resulted in an immediate jeopardy. Medical Records: The QA & A committee failed to identify the need to develop and implement processes to ensure medical records were readily accessible to facility staff and the survey team. Staff were not knowledgeable of how to access the pharmacist's monthly medication reviews. This lack of knowledge resulted in an inability for staff to use and/or provide essential information which was only available in the facility's computer program. These practices, which had the potential to affect all residents, were identified during the survey from June 16, 2014 through June 27, 2014. Resident identifiers: #2, #14, #21, #29, #40, #42, #46, #50, #56, #59, #64, #69, #71, #72, #88, #92, #95, #98, #100, and #110. Facility census: 77 Findings include: a) Residents #98, #71, #29, and #2 were not afforded the opportunity to exercise their rights regarding the use of side rails. These residents and families expressed serious concerns regarding the facility's decision to discontinue the use of side rails because the used the side rails for turning and repositioning. The side rails were discontinued without discussion with the residents and/or families, and without the provision of alternative assistive devices to maintain each resident's independence. b) Resident #64 was not free from a restraint used for staff convenience, and not used for an assessed medical need. The facility maintained the resident in a reclining Broda chair (a tilting and reclining positioning chair) with a pelvic sling applied. The sling was tied behind and under the seat of the Broda chair. There was no assessment for the restraint, and no plan to systematically and gradually reduce the use of the restraint. Neither the resident's current minimum data set (MDS) nor the current care plan reflected the resident had a physical restraint. c) Residents #100 and #95 were not afforded the right to be free from physical abuse. Each resident alleged staff treated them rough during care. The QA & A committee failed to recognize the abuse and failed to address the allegations of physical abuse. 1. Resident #100's family reported abuse to facility staff during a care plan meeting. Review of reported allegations of abuse and neglect found no evidence of a report or an investigation of any concerns related to the resident. This was further evidence the QA & A committee did not recognize the need to address alleged abuse. Employee #3, a registered nurse, was interviewed on 06/19/14 at 11:06 a.m. She stated she remembered the resident's family told the care plan team a staff member had been rough with the resident during care. Employee #3 said she believed the social worker investigated the situation. The social worker, Employee #63, was interviewed at 12:58 p.m. on 06/19/14. She confirmed the resident's wife told her, Someone had been rough with him. The social worker did not report the incident because she said she was not able to Confirm the who, what, where and when. I took this upon myself not to report it because some people are just rougher than others. She stated she did not think it was abuse, 2. Resident #95 was interviewed at 3:55 p.m. on 06/17/14. She reported a nursing assistant was rough with her when taking her to the commode, bruising her wrist and making her ribs sore. An interview with the resident's son, on 06/19/14 at 1:45 p.m., revealed his mom told him someone had been rough with her, and he reported this to Employee #61 (social worker). When interviewed on 06/19/14 at 2:20 p.m., Employee #61 confirmed she was notified of the resident's allegation. The social worker provided information that indicated she interviewed the resident, but there was no evidence of a thorough investigation She did not report the allegation to the required agencies because she did not feel the allegation was substantiated. d) The Q A & A committee failed to identify the need to develop and implement processes to ensure allegations of mistreatment, neglect, and/or abuse were reported and/or thoroughly investigated for Residents #59 and #110. In addition, the QA & A committee failed to ensure complete and thorough background investigations were conducted. Employee #103's background check was not thorough. 1. Resident #59 had a fall resulting in a head injury on 03/11/14. Review of the nurse's notes, on 06/18/14 at 3:00 p.m., revealed a note dated, 03/11/14 at 3:11 p.m., which described the resident fell on to the bathroom floor while being assisted in toileting. An interview with Employee #2, a registered nurse (RN), on 06/19/14 at 1:21 p.m., revealed only one (1) nursing assistant was assisting the resident when he fell . Review of the resident's care plan, on 06/19/14 at 9:20 a.m., found it indicated the resident required extensive assist of two (2) with transfers and total assist of two (2) with toileting. There was no evidence this incident was thoroughly investigated. At 2:47 p.m. on 06/19/14, the director of nursing said, Social services reminded me we did not investigate the matter because the physician wrote a note that the resident was having a stroke prior to or during the fall. This did not negate the fact the resident was transferred by one (1) person instead of two (2). That part of the incident, neglect, required reporting and investigation. 2. Resident #110's medical record indicated she was sent to the hospital on [DATE] to have a Rape kit done. She had stated a male nursing assistant had raped her. There was no evidence the allegation was investigated by the facility. An interview with Employee #63, a Social Worker (SW), on 06/26/14 at 1:35 p.m., revealed the facility did not do an investigation of the allegation because the hospital report showed no evidence the resident was raped and the resident had no memory of the allegation. Upon inquiry, the SW confirmed she had not considered the possibility that something happened to the resident which required an investigation, even though it was not rape. 3. On 06/17/14 at 1:20 p.m., the personnel file review revealed Employee #103 (resident service provider) came to work at the facility on 06/01/10. This employee listed on her application she had worked in a neighboring state until 2007. The facility had completed a criminal background check for the state of West Virginia at the time the employee was hired. The personnel file contained no evidence showing the facility had conducted a criminal background check outside of West Virginia. On 06/23/14 at 1:30 p.m. Employee #99 (bookkeeper) said the facility had not conducted a criminal background check in the neighboring state for Employee #103. e) The QA & A committee failed to identify the need to develop and implement processes to ensure the operationalization of abuse policies and procedures (P & P) to prevent, identify, investigate, and report abuse and mistreatment. In addition, the policy referred to a Federal requirement which does not exist, and to an outdated State Licensure rule regarding abuse. The QA & A committee failed to ensure the facility operationalized their policies and procedures for Residents #95, #100, and #59, as the facility failed to investigate all alleged abuse and neglect; failed to obtain statements from all witnesses, employees, residents; and failed to document all interviews with witnesses. 1. Review of the facility's abuse policies and procedures found all aspects of the seven (7) required components were not accurate and/or developed. The QA & A committee failed to evaluate the policy to ensure all components were in accordance with current regulations: -- The procedures for reporting did not include the requirement to immediately (within 24 hours) report all allegations of abuse or neglect to the appropriate State agencies. -- The policy refers to F228, a regulation which does not exist. -- The policy refers to the Nursing Home rule dated June 18, 2001; however, this is not the most current rule. 2. Resident #95: The facility failed to operationalize their P & P to report and investigate an allegation of abuse regarding Resident #95. During an interview with Resident #95, at 3:55 p.m. on 06/17/14, she reported, a nursing assistant was rough with her, bruising her wrist and made her ribs sore, when she took her to the commode. The resident's family was interviewed on 06/19/14 at 1:45 p.m. The family member said Resident #95 told him someone had been rough with her. According to the family, this allegation was reported to Employee #61 (social worker). Upon inquiry on 06/19/14 at 2:20 p.m., Employee #61, social worker, provided a copy of the resident's allegation dated 01/14/14. Review of the document revealed Employee #61 was made aware of the alleged incident and interviewed the resident, but failed to conduct a thorough investigation. The social worker said she did nothing further because she did not feel the allegation was substantiated. Review of the facility's reportable allegations, on 06/19/14 at 3:00 p.m., revealed no record the allegation was reported to the required agencies. The review also revealed no evidence of a thorough investigation. 3. Resident #100: The facility failed to operationalize their P &P to report and investigate an allegation of abuse regarding Resident #100. On 06/16/14 at 6:32 p.m., the family member of Resident #100 stated staff had been rough with the resident during care. The family member said the incident was reported to facility staff during a care plan meeting, and the facility assured them the incident would be investigated. The facility's reported allegations of abuse and neglect, which had been reported to the State, contained no reporting or investigation of any concerns related to Resident #100. Employee #3, a registered nurse, was interviewed on 06/19/2014 at 11:06 a.m. Employee #3 stated she remembered the meeting when the resident's family told the care plan team a staff member had been rough with the resident during care. Employee #3 said she believed the social worker investigated the situation. The social worker, Employee #63, was interviewed at 12:58 p.m. on 06/19/14. She stated the resident's wife told her, Someone had been rough with him. The social worker said she did not report the incident because she said she was not able to confirm the who, what, where and when. She said she took it upon herself to not report it because some people are just rougher than others. 4. The facility's policy entitled, Procedure for Patient Abuse Investigation was reviewed on 06/25/14 at 3:00 p.m. It included: The facility shall investigate and report alleged abuse as follows: -- Report incident to Administrator, Director of Nursing and Social Services Director. The Social Services Director, upon preliminary investigation, shall notify the Office of Health Facility Licensure and Certification and the Department of Health and Human Resources, Adult Protective Services about the alleged abuse. -- The facility will investigate reports of alleged abuse and neglect to determine if the conduct of the employee is in violation of any standard of care -- As part of the investigation process the following will be done: -- Obtain statement from all witnesses, employees, residents or visitors. -- The facility will document all interviews with witnesses The QA & A committee failed to identify staff were not implementing their written policies. 5. Resident #59 fell , on 03/11/14 (the time was not identified), while being assisted with toileting. Review of the resident's care plan revealed the resident required extensive assistance of two (2) with transfers and total assistance of two (2) with toileting. At 1:21 p.m. on 06/19/14, Employee #2, a registered nurse (RN), was asked how many staff members were assisting the resident at the time of his fall on 03/11/13. She stated only one (1) staff member was assisting Resident #59 at the time of the fall. At 2:47 p.m. on 06/19/2014, the DON reported the the facility did not investigate the matter. The facility failed to operationalize their P & P to report and investigate this alleged neglect of Resident #56. f) The QA &A committee failed to identify the need to develop and implement processes to ensure a dignified dining experience for residents who had their meals in the main dining room. Several residents were still eating when a staff member removed their plates without asking if they were finished. In addition, the staff member scraped unconsumed food and beverages into a bucket in view of the residents. g) The QA & A committee failed to identify the need to develop and implement processes to ensure residents were free to exercise autonomy regarding what the residents considered important aspects of their lives. Residents #2, #98, #71, and #29 were not free to exercise autonomy regarding the use of side rails. Residents #21 and #100 did not have a choice regarding the number of showers they received each week. 1. Resident #2 said she was upset on 06/17/14 at 4:25 p.m., because the facility discontinued her side rails. she said she felt safer with them. An observation and interview with Resident #2, on 06/20/14 at 9:10 a.m., revealed she could only raise the height of her bed. She was not able to reposition herself in bed or raise the head of the bed because the controls were located on the lowered side rail., which was secured in the lower position with two (2) plastic zip ties. Review of the side rail assessment, completed on 05/04/14, revealed the resident required side rails for turning and repositioning, as well as to transfer herself in and out of the bed. Review of the resident care plan revealed an intervention, dated 11/07/13, which stated: May have 1/4 to 1/2 side rails to head of bed for mobility. 2. Resident #98 was interviewed, along with his wife, on 06/23/14 at 1:47 p.m. They were concerned because the facility informed them the resident could no longer use his side rails. Observation revealed the resident's two (2) 1/4 side rails were secured in the lowered position with two (2) zip ties on each side rail . The resident could not turn and reposition himself independently when the side rails were down. Without the side rails, the resident had to call staff to assist him to turn and reposition. During the interview, the resident asked if he would again be able to use his side rails. The resident and his wife said they were not consulted in the decision regarding discontinuation of the use of the side rails. 3) Resident #71 was observed in her bed on 06/25/14 at 3:30 p.m Her side rails were in the down position, and were secured with two (2) zip ties on each side rail . The resident said she wished she still had her side rails, because she used them to position herself in the bed. She asked if she would ever get them back. During a telephone conversation, on 06/25/14 at 5:00 p.m., with the MPOA for Resident #71, the resident's MPOA said the resident was very upset about losing her side rails, as she was able to turn and reposition independently while in bed. She said the resident longer feels safe in bed, and now requires assistance to turn and reposition. The MPOA said it was her opinion, the resident could do more and felt safer with the side rails. She said she wanted the resident to once again be able to utilize her side rails. 4. Resident #29, when interviewed on 6/17/14 at 4:20 p.m., said her side rails were removed about a week ago. She said she was informed by staff that she could no longer use them. On 06/25/14 at 11:20 a.m., during another interview, Resident #29 said she almost fell getting out of bed that morning because she did not have her side rail to assist her. Several times during the conversation, she expressed a fear of falling. The resident said she used to be able to get out of bed herself using the side rail and the arm of her recliner. She said she now no longer attempted to get out of bed, without staff, due to a fear of falling. The resident said when she had her side rails, she was not fearful of falling. She said her anxiety was higher now because she cannot have her side rails. During a telephone interview with the resident's MPOA, on 06/25/14 at 11:31 a.m., the MPOA said she really believed Resident #29 needed her side rails. She voiced fear the risk of injury to the resident was greater without the side rails than with the side rails. The MPOA said she thought the decision made the resident require staff assistance in areas in which she did not previously need assistance. The MPOA also said the entire situation has made the resident's anxiety worse. 5. During an interview with Employee #1 (director of nursing), on 06/24/14 at 9:30 a.m., she reported the side rails were discontinued on 06/11/14 at the request of the medical director. When asked what alternatives were offered the residents, she said the side rails were discontinued prior to the alternative devices being in place. An interview with the medical director, on 06/25/14 at 8:00 a.m., revealed residents were to be assessed by physical therapy and alternate bed control and positioning devices were to be in place prior to the discontinuation of the bed rails. She confirmed the facility had not completed the physical therapy evaluations, and did not have alternate positioning devices prior to the discontinuation of the side rails. h) The QA & A committee failed to identify the need to develop and implement processes to ensure residents were provided reasonable accommodations of individual needs and preferences. The environment and staff behaviors were not directed toward assisting each resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible. For Residents #2, #29, #71, #98, and #56, the facility did not evaluate each resident's unique needs and preferences, to ensure each resident was reasonably accommodated, when their side rails were removed from use. The plan was for residents to be assessed by physical therapy and alternate bed control and positioning devices were to be in place prior to the discontinuation of the bed rails. The facility had not done the physical therapy evaluations and had not provided alternatives to the side rails prior to discontinuing them. i) The QA & A committee failed to identify the need to develop and implement processes to to ensure residents were notified before a room change occurred. During an interview, at 1:16 p.m. on 06/17/14, Resident #21 stated he was moved from the first floor to the second floor without explanation. Review of the nurse's note, dated 06/06/14, confirmed the resident was moved from room [ROOM NUMBER] to room [ROOM NUMBER] on 06/06/14. According to the note, the medical power of attorney was called about the room move; however, there was no evidence the resident was notified of the room move. The director of nursing was interviewed at 12:52 p.m. on 06/25/14. She was unable to provide evidence the room move was discussed with Resident #21 before he was moved. j) The QA &A committee failed to identify the need to develop and implement processes to ensure effective maintenance services in 20 of 39 resident rooms/bathrooms and a resident common area. The ceramic tiles around the sink area in resident rooms were cracked. Bathroom doors had deep scratches in the wood surfaces. Door facings going into bathrooms had chipped paint. Exhaust fans in the bathrooms were rusted. The ceiling in one (1) resident room had peeling plaster/paint. Doorknob plates were loose. Chairs in the dining area on first floor had scratched arms and legs. The hand rail across from the nursing station on second floor was loose. In addition, the QA & A committee failed to identify the need to develop and implement processes to ensure effective housekeeping and/or maintenance services. Two (2) of 77 residents, observed through random observations, had dirty wheelchairs. Five (5) of 35 census sample residents and one (1) resident observed through random observations had cracked wheelchair and/or Broda chair coverings. These cracks in the coverings rendered the equipment unable to be effectively cleaned. k) The QA & A committee failed to identify the need to develop and implement processes to ensure the Resident Assessment Instrument (RAI) was used to accurately assess residents using the Minimum Data Set (MDS), to develop care plans, to revise care plans as needed, and/or to implement care plans. 1. Resident #64's MDS was not accurate. The MDS did not indicate the resident used a restraint or that the resident had a fall. The resident was observed restrained with a pelvic sling in a reclining Broda chair (a tilting and reclining positioning chair). The sling was tied behind and under the seat of the Broda chair. The pelvic restraint was observed in use on 06/17/14 at 2:22 p.m., 06/18/14 at 12:30 p.m.,06/19/14 at 9:00 a.m., 06/20/14 at 10:17 a.m., and 06/23/14 at 1:26 p.m. On 06/24/14 the resident was observed with the sling in place continuously from 8:15 a.m. until 9:51 a.m. On 06/25/14 the resident was observed from 9:00 a.m. to 9:33 a.m., and at 5:13 p.m. with the sling in place. The resident was also observed seated in this manner on 06/26/14 at 11:46 a.m. Review of the medical record, on 06/24/14, found the resident's last annual MDS had an assessment reference date (ARD) of 03/06/14. Section P of the MDS was not coded to reflect the resident had a physical restraint. Medical record review, on 06/25/14, found the resident fell from her bed on 12/13/13. Review of the resident's annual MDS with an ARD of 03/06/14, Section J (Health Conditions), indicated the resident had no falls since her last assessment, which was a quarterly MDS with an ARD of 12/06/13. 2. Resident #14's MDS was not accurate. During an interview with the resident, on 06/16/14 at 2:00 p.m., she stated, The dentist pulled some teeth a long time ago. When asked if her teeth hurt her, she replied sometimes. review of the resident's medical record revealed [REDACTED]. Section (L) Oral Dental Status indicated the resident had no dental problems. Employee #12 (licensed practical nurse) was asked to assess the resident's mouth on 06/16/14 at 2:20 p.m. She confirmed several of the resident's bottom molars were missing, her teeth were discolored, an upper left tooth next to the front tooth was cracked, and food particles were on the resident's teeth. 3. Resident #56 did not have a comprehensive care plan to address the resident's [MEDICAL CONDITION]. On 06/20/14 at 8:56 a.m., medical record review showed Resident #56 was taking [MEDICATION NAME] 40 milligram (mg) 1 tablet every day for [MEDICAL CONDITION]. Review of medical records, on 6/24/14 at 8:50 a.m., revealed pertinent [DIAGNOSES REDACTED]. The resident's care plan did not identify [MEDICAL CONDITION] as a problem. The only mention of [MEDICAL CONDITION] was in a problem statement under dehydration, created on 1/14/14, which stated . on a diuretic for [MEDICAL CONDITION] which puts her at risk for dehydration. Employee #18, a Licensed Practical Nurse (LPN), was interviewed, on 6/24/14 at 10:45 a.m. She reported the resident had bilateral lower extremity [MEDICAL CONDITION] that comes and goes, and the resident was encouraged to keep her legs elevated The resident's care plan did not discuss elevating the resident's legs, or directives to monitor the resident's [MEDICAL CONDITION]. On 6/25/14 at 5:50 p.m., Employee #2, a MDS nurse, was interviewed. She reviewed Resident's #56's care plan and confirmed the only care plan concerning [MEDICAL CONDITION] was under dehydration. When asked how staff knew what care the resident required to address the [MEDICAL CONDITION] (such as elevating the resident's legs and monitoring), Employee #2 replied: . they wouldn't, because it wasn't in the care plan . 4. Resident #64 did not have a care plan related to the use of a restraint. Observation, on 06/16/14 at 12:45 p.m., revealed this resident was reclined in a Broda chair. The resident also had a pelvic sling tied under the Broda chair, and out of reach of the resident. Her legs were elevated with the foot rest of the chair. The pelvic sling, which was between the resident's legs and tied to the chair, rendered the resident incapable of turning and repositioning herself. The care plan was reviewed on 06/20/14 at 10:33 a.m. There were no interventions for position changes while the resident was in the Broda chair and using a pelvic sling. On 06/25/14 at 2:15 p.m., an interview was held with Employee #2, a MDS nurse. She reviewed the care plan and confirmed there was no care plan regarding how and when the resident should be repositioned. 5. Resident #59's care plan was not revised related to falls or to reflect the number of staff needed for assistance. The care plan, with a start date of 01/20/14, was reviewed on 06/20/14 at 9:20 a.m. The category of ADL function / Rehabilitation Potential stated: extensive assist of two (2) with transfers and total assist of two (2) with toileting. It had an edited date of 02/28/14. The category of Falls, listed five (5) falls from 02/10/14 - 03/11/14. A fall that occurred on 03/09/14 was not identified on the care plan which was updated on 03/12/14. The approach / intervention, dated for 03/12/14, was for the resident to have assist of two (2) for all transfers. The MDS, with an assessment reference date (ARD) of 02/24/14, was reviewed on 06/19/14 at 10:32 a.m. It indicated a change/or correction in the resident's level of functioning was needed. The previous MDS, with an ARD of 02/03/14, indicated the resident was extensive assist of two (2) for transferring and toileting (weight bearing). The correction/or change, on the MDS with an ARD of 02/24/14, stated he was extensive assist of one (1) staff member for transferring and toileting. On 06/19/14 at 4:06 p.m., Employee #1, the director of nursing (DON) provided the MDS dated [DATE] that indicated the resident was extensive assist of one (1) for toileting. She stated that the MDS was correct and the care plan was incorrect. The care plan was not revised to reflect the resident's current assessed needs. 6. Resident #2's care plan revealed an intervention, dated 11/07/13, which stated May have 1/4 to 1/2 side rails to head of bed for mobility. The care plan indicated the last review was done on 05/13/14. The facility discontinued this resident's side rails on 06/11/14. The care plan was not revised regarding the side rails and/or the need for an alternative device for bed mobility. 7. Resident #59's care plan was not implemented regarding the amount of assistance he needed, resulting in harm when he fell and injured his head. Review of the Nurses notes,on 06/24/14 at 8:35 a.m., revealed an entry dated 03/11/14 at 3:11 p.m. indicating the resident fell while being assisted in the bathroom. An interview with Employee #2, a registered nurse (RN), on 06/19/14 at 1:21 p.m., revealed Employee #32, a nurse aide (NA) was the only staff member assisting Resident #59 at the time of the fall. On 06/20/14 at 9:20 a.m., the resident's care plan at the time of the fall, with a start date of 01/20/14 (edited on 02/28/14 and updated on 03/12/14) was reviewed. The care plan contained an intervention requiring the assistance of two (2) for toileting. The category of ADL function / Rehabilitation Potential stated the resident required extensive assistance of two (2) with transfers and total assistance of two (2) with toileting. Upon inquiry, on 06/19/14 at 4:06 p.m., Employee #1, the director of nursing (DON), said the nurse aides (NAs) identified how much assistance was needed for each resident's individual needs by looking at the the resident profiles. She explained the resident profiles were based on the residents' care plans, and were accessible to the NAs on the computers located on each hall. On 06/24/2014 at 9:37 a.m., the resident profile which was to have been used by the NA to provide care for Resident #59 on 03/11/14 was reviewed. It indicated Resident #59 was to have extensive assist of two (2) with bed mobility, transfers, hygiene, and total assist of two (2) with toileting. 8. Resident #2's care plan for positioning and support was not implemented. On 06/16/14 at 12:00 p.m., Resident #2 was observed sitting in her wheelchair with her lower extremities unsupported. The resident's feet did not reach the floor and no foot rests were observed on the wheelchair. The resident was observed in the same circumstances on 06/16/14 at 2:00 p.m., and again on 06/17/14 at 1:00 p.m. During an interview with Employee #2 (registered nurse), on 06/ (TRUNCATED)",2018-04-01
7074,GREENBRIER HEALTH CARE CENTER,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2014-09-12,157,D,1,0,H9YP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the resident's physician was immediately notified when there was an accident involving the resident which resulted in an injury and had the potential for requiring physician intervention or when there was a significant change in the resident's physical status. Resident #84 experienced a fall with an injury and began experiencing pain in her right hip. The physician was not notified until the next day. Resident #72 sustained a fall, had an elevated blood pressure, and later complained of hitting her head with the fall as well as continuing to have elevated blood pressures. The physician was not immediately notified. Two (2) of three (3) resident's reviewed had an accident that had the potential to require physician intervention. Both residents were sent to a hospital for x-rays once the physician was notified. Resident identifiers: #84 and #72. Facility census: 82. Findings include: a) Resident #84 Medical record review on 09/09/14 at 1:00 p.m., revealed the resident fell on [DATE] at 6:20 p.m. The progress note stated, (typed as written) Called residents room. Resident sitting bathroom shower floor. Blood on hands and wall. Resident stated she hit her head trying to go to the bathroom. 1/2 in (inch) laceration with bruise and goose egg. Resident alert and responds to commands speech normal. grips wnl (within normal limits). No other injuries. BP (blood pressure) 152/80, p (pulse) 100, sat (saturation) 89% room air temp 98.1. MOA (medical power of attorney) made aware will continue to follow. A note dated 08/15/14 9:40 p.m. stated PRN (as needed) [MEDICATION NAME] given to resident at 8 pm. Resident complaining of right hip pain when daughter was in room visiting. This nurse stated that if the pain medication didn't help her pain that we could send her to the hospital to be evaluated Another progress note dated 08/16/14 5:57 a.m. Resident received PRN [MEDICATION NAME] at 1:30 am for right hip pain. Resident was monitored closely throughout the night in which resident slept soundly. Resident received PRN Tylenol at 4:00 a.m. for pain prevention. When asked if the resident was hurting anywhere she shook her head no. Resident is resting well in bed at current time with no signs/symptoms of pain. A note dated 08/16/14 9:04 a.m. Per shift report from previous nurse resident had a fall on 08/15/14 and daughter wanted to 'wait and see how she did throughout the night before sending to the hospital.' This nurse went back to assess resident and at that time resident complained of 'really bad' pain in the right shoulder as well as in the right hip extending down the right leg. Resident was unable to stand up straight when attempted and stated 'Honey, I just can't. It hurts too bad.' This nurse contacted physician and obtained verbal order to send to hospital for x-rays to bilateral hips as well as right shoulder On 09/09/14 at 2:00 p.m., the director of nursing (Employee #1) indicated the nursing staff should have contacted Resident #84's physician prior to 08/16/14 at 9:05 a.m. b) Resident #72 Medical record review for Resident #72, on 09/10/14 at 11:00 a.m., revealed Resident #72 fell on [DATE] at 4:00 a.m. The progress note (typed as written) stated: Resident bathroom emergency light sounding. Entered room, observed resident lying in bathroom floor in doorway on her back. Range of motion within normal limits. Observed large skin tear on left elbow. Resident assisted to bed with assist x 3. Vital signs 250/100, 60, 20, 97.2, 93%, (blood pressure, pulse, respirations, temperature, and oxygen saturation) on 2 liters (of oxygen). Resident stated she did not hit her head. Pupils equal, reactive. Administered morning blood pressure medications for elevated blood pressure. Skin tear cleansed. 3 steri strips applied. Covered with mepore. Recheck blood pressure 0445 am with results 200/80. Resident states at this time that she did hit the back of her head. No swelling or redness noted. Recheck blood pressure again at 5:30 am with result 188/78. Order written for staff to observe frequently while in room. The progress notes revealed the facility contacted the physician at 7:30 a.m. on 08/27/14. The physician gave orders for the facility to send the resident to the emergency room for x-rays. The facility had not contacted the physician about the accident and the resident's condition prior to 08/27/14 at 7:30 a.m. On 09/10/14 at 12:00 p.m., the director of nursing (DON) was informed the facility had not consulted with Resident #72's physician when she had a fall, elevated blood pressures, and later complained of hitting her head with the fall as well as continuing to have elevated blood pressures. The director of nursing (Employee #1) had no further comments.",2017-09-01
7075,GREENBRIER HEALTH CARE CENTER,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2014-09-12,309,D,1,0,H9YP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide the necessary care and services to ensure residents received the highest practicable level of well-being. One (1) of three (3) residents reviewed had pain while performing physical therapy which affected her ability to participate in therapy. The physical therapy staff did not inform the nursing staff of the resident's complaints of pain. Resident identifier: #84. Facility census: 82. Findings include: a) Resident #84 On 09/09/14 at 1:00 p.m., medical record review for Resident #84 found progress notes identifying the resident came to the facility on [DATE] for rehabilitation after suffering a left [MEDICAL CONDITION]. The resident received physical therapy services in July, August, and September 2014. The physical therapy notes dated 07/09/14 stated Pt (patient) complained of L (left) leg pain. On 07/15/14, the progress note stated, pt. (patient) reports hip p (pain)! with Amb (ambulation). Subsequent physical therapy notes were: - 07/18/14 a physical therapy note included, Pt c/o (complained of) increased pain left knee and hip with flexion and amb (ambulation). - 07/23/14 Pt c/o hip pain and not feeling good today. Refused to ambulate farther than 30' (feet). - 07/24/14 Pt. continued to c/o discomfort in her joints. -07/30/14 c/o high pain levels L (left) lower extremity whole thing. -07/31/14 Pt (patient) c/o to much pain to walk more than 45' (feet). - 08/04/14 Pt c/o L (left) LE (lower extremity) pain asked to stop amb due to (sign for increased) L (left) lower extremity pain. - 08/06/14 Pt c/o hip pain and stomach pain. Pt. unable to tolerate more walking due to stomach discomfort. - 08/14/14 Pt c/o L hip and abdominal pain today again. - 08/18/14 Pt continues to c/o L hip pain which limited ambulation - 08/20/14 Pt c/o hip pain during Ambulation. Pt. very difficult to engage in exercises - 08/25/14 Pt only able to walk 10' due to pain and motivation On 08/25/14, the nursing progress note indicated the resident had complained of bilateral hip and back pain. The facility asked the resident's responsible party if they would like the resident to have a stronger pain medication. The resident's responsible party declined a stronger pain medication. On 09/01/14, the resident's daughter requested the facility administer ([MEDICATION NAME]) on a scheduled basis instead of prn (as needed). The resident had received [MEDICATION NAME] since 07/30/14. Prior to 07/30/14 the resident had received Tylenol OTC (over the counter) tablet 325 mg (milligram) two (2) tablets orally twice a day (morning and evening). During an interview with the physical therapy assistant (PTA) (Employee #115), on 09/10/14 at 4:00 p.m., the PTA said the therapy department will inform nursing staff verbally when residents complain of pain during therapy. He did not have any specific information related to whether or not he informed nursing staff of Resident #84's episodes of pain during therapy on the dates listed previously. On 09/10/14 at 4:15 p.m. the director of nursing (Employee #1) agreed the facility needed better communication with the therapy department to ensure a better continuity of care for residents.",2017-09-01
7076,GREENBRIER HEALTH CARE CENTER,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2014-09-12,514,D,1,0,H9YP11,"Based on medical record review and staff interview, the facility failed to ensure medical records were accurate and complete for two (2) of three (3) residents whose medical records were reviewed. Resident #84's medical record review revealed inaccuracies in progress notes, event reports, and neurological evaluations related to a fall. Resident #42's medical record contained inaccuracies in a progress note related to a fall. Resident identifiers: #84 and #42. Facility census: 82. Findings include: a) Resident #84 On 09/09/14 at 1:00 p.m., the medical record review for Resident #84 revealed a progress note dated 08/15/14 at 7:22 p.m. The note stated, (typed as written) Called residents room. Resident sitting bathroom shower floor. Blood on hands floor and wall. Resident stated she hit her head trying to get to the bathroom. ? laceration with bruise and goose egg. Resident alert responds to commands speech normal, grips wnl (within normal limits). No other injuries noted. BP (blood pressure) 152/40 p (pulse) 100 sat (saturation) 89% room air temp 98.1. MPOA (medical power of attorney) made aware. Will continue to follow. Further medical record review revealed inaccuracies in the progress note, event report and neurological assessments pertaining to the fall on 08/15/14. The three pieces of documentation all listed the fall as occurring at different times. On 09/10/14 at 4:15 p.m. Employee #13 (licensed practical nurse) said she worked the evening of 08/15/14 and completed the progress note, event report, and neurological assessment. She said the fall occurred on 08/15/14 at 6:20 p.m. She confirmed the progress note and event report were not accurate regarding the time the fall occurred. A review of the neurological assessment completed after the fall on 08/15/14 revealed the assessment on 08/16/14 at 6:20 a.m. was not completed. This assessment listed the resident as MLOA (medical leave of absence) at 6:20 a.m. on 08/16/14. The progress notes review showed the resident left the facility at 9:04 a.m. on 08/16/14. The director of nursing (Employee #1) verified on 09/10/14 at 4:20 p.m., the inaccuracy on the neurological assessment form. She indicated the nursing staff should have completed the neurological assessment on 08/16/14 at 6:20 a.m. She also confirmed the progress note and event report were inaccurate regarding the time the fall occurred. b) Resident #42 Medical record review for Resident #42 on 09/11/14 at 11:00 a.m., revealed a progress note dated 09/05/14 at 7:07 a.m. The note stated, Aide on evening called me to resident's room. When I came into room I saw resident sitting in the bathroom floor with towel underneath her. Resident stated she got weak and slowly sit herself down in the floor. Aide was in the room so it was witnessed. Resident stated that she had no pain. I took vitals and all vitals were in normal limits. No complaints of pain throughout the shift. The director of nursing (Employee #1) stated, on 09/11/14 at 11:15 a.m., the facility did not have an event report for this occurrence. She said based on the note documented on 09/05/14 she did not know the exact time the fall occurred on 09/04/14. Employee #1 confirmed the licensed practical nurse who completed the note on 09/05/14 did not complete the documentation to reflect a late entry.",2017-09-01
7671,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-01-17,224,D,0,1,C1G011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and resident interview, the facility failed to ensure one (1) of twenty-five (25) Stage 2 residents was free from neglect. The facility failed to assess, monitor, and provide medical interventions in a timely manner for a resident with diabetes and recurrent urinary tract infections. There was no evidence of physician's orders [REDACTED]. There was also no evidence of interventions to prevent the urinary tract infections this same resident was experiencing. This lack of monitoring and interventions for both the glucose level and urinary tract infections had the potential to adversely affect the physical comfort, mental, and psychosocial well-being for one (1) of four (4) residents reviewed for diabetic care, who was also one (1) of five (5) residents reviewed for urinary tract infections. Resident identifier: #15. Facility census: 88. Findings include: a) Resident #88 This resident had a [DIAGNOSES REDACTED]. Upon review of physician's orders [REDACTED]. Review of the medical record revealed evidence of concern related to diabetes which included a [DIAGNOSES REDACTED]. A nursing note, dated 07/15/12 at 2:36 p.m., revealed the resident had a blood glucose level of 294. There was no order for this test, and no documentation regarding why this test was obtained. Additionally, there was no evidence the results of this test were provided to anyone, including the physician or any nursing administrative personnel. According to the American Diabetes Association, the blood glucose target range for diabetics is 70-130 before meals and less than 180 after meals. Employee #3, a registered nurse, was requested to provide the most recent glucose values for Resident #15. Employee #3 presented a medication administration sheet, dated 10/01/06 to 10/31/06, in which blood glucose values were completed twice per day. Employee #3 also presented a physician's orders [REDACTED]. No other evidence was presented by Employee #3 that blood glucose levels or Hemoglobin A1C values were obtained between 11/02/06 and the date of the investigation, 01/10/13. On 01/10/13 at 4:00 p.m., the director of nursing (DON) stated she would look for additional information pertaining to glucose levels for Resident #15. On 01/14/13 at 9:00 a.m., the DON stated she was unable to find further information. At On 01/16/13 at 8:45 a.m. Resident #15 stated her leg was removed after she went to a doctor to get her toenails trimmed. Resident #15 stated the toe became infected, her toes turned black and eventually her leg was removed. Resident #15 stated this occurred because she was a diabetic. 2) Review of Resident #15 ' s lab results revealed the resident had urinary tract infections seven (7) times between 06/08/12 and 01/01/13. Six (6) of these lab results were positive for Escherichia-coli. Antibiotics were ordered. There was no evidence of interventions to assess causal factors and/or prevent UTIs. Nursing notes were reviewed. The notes revealed the resident was catheterized to obtain a urine sample nine (9) times between 08/01/12 and 01/16/13. These same notes contained numerous references to the resident being confused with acting out behaviors. On 01/14/13, during Stage II of the survey, the facility was informed about the findings of multiple UTIs for Resident #15. The infection control nurse, Employee #7, was asked to provide information regarding care planning/interventions concerning this matter. On 01/15/13 at 4:00 p.m., Employee #7 provided a training/in-service for prevention of urinary tract infections/personal hygiene care dated 01/15/13. This document was signed by fifteen (15) employees dated 01/15/13 and 01/16/13. This in-service was provided after the situation was brought to the attention of the facility during the survey. No other evidence was provided to confirm the facility had addressed the recurrent UTIs the resident was experiencing. Employee #59, medical records, presented a copy of Resident #15 ' s most recent urologist consult on 01/16/13. The consultation was dated 03/24/10. The consultation noted the resident had a history of [REDACTED]. At the time of the consultation, Resident #15 was prescribed [MEDICATION NAME] daily. The recommendation on the consult was to continue [MEDICATION NAME] every day. A follow-up appointment was set for 03/31/11; however, the resident did not go to the appointment. On 01/16/13 at 4:00 p.m., Employee #59 stated Resident #15 was hospitalized around that time, her leg was amputated, and the facility did not reschedule an urologist follow-up appointment. No other urologist consultation was presented by the facility.",2017-03-01
7672,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-01-17,241,E,0,1,C1G011,"Based on observation, medical record review, and staff interview, the facility failed to maintain resident dignity. A urinary catheter bag was not covered for one (1) of three (3) residents observed who had catheters. In addition, the facility did not ensure direct care staff displayed identification badges while providing care, so residents could identify them. This was observed for three (3) direct care staff members during observations on the 100 hall. These practices had the potential to affect more than an isolated number of residents. Resident Identifier: #112. Employee identifiers #37, #35, and #38. Facility census: 88. Findings Include: a) Resident #112 Resident #112 was observed on 01/14/13 at 1:45 p.m. The resident was resting in bed. Observation revealed the resident's urinary catheter drainage bag was not covered. Review of the resident's care plan was conducted on 01/14/13 at 2:10 p.m. The care plan stated the resident's urinary catheter drainage bag was to be covered at all times. Interview with the Clinical Care Manager (CCM), a registered nurse (RN), Employee #7, was conducted at 2:20 p.m. on 01/14/13. During that interview, Employee #7 stated all resident urinary catheter bags were to be covered at all times. At that time, Employee #7 was informed the urinary catheter bag for Resident #112 was not covered. Employee #7 expressed understanding of this finding. b) Employee #37 At 4:45 p.m. on 01/08/13, this employee was approached on the 100 Hallway to inform her a resident needed assistance. She was not wearing an identification badge, so she was asked if she was a nursing assistant. The employee replied Yeah, as she pulled her identification badge out of her shirt pocket, then quickly put it back in the pocket. One (1) hour later, at 5:45 p.m. this employee was observed again in the dining area. She still was not wearing her identification badge. b) Employee #45 At 5:15 p.m. on 01/08/13, this employee was observed in the dining area on 100 Hallway. She was not wearing an employee identification badge. c) Employee #28 On 01/08/13 at 5:30 p.m., this employee was observed in the dining area on 100 Hallway. She was not wearing an employee identification badge. d) During the dining observation in the 100 Hallway dining area at 6:00 p.m. on 01/08/13, Employee #45 told Employee #28 she obtained an identification badge from the facility's front office. She advised Employee #28 she could obtain a name badge from the front office. Employee #28 replied she lost her identification badge. One (1) hour later, at 7:00 p.m., Employee #28 was observed in the 100 Hallway, still not wearing an identification badge.",2017-03-01
7673,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-01-17,279,E,0,1,C1G011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, policy review, and observation, the facility's interdisciplinary team failed to develop a comprehensive care plan to address the care needs and to describe the services needed for residents to maintain a safe environment, to prevent further decline, and to prevent complications in their conditions. The care plans were not complete and/or did not contain measurable interventions to provide care in areas of anticoagulant ([MEDICATION NAME]) therapy, accident/falls, assistance needed with meals, antipsychotic/ antidepressant medication, end stage [MEDICAL CONDITION] requiring [MEDICAL TREATMENT], chronic obstruction [MEDICAL CONDITION] disease, nutrition, diabetes, indwelling catheter, urinary tract infection, pressure ulcer, contractures, pain, [MEDICAL CONDITION] disorder with use of [MEDICATION NAME], and [MEDICAL CONDITION]. This was evident for eleven (11) of twenty-five (25) stage two sample residents. Resident identifier: #4, #5, #15,#18, #22, #31, #39, #60, #61, #89, and #99. Facility Census: 88. Findings include: a) Resident #18 A review of the discharge summary from the hospital, dated 12/31/12, revealed a [DIAGNOSES REDACTED]. Review of the current interdisciplinary care plan, on 01/15/13 at 3:34 p.m., found no care plan related to use of anticoagulant ([MEDICATION NAME]) therapy, which impacted the resident's care needs. On 01/15/13 at 3:46 p.m., an interview was conducted with Employee #6, registered nurse (RN). She verified the care plan did not address the need for anticoagulant ([MEDICATION NAME]) therapy. On 01/16/13 at 10:38 a.m., an interview with Employee #1, director of nursing (DON), confirmed the current care plan did not address the use of anticoagulant ([MEDICATION NAME]) therapy. b) Resident #99 1) Review of the Minimum Data Sets (MDS) with Assessment Reference Dates (ARD) of 07/02/12, 10/01/12, and 12/23/12, revealed this [AGE] year old resident experienced repeated falls. Also, her cognitive ability could not be scored due to her advanced stage of dementia. Fall risk assessments completed on 07/01/12, 10/07/12 and 01/10/13, had scores of 20, 18, and 18 respectively, indicating she was at high risk for falls. [DIAGNOSES REDACTED]. Review of the care plan found no focus on the problem area of falls, although falls were identified in the MDS's. Record review found evidence of falls on 07/20/12, 09/28/12, 10/20/12, 10/21/12, 11/30/12, 12/01/12, 12/16/12, 12/31/12, and 01/01/13. During an interview with the Director of Nursing (DON) and the MDS coordinator on 01/15/13 at 9:35 a.m., the DON said the care plan should have included falls, but it did not. She said they used to bring the care plans to the risk management meetings, but have gotten away from that practice. The MDS nurse said they suspect that sometimes this resident just sits down on the floor, as the falls are not always witnessed; rather, they just find her sitting on the floor. 2) Review of the MDS assessment, with an ARD of 07/02/12, 10/01/12, and 12/23/12, revealed Resident #99 had received antipsychotic and antidepressant medications daily in the seven (7) day look back period. Record review found this resident was prescribed an antidepressant, Trazedone 25 mg every evening, and an antipsychotic medication, [MEDICATION NAME] 5 mg daily at bedtime. Review of the care plan found no mention of the use of psychoactive medications. There were no measurable goals for treatment with psychoactive medications, targeted behaviors, or potential side effects of these medications. During an interview with the DON on 01/15/13 at 9:35 a.m., she acknowledged the current care plan did not address the use of psychoactive medications. c) Resident #31 The MDS, with an ARD of 11/27/12, identified this resident had an indwelling Foley catheter. Additionally, the resident had a urinary tract infection within the preceding 30 (thirty) days. Record review revealed he had an abnormal urinalysis on 12/07/12. A culture and sensitivity report dated 12/09/12 revealed the growth of two (2) organisms, each with colony counts greater than 100,000. Review of the care plan revealed the absence of specific and measurable goals for the use of the Foley catheter, and no interventions related to the problem of having a Foley catheter and urinary infections. During interview with the DON on 01/16/13 at 11:00 a.m., she acknowledged the resident had a Foley catheter and urinary tract infection which were not care planned. d) Resident #60 Record review found this resident had no pressure ulcer upon admission, but developed one (1) on her heel on 10/31/12. Measurement of the pressure ulcer was 1 centimeter by 1.2 centimeters. Treatment orders included cleansing with normal saline and applying Mepiplex border every three (3) days until healed. Review of the care plan found no mention of the pressure ulcer, treatment goals, or interventions. During an interview with the DON, on 01/15/13 at 9:35 a.m., she acknowledged the care plan did not address the development of the pressure ulcer and/or the prevention of new pressure ulcers. e) Resident #61 A medical record review was conducted on 01/16/13 at 9:48 a.m. The review revealed Resident #61 had physician's orders [REDACTED]. The care plan, written on 06/25/12 and revised on 09/13/12, did not address any interventions regarding the resident's fluid restriction of 946 ml (milliliters) daily or monitoring of her blood pressure following the [MEDICAL TREATMENT] treatment for [REDACTED]. The care plan further failed to address the resident's need to have her glucose levels monitored by 3 (three) finger sticks daily for the proper dosage of [MEDICATION NAME] R 100 unit/ml as related to her diabetes mellitus. An interview was conducted on 01/16/13 at 2:42 p.m. with Employee #3, a registered nurse (RN). At that time, the RN verified the current care plan did not address the interventions or monitoring of fluid restrictions, blood pressure, oxygen saturations, or glucose monitoring for this resident. f) Resident #4 A medical record review was conducted on 01/15/13 at 10:11 a.m. The review revealed Resident #4 had a physician's orders [REDACTED]. The care plan, last revised on 10/29/12, failed to address any monitoring for the resident's [MEDICATION NAME] levels, which were to be monitored by laboratory work completed every 3 (three) months, related to her [MEDICAL CONDITION] disorder. The care plan further failed to address the resident's need to have her glucose levels monitored by 3 (three) finger sticks daily for the proper dosage of [MEDICATION NAME] R 100 unit/ml (milliliters), related to her diabetes mellitus. On 01/15/13 at 3:48 p.m., an interview was conducted with Employee #7, an RN, who agreed the current care plan did not address [MEDICATION NAME] monitoring by lab work every 3 (three) months or the resident's need for finger sticks three (3) times daily for the correct amount of [MEDICATION NAME] R 100/ml to be administered. g) Resident #39 1) Review of the most recent minimum data set (MDS), with an assessment reference date (ARD) of 10/13/12, revealed Resident #39 received scheduled medication for pain. Review of physician's orders [REDACTED].#39 was prescribed scheduled Tylenol. Further review of of the medical administration record (MAR) revealed Resident #39 was administered scheduled Tylenol. The facility's pain management policy was reviewed. The care plan development section of this policy revealed: An interdisciplinary care plan will be developed and implemented upon admission/readmission for all residents assessed as experiencing acute, chronic non-malignant or chronic malignant pain. Review of Resident #39's care plan, dated 10/28/12, revealed the facility failed to care plan pain as a problem. There were no goals and interventions related to pain. 2) Review of Resident #39 medical records revealed Resident #39 was sent to the emergency roiagnom on [DATE] and returned to the facility on [DATE], The resident had new orders for end-of life-care, including the placement of a Foley catheter. Additionally, all medications were discontinued, except the pain medication. Physician orders, which were reviewed on 01/07/13, revealed Resident #39 was prescribed a [MEDICATION NAME] for pain and Roxinol for pain. In addition, there was an order for [REDACTED].>Medical record review revealed the facility added a care plan problem, on 01/07/13, which described, Resident has the potential for social isolation R/T (related to) comfort measures for end of life. This care plan did not reference pain or Foley catheter care. On 01/11/13 the facility added an additional care plan problem, Death and Dying issues R/T [DIAGNOSES REDACTED]. The care plan interventions included, Offer family Hospice to intervene to incude (sic) visits by Hospice team members to provide added comfort oriented care to Resident to incude (sic) pain control and symptom management of end stage disease. In addition, on 01/11/13, an intervention to Administer medications as ordered and monitor for side effects and/or effectiveness was added. Resident #39 passed away on 01/11/13. The facility failed to care plan for pain until the day the resident passed away, and did not put a care plan in place, at all, for the Foley catheter. Review of the facility's pain management policy, under care plan development, revealed, An interdisciplinary care plan will be developed and implemented upon admission/readmission for all residents assessed as experiencing acute, chronic non-malignant or chronic malignant pain. On 01/10/13 at 4:00 p.m., when questioned about why Resident #39's care plan did not contain information related to the Foley catheter or pain, the director of nurses, Employee #1, stated the care plan for these issues were not developed because the death process happened so fast. h) Resident #15 1) Review of Resident #15's minimum data set (MDS), with an assessment reference date (ARD) of 12/23/12, revealed a [DIAGNOSES REDACTED].#15's [DIAGNOSES REDACTED]. On 01/16/13 at 8:45 a.m., Resident #15 explained her leg was removed after she went to a doctor to get her toenails trimmed. Resident #15 stated the toe became infected, her toes turned black and eventually her leg was removed. Resident #15 stated this occurred because she was a diabetic. Further review of medical records revealed Resident #15's leg was removed in April 2011, while she was a resident at the facility. Review of Resident #15 ' s care plan, dated of 04/02/13, revealed a problem of, Potential nutritional problem . related to diabetes. An intervention of, Provide and serve Regular diet with (one-half) ? portion desserts as ordered. On 01/14/13 at 11:00 a.m., Employee #59, medical records, explained diabetics received a regular diet with a one-half (?) serving of dessert. Upon further review of the care plan, there were no other goals/interventions specifically related to the [DIAGNOSES REDACTED]. 2) Review of Resident #15's MDSs, with ARDs of 10/01/12 and 12/23/12, both revealed a [DIAGNOSES REDACTED]. Review of medical records revealed an episodic plan of care for UTIs, dated 09/21/12, 12/07/12, 12/19/12, and 01/03/13. Review of laboratory (Lab) results revealed Resident #15 had UTIs seven (7) times between 06/08/12 and 01/01/13. Six (6) of these lab results were positive for Escherichia-coli. The current care plan, dated 04/02/13, contained no interventions for the recurrent urinary tract infections. On 01/14/13, during Stage II of the survey, the facility was informed about the findings of multiple urinary tract infections for Resident #15. The infection control nurse, Employee #7, was asked to provide evidence the facility had implemented interventions concerning this matter. Instead of providing evidence of interventions, on 01/16/13 at 4:00 p.m., Employee #7 presented documentation of the provision of an in-service, regarding the prevention of urinary tract infections/personal hygiene, which the facility provided nursing personnel on 01/15/13 and 01/16/13, after the concern was brought to the attention of the facility. i) Resident #5 1) Review of the most recent MDS, with an assessment reference date (ARD) of 12/16/12, revealed Resident #5 received scheduled medication for chronic allergic [MEDICAL CONDITION]. Review of physician's orders [REDACTED].#5 was prescribed scheduled medication for chronic allergic [MEDICAL CONDITION]. Further review of the Medication Administration Record [REDACTED]. Resident #5's care plan with a review date of 12/24/12 was reviewed. This revealed the facility did not care plan chronic allergic [MEDICAL CONDITION] as a problem with goals and interventions. Reference to chronic allergic [MEDICAL CONDITION] was not referenced in any other part of the same care plan. 2) The most recent MDS, with an ARD of 12/16/12, revealed Resident #5 received scheduled medication for pain. Review of physician's orders [REDACTED].#5 was prescribed scheduled medication for pain. Further review of the MAR indicated [REDACTED]. Review of the facility's pain management policy, under care plan development, revealed, An interdisciplinary care plan will be developed and implemented upon admission/readmission for all residents assessed as experiencing acute, chronic non-malignant or chronic malignant pain. Resident #5's care plan, dated 12/24/12, contained nothing related to this resident's pain. On 01/15/13 at 8:15 a.m., Employee #59, medical records, stated a consultant for the facility said the facility's care plans were too long, and the facility should only care plan the the care area assessment (CAA) of the MDS. Pain did not trigger on the current CAA. j) Resident #22 The resident's medical record was reviewed on 01/10/13 at 10:00 a.m. Her comprehensive assessment of 11/17/12 noted she had a contracture of the right shoulder. Medical record review revealed the resident had a history of [REDACTED]. Review of the resident's current comprehensive care plan revealed no care plan for the contracture of the right shoulder and pain management due to the contracture. An interview, conducted on 01/10/13 at 11:00 a.m., with Employee #3, minimum data set (MDS) coordinator, confirmed there was no care plan to address the contracture of right shoulder and associated pain. k) Resident #89 On 01/15/13 at 11:00 a.m., a review of the resident's medical record was completed. The resident was total care for activities of daily living (ADLs). He was also non-ambulatory. The resident was observed at 11:15 a.m., in the resident dining room on 1st floor, on 01/15/13. The resident was up in a Broda Chair. He was observed having spontaneous movements of his head and lower extremities. His head was extended back a moderate degree. The resident's left hand was rigid, slightly bent, and was partially closed. Medical record review revealed evaluations by physical therapy (PT) and occupational therapy (OT). The resident was no longer considered an appropriate candidate for these services. Interview with a licensed practical nurse (LPN), Employee #19, on 01/15/13 at 11:30 a.m., as well as review of the resident's restorative record, revealed the resident was currently receiving no range of motion (ROM) therapy from restorative staff. The resident received ROM therapy to both legs from May of 2012 to August of 2012. Review of the care plan, on 01/15/13 at 12:30 p.m., revealed there was no care plan in place to address further decline in ROM for this resident. In addition, there was no care plan to address potential pain for this resident with severely limited mobility.",2017-03-01
7674,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-01-17,280,D,0,1,C1G011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to revise care plans to reflect changes in residents' conditions for three (3) of twenty-five (25) residents reviewed. Care plans were not revised for a resident who developed a Stage II pressure ulcer, another who declined in her ability to feed herself, and another who had sustained falls with no care plan revision for new interventions. Resident identifiers: #31, #57, and #99. Facility census: 88. a) Resident #31 Minimum Data Set (MDS) review, with an Assessment Reference Date (ARD) of 11/27/12, revealed this resident had no pressure ulcers upon admission, and no history of pressure ulcers. Medical record review revealed this resident developed a Stage II pressure ulcer to the left buttock on 12/12/12. Review of the care plan found the identification of only the potential for altered skin integrity. There was no revision to indicate a Stage II pressure ulcer had developed. During interviews with the director of nursing (DON) and the MDS nurse, on 01/15/13 at 9:30 a.m., the DON acknowledged the Stage II pressure ulcer to the left buttock was discovered on 12/12/12, but the care plan had not been revised b) Resident #99 Review of the MDS, with an ARD of 07/02/12, revealed this resident required supervision with eating, such as oversight, encouragement, or cueing. The MDSs with ARDs of 10/01/12 and 12/23/12, indicated a decline in her ability to feed herself, whereby the resident now required a one-person physical assist with feeding. The current care plan was reviews. There was no evidence of the problem of assistance needed with meals, although this decline was identified in the quarterly MDSs. Review of the resident's weights since admission found she had declined from 106 pounds on 04/17/12, to 97 pounds on 01/01/13. Observation of the resident during meals in the dining area found she often stared into space, and required staff assistance to complete her meal. During an interview with the DON, on 01/15/13 at 9:35 a.m., she agreed the current care plan was not revised to include the decline in the resident's ability to feed herself. c) Resident #57 Review of the facility's Fall Incident Report, at 9:49 a.m. on 01/14/2013, revealed the resident had sustained 3 (three) falls. These occurred 09/28/12, 10/16/12, and 01/07/13. Review of the resident's care plan, at 10:00 a.m. on 01/14/13, revealed new interventions for the fall sustained on 09/28/2012; however, there was were no interventions after the falls which occurred on 10/16/2012 or 01/07/13. An interview with a Licensed Practical Nurse (LPN), Employee #15, was conducted at 10:15 a.m. on 01/14/2013. Employee #15 was interviewed regarding the fall on 10/16/12. When discussing the lack of interventions for this fall on the resident's care plan. the employee produced a written physician's orders [REDACTED]. She confirmed the care plan was not updated to reflect these interventions. Resident #57 was observed up in her wheelchair on 01/14/2013 at 11:00 a.m., with a chair alarm in place. Observation of the resident's room (bed) at 11:15 a.m. on 01/14/13, revealed the resident had a bed alarm in place as well. Neither the chair alarm nor the bed alarm were addressed on the resident's care plan. An interview with the Clinical Care Manager (CCM), an RN, Employee #7, was conducted at 11:48 a.m. on 01/14/2013. Upon discussion regarding the resident's bed and chair alarms and interventions for the fall on 01/07/13 were was not on the care care plan, Employee #7 acknowledged these interventions should be on the care plan. At that time, Employee #7 added the bed and chair alarms , in writing, to the care plan.",2017-03-01
7675,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-01-17,309,D,0,1,C1G011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and resident interview, the facility failed to ensure one (1) of four (4) Stage 2 sample residents, reviewed for diabetic care, received the necessary care and services to attain or maintain the highest practicable physical well-being. There was no evidence of ongoing monitoring of the resident's glucose levels. Additionally, the facility failed to administer medications to two (2) residents in a manner which reduced the potential for side effects and/or in a manner which was effective for the condition requiring the medication. Resident identifiers: #15, #69, and #94 Facility Census: 88. Findings include: a) Resident #15 Review of Resident #15's minimum data set (MDS), with assessment reference dates (ARDs) of 10/01/12 and 12/23/12, revealed a [DIAGNOSES REDACTED]. Further review of Resident #15's medical record revealed no evidence the resident was being monitored and evaluated for diabetes. A request was made of Employee #3, a registered nurse, to provide the most recent information concerning the monitoring of Resident #15's diabetes. Employee #3 presented a Medication Administration Record [REDACTED]. This MAR indicated [REDACTED]. Employee #3 also presented a physician's orders [REDACTED]. Upon request, Employee #3 could not provide evidence the facility monitored Resident #15's blood glucose level after 11/02/06. On 01/10/13 at 4:00 p.m., the director of nursing (DON) stated she would attempt to find additional information regarding glucose levels for Resident #15. Upon inquiry on 01/14/13 at 9:00 a.m., the DON reported she was unable to locate any additional information regarding monitoring of this resident's glucose/diabetes. Medical record review revealed Resident #15 had a leg removed in April 2011. On 01/16/13 at 8:45 a.m., the resident stated, during an interview, her leg was removed after she went to a doctor to get her toenails trimmed. She said the toe became infected, her toes turned black, and eventually her leg was removed. Resident #15 stated this occurred because she was a diabetic. b) Resident # 69 Observation on 01/10/13 at 8:51 a.m., found that a nurse, Employee #20, assisted this resident in the use of a corticosteroid inhaler, [MEDICATION NAME]. The nurse did not caution the resident to wait a minute between puffs, or to rinse her mouth with water and spit after using the inhaler. Observation found the resident did two (2) quick, successive inhalations, then drank some water and swallowed. Review of the facility's Mosby's 2011 Drug Reference, 24th Edition related to [MEDICATION NAME] administration, states to Give at 1 (one) minute intervals, and to rinse mouth after inhaled product to decrease risk of oral candidiasis. During an interview with the DON, on 01/14/13 at 1:00 p.m., she said she would expect a nurse to space the inhalations at least a minute apart, and to instruct the resident to rinse her mouth and spit after using the inhaler. c) Resident #94. On 01/15/13 at 8:22 a.m., during medication pass observation, Employee #16 licensed practical nurse (LPN) administered [MEDICATION NAME] by mouth (PO) using a spoon. A review of medical record conducted on 01/15/13 at 9:30 a.m., revealed a physician order [REDACTED]. An interview conducted on 01/15/13 at 3:00 p.m. with Employee #1 director of nursing (DON) and was informed the [MEDICATION NAME] was given PO instead of SL, which was the improper route.",2017-03-01
7676,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-01-17,312,D,0,1,C1G012,"**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 resident, who was unable to complete her own daily care received assistance with personal hygiene. When a palm protector, ordered to prevent further contractures to the resident's left hand, was removed, a rank, sour odor emanated from the resident's hand. This was true for one (1) random observation made during a re-visit to the facility's Quality Indicator Survey (QIS) completed on 01/17/13. Resident identifier: #8. Facility census: 88. Findings include: a) Resident #8 The minimum data set (MDS), with an assessment reference date (ARD) of 12/30/12, Section S, identified the resident as having a contracture of the left hand. A physician's orders [REDACTED]. (hours) and PRN (as needed) for monitoring of skin breakdown. Further review of the resident's care plan revealed a problem of potential for altered skin integrity. An approach to this problem was, Palm protector L (left) hand digits 1-3 contracture. On 03/19/13 at 9:06 a.m., the residents' left hand was observed with a palm protector in place. The resident was in her room seated in a reclining geri-chair. During this observation, a sour odor could be detected from approximately two (2) feet from the resident. Two (2) employees, Employee #8, a licensed practical nurse, and Employee #48, a certified nursing assistant, were asked to remove the palm protector from the resident's hand. When Employee #8 removed the palm protector a rank, sour odor emanated from the resident's hand. Employee #8 verified the hand need cleaned and the palm protector needed washed. Employee #2, the registered nurse MDS coordinator, was interviewed at 10:58 on 03/19/13. She verified the care plan did not address removal of the palm protector every two (2) hours as directed by the physician's orders [REDACTED]. Employee #2 stated directions to the nursing assistants should have been provided on the Kardex. She produced a copy of the Kardex for March 2013, which did not address removal of the palm protector and cleaning of the resident's left hand. The shower schedule for this resident was reviewed with Employee #2 at 10:58 on 03/19/13. According to the shower schedule the resident was showered every seven (7) days. Her last shower occurred on 03/12/13. Employee #2 stated the resident was scheduled for a shower today, 03/19/13, on the afternoon shift.",2017-03-01
7677,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-01-17,315,G,0,1,C1G011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to ensure two (2) of five (5) Stage II sample residents, reviewed for urinary tract infections (UTIs), received necessary treatment and services to prevent urinary tract infections. There was no evidence causal factors for the urinary tract infections were assessed, and no evidence of individualized interventions to prevent the recurrent UTIs. In addition, the facility failed to provide prompt interventions when a UTI was diagnosed . Resident identifiers: #15 and #31. Facility census: 88. Findings include: a) Resident #15 On 01/14/13 this resident's medical record was reviewed. The minimum data sets (MDSs) with assessment reference dates (ARDs) of 10/01/12 and 12/23/12 , both revealed [DIAGNOSES REDACTED]. Review of medical records revealed episodic plans of care for UTI's dated 09/21/12, 12/07/12, 12/19/12 and 01/03/13; however, the facility did not have an ongoing care plan for this resident's recurrent UTIs. Review of laboratory (lab) results revealed Resident #15 was diagnosed with [REDACTED]. This included 06/08/12, 07/16/12, 09/19/12, 10/01/12, 12/03/12, 12/17/12, and 01/01/13. Six (6) of these seven (7) lab results were positive for Escherichia-coli. The UTI on 10/01/12 was positive for Proteus mirabilis. The only intervention for each of these infections was the provision of antibiotics. There were no interventions related to the prevention of UTIs for this resident. On 01/14/13, during Stage II of the survey, the facility was informed about the findings of multiple UTIs for Resident #15. The infection control nurse, Employee #7, was asked to provide evidence of staff education, care planning, and/or any interventions for Resident #15, in an effort to determine causal factors and/or provide interventions to prevent the recurrent UTIs. Instead of providing evidence of interventions, on 01/16/13 at 4:00 p.m., Employee #7 presented documentation of the provision of an in-service, regarding the prevention of UTIs/personal hygiene, which the facility provided nursing personnel on 01/15/13 and 01/16/13, after the problem was brought to the attention of the facility during the survey. No evidence was provided which verified the facility had addressed the recurrent UTI's Resident #15 was experiencing. Upon inquiry on 01/16/13, Employee #59, medical records, provided a copy of Resident #15's most recent urology consultation, dated 03/24/10. The consultation was scheduled due to the resident's UTIs. An antibiotic was ordered and a follow-up appointment was set for 03/31/11. The resident did not go to this appointment. As of 01/17/13, there was no evidence of a consultation after 03/24/10. On 01/16/13 at 4:00 p.m., Employee #59 stated the resident was too sick to go to the appointment on 03/24/10. Employee #59 confirmed the facility did not reschedule a urological follow-up appointment for the resident. b) Resident #31 Record review revealed a urinalysis, completed on 12/07/12, was positive for a urinary tract infection. The report indicated cloudiness, a large amount of blood, protein, leukocytes and white blood cells in the urine, and a 1+ (one plus) in bacteria. The accompanying urine culture reported a colony count of greater than 100,000 for two (2) organisms. A notation on the bottom of the urinalysis report and the culture report indicated the results were faxed to the physician on 12/08/12 and 12/10/12 respectively. A nurse progress note, dated 12/16/12 at 3:24 p.m., was reviewed. This revealed the resident's breaths on expiration were with grunts, and the spouse spoke her belief the resident might have a urinary tract infection. According to the same nurse progress note, a licensed nurse, Employee #16, called the physician and reviewed the urine culture results with him. Results indicated IV (intravenous) antibiotics needed. Review of a nurse's progress note, dated 12/16/12 at 9:50 p.m., revealed the resident was short of breath at shift change. His wife requested he be transferred to a hospital for treatment, rather than receiving IV antibiotics at the facility. The emergency squad transported him out of the building. During interview with a licensed nurse, Employee #10, on 01/16/13 at 10:45 a.m., she said she faxed the urinalysis report to the physician on 12/08/12, and stated another licensed nurse, Employee #21, faxed the physician with the urine culture and sensitivity report on 12/10/12. Employee #10 said the physician had returned from deployment around that time and changed offices. She surmised the faxes sent may have gotten misplaced in the office building, or the fax numbers may have changed during the transition. Further review of the urine and culture laboratory results, found the physician signed and dated them on 12/26/12, and added he did not receive the results on the date noted on the lab forms. Review of a discharge summary, dated 12/26/12, found the resident left the facility at his wife's request to go to the hospital. Pertinent diagnostic findings included altered mental status and shortness of breath. During an interview with the Director of Nursing (DON), on 01/16/13 at 11:00 a.m she said she was not sure where the ball was dropped. She said the urinalysis report and the culture and sensitivity report would have been known by the nurses who faxed them. Also, the infection control nurse would have received a copy of the results. Furthermore, the culture results should have been placed on the 24 hour shift report, and the nurse manager should have been alerted to the results of the colony counts over 100,000. As for the original laboratory forms, they should have been either placed in the physician's folder, or filed on the chart, with a sticker to note that the doctor needed to sign it upon his next visit to the facility. .",2017-03-01
7678,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-01-17,318,G,0,1,C1G011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure one (1) of two (2) residents, reviewed related to contractures, maintained the highest level of range of motion. The facility failed to provide services to prevent a decrease in range of motion and failed to ensure the resident did not develop a new contracture. Resident #89. Facility census: 88 Findings include: a) Resident #89 On 01/15/13 at 11:00 a.m., a review of the resident's medical record was completed. The resident was total care for activities of daily living (ADLs). He was nonambulatory. [DIAGNOSES REDACTED]. The resident was observed at 11:15 a.m., in the resident dining room on 1st floor, on 01/15/13. The resident was up in a Broda Chair. He was observed having spontaneous movements of his head and lower extremities. His head was extended back a moderate degree. His eyes were shut, but opened partially when he was addressed by his name. There was no verbal response at that time. The resident's left hand was noted to be rigidly and slightly bent, and was partially closed. Interview with a licensed practical nurse (LPN), Employee #19, on 01/15/13 at 11:30 a.m., as well as review of the resident's restorative record, revealed the resident was currently receiving no range of motion (ROM) therapy from restorative staff. The resident received ROM therapy to both legs from May of 2012 to August of 2012. The last physical therapy (PT) evaluation was completed on 06/06/12. The physical therapist at that time, felt the resident was no longer a candidate for PT. An occupational therapy (OT) evaluation, dated 06/06/12 stated, When OT has observed res., he has been sleeping and neck has been extended at 20 (degrees) to 30 (degrees). Res cognitive fxn'ing (functioning) has been steadily declining resulting in a (decrease) in ADL and mobility status. OT does not feel resident is appropriate for therapy due to cognitive - unable to follow any commands, and resident does not appear in distress or pain. The resident did receive PT from 09/16/11 to 11/01/11. The last OT evaluation was conducted on 12/05/12. It stated there were no changes from the previous review on 08/12/12. The restorative order for leg stretches ended on 08/01/12 after discussion between the restorative nurse and the physical therapist. The physical therapist felt the resident had reached his maximum potential and had no possibility for improvement past that point. There was documentation of this conversation between the restorative, registered nurse (RN) and the physical therapist. Review of the care plan, on 01/15/13 at 12:30 p.m., revealed there was no care plan in place to address further decline in ROM for this resident. In addition, there was no care plan to address potential pain for this resident with severely limited mobility. Observation of the resident was conducted in his room, at 1:05 p.m. on 01/15/13, accompanied by physical therapist, Employee #109, and restorative aide (RA), Employee #114. The physical therapist stated the resident's left hand had potential for contracture, but was not yet a contracture. He stated the hand was tight. The resident attempted to pull his hand away when the physical therapist was touching it. The resident was verbal at this time and stated, Your hands are cold. The physical therapist stated he would speak with occupational therapist, Employee #112 tomorrow, as she was not in the building that day, and see if she was aware of the drawing of the resident's left hand, since she stated no changes on her last OT Screen dated 12/05/12. At this time, the RA, Employee #114, stated the resident would Resist stretching of the lower extremities, and he wouldn't relax his legs. We even tried to do stretches on the resident while he was lying down but he would become agitated. We would return later and try again. So we eventually stopped the restorative nursing program therapy. A discussion was held with the restorative nurse, an RN, Employee #8, at 2:10 p.m. on 01/15/13. She stated they had what was called a 'Pace Form' that was given to therapy for therapy screens on all residents. This screening was set for the date of the resident's quarterly MDS Assessment Reference Date (ARD). This way, it was assured all residents were evaluated by therapy every three (3) months. She presented a copy of the PACE schedule. This resident was due again for evaluation on 03/26/13, which was three (3) months since the last therapy screen. However, it was decided OT would evaluate the resident's left hand the following day, on 01/16/13. At 3:30 p.m. on 01/16/13, the DON presented a copy of a newly created policy addressing discontinued restorative therapy. The new policy was regarding continuing assessment of the resident by the restorative nurse. These assessments were to be done between therapy screens for this resident population. An interview was conducted with the occupational therapist, Employee #112, on 01/16/12 at 9:45 a.m She stated she had screened the resident for the issue with the left hand. She said the resident had some deviation to the thumbs. In her OT note dated 01/16/13, she stated the resident had a palmer adduction contracture B of thumbs. According to the occupational therapist, splinting would increase pain for the resident. She stated she was able to open the resident's left hand without difficulty. She said she would speak to the restorative nurse, Employee #8, to see if the resident could be picked up again for restorative ROM. During an interview with the restorative nurse, at 10:30 a.m. on 01/16/13, she stated restorative nursing would pick this resident back up for ROM to all extremities three to five (3-5) times a week.",2017-03-01
7679,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-01-17,323,D,0,1,C1G012,"Based on medical record review and staff interview, the facility failed to ensure a resident received adequate supervision to prevent an accident. Instructions provided on the care plan for the number of staff required to transfer the resident were unclear and did not match the instructions provided on the plan of care Kardex, also used by the nursing assistants to determine the number of staff required to transfer a resident. This was true for one (1) random resident reviewed during the re-visit to the facility's Quality Indicator Survey (QIS) which ended on 01/17/13. Resident identifier: #18. Facility census: 88. Findings include: a) Resident #18 Review of a nurse's note, dated 02/28/13, found the following, Called to Resident's bathroom at 9pm by (name of nursing assistant -CNA). Resident was seated on the floor in front of the toilet. CNA stated she was assisting Resident to rise from toilet and shower chair and was going to pull up her brief when Residents feet slid out from under her. CNA lowered Resident to floor. MAEW (DON stated this was the abbreviation for, moved all extremities well). No malformations or abnormalities present. Review of the care plan found a problem, At risk for skin breakdown r/t related to hx (history) of PU (pressure ulcers). An approach to this problem found the intervention, Assist of two with transfers and assist of one with toileting. Employee #12, the licensed practical nurse-unit charge manager, was asked where a nursing assistant would find directions on how to transfer a resident on 03/20/13 at 9:00 a.m She replied, by reading the care plan. Employee #1, the director of nursing (DON) was interviewed on 03/20/13 at 9:30 a.m. She was asked to explain how a a resident who required the assistance of two (2) staff members for transferring could be toileted by one staff member when toileted required transferring the resident. The DON agreed that toileting of this resident would involve transferring and the intervention for transferring the resident, as directed by the care plan, was unclear. The DON further stated the resident's Kardex should be reviewed to determine how much assistance was required for toileting. She provided a copy of the Kardex for February 2013, which included directions for toileting. According to the Kardex, toilet use required the assistance of two (2) staff members. The DON agreed the directions provided on the care plan were not clear and were in conflict with the directions for transferring the resident on the Kardex. She verified the CNA had access to both documents.",2017-03-01
7680,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-01-17,371,F,0,1,C1G011,"Based on observation and staff interview, the facility failed to store and serve food under sanitary conditions. Numerous undated opened food items were stored in the dietary kitchen refrigerators. Also, dietary employees were observed touching the serving areas of plates and the insides of bowls with bare, ungloved fingers, immediately before placing food in those receptacles to serve to residents in the facility. These practices had the potential to affect all residents who received nourishment from the dietary. Facility census: 88. Findings include: a) During the initial tour of the dietary department, on 01/08/13 between 4:15 p.m. and 5:10 p.m., numerous opened items stored in the walk-in and reach-in refrigerators were found to have no dates indicating when those food items had been opened, and/or when they should be discarded: 1) An opened, nearly full gallon jar of sliced dill pickles was dated in black marker 12/30/10. There was no other written dates to indicate when it had been opened or should be discarded. 2) A partially used gallon jug of Kraft Miracle Whip was dated on the lid with a black marker 11/21/12. There were no other dates to indicate when it had been opened or should be discarded. 3) An 8.5 pound jar of Pasado Salsa, with approximately one cup missing, was dated in black marker 06/28/12. There were no other dates to indicate when it had been opened or should be discarded. 4) A one gallon jug of Italian dressing, with a small amount missing, was dated in black marker 10/23/12. There were no other dates to indicate when it had been opened or should be discarded. 5) A half full gallon container of sliced dill pickles contained the date 03/01/12 written in black marker. There were no other dates to indicate when it had been opened or should be discarded. 6) A partially used 21 ounce jar of olives had no dates to indicate when it was received or opened. 7) A nearly empty one-gallon container of mustard, dated in black marker as received on 04/26/12. It was dated as opened on 09/24/12. It had dried, crusty mustard on the outside of the container just below the lid area. 8) An opened, nearly full bottle of Worcestershire sauce, was dated on the top and one side of the bottle in black marker, 06/09/11. It was wet and sticky on the outside below the green cap. There were no other dates to indicate when it was opened or should be discarded. 9) A nearly empty, one-gallon jug of Kraft barbecue sauce, was dated in black marker 07/05/12. There were no other dates to indicate when it had been opened or should be discarded. 10) A large puddle of water had pooled in the back portion of the lowest shelf in the reach-in refrigerator. 11) A five-pound plastic container of cottage cheese with about one third remaining had no dates to indicate when it had been received, when it had been opened, or when it should be discarded. 12) An opened package of cheese slices had no date indicating when it had been opened. The outer wrapper had been opened, then folded back beneath the cheese food, not securely closed. 13) Two unopened 32 ounce packages of sliced turkey breast, and one unopened package of bologna, had no date indicating when they had been removed from the freezer and allowed to thaw. One unopened package of bologna was written in black marker with the date 11/15/12. 14) Two (2) ice cream sandwiches and an uncooked frozen biscuit was on the floor of the walk-in freezer. 15) A nearly empty, 46-ounce bottle of grape juice, dated in black marker 12/06/12, was stored in the walk-in refrigerator. There were no other dates to indicate when it had been opened or should be discarded. 16) An opened carton of Minute Maid low acid orange juice was dated in black marker 12/13/12 and stored in the walk-in refrigerator. There were no other dates to indicate when it had been opened or should be discarded. 17) Four (4) unopened, thirty-two ounce cartons of orange juice concentrate was stored in the walk-in refrigerator. There were no dates to indicate when they had been received, or a use by date from the manufacturer. 18) A partially used eight ounce can of Ensure was covered with a plastic wrap. There was no date to indicate when it had been opened. 19) A 32-ounce carton of buttermilk, with about one-third remaining, had no date to indicate when it had been opened. The manufacturer's date was stamped to sell by 12/24/12. 20) A bag of sliced apples had been opened, with about a fifth of a bag remaining, and stored in the walk-in refrigerator. The apples had areas of discoloration and mushiness. The bag the apples were in had been folded over, with the remaining apple slices holding down the folded area. There was no date indicating when the bag had been opened or received. 21) An 18-ounce jar of mayonnaise was nearly empty, and stored in a reach-in refrigerator There were no dates to indicate when it had been received or when it had been opened. 22) Two (2) sixteen ounce jars of blue cheese dressing were marked with black marker with the date 08/29/12. Both jars had been opened, and both were half full. There were no dates to indicate when they had been opened. 23) A half-full, 32-ounce jar of strawberry jam was stored in a reach-in refrigerator. There were no dates to indicate when it had been received or opened. 24) A 24-ounce, two-third's full bottle of table syrup was stored in a reach-in refrigerator. There were no dates to indicate when it had been received or when it had been opened. These items were reviewed with dietary Employee #70, at the end of the initial tour on 01/08/13 at 5:10 p.m. b) During an interview with dietary Employee #61 and the dietary manager, Employee #63, on 01/10/13 at noon, they confirmed the opened items in the refrigerators should have been dated when opened, and were not. They said foods taken from the freezer should have been dated when moved to the refrigerator, such as the bologna and turkey slices, and the orange juice concentrate. They said cottage cheese must be discarded within seven (7) days of opening, and should have been dated when opened. These employees pointed out numerous signs posted about the kitchen that directed staff to label and date each item before placing them in the refrigerators. These signs were observed during the initial tour of the kitchen on 01/08/13. Employees #61 and #63 said sometimes the activity department stored items in their refrigerators, such as the strawberry jam, blue cheese dressing, jar of olives, the 18 ounce jar of mayonnaise, and the bottle of table syrup. They reported dietary staff were not supposed to store opened cans of liquid in the refrigerator, such as the Ensure. They also said opened food items, such as the cheese slices and apples, should have been stored in airtight sealed packages or containers. They said they thought the water collection in the reach-in refrigerator had been corrected by maintenance, and they would put in another work request to address that problem. c) During observation of the tray line, on 01/09/13 at 12:00 p.m., dietary Employees #72 and #65 were observed, several times, placing bare, ungloved fingers into serving bowls prior to placing food in those bowls for residents' consumption. Dietary Employee #65 was observed, several times, placing bare, ungloved fingers on the surfaces of plates prior to placing food on those plates for residents' consumption. During an interview with the dietary manager, on 01/09/13 at 2:00 p.m., she said these were not acceptable practices.",2017-03-01
7681,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-01-17,373,D,0,1,C1G011,"Based on policy review and staff interview, the facility failed to ensure paid feeding assistants only fed residents who had no complicated feeding problems. Additionally the facility failed to maintain a record, and failed to communicate to direct care staff (licensed nurses), all of the individuals used by the facility as feeding assistants. This practice has the potential to affect all residents who had complicated feeding problems and who required assistance with meals. Facility census: 88 Findings include: a) Review of the facility's policy for paid feeding assistants revealed the facility was to maintain a record of all individuals, used by facility as feeding assistants, who had successfully completed the training course for paid feeding assistants. The policy also indicated the facility must ensure a feeding assistant fed only those residents who had no complicated feeding problems. b) Confidential interviews were held with staff who had successfully completed the feeding assistant program. They were asked how the feeding assistants knew who to assist with feeding, and how they knew which residents had complicated feeding problems. The responses were all the same: We don't know. The feeding assistants stated there was a list of complicated feeders in the assignment book, but stated it was not kept up to date. The feeding assistants also said they were not aware of a list of individuals who had completed the feeding assistant program. c) The list of residents with complicated feeding issues found in the assignment book, on 01/15/13 at 12:00 p.m., and the list provided by Employee # 1, director of nursing (DON), were reviewed on 01/16/13 at 11:00. The lists did not include the same residents. Additionally, the list available for the feeding assistants did not include all facility residents with documented complicated feeding problems. d) An interview, conducted on 01/15/13 at 11:00 a.m., with the DON, revealed a list of employees who had successfully completed the feeding assistant program had not been maintained. A list was provided by the DON, on 01/16/13 at 11:00 a.m.",2017-03-01
7682,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-01-17,441,D,0,1,C1G011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to maintain a sanitary environment to assist in the prevention of the development and transmission of disease and infection. Additionally,, the facility failed to maintain an effective infection control program by failing to monitor and initiate corrective actions related to urinary tract infections for one (1) of five (5) residents reviewed for urinary incontinence and/or urinary infection. Resident Identifiers: #78 and #15. Facility Census: 88 Findings include: a) Resident #78 During random observation, at 4:45 p.m. on 01/08/13, Resident #78 was observed lying in bed. One (1) of the resident's pillows was lying on the floor next to the bed. The resident was moving and was very close to the edge of the bed. A nursing assistant (NA), Employee #37 was alerted to the resident's positioning in bed. The NA entered the room and asked the resident if he was ready to get up for supper. The resident replied yes. Employee #37 then repositioned the resident in the bed, and advised the resident she was going to get help to get him up. The NA picked up the resident's pillow from the floor and placed it back in the bed with the resident, in front of the resident's abdomen. A conversation was held, on 01/09/13 at 1:35 p.m., with the infection control nurse, a registered nurse, Employee #2 and the director of nursing, Employee #1, regarding Employee #37 picking up a pillow from the floor and placing it back in bed with Resident #78. Employees #1 and #2 confirmed it was an infection control issue. b) Resident #15 On 01/14/13 this resident's medical record was reviewed. The minimum data sets (MDSs) with assessment reference dates (ARDs) of 10/01/12 and 12/23/12 , both revealed [DIAGNOSES REDACTED]. Review of medical records revealed episodic plans of care for UTIs dated 09/21/12, 12/07/12, 12/19/12 and 01/03/13. Review of laboratory (lab) results revealed Resident #15 was diagnosed with [REDACTED]. This included 06/08/12, 07/16/12, 09/19/12, 10/01/12, 12/03/12, 12/17/12, and 01/01/13. Six (6) of these seven (7) lab results were positive for Escherichia-coli. The UTI on 10/01/12 was positive for Proteus mirabilis. resident. On 01/14/13, during Stage II of the survey, the facility was informed about the findings of multiple UTIs for Resident #15. The infection control nurse, Employee #7, was asked to provide evidence of staff education and interventions for Resident #15, in an effort to determine causal factors and/or provide interventions to prevent the recurrent UTIs. Instead of providing evidence of interventions, on 01/16/13 at 4:00 p.m., Employee #7 presented documentation of the provision of an in-service, regarding the prevention of UTIs/personal hygiene, which the facility provided nursing personnel. These in-services were conducted on 01/15/13 and 01/16/13, after the resident's recurrent UTIs were brought to the facility's attention. The facility's surveillance of infections was requested. Employee #7 provided information the facility was aware of the infections, but was unable to provide evidence the infections were evaluated and/or addressed in an effort to control the recurrent UTIs the resident was experiencing.",2017-03-01
7683,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-01-17,490,F,0,1,C1G012,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the results obtained through observations, record reviews, and staff interview, during the re-visit survey beginning on 03/18/13, the governing body failed to ensure all deficient practices cited during the Quality Indicator Survey (QIS) ending on 01/17/13 were corrected, as alleged in the plan of correction signed by the administrator on 02/22/13. Deficient practices remained in the following Federal Regulatory Groupings: Resident Behavior and Facility Practices and Quality of Care. This had the potential to affect all residents in the facility. Facility census: 88. Findings include: a) Resident behavior and facility practices. 1. Based on medical record review and staff interview, the facility failed to ensure Residents #116 and #72 were free from neglect. Medical services were not provided in a timely manner for these two (2) residents who had infections. b) Quality of care 1. Based on medical record review and staff interview, the facility failed to ensure Residents #116 and #72 received timely treatment for [REDACTED]. 2. Based on observation, record review, and staff interview the facility failed to ensure a dependent resident (Resident #8) received care and services to maintain good personal hygiene and to prevent further contractures of her left hand. Staff interview with the administrator and director of nursing, on 03/19/13 at 2:00 p.m., revealed the issues identified from the previous QIS had been addressed with the quality assessment and assurance committee (QA committee). The administrator stated the deficiencies were thought to have been corrected. On 03/20/13 at 11:15 a.m. an interview was conducted with the medical director who stated the facility had worked hard to correct the deficiencies and thought everything was fixed. The deficiencies found during the re-visit were again discussed with the administrator on 03/20/13 at 1:15 p.m. She verified QA meetings were held and a plan of correction had been put in place to assure past deficient practices were corrected.",2017-03-01
7684,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-01-17,520,F,0,1,C1G012,"Based on medical record reviews, observation, staff interviews, and policy review, the facility's quality assurance program failed to develop and implement plans of action to correct identified quality deficiencies. Seven (7) deficient practices identified during the annual Quality Indicator Survey (QIS), which ended on 01/17/13, were still out of compliance during the re-visit survey which ended on 03/20/13. The facility submitted a plan of correction for these deficiencies, but failed to implement the plans and/or correct the deficiencies cited at F224, F279, F280, F309, F318, F371, and F441. This had the potential to affect all residents in the facility. Facility census: 88. Findings include: a) Interview with the administrator and director of nursing, on 03/19/13 at 2:00 p.m., revealed the issues identified from the previous QIS had been addressed with the quality assessment and assurance committee (QA committee). The administrator stated the deficiencies were thought to have been corrected. On 03/20/13 at 11:15 a.m., an interview was conducted with the medical director who stated the facility had many QA meetings and had worked hard to correct the deficiencies. The deficient practices found during the re-visit were again discussed with the administrator on 03/20/13 at 1:15 p.m. She verified QA meetings were held and a plan of correction had been put in place to ensure past deficient practices were corrected. The QA committee did not ensure the deficient practices cited during the survey, which ended on 01/17/13, were corrected. A plan of correction for these deficiencies was submitted by the facility. These plans were not effectively implemented for the deficiencies previously cited at F224, F279, F280, F309, F318, F371, and F441. b) Staff failed to ensure two (2) residents (Residents #116 and #72) were free from neglect. The residents were not treated timely for infections (urinary tract infection and pneumonia). c) Medical record review and staff interview revealed the facility failed to complete a comprehensive care plan addressing the removal of a palm protector, applied daily to the resident's left hand to prevent contractures. The care plan also failed to address the cleaning of Resident #8's contracted hand. d) Medical record review and staff interviews revealed the facility failed to revise the care plans for Resident #18, who had a pressure ulcer, and for Resident #8, who required the assistance of two staff members for transfers. e) Medical record review and staff interview revealed the facility failed to timely treat infections for two residents (#116 and #72). Laboratory results and a chest x-ray was not obtained in a timely manner resulting in a delay in treatment for one resident with pneumonia and one resident with a urinary tract infection. f) The facility failed to ensure Resident #8 was receiving care, as ordered by the physician, for further deterioration of a contracture of the left hand. g) Observation and staff interview revealed the facility failed to ensure proper storage of food items in the kitchen. Raw chicken was stored in a plastic bag on top of a box of celery. h) Review of infection control surveillance data and analysis of that data, review of facility policy, and staff interview, reveal the failed to maintain an effective infection control program. The facility failed to complete surveillance logs, and identify organisms for tracking and trending to prevent the onset and the spread of infections.",2017-03-01
8357,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-07-25,279,D,1,0,OEND11,"**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 nine (9) residents had a care plan developed that reflected goals and interventions to reduce injuries of unknown origin. Resident #79 had sustained five (5) injuries of unknown origin between 12/28/12 and 06/06/13. The facility had not addressed this issue in the resident's care plan. Resident identifier: #79. Facility census: 89. Findings include: a) Resident #79 On 07/24/13 at 1:00 p.m., the medical record review for Resident #79 revealed a resident who was dependent in all activities of daily living except eating. The resident had a [DIAGNOSES REDACTED]. A review of the incident/accident reports revealed reports dated 12/28/12, 02/01/13, 02/09/13, and 06/06/13 regarding this resident. The reports were: -- 12/28/13 Resident found on floor beside bed sitting on her knees leaning against side rails. VS (vital signs) WNL (within normal limits), ROM (range of motion) WNL. Neuro checks initiated. Transferred back into bed. Knees bruised right and and right side of forehead red. -- 02/01/13 Resident has large, dark purple bruise on left knee area, possibly from bumping against a table or bumping an object during transfer. -- 02/09/13 stated Observed bruises on both knees after resident legs were stuck under dining room table. Reported to other staff to monitor. -- 06/06/13 Resident up in dining room in Geri chair. Prior to breakfast when staff notice residents left eye was purple, swollen and bruised. A nursing entry, dated 04/16/13, noted (Employee #48, nurse aide) called me back to this resident's room. A 5cm laceration was noted on resident's left lower leg at 7am. No bleeding was noted at the time. Unknown how this happened. Area was cleansed with normal saline solution and steri strips were applied. Laceration was very deep with muscle exposed. I had (director of nursing), RN DON check area. (Physician's name) was notified at 7:30 a.m. with orders received and noted. Send resident to ER (emergency room ) today to get sutures to area. Resident was sent out at 10:45 a.m. with 2 attendants. Daughter (name) was notified at 10:15 am. and (local emergency room ) was notified as well. Resident returned at 12:40 pm with new orders. Resident has 8 sutures intact to leg. Sutures are to be removed in 14 days. On 07/24/13 at 2:00 p.m., the administrator (Employee #90) and the director of nursing (Employee #1) both said the facility had investigated the accidents and could not determine how the injuries occurred. A review of the resident's care plan revealed the facility had not addressed the resident's frequent injuries of unknown origin and the need for more close supervision. On 07/24/13 at 2:00 p.m., the director of nursing (Employee #1) indicated the facility had put an intervention in place after the 02/01/13 and 02/09/13 incident. They had elected to use an over-bed table in the dining room for the resident to eat meals. This prevented her legs from getting stuck under the table. A review of the care plan revealed this intervention was not mentioned. The director of nursing indicated she had addressed with the nursing staff the importance of not wearing any jewelry other than wedding bands. She felt a piece of jewelry may have caused the resident's laceration to the leg. This was not addressed in the resident's care plan. The care plan for Resident #79 did not address her injuries of unknown origin.",2016-07-01
9478,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,156,D,0,1,SJCY11,"Based on medical record review, review of information provided to residents upon admission, and staff interview, the facility failed to inform one (1) of thirty-two (32) Stage II sample residents, both orally and in writing, of all the rules and regulations governing resident conduct and responsibilities during the stay in the facility. There was no evidence and/or acknowledgement in writing the resident was notified of the facility's smoking policy prior to or upon admission to the facility. Resident identifier: #109. Facility census: 84. Findings include: a) Resident #109 Closed record review, on 01/26/11, revealed this resident was admitted from the hospital to the facility for rehabilitation services on 12/16/10. The resident had been determined to possess the capacity to understand and make informed making health care decisions. Further review revealed the resident left the facility against medical advice (AMA) on 01/24/11. Interview with the director of nursing (DON - Employee #1), at 10:00 a.m. on 02/01/11, revealed the resident left AMA because he wanted to smoke and the facility was a non-smoking facility. Additional medical record review revealed no evidence the resident was informed, prior or at the time admission, that he would not be able to smoke at the facility. There was no discussion in the record that the resident had been informed of this rule, and there was nothing within the record which the resident had signed acknowledging his understanding of this facility rule. Review of the facility's admission contract revealed it did not contain information relative to the facility's smoke-free status. Additionally, the facility had no formal means of assuring residents were made aware of this facility policy prior to or upon admission. On 02/02/11 at 12:00 p.m., an interview was conducted with one (1) of the facility's social workers (Employee #51). Employee #51 confirmed the facility had not provided Resident #109 with written information regarding the facility's smoking policy. At that time, Employee #51 also confirmed the facility's smoking policy had not been a part of the facility's admission information at the time this resident was admitted .",2015-11-01
9479,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,164,D,0,1,SJCY11,"Based on observation and staff interview, the facility failed to ensure each resident has the right to confidentiality of his or her clinical records, as evidenced by staff leaving confidential clinical records unattended / open to public view during medication administration. This affected two (2) residents of random observation. Facility census: 84. Findings include: a) An observation made during medication administration, on 01/25/11 at 8:40 a.m., found a registered nurse (RN - Employee #2) left the medication cart unattended in the hallway with the Medication Administration Record [REDACTED]. An observation made during medication administration, on 02/02/11 at 7:40 a.m., found Employee #2 again left the medication cart unattended in the hallway with the MAR indicated [REDACTED]. On 02/02/11 at 1:00 p.m., an interview with the director of nursing (DON - Employee #1) revealed it was a violation of a resident's privacy for the MAR indicated [REDACTED].",2015-11-01
9480,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,241,E,0,1,SJCY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and medical record review, the facility failed to provide residents with a dining experience that promoted independence and dignity. The facility used plastic cutlery and paper dishware for three (3) of thirty-two (32) Stage II sample residents (#111, #55, and #98) who were on contact precautions, and these disposable products were also used for one (1) of thirty-two (32) Stage II sample residents who engaged in socially unacceptable behavior (#74). In addition, staff did not encourage and assist Resident #111 to dress in her own clothes appropriate to the time of day and her individual preference (rather than in hospital gowns). Resident identifiers: #111, #55, #98, and #74. Facility census: 84. Findings include: a) Residents #111, #55, and #98 During meal times on 01/24/11 and 02/01/11, residents in contact isolation precautions for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) and/or [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE) were served meals in paper dishware and with plastic cutlery. Residents #111, #55, and #98 all received the disposable products. When interviewed on 01/25/11 at approximately 8:45 a.m., Resident #111 reported she did not know why she had plastic cutlery and paper dishware; however, she said she thought it had to do with her infection. On 01/27/11 at approximately 3:00 p.m., the infection control registered nurse (Employee #8) indicated she did not know these three (3) residents did not need to be served with plastic cutlery and paper dishware. She said she thought they needed these products due to their infection. Employee #8 was informed that all dishes, glasses, and trays are cleaned and disinfected by using hot water and detergent and by drying at high temperature; this process kills the bacteria. Therefore, the facility did not need to use paper plates or plastic silverware for these residents. The residents continued to receive the plastic and paper products after this interview with Employee #8 on 01/27/11. On 02/01/11 at approximately 11:30 a.m., Employee #8 called the dietary department and informed them these three (3) residents did not need plastic cutlery and paper dishware. -- b) Resident #111 On 01/25/11 at approximately 10:30 a.m., Resident #111 participated in an interview regarding her satisfaction with the time she got dressed in the mornings. She said she did not like getting dressed and cleaned up for the day so late in the morning. She preferred to have staff get her cleaned up and dressed earlier. As of the time of the interview, Resident #111 still had on a hospital gown and her hair had not been combed, nor had she received any other morning hygienic care. On 02/02/11 at approximately 11:30 a.m., Resident #111 remained in a hospital gown that she had slept in the night before. She said she did not want to be left in these clothes this late in the morning. When interviewed shortly thereafter, Employee #49 (a nurse aide) stated she had not had time to get to Resident #111's morning care needs. Employee #11 (a licensed practical nurse - LPN) said she only had one (1) nurse aide absent on this date. The LPN said she would talk to the night shift staff and ask if they could get Resident #111 up prior to the day shift staff coming on duty. -- c) Resident #74 During meal service observation at 12:00 p.m. on 01/25/11, Resident #74's meal was observed served on disposable dishware. Upon inquiry, the dietary manager (DM - Employee #61) stated the resident urinated in bowls, thus the disposable products were used. Employee #61 confirmed she had not considered this use of disposable products as an undignified manner for presenting foods for the resident. At that time, the DM confirmed a properly working dishwasher was capable of sanitizing dishware soiled by this resident.",2015-11-01
9481,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,272,E,0,1,SJCY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed to conduct a comprehensive assessment for the dental needs of one (1) of thirty-two (32) Stage II sample residents and the nutritional needs for five (5) of thirty-two (32) Stage II sample residents, resulting in a failure to address in an individualized care plan the services necessary to meet these residents' needs. Resident identifiers: #7, #37, #84, #31, #35, and #28. Facility census: 84. Findings include: a) Resident #7 During a Stage I interview on 01/26/11 at 8:55 a.m., observation revealed Resident #7's natural teeth were in very poor condition, and many were missing. When the resident was asked the interview questions about dental condition, she stated her teeth were half gone. review of the resident's medical record revealed [REDACTED]. This assessment was not accurate, as it was the resident's natural teeth which were in poor condition. There was no further assessment, evaluation, or plan to address the resident's dental needs. This was brought to the attention of the director of nursing (DON - Employee #1) at 10:00 a.m. on 02/01/11. When asked to provide any additional information regarding an assessment of the resident's dental needs; however, Employee #1 was unable to locate any additional information. -- b) Resident #37 Observation of the preparation of this resident's meal, at noon on 01/27/11, revealed dietary staff was adding water to portions of pureed foods and was attempting to push the foods through a small strainer. A small amount of thin liquid came through the strainer. Staff then added more water and pushed it through. This continued until a portion of watery food substance was acquired for each food item. At 12:00 p.m. on 01/27/11, this was discussed with the dietary manager (DM - Employee #61), who stated the resident's family wanted the resident to be able to drink his meal through a straw. When the nutritional content of the meal as prepared was discussed, the DM confirmed the manner dietary staff were preparing this resident's meals was not a method which assured the provision of adequate nutrition. When asked if this had been assessed by the consultant registered dietitian (RD), the DM was unsure. Review of the resident's dietary assessments revealed no evidence the RD had assessed how this resident's meals should be provided and/or if the manner they were provided was meeting the resident's nutritional needs. -- c) Residents #84, #31, #35, and #28 Observation of the preparation of these residents' meals, at noon on 01/27/11, revealed they were each provided half portions of each food item. At 12:00 p.m. on 01/27/11, this was discussed with the DM, who stated the dietitian had planned this for the specific residents. When asked if the dietitian had assessed whether the half portions were meeting each residents' needs, the DM was unsure. Review of the residents' dietary assessments revealed no evidence the RD had assessed whether the serving of half portions of foods at each meal was meeting the individual needs of each of these residents.",2015-11-01
9482,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,279,E,0,1,SJCY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed to develop a comprehensive plan of care for seven (7) of thirty-two (32) Stage II sample residents. There were no care plans to address the dental needs for two (2) residents or the nutritional needs for five (5) residents. Resident identifiers: #7, #37, #84, #31, #35, #28, and #79. Facility census: 84. Findings include: a) Resident #7 During a Stage I interview on 01/26/11 at 8:55 a.m., observation revealed Resident #7's natural teeth were in very poor condition, and many were missing. When the resident was asked the interview questions about dental condition, she stated her teeth were half gone. review of the resident's medical record revealed [REDACTED]. This assessment was not accurate, as it was the resident's natural teeth which were in poor condition. There was no further assessment, evaluation, or plan to address the resident's dental needs. This was brought to the attention of the director of nursing (DON - Employee #1) at 10:00 a.m. on 02/01/11, at which time the DON confirmed the resident should have a care plan if she had dental needs. -- b) Resident #37 Observation of the preparation of this resident's meal, at noon on 01/27/11, revealed dietary staff were adding water to portions of pureed foods and were attempting to push the foods through a small strainer. A small amount of thin liquid came through the strainer. Staff then added more water and pushed it through. This continued until a portion of watery food substance was acquired for each food item. At 12:00 p.m. on 01/27/11, this was discussed with the dietary manager (DM - Employee #61), who stated the resident's family wanted the resident to be able to drink his meal through a straw. When the nutritional content of the meal as prepared was discussed, the DM confirmed the manner dietary staff were preparing this resident's meals was not a method which assured the provision of adequate nutrition. When asked if this had been assessed by the consultant registered dietitian (RD), the DM was unsure. Review of the resident's dietary assessments revealed no evidence the RD had assessed how this resident's meals should be provided and/or if the manner they were provided was meeting the resident's nutritional needs. Additionally, review of this resident's care plan revealed no plan to provide the resident with foods in this consistency while also meeting the resident's nutritional needs. -- c) Residents #84, #31, #35, and #28 Observation of the preparation of these residents' meals, at noon on 01/27/11, revealed they were each provided half portions of each food item. At 12:00 p.m. on 01/27/11, this was discussed with the DM, who stated the dietitian had planned this for the specific residents. When asked if the dietitian had assessed whether the half portions were meeting each residents' needs, the DM was unsure. Review of the residents' dietary assessments revealed no evidence the RD had assessed whether the serving of half portions of foods at each meal was meeting the individual needs of each of these residents. In addition, review of each resident's care plan revealed no plan regarding what additional nutrients, if any, were necessary to assure each resident's nutritional needs were met while being provided half portions of foods by dietary. -- d) Resident #79 On 02/01/11 at 3:05 p.m., review of the resident's admission nursing assessment, dated 11/23/10, revealed the resident wore a partial, had obvious or likely cavity or broken natural teeth, and her remaining teeth were in poor shape. Review of the resident's initial social review revealed the resident had natural teeth, but they were in poor condition. No further information given. On 02/01/11 at 3:50 p.m., an interview with a licensed practical nurse (LPN - Employee #11) revealed she was not aware whether the resident had had a dental appointment since admission, and the resident had not mentioned any gum soreness to Employee #11 Review of the resident's care plan found no plan to address dental problems. On 02/01/11 at 4:10 p.m., a follow-up interview with the DON revealed Resident #79 had not had a dental appointment since admission nor any further intervention.",2015-11-01
9483,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,280,E,0,1,SJCY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, and care plan review, the facility failed to revise the activity care plans for three (3) of thirty-two (32) Stage II sample residents (#111, #55, and #98) who were in contact isolation. In addition, the facility failed to ensure two (2) of thirty-two (32) Stage II sample residents (#28 and #7) were invited to their quarterly care plan meetings. Resident identifiers: #111, #55, #98, #28, and #7. Facility census: 84. Findings include: a) Residents #111, #55, and #98 A review of Resident #111, #55, and #98's medical records, on 01/25/11, revealed all three (3) were currently in contact isolation precautions due to having [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) and/or [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE). Resident #111 was diagnosed with [REDACTED]. Resident #98 was diagnosed with [REDACTED]. Resident #55 was diagnosed with [REDACTED]. The care plans for the three (3) residents were revised to address the provision of contact isolation precautions after these [DIAGNOSES REDACTED]. On 01/25/11 at 3:00 p.m., a licensed practical nurse (LPN - Employee #11) reported that, since these residents were in contact isolation, they could not come out of their rooms. On 01/27/11 at approximately 2:00 p.m., the activity director (Employee #54) reported these residents could not participate in out of room activities, because they were in contact isolation. She also stated she had particular concerns about residents on contact isolation attending food-related activity programs. She said she had ensured these residents had things in their rooms they enjoyed doing. She also said her staff provided one-on-one visits for these residents. On 02/02/11 at approximately 3:00 p.m., the activity director indicated she had not updated the three (3) residents' care plans after they were placed on contact isolation. She agreed these updates were important to ensure the residents were not denied participation in activities they wished to attend. She stated she would consult with the infection control nurse to determine an appropriate care plan for these three (3) residents. -- b) Resident #28 During a Stage I interview in 01/25/11 at 9:30 a.m., Resident #28 reported she had never been invited to a care plan meeting. Review of Resident #28's medical record revealed no evidence that she had been invited to a care plan meeting. On 01/31/11 at 2:05 p.m., an interview with an LPN (Employee #22) revealed residents are always invited to care plan meetings. In an interview on 01/31/11 at 2:55 p.m., one (1) of the facility's social workers (Employee #53) reported Resident #28 had been invited to all care plan conferences, but she did not have any documentation regarding these invitations. She further stated Employee #89 (who worked in the front office) always invited residents to care plan conferences. On 01/31/11 at 3:10 p.m., an interview with Employee #89 revealed she asked all residents if they would like to attend care plan meetings; she further stated she did not have any documentation of this. -- c) Resident #7 During a Stage I interview on 01/25/11, when asked if she participated in planning her care and treatment, Resident #7 replied, No. Further probes were made to determine if the resident had the opportunity to select between alternative treatments. The resident again stated she had not been involved in these decisions. Record review revealed this resident was admitted to the facility on [DATE]. Further review of her record, on 02/0211, found no evidence of discussions with the resident, by any means, regarding the provision of her care while residing in the facility. Nothing was found to reflect any involvement by the resident in the care planning process, including but not limited to evidence she had been invited and/or attended her initial care planning session. Interview with Employee #53, at 11:45 a.m. on 02/02/11, revealed the facility had not been keeping any type of record that residents were invited to care plans.",2015-11-01
9484,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,282,D,0,1,SJCY11,"Based on medical record review and staff interview, the facility failed to assure the care plans for oral care and hydration were implemented for one (1) of thirty-two (32) Stage II sample residents. Resident identifier: #37. Facility census: 84. Findings include: a) Resident #37 Review of Resident #37's care plan, on 02/01/11, noted the resident was to be provided 30 cc of fluid every hour, and his mouth was to be wiped with swabs every hour. Review of the February 2011 nursing assistant flow sheets revealed no directives to offer 30 cc fluids every hour, and the directives for mouth care stated the resident's mouth was to be swabbed in the morning and the evening (and not hourly). The medication administration records (MARs) were also reviewed for the provision of these services. There was nothing relative to the provision of 30 cc fluids hourly or swabbing of the mouth hourly in the February MARs. According to the director of nursing (DON - Employee #1), at 12:30 p.m. on 02/02/11, the nursing assistant flow sheets were where staff was to find the resident-specific directives regarding the provision of care. When asked, the DON was unable to provide any evidence to support the care plan interventions (for 30 cc fluids every hour and mouth to be wiped with swabs every hour) were being implemented.",2015-11-01
9485,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,312,D,0,1,SJCY11,"Based on resident interview, record review, and staff interview, the facility failed to ensure two (2) of thirty-two (32) Stage II sample residents, who were dependent in the areas of oral care and bathing, received necessary services to maintain good grooming and personal and oral hygiene. Resident identifiers: #111 and #37. Facility census: 84. Findings include: a) Resident #111 During an interview on 01/25/11 at approximately 10:15 a.m., Resident #111 reported she had not had a shower since her admission (on 01/11/11). She stated she would like to have a shower. At approximately 10:30 a.m. on 01/25/11, nurse aides came in to give the resident a shower. Review of the resident's plan of care kardex revealed she received her first shower on 01/25/11. Further review of her kardex revealed staff had recorded B to indicate the resident received a bath on 01/12/11, 01/13/11, 01/14/11, 01/15/11, and 01/16/11. On 01/17/11 and 01/18/11, there was no documentation to indicate what kind of bathing the resident received. On 01/19/11, 01/20/11, 01/21/11, 01/22/11, 01/23/11, and 01/24/11, staff again recorded B to indicate the resident received a bath on these dates. When interviewed, Employee #18 (a licensed practical nurse - LPN) reported all residents receive one (1) shower per week. Employee #13 (an LPN) indicated Resident #111 had refused her showers; however, the documentation did not reflect the resident had refused any showers. The resident also did not have a care plan for refusing showers. -- b) Resident #37 Review of the resident's current care plan noted he was to be provided 30 cc of fluid every hour, and his mouth was supposed to be wiped with swabs every hour. Review of the February 2011 nursing assistant flow sheets revealed no directives to offer 30 cc fluids every hour, and the directives for mouth care stated the resident's mouth was to be swabbed in the morning and the evening (and not hourly). The medication administration records (MARs) were also reviewed for the provision of these services. There was nothing relative to the provision of 30 cc fluids hourly or swabbing of the mouth hourly in the February MARs. According to the director of nursing (DON - Employee #1), at 12:30 p.m. on 02/02/11, the nursing assistant flow sheets were where staff was to find the resident-specific directives regarding the provision of care. When asked, the DON was unable to provide any evidence to support the care plan interventions (for 30 cc fluids every hour and mouth to be wiped with swabs every hour) were being implemented.",2015-11-01
9486,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,318,D,0,1,SJCY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observation, medical record review, and staff interview, the facility failed to ensure a resident with limited range of motion (ROM) received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM, as evidenced failure of the staff to apply a palm protector with finger separators to the resident's left hand in accordance with physician orders [REDACTED]. Resident identifier: #22. Facility census: 84. Findings include: a) Resident #22 On 01/31/11 at 3:05 p.m., observation found Resident #22 had contractures of both hands and arms. She had a rolled washcloth in her right hand, but there was no device in her left hand. On 01/31/11 at 3:45 p.m., an interview with a licensed practical nurse (LPN - Employee #9) confirmed Resident #22 had contractures of bilateral hands, arms, and legs. According to Employee #9, Resident #22 was supposed to have rolled washcloths rolls in both hands; she did not use splints due to swelling. Review of the physician's orders [REDACTED]. Remove for bathing and hygiene. On 02/01/11 at 9:15 a.m., the resident was observed in the dining room with no palm protector in her left hand. On 02/02/11 at 8:30 a.m., the resident was again observed in the dining room; she was sitting up in her chair with rolled washcloths in both hands, but there was no palm protector in her left hand. On 02/02/11 at 11:55 a.m., the resident was again observed sitting up in a chair in the dining room, with no palm protector in her left hand. On 02/02/11 at 12:00 p.m., an interview with another LPN (Employee #19) revealed the resident was to be wearing a palm protector in her left hand, and she was unsure why the resident would not be wearing it. It may be in the laundry. She also observed, with this surveyor, that Resident #22 was not wearing a palm protector in her left hand.",2015-11-01
9487,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,323,E,0,1,SJCY11,"Based on observation and staff interview, the facility failed to ensure the resident environment remains as free of accident hazards as is possible, as evidenced by staff leaving a medication cart unlocked while unattended, leaving a medication drawer open, and leaving medications on top of the cart while unattended. These practices have the potential to affect more than an isolated number of residents. Facility census: 84. Findings include: a) An observation made during medication administration, on 01/25/11 at 8:40 a.m., found a registered nurse (Employee #2) left the medication cart unattended in the hallway unlocked and with a medication drawer open. An observation made during medication administration, on 02/02/11 at 7:40 a.m., found Employee #2 left medication on top of the medication cart while the cart was unattended. An observation made during medication administration, on 02/02/11 at 8:00 a.m., revealed Employee #2 left medication on top of the medication cart and left a medication drawer open while the cart was unattended. On 02/02/11 at 1:00 p.m., an interview with the director of nursing (DON - Employee #1) confirmed that leaving a medication cart unlocked while unattended, leaving a medication drawer open, and leaving medications on top of the cart while unattended were unsafe practices.",2015-11-01
9488,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,329,D,0,1,SJCY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs, as evidenced by continuing to administer a steroid medication to a resident who had an allergy to that steroid medication. One (1) of thirty-two (32) residents in the Stage II sample was affected. Resident identifier: #79. Facility census: 84. Findings include: a) Resident #79 Review of Resident #79's physician's orders [REDACTED]. Review of Resident #79's admission nursing assessment, dated 11/23/10, revealed she was allergic to steroids. Review of Resident #79's admission orders [REDACTED]vision problems. On 02/01/11 at 2:05 p.m., an interview with the director of nursing (DON - Employee #1) revealed the staff should have clarified the order for the [MEDICATION NAME] with the resident's attending physician due to the steroid allergy.",2015-11-01
9489,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,353,C,0,1,SJCY11,"Based on review of the nursing staffing schedule and staff interview, the facility failed to designate a licensed nurse to serve as a charge nurse on each tour of duty. This had the potential to affect all residents in the facility. Facility census: 84. Findings include: a) Review of the nursing staffing schedule for 02/01/11 revealed no licensed nurse had been designated to serve as charge nurse for each shift. On 02/01/11 at 9:35 a.m., interview with a registered nurse (Employee #8) revealed that each nurse was in charge of there own hallway, but we do not have one specific nurse designated as a charge nurse on the schedule each shift.",2015-11-01
9490,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,364,F,0,1,SJCY11,"Based on observation, medical record review, menu review, and staff interview, the facility failed to provide food prepared by methods that conserved nutritive value, flavor, and appearance. One (1) resident (#37) was provided a thinned diet which contained very little nutritive value; residents on pureed diets were provided foods which were too thin and ran onto each other when plated; and spaghetti was not portioned in a manner which assured portions as directed by the menu. Resident #37 was affected, as were all other residents who received nourishment from the dietary department. Resident identifier: #37. Facility census: 84. Findings include: a) Resident #37 Observation of the preparation of this resident's meal, at noon on 01/27/11, revealed dietary staff was adding water to portions of pureed foods and was attempting to push the foods through a small strainer. A small amount of thin liquid came through the strainer. Staff then added more water and pushed it through. This continued until a portion of watery food substance was acquired for each food item. At 12:00 p.m. on 01/27/11, this was discussed with the dietary manager (DM - Employee #61), who stated the resident's family wanted the resident to be able to drink his meal through a straw. When the nutritional content of the meal as prepared was discussed, the DM confirmed the manner dietary staff were preparing this resident's meals was not a method which assured the provision of adequate nutrition. When asked if this had been assessed by the consultant registered dietitian (RD), the DM was unsure. Review of the resident's dietary assessments revealed no evidence the RD had assessed how this resident's meals should be provided and/or if the manner they were provided was meeting the resident's nutritional needs. -- b) Residents who required pureed foods Observation of the portioning of these residents' meals, at noon on 01/27/11, revealed the spaghetti and other foods placed on the plates ran together, creating an unattractive presentation for these residents. When this was brought to the attention of the DM at 12:00 p.m. on 01/27/11, she stated she was aware pureed foods were supposed to be the consistency of mashed potatoes. -- c) Residents who did not require pureed foods Regular spaghetti was observed being served to all residents who did not require pureed spaghetti. The cook served the spaghetti with tongs, which did not provide an accurate portion size. When asked how much spaghetti the residents were to receive, the cook stated 3 ounces. Review of the menu revealed a 1 cup portion of the spaghetti was supposed to be served at this meal. At 12:00 p.m. on 01/27/11, the DM confirmed staff should have used some type of portioning device to assure accuracy. The DM also stated staff should have been aware of the correct portion size for the spaghetti for that meal.",2015-11-01
9491,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,371,F,0,1,SJCY11,"Based on observations and staff interview, the facility failed to assure foods were prepared and served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. These practices had the potential to affect all facility residents who received nourishment from the dietary department. Facility census: 84 Findings include: a) Employee #63 (dietary personnel) accompanied the tour of the kitchen at approximately 2:30 p.m. on 01/24/11. The facility had an insulated cooler in the walk-in refrigerator, in which were stored individual pats of butter. On 01/25/11 at approximately 11:00 a.m., the surveyor checked the temperature of the individual pats of butter while they were stored in the cooler located inside the refrigerator; the temperature registered at 45 degrees Fahrenheit (F). The surveyor explained to the dietary manager (DM - Employee #61) that the insulation in the cooler prevented the cool air from the refrigerator from reaching the products stored inside. An acceptable cool temperature for these pats of butter would register at 41 degrees F or cooler. The DM acknowledged the 45 degree F temperature was too warm. b) At 11:00 a.m. on 01/25/11, a walk through of the kitchen was completed with the dietary manager (DM). The following sanitation infractions were identified: 1. A dietary staff member was washing pots and pans in the 3-compartment sink. She was asked to test the chlorine solution in the sanitizing sink. A test strip was inserted, but there was no color chart accessible to use to check the chlorine test strips for adequate concentration of chlorine. 2. Cups, bowls, plate bottoms and lids were observed stacked and/or inverted on trays prior to air drying. This created a medium for bacterial growth. 3. Peeling plastic, with exposed metal, was observed on the dish washer racks for the pellet system. 4. The handwashing sink in the dish room was very soiled. Additionally, a broom and dustpan were hanging close enough to touch a person's clothing while washing hands at this sink. 5. Plastic cups and bowls, which were ready for use, contained dried food debris. Additionally, the finish was worn off many of these food service items, rendering them incapable of being adequately sanitized. 6. A large fan was adjusted toward the paper towels at the hand sink in the dish room. This fan also had a large amount of dusty debris clinging to it.",2015-11-01
9492,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,411,D,0,1,SJCY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to provide routine dental services to meet the needs of each resident, as evidenced by failing to arrange for routine dental services after two (2) residents' assessments revealed poor dental status. Two (2) of thirty-two (32) residents on the Stage II sample were affected. Resident identifiers: #79 and #7. Facility census: 84. Findings include: a) Resident #79 On 02/01/11 at 3:05 p.m., review of the resident's admission nursing assessment, dated 11/23/10, revealed the resident wore a partial, had obvious or likely cavity or broken natural teeth, and her remaining teeth were in poor shape. Review of the resident's initial social review revealed the resident had natural teeth, but they were in poor condition. No further information given. On 02/01/11 at 3:50 p.m., an interview with a licensed practical nurse (LPN - Employee #11) revealed she was not aware whether the resident had had a dental appointment since admission, and the resident had not mentioned any gum soreness to Employee #11 Review of the resident's care plan found no plan to address dental problems. On 02/01/11 at 4:10 p.m., a follow-up interview with the director of nursing (DON - Employee #1) revealed Resident #79 had not had a dental appointment since admission nor any further intervention. -- b) Resident #7 During a Stage I interview on 01/26/11 at 8:55 a.m., observation revealed Resident #7's natural teeth were in very poor condition, and many were missing. When the resident was asked the interview questions about dental condition, she stated her teeth were half gone. review of the resident's medical record revealed [REDACTED]. This assessment was not accurate, as it was the resident's natural teeth which were in poor condition. There was no further assessment, evaluation, or plan to address the resident's dental needs. This was brought to the attention of the DON at 10:00 a.m. on 02/01/11. When asked to provide any additional information regarding an assessment of the resident's dental needs; however, the DON was unable to locate any additional information.",2015-11-01
9493,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,428,D,0,1,SJCY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the pharmacist identified and reported an irregularity in the medical regimen of one (1) of thirty-two (32) Stage II residents. Resident #79 was known to have an allergy to steroid medications. Facility staff continued to administer a steroid medication to this resident after the allergy was made known to staff, and the pharmacist failed to identify and report this irregularity to the attending physician and the director of nursing (DON). Resident identifier: #79. Facility census: 84. Findings include: a) Resident #79 Review of Resident #79's physician's orders [REDACTED]. Review of Resident #79's admission nursing assessment, dated 11/23/10, revealed she was allergic to steroids. Review of Resident #79's admission orders [REDACTED]vision problems. On 02/01/11 at 2:05 p.m., an interview with the DON (Employee #1) revealed the staff should have clarified the order for the Prednisone with the resident's attending physician due to the steroid allergy. Further record review revealed the pharmacist reviewed the resident's medication regimen on 01/22/11 and made no recommendations regarding the use of steroids.",2015-11-01
9494,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,431,E,0,1,SJCY11,"Based on observation, staff interview, and review of facility policy and procedure, the facility failed to appropriately manage and store drugs and biologicals used in the facility, as evidenced by not ensuring drugs and biologicals were labeled in accordance with currently accepted professional principles (including labeling with expiration dates when applicable) and by storing outdated medications on medication carts. This has the potential to affect more than a isolated number of residents. Facility census: 84. Findings include: a) On 01/26/11 at 10:00 a.m., an observation of the 1st floor medication storage room revealed, on the short hall medication cart, Milk of Magnesia with an expiration date of 12/09 and Calcium Carbonate with an expiration date of 05/10. Observation of the long hall medication cart revealed Pepto Bismol with an expiration date of 10/10. Also observed in the medication refrigerator were thirteen (13) vials of insulin without labeling to indicate on what date the vials were opened and Phenergan Suppositories with an expiration date of 04/09. b) On 01/26/11 at 10:45 a.m., an observation of the 2nd floor medication storage room revealed, on the short hall medication cart, Vegetable Laxative with an expiration date of 06/08. Also observed in the medication refrigerator were twelve (12) vials of insulin that were not dated after opening. c) On 01/26/11 at 12:00 p.m., an interview with the director of nursing (DON - Employee #1) revealed these medications should have not been left on the cart after their expiration dates had passed, and all insulin vials should be dated immediately after opening. d) Review of the facility policy and procedure regarding Vials and Ampules of Injectable Medications revealed: The date opened and the initials of the first person to use the vial are recorded on the multidose vial (on the vial label or an accessory label affixed for that purpose).",2015-11-01
9495,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,441,F,0,1,SJCY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, review of recommendations made by the Centers for Disease Control and Prevention (CDC), and review of the facility's transmission-based precautions policy, the facility failed to establish and maintain an infection control program in accordance with current accepted standards and practices. Three (3) of thirty-two (32) Stage II sample residents (#111, #98, and #55) were currently placed in contact isolation due to Methicillin-resistant Staphylococcus aureus(MRSA) and/or [MEDICATION NAME]-resistant [MEDICATION NAME] (VRE) infections. There was no signage at the entrance to these residents' rooms to alert visitors of the need to take special precautions when interacting with them, and these residents were isolated in excess of what is required (according to CDC guidelines) to maintain contact isolation in a nursing home, by being prevented from attending out-of-room activities and being served meals using disposable paper dishware and plastic cutlery. In addition, the facility's dietary department allowed a staff member to work in the kitchen while displaying an open wound resulting from spider bite to the forearm. The staff member prepared food for resident consumption as well as handled various equipment used for food preparation in the kitchen area. This practice had the potential to affect all residents who consumed an oral diet in the facility. Facility census: 84. Findings include: a) Residents #111, #55, and #98 1. On 01/24/11 at approximately 2:30 p.m., observation found three (3) resident rooms with carts sitting outside their doors; each cart contained gowns, gloves and other personal protective equipment. These rooms were occupied by Residents #111, #98, and #55. However, there was no signage posted at the entrances of any of the three (3) rooms to alert visitors of the need to don any of the protective coverings prior to entering the rooms. These residents were later identified by a licensed practical nurse (Employee #11) as having MRSA and/or VRE. CDC recommends the following regarding making family and other visitors aware of precautions to take when a resident has an infection: If a patient in a facility is colonized or infected with MRSA or VRE, what do their visitors / family members need to know? In general, healthy people are at low risk of getting infected with MDROs (multi-drug resistant organisms). Therefore, casual contact - such as kissing, hugging, and touching - is acceptable. Visitors should wash their hands before leaving an infected person's room. Also, disposable gloves should be worn if contact with body fluids is expected. (If excessive contact with body fluids is expected, gowns should also be worn.) It is also acceptable for infants and children to have casual contact with these patients. (The URL for this information is: www.cdc.gov/ncidod/dhqp/ar_multidrugFAQ.html ) On 01/25/11 at 3:00 p.m., the director of nursing (DON - Employee #1) put signs on the doors of the residents' rooms alerting visitors to see a nurse before entering the room. -- 2. During an interview on 01/25/11 at approximately 9:00 a.m., Resident #111 reported she had an infection and could not come out of her room. On 01/25/11 at approximately 3:00 p.m., Employee #11 (a licensed practical nurse - LPN) confirmed Resident #111 had MRSA in her urine and could not come out of her room due to this infection. According to her care plan, Resident #111 went into contact isolation precautions on 01/21/11. Employee #11 also reported Resident #55 had MRSA in wound on his bottom (between the scrotum and anus). He went into contact isolation precautions on 01/14/11. At the point the resident was placed in contact isolation, he was unable to leave his room. The LPN indicated the MRSA infection had cleared, but a culture of the wound tested positive for VRE. The resident went into a private room on 01/25/11, due to the VRE. The resident remained unable to leave his room due to the contact isolation. During an interview on 01/27/11 at approximately 3:00 p.m., Employee #8 (the infection control nurse, also a registered nurse) reported Resident #98 was placed in contact isolation on 12/15/10 due to MRSA in a wound on his left heel. On 01/27/11 at approximately 11:00 a.m., Employee #13 (an LPN) reported Resident #111 was placed in a private room on 01/26/11 due to her MRSA infection. Employee #13 went on to say that all three (3) residents (#111, #55, and #98) were not able to come out of their rooms due to their infections. On 01/27/11 at 12:00 p.m., Employee #36 (a nursing assistant) stated she could not take residents who were in isolation out of their rooms. Contact isolation precautions are defined by the CDC as precautions that 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. According to CDC guidelines, residents of long term care facilities who are on contact precautions do not need confined to their rooms. The CDC recommends the following pertaining to out-of-room activities: It is extremely important to maintain the patients' ability to socialize and have access to rehabilitation opportunities. Infected or colonized patients should be permitted to participate in group meals and activities if draining wounds are covered, bodily fluids are contained, and the patients observe good hygienic practices. (The URL for this information is which can be found at: www.cdc.gov/mrsa/prevent/healthcare/precautions.html) On 01/27/11, Employee #8 agreed the LPNs and nursing assistants were not following the CDC guidelines for contact isolation precautions. She agreed they were too strict in their interpretation of these precautions. -- 3. During meal times on 01/24/11 and 02/01/11, Residents #111, #55, and #98 were served meals in paper dishware and with plastic cutlery. When interviewed on 01/25/11 at approximately 8:45 a.m., Resident #111 reported she did not know why she had plastic cutlery and paper dishware; however, she said she thought it had to do with her infection. On 01/27/11 at approximately 3:00 p.m., Employee #8 reported she did not know these three (3) residents did not need to be served with plastic cutlery and paper dishware. She said she thought they needed these products due to their infection. Employee #8 was informed that all dishes, glasses, and trays are cleaned and disinfected by using hot water and detergent and by drying at high temperature; this process kills the bacteria. Therefore, the facility did not need to use paper plates or plastic silverware for these residents. The residents continued to receive the plastic and paper products after this interview with Employee #8 on 01/27/11. On 02/01/11 at approximately 11:30 a.m., Employee #8 called the dietary department and informed them these three (3) residents did not need plastic cutlery and paper dishware. -- b) On 01/26/11 at 11:30 a.m., a dietary employee entered the kitchen. The sleeves of her uniform were about elbow length, and an obvious wound was visible on her right arm, just below the elbow. Upon inquiry, the employee stated it was a spider bite, and she further stated the bite had been there about three (3) weeks. At the time of this discussion, the dietary manager (DM - Employee #61) was present and suggested the employee cover the bite. The employee stated, It's all right now. The DM insisted the bite be covered, and the employee complied. Interview with the DM, on 01/27/11 at 1:15 p.m., revealed she had not been made aware of the spider bite until 11:30 a.m. on 01/26/11. The DM confirmed the employee should have made her aware of the situation. According to the DM, had she known about the spider bite, she would have had this person see the physician to assure the employee was safe to handle foods and food service items. The DM was unable to implement appropriate infection control measures, because the employee had not informed her of the spider bite and the associated open wound.",2015-11-01
9974,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-03-20,312,D,0,1,C1G012,"**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 resident, who was unable to complete her own daily care received assistance with personal hygiene. When a palm protector, ordered to prevent further contractures to the resident's left hand, was removed, a rank, sour odor emanated from the resident's hand. This was true for one (1) random observation made during a re-visit to the facility's Quality Indicator Survey (QIS) completed on 01/17/13. Resident identifier: #8. Facility census: 88. Findings include: a) Resident #8 The minimum data set (MDS), with an assessment reference date (ARD) of 12/30/12, Section S, identified the resident as having a contracture of the left hand. A physician's orders [REDACTED]. (hours) and PRN (as needed) for monitoring of skin breakdown."" Further review of the resident's care plan revealed a problem of potential for altered skin integrity. An approach to this problem was, ""Palm protector L (left) hand digits 1-3 contracture."" On 03/19/13 at 9:06 a.m., the residents' left hand was observed with a palm protector in place. The resident was in her room seated in a reclining geri-chair. During this observation, a sour odor could be detected from approximately two (2) feet from the resident. Two (2) employees, Employee #8, a licensed practical nurse, and Employee #48, a certified nursing assistant, were asked to remove the palm protector from the resident's hand. When Employee #8 removed the palm protector a rank, sour odor emanated from the resident's hand. Employee #8 verified the hand need cleaned and the palm protector needed washed. Employee #2, the registered nurse MDS coordinator, was interviewed at 10:58 on 03/19/13. She verified the care plan did not address removal of the palm protector every two (2) hours as directed by the physician's orders [REDACTED]. Employee #2 stated directions to the nursing assistants should have been provided on the Kardex. She produced a copy of the Kardex for March 2013, which did not address removal of the palm protector and cleaning of the resident's left hand. The shower schedule for this resident was reviewed with Employee #2 at 10:58 on 03/19/13. According to the shower schedule the resident was showered every seven (7) days. Her last shower occurred on 03/12/13. Employee #2 stated the resident was scheduled for a shower today, 03/19/13, on the afternoon shift. .",2015-08-01
9975,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-03-20,323,D,0,1,C1G012,". Based on medical record review and staff interview, the facility failed to ensure a resident received adequate supervision to prevent an accident. Instructions provided on the care plan for the number of staff required to transfer the resident were unclear and did not match the instructions provided on the plan of care Kardex, also used by the nursing assistants to determine the number of staff required to transfer a resident. This was true for one (1) random resident reviewed during the re-visit to the facility's Quality Indicator Survey (QIS) which ended on 01/17/13. Resident identifier: #18. Facility census: 88. Findings include: a) Resident #18 Review of a nurse's note, dated 02/28/13, found the following, ""Called to Resident's bathroom at 9pm by (name of nursing assistant -CNA). Resident was seated on the floor in front of the toilet. CNA stated she was assisting Resident to rise from toilet and shower chair and was going to pull up her brief when Residents feet slid out from under her. CNA lowered Resident to floor. MAEW (DON stated this was the abbreviation for, moved all extremities well). No malformations or abnormalities present. . . ."" Review of the care plan found a problem, ""At risk for skin breakdown r/t related to hx (history) of PU (pressure ulcers). An approach to this problem found the intervention, ""Assist of two with transfers and assist of one with toileting."" Employee #12, the licensed practical nurse-unit charge manager, was asked where a nursing assistant would find directions on how to transfer a resident on 03/20/13 at 9:00 a.m.. She replied, ""by reading the care plan."" Employee #1, the director of nursing (DON) was interviewed on 03/20/13 at 9:30 a.m. She was asked to explain how a a resident who required the assistance of two (2) staff members for transferring could be toileted by one staff member when toileted required transferring the resident. The DON agreed that toileting of this resident would involve transferring and the intervention for transferring the resident, as directed by the care plan, was unclear. The DON further stated the resident's Kardex should be reviewed to determine how much assistance was required for toileting. She provided a copy of the Kardex for February 2013, which included directions for toileting. According to the Kardex, toilet use required the assistance of two (2) staff members. The DON agreed the directions provided on the care plan were not clear and were in conflict with the directions for transferring the resident on the Kardex. She verified the CNA had access to both documents. .",2015-08-01
9976,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-03-20,490,F,0,1,C1G012,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on the results obtained through observations, record reviews, and staff interview, during the re-visit survey beginning on 03/18/13, the governing body failed to ensure all deficient practices cited during the Quality Indicator Survey (QIS) ending on 01/17/13 were corrected, as alleged in the plan of correction signed by the administrator on 02/22/13. Deficient practices remained in the following Federal Regulatory Groupings: Resident Behavior and Facility Practices and Quality of Care. This had the potential to affect all residents in the facility. Facility census: 88. Findings include: a) Resident behavior and facility practices. 1. Based on medical record review and staff interview, the facility failed to ensure Residents #116 and #72 were free from neglect. Medical services were not provided in a timely manner for these two (2) residents who had infections. b) Quality of care 1. Based on medical record review and staff interview, the facility failed to ensure Residents #116 and #72 received timely treatment for [REDACTED]. 2. Based on observation, record review, and staff interview the facility failed to ensure a dependent resident (Resident #8) received care and services to maintain good personal hygiene and to prevent further contractures of her left hand. Staff interview with the administrator and director of nursing, on 03/19/13 at 2:00 p.m., revealed the issues identified from the previous QIS had been addressed with the quality assessment and assurance committee (QA committee). The administrator stated the deficiencies were thought to have been corrected. On 03/20/13 at 11:15 a.m. an interview was conducted with the medical director who stated the facility had worked hard to correct the deficiencies and thought everything was fixed. The deficiencies found during the re-visit were again discussed with the administrator on 03/20/13 at 1:15 p.m. She verified QA meetings were held and a plan of correction had been put in place to assure past deficient practices were corrected. .",2015-08-01
9977,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-03-20,520,F,0,1,C1G012,". Based on medical record reviews, observation, staff interviews, and policy review, the facility's quality assurance program failed to develop and implement plans of action to correct identified quality deficiencies. Seven (7) deficient practices identified during the annual Quality Indicator Survey (QIS), which ended on 01/17/13, were still out of compliance during the re-visit survey which ended on 03/20/13. The facility submitted a plan of correction for these deficiencies, but failed to implement the plans and/or correct the deficiencies cited at F224, F279, F280, F309, F318, F371, and F441. This had the potential to affect all residents in the facility. Facility census: 88. Findings include: a) Interview with the administrator and director of nursing, on 03/19/13 at 2:00 p.m., revealed the issues identified from the previous QIS had been addressed with the quality assessment and assurance committee (QA committee). The administrator stated the deficiencies were thought to have been corrected. On 03/20/13 at 11:15 a.m., an interview was conducted with the medical director who stated the facility had many QA meetings and had worked hard to correct the deficiencies. The deficient practices found during the re-visit were again discussed with the administrator on 03/20/13 at 1:15 p.m. She verified QA meetings were held and a plan of correction had been put in place to ensure past deficient practices were corrected. The QA committee did not ensure the deficient practices cited during the survey, which ended on 01/17/13, were corrected. A plan of correction for these deficiencies was submitted by the facility. These plans were not effectively implemented for the deficiencies previously cited at F224, F279, F280, F309, F318, F371, and F441. b) Staff failed to ensure two (2) residents (Residents #116 and #72) were free from neglect. The residents were not treated timely for infections (urinary tract infection and pneumonia). c) Medical record review and staff interview revealed the facility failed to complete a comprehensive care plan addressing the removal of a palm protector, applied daily to the resident's left hand to prevent contractures. The care plan also failed to address the cleaning of Resident #8's contracted hand. d) Medical record review and staff interviews revealed the facility failed to revise the care plans for Resident #18, who had a pressure ulcer, and for Resident #8, who required the assistance of two staff members for transfers. e) Medical record review and staff interview revealed the facility failed to timely treat infections for two residents (#116 and #72). Laboratory results and a chest x-ray was not obtained in a timely manner resulting in a delay in treatment for one resident with pneumonia and one resident with a urinary tract infection. f) The facility failed to ensure Resident #8 was receiving care, as ordered by the physician, for further deterioration of a contracture of the left hand. g) Observation and staff interview revealed the facility failed to ensure proper storage of food items in the kitchen. Raw chicken was stored in a plastic bag on top of a box of celery. h) Review of infection control surveillance data and analysis of that data, review of facility policy, and staff interview, reveal the failed to maintain an effective infection control program. The facility failed to complete surveillance logs, and identify organisms for tracking and trending to prevent the onset and the spread of infections. .",2015-08-01
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
11291,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-03-30,272,D,1,0,VSQD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview and medical record review, the facility failed to ensure side rail assessments were accurate and consistent with current care plans and physician orders. The facility's side rail assessments did not accurately reflect the current care being received by the residents. Three (3) of twenty-two (22) residents had side rail assessments that did not reflect their current side rail usage. Resident identifiers: #15, #30, and #68. Facility census: 81. Findings include: a) Residents #15, #30, and #68 On 03/30/11 at approximately 10:00 a.m., Employee #78 (the director of nursing - DON) provided a list of all residents in the facility who currently had side rails on their beds; the list contained the names of twenty-three (23) residents. The list provided by the DON indicated Resident #15 needed side rails for protection, Resident #30 needed side rails for mobility, and Resident #68 had ? side rails at the head of her bed for mobility. Record review revealed all three (3) of these residents had current physician orders [REDACTED].#68's physician order, dated 10/06/10, stated: ""? Side rails at HOB (head of bed) for bed mobility."" Resident #30's physician order, dated 10/06/10, stated: ""Side rails for mobility."" Resident #15's physician order, dated 10/06/10, stated: ""Side rails for protection."" Upon request, the DON provided a copy of the side rail assessments completed by the facility for each of the twenty-three (23) residents with side rails. The assessments for Residents #15, #30, and #68 indicated they did not require side rails. Resident #30's assessments (dated 06/03/09, 06/05/09, 08/18/09, 12/13/09, 04/11/09, 07/23/10, 09/22/10, 01/28/11, and 02/24/11) all reflected no side rails were needed. Resident #68's assessments (dated 10/23/09, 01/30/10, 02/18/10, 05/22/10, 08/15/10, and 02/07/10) all reflected the resident did not have side rails. The assessments stated this resident may benefit from side rails but, as of 02/07/10, the assessment showed side rails were not needed. Resident #15's assessments (dated 01/18/09, 04/18/09, 07/18/09, 07/19/10, 09/26/10, and 11/12/10) all reflected side rails as not needed at the present time. On 03/30/11 at approximately 1:30 p.m., the DON stated the residents' care plans all indicated they had side rails on their beds. She reported her belief that the assessments were inaccurate, because they indicated the residents did not have side rails on their beds. .",2014-07-01
11477,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2010-10-14,280,D,,,LTYG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the care plan of one (1) of four (4) sampled residents was revised to reflect the resident's current problems and needs. The lack of an updated care plan resulted in a lack of goals and interventions to address the most current issues facing the resident. The facility had relocated the resident to a different area of the building in a room by himself, and the care plan failed to address this change in environment and the potential negative impact it could have on the resident. Resident identifier: #28. Facility census: 86. Findings include: a) Resident #28 Record review revealed a social work progress note documenting Resident #28's move to a room on second floor on 09/02/10, due to safety concerns surrounding his aggressive behaviors towards other residents. The resident had spent approximately ten (10) days in an inpatient acute psychiatric hospital from 08/03/10 through 08/13/10, due to increased aggressive behaviors. On 09/02/10, the facility moved Resident #28 to a semi-private room without a roommate on second floor, in order to ensure the safety of other residents and to monitor Resident #28's behavior. The facility also placed an alarm on a gate across the doorway which would sound when the resident came in and out of his room during the night time hours. Resident #28 came to the facility in February 2008. He had lived in a room on first floor with two (2) other roommates for over two (2) years. Due to his increased negative behaviors and the guardian's lack of acceptance of alternatives to promote the safety of the roommates (such as the use of a bed alarm on Resident #28 to alert staff when he was transferring out of bed), the facility elected to move the resident to ensure safety of others and to monitor for further agitation and negative behaviors. After the resident went to live on second floor, the facility failed to revised his care plan to address adjustment issues this resident faced. Resident #28 had [DIAGNOSES REDACTED]. He received [MEDICATION NAME] 0.5 mg twice a day for anxiety / agitation. He also received [MEDICATION NAME] 50 mg once a day for depression, as well as Mirtazepine ([MEDICATION NAME])[MEDICATION NAME](orally disintegrating tablets) 15 mg once a day at bedtime for depression. The care plan addressed specifics as to how the facility would monitor the resident's behavior to protect and ensure the safety of others. However, it failed to address the resident's relocation to a new environment and associated adjustment difficulties, especially in view of his pre-existing [DIAGNOSES REDACTED]. On 10/13/10, medical record review for Resident #28 revealed nursing staff had observed the resident talking to himself in his room on or near 09/29/10. The staff member identified this as a new behavior. Another staff member overheard the resident threatening to harm an incapacitated resident on 09/27/10. On 10/14/10 at approximately 4:00 p.m., the administrator and director of nursing confirmed the facility's interdisciplinary team had not addressed in the care plan how the move would impact the resident's psychosocial well-being. They agreed this was a significant life-changing event for someone with dementia, anxiety, and depression. They also agreed the care plan should have revised with goals, and interventions to assist the resident in reaching the goals, to promote the resident's highest practicable level of well-being.",2014-02-01
11538,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2010-09-03,323,J,,,LWGO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of self-reported events, staff interview, review of quality assurance (QA) committee meeting minutes offered by the facility, medical record review, review of incident / accident reports, and review of the facility's policy and procedure room transfers, the facility failed to provide adequate supervision and/or assistive devices to ensure the safety of two (2) residents who shared a room with a third resident whom staff believed placed the roommates at risk for harm. Resident #26 shared a 3-bed room with Residents #38 and #77. Resident #26 was alert, oriented to person, place, and season, had short-term memory problems, and his cognitive skills for daily decision-making were assessed as being ""modified independence""; he was also independent with activities of daily living (ADLs). Resident #38 was alert with severely impaired cognitive skills for daily decision-making; he did not communicate with others and was totally dependent with ADLs. Resident #77 was alert, oriented, and independent with daily decision-making, required extensive assistance with bed mobility and transfers, did not ambulate, and was totally dependent on staff for locomotion. On the early morning of [DATE], staff responding to Resident #26's call light found Resident #38 on the floor positioned with his pads, bed linens, and positioning wedge placed on and under him as if he were still in bed; Resident #38 was not capable of having transferred out of bed himself. On the late night of [DATE], staff found Resident #38's legs had been repositioned in bed in a different position than one in which staff had put him during their previous rounds. The nurse directed staff to monitor all residents in this room every twenty (20) minutes, because Resident #38 was not physically able to move himself, Resident #77 was not physically able to independently transfer out of his own bed, and Resident #26 was behaving in a suspicious manner. During these monitoring rounds, in the early morning hours of [DATE], staff found Resident #38's legs again had been repositioned, and staff found a pillow had been placed over the face of Resident #77. In [DATE], Resident #26 had shared this same room with another resident (#87) who was also found by staff at that time to have a pillow placed over his face. In response to these findings, the facility met with Resident #26's guardian, who agreed to allow him to be evaluated at a psychiatric hospital. Prior to his transfer on [DATE], the facility stationed a staff member in the room at all times to monitor the residents for safety. Resident #26 returned to the facility on [DATE], to the same room shared with Residents #38 and #77. Although the aftercare plan from the psychiatric hospital included the recommendation that the nursing home ""observe / assess need for further treatment"", the facility failed to review / revise Resident #26's care plan to address this. Upon his return, no additional supervision and/or assistive devices were put into place to monitor Resident #26 (especially at night) and/or ensure the ongoing safety of Residents #38 and #77. This placed Residents #38 and #77 in immediate jeopardy. On [DATE] at 11:00 a.m., the administrator, medical director, director of nursing, social worker (Employee #52), and the clinical care coordinator (Employee #33) were notified of the finding of immediate jeopardy. At 11:40 a.m. on [DATE], the administrator provided an action plan, which was reviewed and accepted by the nurse surveyor at 11:45 a.m. The action plan included the following steps: Resident #26 was transferred to a private room on another floor, staff was instructed to observe and record Resident #26's behavior on an hourly basis, and Resident #26's care plan was revised to reflect these actions. On [DATE] at 1:30 p.m., the nurse surveyor verified that Resident #26 was relocated, and the immediate jeopardy was removed with no deficient practice remaining. Facility census: 87. Findings include: a) Residents #26, #38, and #77 1. Observation, during tour beginning at 9:30 a.m. on [DATE], found Residents #26, #38, and #77 sharing the same 3-bed room. - 2. On [DATE] at 10:25 a.m., review of events self-reported by the facility to the State survey and certification agency during the previous three (3) months revealed the following ""unusual occurrence"": ""On [DATE] at 2:30 a.m. the C.N.A. (certified nursing assistant) had entered the room to respond to Resident (#26) call light when Resident (#38) was found on floor beside his bed. Resident (#38) was found on floor still covered in blankets with pink pad under him and wedge cushion behind his back. ""... due to Resident (#38) need for total assistance with ADL's that (sic) this incident did not appear to be the result of the resident falling out of bed. There is concern that he may have had assistance from his roommate. ... Residents in room will be monitored by staff at more frequent intervals. ... ""Another incident occurred in this same room on the this same date of [DATE] where Resident (#77) was observed by nursing staff with a pillow over his face during the early a.m. (morning) interval checks. Resident (#77) did not know how the pillow got on his face. There were no apparent injuries to either resident."" According to a message confirmation report, this ""unusual occurrence"" was faxed to the State survey agency at 2:45 p.m. on [DATE]. - 3. Review of the medical records for Residents #38 and #77 found entries in the nursing notes relating the same information as stated in the unusual occurrence report mentioned above. - Review of Resident #38's most recent resident assessment, a Medicare 14-day assessment with an assessment reference date (ARD) of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He was alert with long and short term memory problems, he was not oriented to person, place, or season, he was unable to communicate with others, and he was totally dependent upon staff for all ADLs, including bed mobility and transferring. - Review of Resident #77's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. He was alert and oriented and independent with his cognitive skills for daily decision-making, and he required extensive assistance with bed mobility and transfers, did not ambulate, and was totally dependent on staff for locomotion. His [DIAGNOSES REDACTED]. - Review of Resident #26's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. Resident #26 was alert, oriented to person, place, and season, had short-term memory problems, and his cognitive skills for daily decision-making were assessed as being ""modified independence""; he was independent with ADLs. His [DIAGNOSES REDACTED]. - Review of nursing notes in Resident #26's record found no entry by the nurse on the night shift from [DATE] to [DATE]. An entry, recorded by the nurse during the night shift from [DATE] to [DATE] (at 2:00 a.m. on [DATE]), stated, ""Resident up most of the night walking around the room. Denies pain or discomfort."" - Review of Resident #26's Plan of Care Kardex for the month of [DATE] found several notes recorded by nursing assistants, starting on [DATE], regarding Resident #26's behavior towards his roommates. On [DATE] (no time or shift noted), a nursing assistant wrote: ""Res (resident) was standing behind the curtain between his bed and (Resident #38's) bed, ask (sic) him what he was doing & Resident stated he wasn't doing anything. CNA (initials of nursing assistant) ask (sic) him to go lay down in his bed or if he couldn't sleep to sit in his chair, that he just couldn't mess with his Room-mate (sic) (Resident #38) or Room-mates (sic) things. He said all right."" Another note on [DATE] (identified as being written on the 7:00 a.m. to 3:00 p.m. shift) stated, ""Res stands behind curtains when your (sic) trying to give care to roommate."" On [DATE], a nursing assistant wrote: ""Res standing behind the curtain when giving care to roommate"" Another entry (no date / time) stated, ""Resident got upset when taking roommate to Bathroom (sic)."" - On the reverse side of Resident #26's [DATE] ADL flow record, a nursing assistant wrote, on [DATE], ""Resident behind curtain looking and trying to see the patient when staff was giving care."" - Review of the physician's progress notes for Resident #26 found the following entries: - On [DATE]: ""I was called last night by (facility) to call (name of administrator), which I did. She related they had a concern about (Resident #26), that in the room he has 2 other roommates, (Resident #38) and (Resident #77). (Resident #38) was found in the floor twice reported by staff. (Resident #38) is not able to move himself. The staff became suspicious then they went over to see (Resident #77) and a pillow was on his head. When they asked (Resident #77) if he was ok (sic) he said yes (sic) and they asked him how the pillow got there (sic) and he related he did not know how. (Resident #26) had been up during the night. He had gone to the bathroom, (sic) in the morning it was reported to (name of administrator) that something suspicious was going on and they fear it would be (Resident #26). They discussed it with the daughter (of Resident #26) who was upset. They discussed there was (sic) odd behaviors that had gone on with he (sic) and (Resident #87 - previous roommate who is now deceased ) (sic) however they did not get along. I called to talk to the daughter and she was at (facility). She wanted me to come down and talk to her (sic) which I did, this was about 8pm. ... I told her we should have an evaluation by doctor in (name of psychiatric hospital). ..."" (Interview with the administrator, on the morning of [DATE], verified that Resident #38 was found on the floor only once, contrary to what was stated above, although his feet were found to have been moved towards the side of the bed on two (2) separate occasions - which the resident was not capable of doing himself.) - On [DATE]: ""We had a family conference today with the daughter, sister, (name of regional ombudsman), Director (sic) of nurses and myself. We discussed (Resident #26). My recommendation is that he got to (city name) to be evaluated. ... I did discuss with her (daughter / guardian of Resident #26) the night before that he and (Resident #87 - previous roommate no longer at the facility) had some disagreements ... At one time there was a pillow that was found beside (Resident #87) and a pillow was found over his face. ... She knows (Resident #38) was found in the floor. He can not (sic) move himself. Then (Resident #77) was found with a pillow over his head. ... The daughter understands we did not see (Resident #26) do this. We do not know what happened. ... I told her to be safe it was important for him to evaluated. ..."" - 4. A QA committee plan of correction, generated on [DATE] and provided for review to the surveyor by the facility's administrator at 8:00 a.m. on [DATE], revealed the incident involving Resident #38 occurred on the night shift that ran from [DATE] to [DATE], and the incident involving Resident #77 occurred on the night shift that ran from [DATE] to [DATE]; they did not occur within the same 8-hour shift on [DATE]. This [DATE] QA committee plan of correction stated: ""On Monday morning, [DATE], (name) DON (director of nursing) was notified by the nursing staff that there had been a concern with residents in room (Number of room shared by Residents #26, #38, and #77) on Sunday and in the early morning hours of Monday. At approximately 2:30 a.m. resident (#26) had rung his call bell. When the staff responded they observed resident (#38) lying in the floor. When they asked resident (#26) what he needed he said 'nothing'. Resident (#38) was lying in the floor with his under pads, covers and wedge cushion in place. On [DATE] at approximately 11:30 p.m. resident (#38) was observed with his feet over the right side of the bed and at 12:15 a.m. on [DATE] resident (#38) was again observed with his feet over the left side of the bed. Resident (#77) was observed at 12:30 a.m. with a pillow over his face. ... ""INVESTIGATION FINDINGS AND INTERVENTIONS TO CORRECT THE PROBLEM: ""- Resident (#38) is totally dependent upon staff for bed mobility, transfers, ADLS (activities of daily living) and feeding. ""- Call bell is in place for resident (#38) at all times; however, resident does not use call bell independently. ""- Resident (#38) is turned and repositioned q2hrs (every two hours) by staff. ""- Resident (#77) voices needs and wants to staff, rings call bell independently, requires extensive assist of one with bed mobility, transfers with two and dressing, personal hygiene and bathing with the assist of one. ""- Resident (#26) is independent with all ADLs, mobility, ambulates through out (sic) the facility independently, voices needs and wants to staff and rings call bell for assistance as needed. ""- Resident (#26) has documented behaviors related to past roommates. ..."" According to the administrator, due to Resident #26's past behaviors towards roommates and Resident #38's inability to move on his own and his position on the floor with covers and wedge in place, staff questioned whether Resident #26 was involved in removing Resident #38 from bed to floor and his moving feet over the sides of the bed. Staff also questioned whether Resident #26 placed the pillow over Resident #77's face. Checks of the room shared by these three (3) residents were made every twenty (20) minutes for the remainder of the night shift ending on the morning of [DATE]. Staff communicated with the responsible parties of all residents involved and made arrangements to transfer Resident #26 to a psychiatric hospital for evaluation. Until this transfer could be accomplished, the facility assigned a staff member to remain at all times in the room shared by these three (3) residents, since the responsible parties of the residents all refused to allow their family member to be relocated for safety. - 5. Resident #26's guardian agreed to allow him to be transferred to a psychiatric unit for evaluation. According to the nursing notes, the resident was transferred from the facility to the psychiatric hospital at about 2:30 p.m. on [DATE]. - 6. Resident #26 was readmitted to the facility on [DATE] and was placed back into the same room with his previous roommates, Residents #38 and #77. Review of the aftercare plan from the psychiatric hospital, dated [DATE], found the resident was initially admitted for agitation, aggression, and sexually inappropriate behavior. Under the heading ""Patient Treatment Goals / Progress"", staff at the psychiatric hospital wrote: ""Patient has not displayed any agitation or aggression since admission and had not had any sexually inappropriate behavior for several days."" Under the heading ""Diagnosis"" was written: ""Axis I: Dementia, AD (Alzheimer's disease) type /c (with) depressed mood and behavioral disturbance. Axis II: Schizoid Personality D/O (disorder). ... Axis IV: NH (nursing home) placement. ..."" Under the heading ""Discharge Recommendations / Plan"" was written: ""NH to observe and assess for further treatment."" An interview with the administrator, on [DATE] at 4:00 p.m., found Resident #26's guardian refused to allow the resident to be moved. She also indicated Residents #38's responsible party and Resident #77 (who had capacity) did not want to change rooms. - 7. In an interview on [DATE] at 8:30 a.m., the medical director acknowledged her awareness of the situation regarding Resident #26. She had questions about the ability to move a resident to another without the health care decision maker's consent. On [DATE] between 8:30 a.m. and 9:45 a.m., intermittent observations made with the medical director found all three (3) residents together in the same room with no specific measures in place to ensure the safety of the roommates. At 9:45 a.m. on [DATE], the facility's ""Resident Transfer"" policy (no date), was requested of and provided for review by the administrator. Review of the policy revealed the following: ""Policy: 1. Transfer of Residents Within the Manor: ... C. In the case of emergency the facility reserves the right to make a move but will notify the resident or their responsible party."" ""Procedure: Transfer of Patient: ... 8. Due to changes in patient's condition, we reserve the right to transfer the patient to the area where we can best meet his or her needs."" This information was shared with the medical director. - 8. One (1) of the facility's social workers, (Employee #52) was interviewed at 10:30 a.m. on [DATE]. She sat in on a meeting with Resident #26, his daughter / guardian, and his sister on [DATE]. The resident was sent to the psych unit to determine if he had tendencies to be physically aggressive towards other residents. - 9. Employee #19 (the LPN who completed the above-referenced incident reports for Residents #38 and #77) provided handwritten notes, as well as documentation of observations made by staff of Residents #26 and #38 every twenty (20) minutes from 1:00 a.m. to 6:20 a.m. on [DATE], to the director of nursing (DON) on [DATE]. The DON provided copies of this documentation for review to this nurse surveyor at 10:40 a.m. on [DATE]. The first note stated: ""On [DATE] at 2:30 AM (sic) The CNA's were responding to (Resident #26)'s call light. When they went into the room he said he didn't need anything and that's (sic) when they found (Resident #38) lying on the floor. On the (L) side of the bed on his back. He still had his pads underneath him & his blankets were wrapped around him and the wedge they place behind his back was tucked under his (L) side. Both bedrails were also up. Prior to him being in the floor (sic) (Resident #38) was positioned in bed on his (R) side /c (with) the wedge behind his back. I am letting you know about this b/c (because) I find his falling in the floor suspicious and don't see how he could have ended up in the floor like that on his own."" - The second note stated: ""Just for clarification - On ,[DATE] @ 2:30 AM (Resident #38) was in the floor on the (L) side of his bed in between the bed & the rocker chair. He was on his back /c pads underneath him & blankets wrapped around his legs & the wedge was underneath his (L) hand side. His bed rails were up & his bed was in (sic) low position. Prior to him being in the floor he was positioned on his (R) side /c wedge behind him on the left side of his back. ""On ,[DATE] @ 1130 PM when walking up the hall his feet were pulled to the (R) side of the bed and he was laying (sic) on his (R) side. ""At 12:15 AM - now [DATE] Resident was lying on (R) side and his feet were pulled to the (L) side of the bed. ""After that is when we found (Resident #77) with the pillow on his face. ""That's (sic) when I initiated the 20 minute check paper for the CNA to fill out."" (During an interview on [DATE] at 5:15 p.m., Employee #19 verified her statements.) - 10. The DON, when interviewed on [DATE] at 10:45 a.m., reported a resident service provider (RSP) was assigned to provide one-on-one supervision of Resident #26 from [DATE] at 2:30 p.m. through [DATE] at 2:30 p.m., when he went to the hospital. The DON reported became suspicious of Resident #26's behavior after she reviewed the 24-hour shift reports for [DATE] and [DATE], which indicated Resident #38 was found on the floor during the early morning hours on [DATE] (on the night shift starting on [DATE]) and was found two (2) times with his feet hanging off the bed during the night shift starting on [DATE]. Documentation on the 24-hour shift report for [DATE] stated, ""[DATE] 2:30 a.m. Resident (#38) found in floor no apparent injury. Family (MPOA) needs to be notified"" and ""fell last noc (night). Be sure he is in middle of bed."" For Resident #77, staff recorded ""Lethargic"". There was no entry for Resident #26. Documentation on the 24-hour shift report for [DATE] for Resident #38 stated, ""Ntd (noted) feet off bed 2X's (two times) throughout night ... call family any time day and night."" For Resident #77, staff recorded, ""Lethargic [DATE]; wouldn't take 6 a.m. meds [DATE] c/o (complaint of) pain; admitted to hosp with UTI."" For Resident #26, staff recorded, ""Restless up in room several X's throughout night."" - 11. Review of the closed record of Resident #87 (identified in the [DATE] physician's progress note as Resident #26's previous roommate) found a nursing note, dated [DATE] at 2:10 p.m., stating, ""CNA reported as she came up the hall (sic) resident had a pillow across his face. ..."" At the time of this occurrence, Resident #87 shared the same 3-bed room with Resident #26, and the third bed was unoccupied. The DON verified, in an interview at 10:30 a.m. on [DATE], there were no other residents in the room at the time of this incident. Review of Resident #26's thinned records from 2009 found the following regarding his interactions with Resident #87: On [DATE] (no time given), "" ... Later, resident came up to nurse's med cart, watched as nurse was attempting to give roommate (Resident #87) his med. Roommate accidentally ran over nurse's foot. Resident then states to nurse (sic) know what you should do /c the 'bastard'. I've popped him a couple of times. (sic) I asked resident if (sic) had hit the roommate, he stated yes. ..."" - 12. Review of Resident #26's care plan, revised on [DATE] with target dates for goal achievement of [DATE], found the following problem (P), goal (G), and interventions (I) with an initiation date of [DATE]: P: ""Mood problem AEB (as evidence by): Resident becomes easily annoyed with staff and others (particularly his roommate) at times R/T (related to) depression, and dementia, psychosis diagnosis, hx (history) of episodes of agitation."" G: ""Will have improved mood state AEB: calmer appearance, with no more then (sic) 2 episodes weekly of becoming easily annoyed with his roommate or any other S/S (signs / symptoms) of depression, anxiety or sad mood by review date."" (The revised review date for this goal was [DATE].) I: ""Assist in developing more appropriate methods of coping and interacting. Encourage to express feelings appropriately, let staff know when s/he (sic) is getting upset; Administer medications as ordered and monitor for side effects, effectiveness; Observed mood patterns and document S/S of depression, anxiety, sad mood; Ongoing assessment, attempt to determine if problems seems to be related to external causes, ie medications, treatments, concerns over diagnosis, noise level or pain; Spend time talking to resident, family. Encourage to express feelings; Assist resident to identify strengths, positive coping skills and reinforce these; Invite to attend activities and encourage participation."" The interdisciplinary team also addressed the following problem, also with an initiation date of [DATE]: ""Potential for increased behavior problems R/T: [DIAGNOSES REDACTED]."" The goal for this problem statement was: ""Resident will continue to have not episodes of socially inappropriate behavior weekly by review date."" (The revised review date for this goal was [DATE].) The interventions included: ""... Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, situations. Document behavior and potential causes; Intervene as needed to protect the rights and safety of others. Approach / speak in calm manner. Divert attention. Remove from situation and take to another location as needed. ..."" The care plan did not describe what these ""socially inappropriate behaviors"" were. There was no evidence to reflect the care plan was revised upon Resident #26's return to the facility on [DATE], to address the need to ""observe / assess for further treatment"" - as directed in the aftercare plan resulting from his stay at the psychiatric hospital. There was no plan to reinstitute either of the monitoring activities that had been in place prior to his transfer to the psychiatric facility (every twenty (20) minutes beginning on [DATE] or direct supervision of the room shared by these three (3) residents at all times beginning on [DATE]) - especially at night. - 13. At [DATE] at 11:00 a.m., the administrator, medical director, DON, social worker (Employee #52), and the clinical care coordinator (Employee 33) were informed the nurse surveyor identified that Residents #38 and #77 were in immediate jeopardy, as Resident #26 returned to the same room following his discharge from the psychiatric hospital, and the facility failed to implement any measures (e.g., additional monitoring / supervision) to ensure the residents in this room were safe. A plan of correction was requested. - 14. A plan of correction, given to the surveyor on [DATE] at 11:20 a.m., was reviewed and returned to the administrator for revision. At 11:40 a.m., a revised plan of correction was given to the surveyor, reviewed, and accepted at 11:45 a.m. The revised plan of correction stated: ""To correct the safety issues identified during the survey this date, with residents (#26), (#18), and (#77), a room change will be made. Resident (#26) will be moved into room (number of room on second floor). Resident (name) who is currently in room (number of room now occupied by Resident #26) will be moved to (number of room previously occupied by Resident #26). ""Monitoring of resident (#26) will be accomplished by the following: Resident will be in a room by himself. This room is located close to the nurses (sic) station in direct line of all traffic. Nurses or Certified Nursing Assistants will check on him on an hourly basis for any abnormal behaviors. Psychiatric evaluation or placement will be pursued if behavior warrants. Documentation of all abnormal behavior will be monitored on a daily basis by nursing staff."" - 15. On [DATE] at 1:30 p.m., after Resident #26 was relocated and this was verified by direct observation, the administrator was notified the immediate jeopardy was lifted. - 16. During an interview on [DATE] at 6:45 p.m., a nursing assistant (Employee #34) confirmed he found a pillow over Resident #77's face at about 12:30 a.m. on [DATE]. He indicated he had last checked on the resident at 12:00 a.m. on [DATE]. He documented twenty (20) minute checks on Residents #26 and #38 from 1:00 a.m. through 6:20 a.m. on [DATE]. (A copy of this documentation was provided by the DON on [DATE] at 10:40 a.m.) - 17. On [DATE] at 9:00 a.m., the administrator presented evidence that inservices were held [DATE] with staff who provide care to Resident #26. The memorandum on which this inservice was documented, issued by the DON, had in its subject line: ""Precautions related to (Resident #26)"". In the body of the memorandum was: ""(Resident #26) needs to be monitored every hour for behaviors that may affect self or others and documented on appropriate form. (Resident #26) needs to be documented on each shift in the nurses notes related to behaviors whether there are any or not. ""Concerns for (Resident #26) possibly being of danger to other residents has (sic) prompted this."" The bottom of the memorandum contained the signatures of nursing staff. - The facility also revised the care plan for Resident #26 on [DATE], to include the following: P - ""Potential for increased behaviors (physical aggressive (sic) staff or residents) (sexual inappropriate (sic) with staff) (attempting to harm residents) R/T (related to) [DIAGNOSES REDACTED]."" G - ""Resident will have less than weekly episodes of socially inappropriate behaviors by review date."" G - ""Resident will have no episodes of attempting harm other residents through review date."" Interventions included: ""Nursing staff will do hourly checks on resident for behaviors. Nurses will document q (every) shift on behaviors; Resident has been moved to a private room. Psychiatric evaluation and treatment as ordered."" .",2014-01-01
11539,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2010-09-03,520,J,,,LWGO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of self-reported events, staff interview, review of quality assessment and assurance (QAA) committee meeting minutes offered by the facility, medical record review, review of incident / accident reports, and review of the facility's policy and procedure room transfers, the facility's quality assessment and assurance (QAA) committee failed to implement an action plan to ensure the safety of residents sharing a room with Resident #26, upon his return from a psychiatric hospital after being evaluated for possible aggressive tendencies towards others. Resident #26 shared a 3-bed room with Residents #38 and #77. On the early morning of [DATE], staff responding to Resident #26's call light found Resident #38 on the floor positioned with his pads, bed linens, and positioning wedge placed on and under him as if he were still in bed; Resident #38 was not capable of having transferred out of bed himself. On the late night of [DATE], staff found Resident #38's legs had been repositioned in bed in a different position than one in which staff had put him during their previous rounds. The nurse directed staff to monitor all residents in this room every twenty (20) minutes, because Resident #38 was not physically able to move himself, Resident #77 was not physically able to independently transfer out of his own bed, and Resident #26 was behaving in a suspicious manner. During these monitoring rounds, in the early morning hours of [DATE], staff found Resident #38's legs again had been repositioned, and staff found a pillow had been placed over the face of Resident #77. In [DATE], Resident #26 had shared this same room with another resident (#87) who was also found by staff at that time to have a pillow placed over his face. In response to these findings, the facility met with Resident #26's guardian, who agreed to allow him to be evaluated at a psychiatric hospital. Prior to his transfer on [DATE], the facility stationed a staff member in the room at all times to monitor the residents for safety. Resident #26 returned to the facility on [DATE], to the same room shared with Residents #38 and #77. Although the aftercare plan from the psychiatric hospital included the recommendation that the nursing home ""observe / assess need for further treatment"", the facility failed to review / revise Resident #26's care plan to address this. Upon his return, no additional supervision and/or assistive devices were put into place to monitor Resident #26 (especially at night) and/or ensure the ongoing safety of Residents #38 and #77. This placed Residents #38 and #77 in immediate jeopardy. The facility's QAA committee failed, upon Resident #26's return to the facility, to implement measures to ensure the safety of Residents #38 and #77, even though staff strongly suspected Resident #26 of having removed Resident #38 from his bed on the early morning on [DATE], repositioned Resident #38 in his bed on the late evening of [DATE], and placed a pillow over the face of Resident #77 on the early morning of [DATE], especially in light of having found a previous roommate of Resident #87 with a pillow over his face in [DATE]. Facility census: 87. Findings include: a) Residents #26, #38, and #77 1. Observation, during tour beginning at 9:30 a.m. on [DATE], found Residents #26, #38, and #77 sharing the same 3-bed room. - 2. On [DATE] at 10:25 a.m., review of events self-reported by the facility to the State survey and certification agency during the previous three (3) months revealed the following ""unusual occurrence"": ""On [DATE] at 2:30 a.m. the C.N.A. (certified nursing assistant) had entered the room to respond to Resident (#26) call light when Resident (#38) was found on floor beside his bed. Resident (#38) was found on floor still covered in blankets with pink pad under him and wedge cushion behind his back. "" ... due to Resident (#38) need for total assistance with ADL's that (sic) this incident did not appear to be the result of the resident falling out of bed. There is concern that he may have had assistance from his roommate. ... Residents in room will be monitored by staff at more frequent intervals. ... ""Another incident occurred in this same room on the this same date of [DATE] where Resident (#77) was observed by nursing staff with a pillow over his face during the early a.m. (morning) interval checks. Resident (#77) did not know how the pillow got on his face. There were no apparent injuries to either resident."" According to a message confirmation report, this ""unusual occurrence"" was faxed to the State survey agency at 2:45 p.m. on [DATE]. - 3. Review of the medical records for Residents #38 and #77 found entries in the nursing notes relating the same information as stated in the unusual occurrence report mentioned above. - Review of Resident #38's most recent resident assessment, a Medicare 14-day assessment with an assessment reference date (ARD) of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He was alert with long and short term memory problems, he was not oriented to person, place, or season, he was unable to communicate with others, and he was totally dependent upon staff for all ADLs, including bed mobility and transferring. - Review of Resident #77's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. He was alert and oriented and independent with his cognitive skills for daily decision-making, and he required extensive assistance with bed mobility and transfers, did not ambulate, and was totally dependent on staff for locomotion. His [DIAGNOSES REDACTED]. - Review of Resident #26's most recent resident assessment, a quarterly assessment with an ARD of [DATE], revealed this [AGE] year old male was admitted to the facility on [DATE]. Resident #26 was alert, oriented to person, place, and season, had short-term memory problems, and his cognitive skills for daily decision-making were assessed as being ""modified independence""; he was independent with ADLs. His [DIAGNOSES REDACTED]. - Review of nursing notes in Resident #26's record found no entry by the nurse on the night shift from [DATE] to [DATE]. An entry, recorded by the nurse during the night shift from [DATE] to [DATE] (at 2:00 a.m. on [DATE]), stated, ""Resident up most of the night walking around the room. Denies pain or discomfort."" - Review of Resident #26's Plan of Care Kardex for the month of [DATE] found several notes recorded by nursing assistants, starting on [DATE], regarding Resident #26's behavior towards his roommates. On [DATE] (no time or shift noted), a nursing assistant wrote: ""Res (resident) was standing behind the curtain between his bed and (Resident #38 ' s) bed, ask (sic) him what he was doing & Resident stated he wasn't doing anything. CNA (initials of nursing assistant) ask (sic) him to go lay down in his bed or if he couldn't sleep to sit in his chair, that he just couldn't mess with his Room-mate (sic) (Resident #38) or Room-mates (sic) things. He said all right."" Another note on [DATE] (identified as being written on the 7:00 a.m. to 3:00 p.m. shift) stated, ""Res stands behind curtains when your (sic) trying to give care to roommate."" On [DATE], a nursing assistant wrote: ""Res standing behind the curtain when giving care to roommate"" Another entry (no date / time) stated, ""Resident got upset when taking roommate to Bathroom (sic)."" - On the reverse side of Resident #26's [DATE] ADL flow record, a nursing assistant wrote, on [DATE], ""Resident behind curtain looking and trying to see the patient when staff was giving care."" - Review of the physician's progress notes for Resident #26 found the following entries: - On [DATE]: ""I was called last night by (facility) to call (name of administrator), which I did. She related they had a concern about (Resident #26), that in the room he has 2 other roommates, (Resident #38) and (Resident #77). (Resident #38) was found in the floor twice reported by staff. (Resident #38) is not able to move himself. The staff became suspicious then they went over to see (Resident #77) and a pillow was on his head. When they asked (Resident #77) if he was ok (sic) he said yes (sic) and they asked him how the pillow got there (sic) and he related he did not know how. (Resident #26) had been up during the night. He had gone to the bathroom, (sic) in the morning it was reported to (name of administrator) that something suspicious was going on and they fear it would be (Resident #26). They discussed it with the daughter (of Resident #26) who was upset. They discussed there was (sic) odd behaviors that had gone on with he (sic) and (Resident #87 - previous roommate who is now deceased ) (sic) however they did not get along. I called to talk to the daughter and she was at (facility). She wanted me to come down and talk to her (sic) which I did, this was about 8pm. ... I told her we should have an evaluation by doctor in (name of psychiatric hospital). ..."" (Interview with the administrator, on the morning of [DATE], verified that Resident #38 was found on the floor only once, contrary to what was stated above, although his feet were found to have been moved towards the side of the bed on two (2) separate occasions - which the resident was not capable of doing himself.) - On [DATE]: ""We had a family conference today with the daughter, sister, (name of regional ombudsman), Director (sic) of nurses and myself. We discussed (Resident #26). My recommendation is that he got to (city name) to be evaluated. ... I did discuss with her (daughter / guardian of Resident #26) the night before that he and (Resident #87 - previous roommate no longer at the facility) had some disagreements ... At one time there was a pillow that was found beside (Resident #87) and a pillow was found over his face. ... She knows (Resident #38) was found in the floor. He can not (sic) move himself. Then (Resident #77) was found with a pillow over his head. ... The daughter understands we did not see (Resident #26) do this. We do not know what happened. ... I told her to be safe it was important for him to evaluated. ..."" - 4. A quality assurance (QA) committee plan of correction, generated on [DATE] and provided for review to the surveyor by the facility's administrator at 8:00 a.m. on [DATE], revealed the incident involving Resident #38 occurred on the night shift that ran from [DATE] to [DATE], and the incident involving Resident #77 occurred on the night shift that ran from [DATE] to [DATE]; they did not occur within the same 8-hour shift on [DATE]. This [DATE] QA committee plan of correction stated: ""On Monday morning, [DATE], (name) DON (director of nursing) was notified by the nursing staff that there had been a concern with residents in room (Number of room shared by Residents #26, #38, and #77) on Sunday and in the early morning hours of Monday. At approximately 2:30 a.m. resident (#26) had rung his call bell. When the staff responded they observed resident (#38) lying in the floor. When they asked resident (#26) what he needed he said 'nothing'. Resident (#38) was lying in the floor with his under pads, covers and wedge cushion in place. On [DATE] at approximately 11:30 p.m. resident (#38) was observed with his feet over the right side of the bed and at 12:15 a.m. on [DATE] resident (#38) was again observed with his feet over the left side of the bed. Resident (#77) was observed at 12:30 a.m. with a pillow over his face. ... ""INVESTIGATION FINDINGS AND INTERVENTIONS TO CORRECT THE PROBLEM: ""- Resident (#38) is totally dependent upon staff for bed mobility, transfers, ADLS (activities of daily living) and feeding. ""- Call bell is in place for resident (#38) at all times; however, resident does not use call bell independently. ""- Resident (#38) is turned and repositioned q2hrs (every two hours) by staff. ""- Resident (#77) voices needs and wants to staff, rings call bell independently, requires extensive assist of one with bed mobility, transfers with two and dressing, personal hygiene and bathing with the assist of one. ""- Resident (#26) is independent with all ADLs, mobility, ambulates through out (sic) the facility independently, voices needs and wants to staff and rings call bell for assistance as needed. ""- Resident (#26) has documented behaviors related to past roommates. ..."" According to the administrator, due to Resident #26's past behaviors towards roommates and Resident #38's inability to move on his own and his position on the floor with covers and wedge in place, staff questioned whether Resident #26 was involved in removing Resident #38 from bed to floor and his moving feet over the sides of the bed. Staff also questioned whether Resident #26 placed the pillow over Resident #77's face. Checks of the room shared by these three (3) residents were made every twenty (20) minutes for the remainder of the night shift ending on the morning of [DATE]. Staff communicated with the responsible parties of all residents involved and made arrangements to transfer Resident #26 to a psychiatric hospital for evaluation. Until this transfer could be accomplished, the facility assigned a staff member to remain at all times in the room shared by these three (3) residents, since the responsible parties of the residents all refused to allow their family member to be relocated for safety. - 5. Resident #26's guardian agreed to allow him to be transferred to a psychiatric unit for evaluation. According to the nursing notes, the resident was transferred from the facility to the psychiatric hospital at about 2:30 p.m. on [DATE]. - 6. Resident #26 was readmitted to the facility on [DATE] and was placed back into the same room with his previous roommates, Residents #38 and #77. Review of the aftercare plan from the psychiatric hospital, dated [DATE], found the resident was initially admitted for agitation, aggression, and sexually inappropriate behavior. Under the heading ""Patient Treatment Goals / Progress"", staff at the psychiatric hospital wrote: ""Patient has not displayed any agitation or aggression since admission and had not had any sexually inappropriate behavior for several days."" Under the heading ""Diagnosis"" was written: ""Axis I: Dementia, AD ([MEDICAL CONDITION]) type /c (with) depressed mood and behavioral disturbance. Axis II: Schizoid Personality D/O (disorder). ... Axis IV: NH (nursing home) placement. ..."" Under the heading ""Discharge Recommendations / Plan"" was written: ""NH to observe and assess for further treatment."" An interview with the administrator, on [DATE] at 4:00 p.m., found Resident #26's guardian refused to allow the resident to be moved. She also indicated Residents #38's responsible party and Resident #77 (who had capacity) did not want to change rooms. - 7. In an interview on [DATE] at 8:30 a.m., the medical director acknowledged her awareness of the situation regarding Resident #26. She had questions about the ability to move a resident to another without the health care decision maker's consent. On [DATE] between 8:30 a.m. and 9:45 a.m., intermittent observations made with the medical director found all three (3) residents together in the same room with no specific measures in place to ensure the safety of the roommates. At 9:45 a.m. on [DATE], the facility's ""Resident Transfer"" policy (no date), was requested of and provided for review by the administrator. Review of the policy revealed the following: ""Policy: 1. Transfer of Residents Within the Manor: ... C. In the case of emergency the facility reserves the right to make a move but will notify the resident or their responsible party."" ""Procedure: Transfer of Patient: ... 8. Due to changes in patient's condition, we reserve the right to transfer the patient to the area where we can best meet his or her needs."" This information was shared with the medical director. - 8. One (1) of the facility's social workers, (Employee #52) was interviewed at 10:30 a.m. on [DATE]. She sat in on a meeting with Resident #26, his daughter / guardian, and his sister on [DATE]. The resident was sent to the psych unit to determine if he had tendencies to be physically aggressive towards other residents. - 9. Employee #19 (the LPN who completed the above-referenced incident reports for Residents #38 and #77) provided handwritten notes, as well as documentation of observations made by staff of Residents #26 and #38 every twenty (20) minutes from 1:00 a.m. to 6:20 a.m. on [DATE], to the director of nursing (DON) on [DATE]. The DON provided copies of this documentation for review to this nurse surveyor at 10:40 a.m. on [DATE]. The first note stated: ""On [DATE] at 2:30 AM (sic) The CNA's were responding to (Resident #26)'s call light. When they went into the room he said he didn't need anything and that's (sic) when they found (Resident #38) lying on the floor. On the (L) side of the bed on his back. He still had his pads underneath him & his blankets were wrapped around him and the wedge they place behind his back was tucked under his (L) side. Both bedrails were also up. Prior to him being in the floor (sic) (Resident #38) was positioned in bed on his (R) side /c (with) the wedge behind his back. I am letting you know about this b/c (because) I find his falling in the floor suspicious and don't see how he could have ended up in the floor like that on his own."" - The second note stated: ""Just for clarification - On ,[DATE] @ 2:30 AM (Resident #38) was in the floor on the (L) side of his bed in between the bed & the rocker chair. He was on his back /c pads underneath him & blankets wrapped around his legs & the wedge was underneath his (L) hand side. His bed rails were up & his bed was in (sic) low position. Prior to him being in the floor he was positioned on his (R) side /c wedge behind him on the left side of his back. ""On ,[DATE] @ 1130 PM when walking up the hall his feet were pulled to the (R) side of the bed and he was laying (sic) on his (R) side. ""At 12:15 AM - now [DATE] Resident was lying on (R) side and his feet were pulled to the (L) side of the bed. ""After that is when we found (Resident #77) with the pillow on his face. ""That's (sic) when I initiated the 20 minute check paper for the CNA to fill out."" (During an interview on [DATE] at 5:15 p.m., Employee #19 verified her statements.) - 10. The DON, when interviewed on [DATE] at 10:45 a.m., reported a resident service provider (RSP) was assigned to provide one-on-one supervision of Resident #26 from [DATE] at 2:30 p.m. through [DATE] at 2:30 p.m., when he went to the hospital. The DON reported became suspicious of Resident #26's behavior after she reviewed the 24-hour shift reports for [DATE] and [DATE], which indicated Resident #38 was found on the floor during the early morning hours on [DATE] (on the night shift starting on [DATE]) and was found two (2) times with his feet hanging off the bed during the night shift starting on [DATE]. Documentation on the 24-hour shift report for [DATE] stated, ""[DATE] 2:30 a.m. Resident (#38) found in floor no apparent injury. Family (MPOA) needs to be notified"" and ""fell last noc (night). Be sure he is in middle of bed."" For Resident #77, staff recorded ""Lethargic"". There was no entry for Resident #26. Documentation on the 24-hour shift report for [DATE] for Resident #38 stated, ""Ntd (noted) feet off bed 2X's (two times) throughout night ... call family any time day and night."" For Resident #77, staff recorded, ""Lethargic [DATE]; wouldn't take 6 a.m. meds [DATE] c/o (complaint of) pain; admitted to hosp with UTI."" For Resident #26, staff recorded, ""Restless up in room several X's throughout night."" - 11. Review of the closed record of Resident #87 (identified in the [DATE] physician ' s progress note as Resident #26's previous roommate) found a nursing note, dated [DATE] at 2:10 p.m., stating, ""CNA reported as she came up the hall (sic) resident had a pillow across his face. ..."" At the time of this occurrence, Resident #87 shared the same 3-bed room with Resident #26, and the third bed was unoccupied. The DON verified, in an interview at 10:30 a.m. on [DATE], there were no other residents in the room at the time of this incident. Review of Resident #26's thinned records from 2009 found the following regarding his interactions with Resident #87: On [DATE] (no time given), "" ... Later, resident came up to nurse's med cart, watched as nurse was attempting to give roommate (Resident #87) his med. Roommate accidentally ran over nurse's foot. Resident then states to nurse (sic) know what you should do /c the 'bastard'. I've popped him a couple of times. (sic) I asked resident if (sic) had hit the roommate, he stated yes. ..."" - 12. Review of Resident #26's care plan, revised on [DATE] with target dates for goal achievement of [DATE], found the following problem (P), goal (G), and interventions (I) with an initiation date of [DATE]: P: ""Mood problem AEB (as evidence by): Resident becomes easily annoyed with staff and others (particularly his roommate) at times R/T (related to) depression, and dementia, [MEDICAL CONDITION] diagnosis, hx (history) of episodes of agitation."" G: ""Will have improved mood state AEB: calmer appearance, with no more then (sic) 2 episodes weekly of becoming easily annoyed with his roommate or any other S/S (signs / symptoms) of depression, anxiety or sad mood by review date."" (The revised review date for this goal was [DATE].) I: ""Assist in developing more appropriate methods of coping and interacting. Encourage to express feelings appropriately, let staff know when s/he (sic) is getting upset; Administer medications as ordered and monitor for side effects, effectiveness; Observed mood patterns and document S/S of depression, anxiety, sad mood; Ongoing assessment, attempt to determine if problems seems to be related to external causes, ie medications, treatments, concerns over diagnosis, noise level or pain; Spend time talking to resident, family. Encourage to express feelings; Assist resident to identify strengths, positive coping skills and reinforce these; Invite to attend activities and encourage participation."" The interdisciplinary team also addressed the following problem, also with an initiation date of [DATE]: ""Potential for increased behavior problems R/T: [DIAGNOSES REDACTED]."" The goal for this problem statement was: ""Resident will continue to have not episodes of socially inappropriate behavior weekly by review date."" (The revised review date for this goal was [DATE].) The interventions included: "" ... Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, situations. Document behavior and potential causes; Intervene as needed to protect the rights and safety of others. Approach / speak in calm manner. Divert attention. Remove from situation and take to another location as needed. ..."" The care plan did not describe what these ""socially inappropriate behaviors"" were. There was no evidence to reflect the care plan was revised upon Resident #26's return to the facility on [DATE], to address the need to ""observe / assess for further treatment"" - as directed in the aftercare plan resulting from his stay at the psychiatric hospital. There was no plan to reinstitute either of the monitoring activities that had been in place prior to his transfer to the psychiatric facility (every twenty (20) minutes beginning on [DATE] or direct supervision of the room shared by these three (3) residents at all times beginning on [DATE]) - especially at night. - 13. At [DATE] at 11:00 a.m., the administrator, medical director, DON, social worker (Employee #52), and the clinical care coordinator (Employee 33) were informed the nurse surveyor identified that Residents #38 and #77 were in immediate jeopardy, as Resident #26 returned to the same room following his discharge from the psychiatric hospital, and the facility failed to implement any measures (e.g., additional monitoring / supervision) to ensure the residents in this room were safe. A plan of correction was requested. - 14. A plan of correction, given to the surveyor on [DATE] at 11:20 a.m., was reviewed and returned to the administrator for revision. At 11:40 a.m., a revised plan of correction was given to the surveyor, reviewed, and accepted at 11:45 a.m. The revised plan of correction stated: ""To correct the safety issues identified during the survey this date, with residents (#26), (#18), and (#77), a room change will be made. Resident (#26) will be moved into room (number of room on second floor). Resident (name) who is currently in room (number of room now occupied by Resident #26) will be moved to (number of room previously occupied by Resident #26). ""Monitoring of resident (#26) will be accomplished by the following: Resident will be in a room by himself. This room is located close to the nurses (sic) station in direct line of all traffic. Nurses or Certified Nursing Assistants will check on him on an hourly basis for any abnormal behaviors. Psychiatric evaluation or placement will be pursued if behavior warrants. Documentation of all abnormal behavior will be monitored on a daily basis by nursing staff."" - 15. On [DATE] at 1:30 p.m., after Resident #26 was relocated and this was verified by direct observation, the administrator was notified the immediate jeopardy was lifted. - 16. During an interview on [DATE] at 6:45 p.m., a nursing assistant (Employee #34) confirmed he found a pillow over Resident #77's face at about 12:30 a.m. on [DATE]. He indicated he had last checked on the resident at 12:00 a.m. on [DATE]. He documented twenty (20) minute checks on Residents #26 and #38 from 1:00 a.m. through 6:20 a.m. on [DATE]. (A copy of this documentation was provided by the DON on [DATE] at 10:40 a.m.). - 17. On [DATE] at 9:00 a.m., the administrator presented evidence that inservices were held [DATE] with staff who provide care to Resident #26. The memorandum on which this inservice was documented, issued by the DON, had in its subject line: ""Precautions related to (Resident #26)"". In the body of the memorandum was: ""(Resident #26) needs to be monitored every hour for behaviors that may affect self or others and documented on appropriate form. (Resident #26) needs to be documented on each shift in the nurses notes related to behaviors whether there are any or not. ""Concerns for (Resident #26) possibly being of danger to other residents has (sic) prompted this."" The bottom of the memorandum contained the signatures of nursing staff. - The facility also revised the care plan for Resident #26 on [DATE], to include the following: P - ""Potential for increased behaviors (physical aggressive (sic) staff or residents) (sexual inappropriate (sic) with staff) (attempting to harm residents) R/T (related to) [DIAGNOSES REDACTED]."" G - ""Resident will have less than weekly episodes of socially inappropriate behaviors by review date."" G - ""Resident will have no episodes of attempting harm other residents through review date."" Interventions included: ""Nursing staff will do hourly checks on resident for behaviors. Nurses will document q (every) shift on behaviors; Resident has been moved to a private room. Psychiatric evaluation and treatment as ordered."" - 18. The facility's QAA committee failed, upon Resident #26's return to the facility, to implement measures to ensure the safety of Residents #38 and #77, even though staff strongly suspected Resident #26 of having removed Resident #38 from his bed on the early morning on [DATE], repositioned Resident #38 in his bed on the late evening of [DATE], and placed a pillow over the face of Resident #77 on the early morning of [DATE], especially in light of having found a previous roommate of Resident #87 with a pillow over his face in [DATE].",2014-01-01
3370,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2018-10-30,880,D,0,1,TPR211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, observations, and facility policy review, the facility failed to ensure that infection control measures were implemented for a resident with an indwelling urinary catheter. This affected one (Resident #22) of two sampled residents reviewed for indwelling urinary catheters. The census was 57. Findings include: A clinical record review was conducted on 10/29/18 at 2:11 PM. The Admission Record identified Resident #22 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#22's bed in the low position along with floor mats. On 08/09/18, the physician ordered an 18 F (French) Foley (indwelling urinary catheter) for [MEDICAL CONDITION]. Further review of the clinical record on 10/29/18 at 2:11 PM revealed a care plan dated as initiated 08/10/18, identified Resident #22 had a Foley catheter and the care plan stated there was a potential for infection and to ensure the catheter bag was located beneath the level of the bladder and did not touch the ground. The care plan stated .keep drainage bag covered at all times . The quarterly Minimum Data Set assessment dated [DATE], Section H for Bowel and Bladder noted the resident had an indwelling catheter. On 10/29/18 at 9:41 AM, Resident #22 was observed in bed with his eyes closed. The observation took place just outside the resident's room. The resident's bed was in the low position and he had a floor mat, adjacent to his bed. The catheter bag was observed on the right side of the bed, towards the foot of the bed and was partially laying on the ground. There was no protective barrier that covered the catheter bag. On 10/29/18 at 11:05 AM, Resident #22 was observed in bed. His catheter bag was on the right side of the bed, towards the foot of the bed. The catheter bag touched the floor mat. There was no protective barrier that covered the catheter bag. On this same date at 2:09 PM, Resident #22 was observed in bed and the bed was in a low position. The catheter bag was on the left side of the bed and on top of the floor mat. The catheter bag had no protective barrier to protect the bag from touching the ground and potentially contaminating the catheter bag. On 10/30/18 at 9:28 AM, Resident #22 was observed in bed. The urinary catheter bag was on the floor on the left side of the bed and on top of his floor mat. There was no protective barrier between the catheter bag and the floor mat. An interview was conducted with Certified Nursing Assistant (CNA) #49 on 10/30/18 at 9:38 AM. CNA #49 said the catheter bag was not to touch the ground. The interview took place in Resident #22's room. CNA #49 verified the catheter bag touched the floor mat. Registered Nurse (RN) #8, the Unit Manager was interviewed on 10/30/18 at 9:49 AM. She was interviewed in Resident 22's room and verified the catheter bag was on the floor. She said the catheter bag should be lower than the resident's bladder, which it was during this interview. She also said she would need to research other means to prevent the catheter bag from touching the ground. The Director of Nursing (DON) was interviewed on 10/30/18 at 1:51 PM. The DON said that they never really considered this issue before since the resident was on a low bed to prevent falls and then recently had a Foley catheter inserted. A facility policy entitled Management of an Indwelling Catheter dated as revised 09/16 noted, .Review the resident's care plan to assess for any special needs of the resident .Keep the collection bag below the level of the bladder at all times. Do not rest the bag on the floor .",2020-09-01
3371,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2017-11-08,156,D,0,1,XW9J11,"Based on staff interview, Center for Medicaid and Medicare Services (CMS) Survey and Certification (S&C) letter review, and a review of liablity notices, the facility failed to provide the correct notice when the resident exhausted their Medicare covered skilled nursing facility benefit days. This failed practice affected one (1) of three (3) residents reviewed. Resident identifier: #6. Facility census: 58. Findings include: a) Resident #6 On 11/07/17 at 1:55 p.m., a review of the liability notices revealed Resident #6 received the Notice of Medicare Non-Coverage (NOMNC) Centers for Medicaid and Medicare Services (CMS) form on 07/07/17. The NOMNC form indicated the resident would exhaust Medicare Part A benefits on 07/12/17. On 11/07/17 at 2:02 p.m., Social Worker (SW) #60 said the resident recieved the NOMNC because he had exhausted his skilled service days. The NOMNC form explained the resident had the right to appeal this decision. SW #60 also said she had previously been issuing the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) along with the NOMNC but now realized this did not need issued each time the NOMNC was issued. According to CMS Survey and Certification (S&C ) letter 09-20, dated 01/09/09, the skilled nursing facility (SNF) must issue the NOMNC when there is a termination of all Medicare Part A services for coverage reasons. The SNF should not issue this notice if the beneficiary exhausts the Medicare covered days as the number of SNF benefit days set in law and the QIO cannot extend the benefit period. Thus, a service termination due to the exhaustion of benefits is not considered a termination for coverage reasons.",2020-09-01
3372,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2017-11-08,272,D,0,1,XW9J11,"Based on observation, record review, and staff interview, the facility failed to ensure a significant change minimum data set (MDS) was accurate for one (1) of three (3) resident's reviewed for the care area of dental status and services. Resident identifier: #64. Facility census: 58. Findings include: a) Resident #64 Observation of the resident's oral cavity, at 12:31 p.m. on 11/06/17, found the resident had one full tooth on the lower jaw area. Several other natural, discolored teeth were broken at the gum line exposing small slivers of tooth fragments protruding upward from the gum. Review of a significant change, MDS with an assessment reference date (ARD) of 06/08/17, found the resident was coded as having no natural teeth or tooth fragments and no broken natural teeth. Observation of the resident's oral cavity with the director of nursing (DON) at 10:45 a.m. on 11/07/17, confirmed the MDS was coded incorrectly. The DON said, The MDS is not correct.",2020-09-01
3373,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2017-11-08,279,D,0,1,XW9J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for activities had a care plan which addressed activities. Resident identifier: #50. Facility census: 58. Findings include: a) Resident #50 A review of Resident #50's care plan revealed goals and interventions pertaining to activities. The goal stated, Resident will participate in group activities of interest such as church, music activities, special events three times each week and will participate in independent activities daily such as watching tv, reading, socializing or watching birds. The focus area for these goals and interventions did not pertain to activities. The focus area associated with the goals and interventions stated, Resident is unable to use ride {sic} (right) side related [MEDICAL CONDITION] and [MEDICAL CONDITION]. On 11/07/17 at 12:49 p.m. Activity Director (AD) #37 reviewed the care plan and agreed the focus area did not correlate with the goals and interventions. She further stated the residents primary interest included watching and feeding birds and daily visits from family as well as others from the community. The visitation from family and friends was not part of the interventions in the resident's care plan.",2020-09-01
3374,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2017-11-08,280,D,0,1,XW9J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview and record review, the facility failed to ensure Resident #47's care plan was updated after the resident experienced a significant change in condition. In addition, Resident #35 was not afforded the right to participate in her care planning and was not advised of the results of an X-ray. This was true for two (2) of eighteen (18) care plans reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #47 and #35. Facility census: 58. Findings include: a) Resident #47 Record review found the resident began receiving Hospice Services on 10/09/17 for a terminal [DIAGNOSES REDACTED]. On 10/09/17, the physician determined the resident lacked capacity to make medical decisions due to a, [DIAGNOSES REDACTED]. A significant change, minimum data set (MDS) with an assessment reference date (ARD) of 10/12/17, was completed due to a decline in the resident's condition. Review of the current care plan found the following focus issue: Capacity: (name of resident) has capacity and the ability to establish her own goals and make her own decisions. The goal associated with the focus issue was: (Name of resident) will remain oriented to person, place, time and situation and maintain current level of decisions making ability through next review period. At 3:40 p.m. on 11/06/17, Employee #72, the Registered Nurse (RN) MDS coordinator verified the care plan should have been updated after the resident lost her capacity on 10/09/17. At 3:50 p.m. on 11/07/17, the director of nursing (DON) confirmed the care plan should have been updated At 10:49 a.m. on 11/08/17, the above situation was discussed with the administrator and the DON. No further information was provided. b) Resident #35 At 1:54 p.m. on 11/06/17, an interview with the resident found she did not feel she was always consulted about her care and treatment. She did not believe she had attended any care plan meetings. Review of the resident's progress notes from the resident's admission date of [DATE] until present - 2:00 p.m. on 11/07/17, found the resident's care plan meeting was held on 11/1/17. A dietary progress note, dated 11/1/17 noted, Resident's admission care plan meeting was held today with her care plan team A activities progress note, dated 11/01/17, noted, (Name of Resident) was discussed during the initial care plan meeting held today . At 2:00 p.m. on 11/07/17, Employee #72, a Registered Nurse MDS coordinator was asked who is responsible for inviting residents to care plan meeting? RN #72 said the social worker was responsible. At 2:04 p.m. on 11/07/17, the social worker was asked, if she had any evidence to validate the resident participated and was invited to attend her care plan. The social worker said the resident did not attend the care plan and the invitation, Was probably by word of mouth, I usually put a note in the point click care (electronic medical record) but I might have missed her. Further review of the medical record found the resident was deemed to have capacity to make decisions by the facility physician, on 10/19/17. The resident's admission minimum data set (MDS), with an assessment reference date (ARD) of 10/24/17, noted the resident's brief interview of mental status (BIMS) score was a 14, indicating the resident is cognitively intact. Further review of the medical record, found the resident had complained of some back pain. On 10/26/17, the resident had an X-ray of the lumbar spine. At 9:21 a.m. on 11/08/17, the resident said she was unaware of the results of the X-ray. The resident's mother was visiting during the interview and she said she was also unaware of the results of the X-ray. At 9:32 a.m. on 11/08/17, the director of nursing (DON) was unable to find any evidence the results of the X-ray were discussed with the resident. At approximately 2:00 p.m. on 11/08/17, RN #72 provided a copy of a care plan note, dated 11/07/17 at 2:38 p.m. stating the care plan meeting was held with the resident and other staff. RN #72 said the social worker was not at the facility and she would not have known if the resident attended the care plan meeting on 11/01/17, although the social worker previously said she was at the meeting and the resident did not attend. RN #72 said she had a, draft note, but she just finished the note on 11/07/17. The note was not present prior to surveyor intervention on 11/07/17. RN #72 was unable to provide any documentation indicating the resident attended her care plan until after surveyor intervention.",2020-09-01
3375,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2017-11-08,371,E,0,1,XW9J11,"Based on observation and staff interview, the facility failed to ensure food was stored in safe and sanitary manner to prevent the spread of food borne illnesses. There were three (3) containers of opened and undated thickened liquids in the walk in cooler. This has the potential to effect seven (7) of the seven (7) residents who receive thickened liquids. Resident identifiers: #43, #27, #48, #62, #32, #35, and #39. Facility Census: 58. Findings include: a) An initial tour of the kitchen with the Certified Dietary Manager (CDM) #75 on 11/06/17 at approximately 11:00 a.m. found the following partially used, opened, and undated items in the walk in cooler in the kitchen: -- Thickened Diary Product 32 ounce; -- Thickened[NAME]Fruit Punch 46 ounce container; and -- Thickened water 46 ounce container. The CDM indicated that all three containers should have been dated when opened.",2020-09-01
3376,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2019-11-13,558,D,0,1,WEXH11,"Based on resident interview, observation, record review, and staff interview the facility failed to provide reasonable accommodation of resident needs and preferences. This failed practice had the potential to affect one (1) out of two (2) residents reviewed for sensory communication. Resident identifiers: # 41. Facility census 59. Findings included: a) Resident # 41 On 11/11/19 at 11:28 AM, Resident s# 41, was feeling all around his night stand, looking for his electric razor. Resident # 41 is blind and said the housekeepers keep moving his things and he cannot find them. He appeared to be frustrated, he said, his razor is normally on top of his radio (which is on top of the night stand). There was a black electric razor in a wash basin in the bathroom on the sink, next to his roommates wash basin. Inside of one (1) basin with the black razor, had personal hygiene items with Resident # 41's name on them. He was asked if that was the razor he was looking for? He said, his roommate had one just like his, and he was not sure if that one was his or his roommates. Registered Nurse (RN) #48 was asked if she could help Resident # 41 find his razor. He stated, that he keeps his cups for his hearing aids and dentures on the window seal, but now he does not know where the cups are now. The cups were found on his bedside, at the bottom of his bed. On 11/11/19 at 11:40 AM, RN #48 returned to say she found his razor in his nightstand drawer. Returning to Resident # 41's room with her, she was shown there was a black razor in a basin with items that have the name of Resident # 41. She asked if the razor in the basin belonged to Resident # 41 or Resident # 2? She removed the razor from the basin and said, she would have to check to see whom it belonged to. RN #48 stated, that he does prefer to have his razor on his radio and his cups on the window seal. However, sometimes he puts them on the heater, and the staff move them off of the the heater. She was asked, should the staff places them in the window seal? She said, yes they should and she would talk to them about it. On 11/12/19 at 9:09 AM, Resident # 41 was resting in his recliner Observation of the personal hygiene supplies in the basins, setting on the sink, both had a black razor inside of the basins. On 11/12/19 at 9:12AM, This was verified with RN #73 that both razors were in the basins in the bathroom and Resident # 41's denture cup was on the bathroom sink, along with his roommates. Resident # 41 repeatedly stated, that he wants his black, electric razor left on top of his radio. During an interview on 11/12/19 at 2:22 PM, Director of Nursing said, that she thinks maybe the Nurse Aide's that are new or do not work on that hall much, might have been moving his things, and she will re-educate all the staff. During a brief interview on 11/12/19 at 3:35 PM, Director of NUrsing said, the nurse aide said, the reason his razor was in the bathroom in the basin and not on his radio, was because he was using it in the bathroom. In front of the mirror.",2020-09-01
3377,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2019-11-13,622,D,0,1,WEXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that the transfer was documented in the resident ' s medical record and appropriate information was communicated to the receiving health care institution for one (1) of three (3) residents reviewed for the care area of hospitalization . Resident identifier: #51. Facility census: 56. Findings included: a) Resident #51 Review of Resident #51's medical records revealed the following progress note written on 10/18/19 at 3:17 PM, Called (hospital name) ER (emergency room ) for report on resident. Nurse states resident will be admitted for UTI (urinary tract infection), [MEDICAL CONDITION], and [MEDICAL CONDITION](increased heart rate). The only other progress note written on 10/18/19 was a skilled nursing evaluation completed at 12:28 AM. This skilled nursing evaluation contained no documentation to indicate the resident's condition required emergency room evaluation. A hospital transfer form was completed for Resident #51 on 10/18/19. According to the hospital transfer form, the resident was transferred to the emergency room at 9:00 AM due to abnormal electrolytes. The section of the hospital transfer form to record the most recent vital signs and the weight had not been completed. Additionally, the section of the transfer form to record risk alerts had not completed. Anticoagulation medication, which can cause bleeding, was one of the risk alerts contained in this section. Resident #51 was taking anticoagulation medication daily. Resident #51's medical records also contained an acute care transfer document checklist to indicate documents that were sent with the resident for her emergency room evaluation. The checklist contained documents recommended to accompany the resident and documents to send if available. None of the documents on the lists had been checked to indicate they had been sent with the resident. During an interview on 11/12/19 at 12:19 PM, the Director of Nursing (DoN) confirmed Resident #51's hospital transfer form did not contain her most recent vital signs and weight nor information that she was taking anticoagulant medication. The DoN also confirmed the checklist had not been completed to indicate documents sent with the resident to the emergency room . During an interview on 11/12/19 at 12:35 PM, the DoN also confirmed the reason for the resident's transfer and the resident's condition at the time of transfer, including vital signs, had not been recorded in the progress notes.",2020-09-01
3378,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2019-11-13,623,D,0,1,WEXH11,"Based on medical record review and staff interview, the facility failed to document a copy of the notice of transfer was sent to the Ombudsman for two (2) of three (3) residents reviewed for the care area of hospitalization . Resident identifiers: #51, #56. Facility census: 56. Findings included: a) Resident #51 Resident #51's medical records revealed she was sent to the emergency room for evaluation on 10/18/19. A notice of transfer or discharge was completed. The notice of transfer or discharge stated, The State Long Term Ombudsman will be notified by fax. The notice contained a section to indicate the date the Ombudsman was notified, as well as the name and signature of the person who notified the Ombudsman. This section had not been completed on the form. During an interview on 11/12/19 at 12:13 PM, the Director of Nursing (DoN) stated she believed the Ombudsman was faxed the notice of transfer or discharge. However, the DoN stated the facility does not keep the facsimile transfer sheet as verification. No further information was provided through the completion of the survey. b) Resident #56 Resident #56's medical records revealed she was sent to the emergency room for evaluation on 08/10/19. A notice of transfer or discharge was completed. The notice of transfer or discharge stated, The State Long Term Ombudsman will be notified by fax. The notice contained a section to indicate the date the Ombudsman was notified, as well as the name and signature of the person who notified the Ombudsman. This section had not been completed on the form. Resident #56's medical records revealed she was also sent to the emergency room for evaluation on 08/27/19. The notice of transfer or discharge indicated the Ombudsman was notified on 08/27/19. However, the name and signature of the person who notified the Ombudsman was not completed. During an interview on 11/12/19 at 12:13 PM, the DoN stated she believed the Ombudsman was faxed the notices of transfer or discharge. However, the DoN stated the facility does not keep the facsimile transfer sheet as verification. No further information was provided through the completion of the survey.",2020-09-01
3379,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2019-11-13,641,D,0,1,WEXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete an accurate Minimum Data Set (MDS) assessment for one (1) of 15 residents reviewed during the long-term care survey process. Resident identifier: #35. Facility census: 56. Findings included: a) Resident #35 Review of Resident #35's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) 10/09/19 revealed the resident was coded to have received anticoagulant medication seven (7) days during the look back period. During an interview on 11/12/19 at 4:33 PM, Registered Nurse Minimum Data Set (RN MDS) coordinator #49 stated Resident #35 was receiving the anticoagulant medication [MEDICATION NAME] ([MEDICATION NAME]). RN MDS Coordinator #49 acknowledged the Resident Assessment Instrument (RAI) manual stated not to code antiplatelet medications such as [MEDICATION NAME] as anticoagulant medication. RN MDS Coordinator #49 stated she did not know this. No further information was provided through the completion of the survey.",2020-09-01
3380,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2019-11-13,656,D,0,1,WEXH11,"Based on Resident interview, staff interview, record review, and observation the facility failed to implement the care plan in the care area of Comm-Sensory. This failed practice had the potential to affect one (1) out of two (2). Resident identifiers: Resident # 41. Facility census 59. Findings included: a) Resident # 41 On 11/11/19 at 11:28 AM, Resident s# 41, was feeling all around his night stand, looking for his electric razor. Resident # 41 is blind and said the housekeepers keep moving his things and he cannot find them. He appeared to be frustrated, he said, his razor is normally on top of his radio (which is on top of the night stand). There was a black electric razor in a wash basin in the bathroom on the sink, next to his roommates wash basin. Inside of one (1) basin with the black razor, had personal hygiene items with Resident # 41's name on them. He was asked if that was the razor he was looking for? He said, his roommate had one just like his, and he was not sure if that one was his or his roommates. Registered Nurse (RN) #48 was asked if she could help Resident # 41 find his razor. He stated, that he keeps his cups for his hearing aids and dentures on the window seal, but now he does not know where the cups are now. The cups were found on his bedside, at the bottom of his bed. On 11/11/19 at 11:40 AM, RN #48 returned to say she found his razor in his nightstand drawer. Returning to Resident # 41's room with her, she was shown there was a black razor in a basin with items that have the name of Resident # 41. She asked if the razor in the basin belonged to Resident # 41 or Resident # 2? She removed the razor from the basin and said, she would have to check to see whom it belonged to. On 11/12/19 at 9:09 AM, Resident # 41 was resting in his recliner Observation of the personal hygiene supplies in the basins, setting on the sink, both had a black razor inside of the basins. On 11/12/19 at 9:12AM, This was verified with RN #73 that both razors were in the basins in the bathroom and Resident # 41's denture cup was on the bathroom sink, along with his roommates. Resident # 41 repeatedly stated, that wants his black, electric razor left on top of his radio. During an interview on 11/12/19 at 2:22 PM, Director of Nursing said, that she thinks maybe the Nurse Aide's that are new or do not work on that hall much, might have been moving his things, and she will re-educate all the staff. b) Care Plan Review of the care plan, Dated: 02/11/19, in the intervention section states: The staff will not rearrange personal items and will keep them within reach for Resident #41, due to he visual impaired.",2020-09-01
3381,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2019-11-13,657,D,0,1,WEXH11,"Based on interview and record review, the facility failed to revise a Resident's care plan after a change in condition. This failed practice had the potential to affect 3 out of 15 residents reviewed for care plan accuracy. Resident identifiers: #6, #32, and #54. Facility census: 56. Findings included: a) Resident #6 During an interview on 11/11/19 at 12:03 PM, Resident stated her feeding tube was removed on 09/26/19. On 11/11/19 at 1:30 PM, review of Resident's care plan indicated Feeding Tube was still in place with active interventions and goals for care regarding adequate nutrition via tube feeding. Record Review revealed progress noted dated 09/26/19 entered at 5:34 PM by Licensed Practical Nurse #86 that stated the Resident returned to back to facility and the PEG (percutaneous endoscopic gastrostomy) feeding tube was removed. Quarterly Nutritional Note dated 11/4/2019 entered at 2:43 PM by the Dietary Manager stated the Resident was ordered a mechanically soft diet and her tube feedings have been discontinued. During an interview on 11/13/19 at 9:02 AM the Diredtor of Nursing (DON) verified the feeding tube was removed on 09/26/19 as referenced by the Consultation Report provided by DON that stated (typed as written), PEG removed. Change dressing tomorrow. See as needed. The DON agreed the care plan should have been updated to reflect the removal of the feeding tube and change in nutritional status. b) Resident #32 Record review of Residents care plan indicated the Resident was receiving an anticoagulant medication, Eliquis (blood thinner medication). Review of Residents active orders and Medication Administration Record [REDACTED]. On 11/13/19 at 08:39 AM, the Director of Nursing (DON) stated the Resident was only on Eliquis for 3 days for dates of 6/21/18 - 6/24/18, and then it was discontinued. The DON agreed and verified the care plan was not updated to reflect the medication changes",2020-09-01
3382,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2019-11-13,695,D,0,1,WEXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and resident interview, the facility failed to ensure resident who needs respiratory care, is provided such care, consistent with professional standards of practice, by administrating oxygen therapy without an order for [REDACTED]. Resident identifiers: # 28. Facility census 56. Findings included: a) Resident # 28 During an observation on 11/11/19 at 2:26 PM, Resident # 28 was asked what is his oxygen flow rate supposed to be set on? He said two (2) liter per minutes (lt). The flow rate was currently set on two and one half (2.5) lt. Review of records revealed there was not an order for [REDACTED].>On 11/12/19 at 9:05 AM, Registered Nurse (RN) #78 verified the oxygen flow rate was set on 2.5 lt. On 11/12/19 at 9:12 AM, RN #21 was asked to find an order for [REDACTED].#21 found a standing order dated: 03/24/16 for shortness of breath or low oxygen saturation less than 90%: May initiate oxygen at 2L/min via nasal cannula and notify the physician. During an interview on 11/12/19 at 10:20 AM, RN # 21 was asked if the standing order was used, then would there have been an order when initiated and was the physician notified? On 11/12/19 at 11:00AM, RN # 21 said, that the reason there was not an order for [REDACTED]. She was asked about yesterday on 11/11/19 he also had the oxygen on that morning. She said, well I don't know. I don't think he needs, but he just requested to have it. On 11/12/19 at 2:40 PM, Director of Nursing stated, that she believes the oxygen order was somehow messed up because a couple of weeks ago they went through all the electronic charts and removed all the PRN (give as needed) oxygen orders.",2020-09-01
3383,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2019-11-13,791,D,0,1,WEXH11,"Based on medical record review, resident interview, and staff interview, the facility failed to provide dental services to meet the needs of one (1) of one (1) residents reviewed for the dental care area. Resident identifier: #35. Facility census: 56. Findings included: a) Resident #35 During an interview on 11/11/19 at 11:37 AM, Resident #35 stated he had bad teeth. He stated he had been sent to a dentist for evaluation but had not heard anything about what was going to be done with his teeth. Review of Resident #35's medical records revealed he had been evaluated in a dental office on 09/18/19. However, no consultant dental report could be located in the medical records. Resident #35's dental assessment on 10/08/19 stated he had obvious or likely cavities or broken teeth. On 11/12/19 at 2:00 PM, the Director of Nursing (DoN) was asked to locate the consultant dental report regarding Resident #35's appointment on 09/18/19. On 11/12/19 at 3:46 PM, the Director of Nursing (DoN) stated the facility had not received the consultant dental report regarding the 09/18/19 appointment because the dentist's office had faxed the report to the wrong number. She stated she requested and received the report today. Review of the consultation report revealed the dentist requested medical clearance for local anesthesia for extraction of 12 non-restorable teeth. The DoN stated the physician came to the facility today and gave medical clearance for Resident #35's teeth extraction. The DoN also stated an appointment would be scheduled for extraction of Resident #35's teeth.",2020-09-01
3384,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2019-11-13,880,F,0,1,WEXH11,"Based on observation, resident interview, record review and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility comingled personal items for Residents #2 and #41. The facility also failed to ensure staff handle, store, and process linens and laundry in accordance with accepted national standards in order to produce hygienically clean laundry and prevent the spread of infection to the extent possible. This failed practice had the potential to affect all residents in the facility. Resident identifiers: #2, #41. Facility census: 56. Findings included: a) Laundry On 11/12/19 at 2:15 PM, a tour of the laundry room was conducted with Laundry Worker #12. Laundry Worked #12 stated covered plastic barrels containing the dirty laundry and linens was brought into a room. Upon inspection, this room was noted to also contain several cardboard boxes labeled as men's and women's clothes. Laundry Worker #12 stated these were clothes that had been left behind when residents left the facility and would be distributed to residents who needed them. The room also contained a cart with blankets, resident gowns, table clothes, and napkins. The cart had a curtain in front of it that could be drawn to retrieve items. The items were covered with plastic, but the plastic was not sealed. Laundry Worker #12 stated these were new items to be used in the facility. Laundry Worker #12 stated the covered plastic barrels containing dirty laundry were brought into a second room for sorting. The washing machines were also located in this room. This room was adjacent to the room where the plastic barrels were initially stored. There was a doorway separating the two (2) rooms but no door. This room had a housekeeping cart with a mop in water, and dry mop heads and wash clothes lying on the cart. Laundry Worker #12 stated the housekeeping cart was stored in here and would be removed to clean the dining room after meals. She stated the water would be changed before mopping. She stated the mop heads and wash clothes were clean. Laundry Worker #12 was informed the area where dirty laundry was sorted was a dirty area, and that clean items could not be stored in dirty areas. She was informed the room adjacent to the laundry sorting room was considered a dirty area because there was no door to separate the two room. She had no further information regarding the matter. Laundry Worker #12 stated the linens and laundry was sorted and either placed directly into one of the washers or placed in a wooden bin to be laundered later. The wooden bin did not contain a liner. Laundry Worker #12 stated the bin was cleaned with a spray solution. However, the corners of the wooden bin contained dirt debris. Laundry Worker #12 had no further information regarding the matter. Laundry Worker #12 stated after washing the laundry was brought into a third room to be placed in the dryers. The laundry was removed in from the dryers was folded in this room. This drying and folding room contained two (2) shelves on which staff personal items were noted to be placed. These personal items were keys, a cell phone, and a plastic soft drink bottle. Laundry Worker #12 stated she used these shelves to sort smaller laundry items, such as residents' underwear. Laundry Worker #12 was informed staff personal items were unclean items and could not be stored where clean laundry was processed. She had no further information regarding the matter. On 11/12/19 at 2:30 PM, the Maintenance Supervisor was shown the above-described deficient practices. The Maintenance Supervisor stated he would remove the housekeeping cart from the dirty laundry area. He also stated he would install a door between the room where laundry was sorted and placed into the washer and the room where new items and clothes from former residents were stored. The Maintenance Supervisor also stated he would obtain a liner for the wooden wooden bin and would instruct laundry workers not to keep personal items where clean laundry was folded. No further information was provided through the completion of the survey. b) Resident #2 On 11/11/19 at 11:40 AM it was discovered, that Resident # 2's black electric razor was in his roommates basin along with his roommate's personal hygiene supplies. This was verified with RN #48. Review of Minimum Data Set (MDS), Section GG 0100: Total dependent. During an interview on 11/12/19 at 2:22 PM, DoN, said, that they (the facility) had identified it was a problem with having both residents basins on the sink. She went on to say, that they have already found a type of storage cabinet the facility is going to purchase for each bathroom, to prevent getting the resident's items from getting mixed up. c) Resident #41 On 11/11/19 at 11:28 AM, Resident # 41, was feeling all around his night stand, looking for his electric razor. Resident # 41 is blind and said the housekeepers keep moving his things and he cannot find them. He appeared to be frustrated, he said, his razor is normally on top of his radio (which is on top of the night stand). There was a black electric razor in a wash basin in the bathroom on the sink, next to his roommates wash basin. Inside of one (1) basin with the black razor, had personal hygiene items with Resident # 41's name on them. He was asked if that was the razor he was looking for? He said, his roommate had one just like his, and he was not sure if that one was his or his roommates. Registered Nurse (RN) #48 was asked if she could help Resident # 41 find his razor. On 11/11/19 at 11:40 AM, RN #48 returned to say she found his razor in his nightstand drawer. Returning to Resident # 41's room with her, she was shown there was a black razor in a basin with items that have the name of Resident # 41. She asked if the razor in the basin belonged to Resident # 41 or Resident # 2? She removed the razor from the basin and said, she would have to check to see whom it belonged to. On 11/12/19 at 9:09 AM, Resident # 41 was resting in his recliner Observation of the personal hygiene supplies in the basins, setting on the sink, both had a black razor inside of the basins. On 11/12/19 at 9:12AM, This was verified with RN #73 that both razors were in the basins in the bathroom and Resident # 41's denture cup was on the bathroom sink, along with his roommates. A review of the Mininmum Data Set (MDS) for Resident #4. In the section GG 0100: Indepentent for, eating, oral hygiene, and limited assistance for bathing.",2020-09-01
4298,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2016-08-19,241,E,0,1,B5HS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interviews, the facility failed to ensure resident confidential information was not posted in resident's rooms and openly visible to others who enter the resident's rooms and failed to ensure a resident's personal furniture was not removed without the resident being made aware. This affect three (3) of three (3) State 2 residents (#3, #29 and #58) reviewed for dignity, and one (1) of five (5) residents (#54) reviewed for unnecessary medications. Resident identifiers: #3, #29, #58, and #54. Facility census: 58. Findings include: a) Resident #3 Review of the medical record revealed Resident #3 had the following relevant Diagnoses: [REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 06/01/16, revealed the resident was cognitively impaired, required extensive assistance of two people for activities of daily living and had impairment of both lower extremities. Further review of Resident #3's medical record found a social service note dated 06/20/16 at 3:15 p.m. that the resident was declared incapacitated and her medical power of attorney was her daughter and son. Review of Physical Therapy Recertification Notes with service dates from 07/22/16 to 07/28/16 revealed a short term goal indicated the resident needed adaptive equipment added to her broda chair. The equipment order was soft wedge foot plates for comfort and safety. Physical Therapy Addendum Notes with service dates from 08/03/16 to 08/03/16 stated therapy had been monitoring staff's ability to follow-through with setting up the resident's foot position and some still needed education and re-education. An observation of Resident #3, 08/16/16 at 10:58 a.m., she was in the hallway near the nurse's station dressed and well-groomed in a reclined geri-chair. The resident was not in a broda chair and did not have a wedge cushion in place. During observation, on 08/15/16 at 10:30 a.m., a sign visible from the doorway of Resident #3's private room was observed posted on a wardrobe facing the doorway. The sign stated Please place wedge cushion over foot plates when resident is in broda chair. Thanks therapy. Observation on 08/16/16 at 10:40 a.m. revealed the sign on the wardrobe had been replaced with one that stated, Staff PLEASE provide a pillow when (resident's name) is in the chair. Also, please see that she has a lightweight blanket on her arms when she is in short sleeves. THANK You! The Family On 08/16/16 at 10:58 a.m., Resident #3 was in the hallway near the nurse's station dressed and well-groomed in a reclined geri-chair. The resident was not in a broda chair and did not have a wedge cushion in place. During interview on 08/16/16 at 11:09 a.m., Speech Therapy Personnel #91 stated the therapy staff only post information in residents' rooms after coordination with the nursing staff. She further stated information included on posting would be documented in the therapy notes. Staff would then be educated regarding specific posting instructions. She stated the concern is to ensure new staff know what to do for resident. During interview on 08/16/16 at 11:20 a.m., the Director of Nursing (DON) #89 verified therapy staff informs the nursing staff of information to be posted in residents room prior to information being posted. DON #89 verified therapy posted the note on the resident ' s wardrobe concerning the use of wedge pillow with the broda chair. She stated the facility did not feel that type of information was confidential. DON #89 stated the use of the broda chair was discontinued the prior week. She stated Resident #3 now used a geri chair, so the wedge cushion was no longer necessary. During an interview with DON #89, on 08/16/16 2:00 p.m., she verified the removal of all signs in resident rooms. b) Resident #54 Review of Resident #54's clinical record on 08/17/16 at 1:00 p.m., revealed the following relevant Diagnoses: [REDACTED]. Observation of Resident #54, on 08/17/16 at 1:00 p.m., found him sitting in a wheelchair in his room. The resident's recliner was noted not in the room. When asked about the whereabouts of the recliner, the resident stated, I don't know what happened to my chair, it was gone when I got up this morning. The resident further stated it bothered him that someone would take his chair. During interview with the Director of Nursing (DON) #89, on 08/17/16 at 1:15 p.m., she stated the resident's chair was removed from his room during the middle of the night when the resident was sleeping in order to accommodate another resident's family. Director of Nursing #89 verified the facility staff did not get the resident's permission to remove the recliner. On 08/17/16 at 1:37 p.m., Resident #54 was observed sitting in the recliner that was previously removed without his permission. The resident stated he was happy the chair had been returned. c) Resident #29 On 08/16/2016 at 10:49 a.m., observations made of Resident #29's room revealed a sign hanging behind the bed that read, Please apply both knee splints for 6 hours at night. A second sign that was typed was posted and hanging on the bulletin board next to the resident's bed. It read, Please put both elbow splints on for 6 hours at bedtime daily, Thanks, Therapy staff. Above the typed message was handwritten note in red ink, Hipsters at all times! During an interview with Nurse Aide (NA) #49, on 08/16/2016 at 10:48 a.m., she stated she did not know who posted the signs in the resident's room. NA #49 stated the nursing staff have care plans and a system in place that lists the things they need to know to care for the residents. During an interview with DON #89, on 08/16/2016 at 11:52 a.m., she verified the signs containing confidential information about the resident's care were posted in the room. The DON stated she was not sure who posted them in the room. The DON stated the nursing staff does have a system in place to identify the type of care and directives for staff. She verified the signs contained confidential information regarding the resident's care visible to the public, and should not be posted. On 08/16/2016 at 2:37 p.m., the facility's Kardex system (a system used by staff when providing care to residents) was reviewed. The Kardex indicated hipsters were to be worn at all times for safety/protection related to falls and splints for contracture management for six hours daily. Resident #29 had the following Diagnoses: [REDACTED]. d) Resident #58 Observations in Resident #58 ' s room, on 08/16/2016 at 10:47 a.m., found a sign hanging on the resident's armoire next to the bed. The sign read, Do not use toilet paper on this resident!!!!! During an interview with Nurse Aide (NA) #49, on 08/16/2016 at 10:48 a.m., she stated she did not know who posted the sign in the resident's room. NA #49 stated the nursing staff have care plans and a system in place that lists the things you need to know to care for residents. During an interview with the DON, on 08/16/2016 at 11:52 a.m., verified the signs containing confidential information about the resident's care were posted in the room. The DON stated she was not sure who posted them in the room. The DON stated the nursing staff does have a system in place to identify the type of care and directives for staff. She verified the signs contained confidential information regarding the resident's care visible to the public, and should not be posted. During an observation and interview with Resident #58, on 08/16/2016 at 12:06 p.m., she stated she did not know who posted the sign in her room on the armoire. Review of the care plan for Resident #58, on 08/16/2016 at 1:30 p.m., found the resident had a prolapsed rectum, and to do not use toilet paper for cleansing after a bowel movement.",2020-02-01
4299,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2016-08-19,272,D,0,1,B5HS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure resident's comprehensive assessments were accurate regarding their oral and pressure ulcer status. This affected two (2) of twenty-eight (28) Stage 2 sampled residents reviewed for comprehensive assessments. Resident identifiers: #37 and #83. Facility census: 58. Findings include: a) Resident #37 Review of the clinical record for Resident #37 found a Dental Assessment, dated 06/17/16, which indicated the resident had broken teeth. Review of the resident's annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/16/15, revealed the resident did not have any obvious or likely cavity or broken natural teeth. Observation of Resident #37, on 08/15/16 at 12:22 p.m., to have two broken front teeth. An interview with Resident #37, on 08/15/16 at 4:00 p.m., verified the two front teeth were chipped. An interview with Registered Nurse #44, on 8/16/16 at 3:45 p.m., verified the resident had two broken teeth that were present on admission. She confirmed the annual MDS with ARD of 12/15/16 was miscoded. b) Resident #83 Review of the medical record for Resident #83 found a Nursing Admission/Readmission assessment dated [DATE] identified the resident had a Stage 2 pressure ulcer on the right buttock measuring 2.5 centimeters (cm) by 2.2 cm and a Stage 2 pressure ulcer on the left buttock measuring 4.5 cm by 2.8 cm. Review of the Weekly Wound Evaluation dated 08/5/16 revealed the right buttock Stage 2 pressure ulcer had increased in size measuring 4 cm by 3.5 cm by 0.2 cm. Review of the admission/Medicare 5 Day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to have two Stage 1 pressure ulcers, and no Stage 2 pressure ulcers. During interview with the MDS Assessment Registered Nurse #44, on 08/16/16 at 10:50 a.m., verified the MDS indicating the resident had two Stage 1 pressure ulcers and no Stage 2 pressure ulcers was miscoded. During interview with the treatment nurse, RN #23, on 08/16/16 at 11:30 a.m., she stated the resident was admitted with right and left buttock Stage 2 pressure ulcers.",2020-02-01
4300,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2016-08-19,364,E,0,1,B5HS11,"Based on observations, staff interviews and review of the recipes for pureed diets, the facility failed to follow written recipes for pureed diets for one evening meal. This affected ten (10) of ten (10) residents who received pureed diets. The facility census was 58. Findings include: Observations of Dietary Cook #3, on 08/15/16 at 4:30 p.m., preparing pureed food for the evening meal. Dietary Cook #3 added ten (10) and a half cup servings of zucchini into the food processor. The cook did not add any other ingredients to the zucchini. The cook continued to the next food item and pureed the chicken breast. The cook placed did not measure the amount of chicken breast placed into the food processor. Then the cook added some unmeasured water to the chicken. During the observation, Dietary Cook #3 when asked if she had recipes to follow, she stated, I do, but she was taught to just make the pureed recipes to a mashed potato consistency. The cook stated does not follow the recipes for the pureed foods. The cook stated she had pureed ten bananas, but did not follow the recipe and did not add orange juice per the recipe. Further during the observation, the cook pureed a second batch of chicken breasts and added water, but did not measure. The cook stated the batch would need some thickener added to it because it was a thinner consistency than the other batch of pureed chicken. The cook sprinkled some thickener into the pan of chicken breasts, but did not measure or follow the recipe. The cook stated she had already pureed the corn and had added some water, but did not follow the recipe for adding thickener or butter. On 08/15/16 at 4:56 p.m., Dietary Cook #3 verified the recipes were not followed and just makes the pureed items to mashed potato consistency. The recipes for all puree foods were reviewed and listed specific ingredients and measurements for the recipe for each item on menu that needed pureed for the meal. On 08/16/16 at 11:34 a.m., interview with Consultant Dietician #88 verified the recipes for pureed diets needed to be followed when making the pureed foods. On 08/16/16 at 11:36 a.m., interview with Administrator #90 verified the staff should be following the recipes to make the pureed foods",2020-02-01
5482,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2015-07-30,272,B,0,1,ZCVH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview it was determined the facility had not conducted an accurate assessment of each resident's condition in the area of medical prognosis and uncessary medications for four (4) of 13 minimum data set (MDS) assessments reviewed. Resident identifiers: #73, #20, #68, and #6. Facility census: 56. Findings include: a) Resident #73 This resident was admitted on [DATE] and had orders for comfort measures only. He was offered Hospice services but declined. According to the medical record, reviewed on the afternoon of [DATE], the resident expired at the facility on [DATE]. The admission MDS with an assessment review date (ARD) of [DATE] did not indicate the resident had a condition or terminal illness which would result in a life expectancy of less than six (6) months. Orders showed the resident had comfort care, which began [DATE], and [MEDICATION NAME] for pain ordered on [DATE]. The most recent care plan contained a problem listed as palliative care due to terminal illness. Nursing notes, dated [DATE], revealed the resident was offered hospice services but declined. On [DATE] and [DATE] there were orders to not provide intravenous (IV) medications, tube feedings, or do lab sticks. b) Resident #20 Review of Resident #20's medical record, on [DATE] at 3:10 p.m., found a history and physical (H&P) dated [DATE]. The H&P revealed the resident was offered Hospice services. The resident denied these services. Nursing notes dated [DATE] reflected the resident as being in the dying process, and taking [MEDICATION NAME] for increasing pain. The resident did expire later on [DATE]. Resident #20 was admitted on [DATE] with a Do Not Resuscitate (DNR) order as well as orders for [MEDICATION NAME] and [MEDICATION NAME]. A physician's orders [REDACTED]. The admission MDS with an assessment reference date of [DATE] did not have yes marked under the prognosis in Section J. This section reflected whether or not he resident had a condition or terminal illness which would lead to a life expectancy of six (6) months or less. Interview with Registered Nurse/Minimum Data Set (RN/MDS) Nurse #32, on [DATE] at 3:10 p.m., verified the resident assessments should have been coded as yes for a prognosis of terminal illness with six (6) months to live under Section J of the MDS assessment.RN/MDS #32 confirmed pain and comfort measures only were in place, plus the offer to provide Hospice were factors associated with an illness leading to a life expectancy of six (6) months or less. c) Resident #68A review of Resident #68's medical record, completed on [DATE] at 2:00 p.m., revealed an admission date of [DATE]. On [DATE] the attending physician completed a History and Physical (H&P) for Resident #68. The assessment and plan read, Metastasis [MEDICAL CONDITION] Comfort end of life care in the dying process. Additionally, a progress note, date [DATE] by the physician read, . Poor prognosis .The medical record contained an admission MDS with an assessment reference date (ARD) of [DATE]. This MDS, under section (J1400 Prognosis), was coded to reflect Resident #68 did not have a condition or chronic disease that may result in a life expectancy of less than six (6) months. Review of the Centers for Medicare & Medicaid Services Long Term Care Facility Resident Assessment Instrument User's Manual Version 3.0 dated (MONTH) 2013 (RAI Manual), on [DATE] at 2:30 p.m., revealed: on page J-24 of the RAI manual, the following was written in regards to (section J1400) of the MDS, Code 1, Yes: If the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. During an interview, on [DATE] at 3:30 p.m., the MDS Coordinator/registered nurse (MDSRN) #49 stated she did not code Resident #68's MDS as yes because the family had refused hospice services and she thought the resident had to be under the care of hospice services. When the physician's H&P and progress notes were reviewed with Employee #49, she then agreed she had not coded Section J1400 accurately. d) Resident #6 A review Resident #6's medical record at 8:41 a.m. on [DATE], found an admission physician order [REDACTED]. The Medication Administration Record [REDACTED]. Further review of the medical record found an admission minimum data set (MDS) revelaed an assessment reference date (ARD) of ,[DATE]//15. Review of this MDS revealed Section N0410. Medication Received E. Anticoagulant, marked with a zero (0) indicating resident #6 did not receive an anticoagulant in the seven (7) day look back period from [DATE]. Section N0410 contained directions to, Indicate the number of days the resident received the following medications during the last 7 (seven) days or since admission/entry or reentry if less than 7 (seven) days. Enter 0 (zero) if medication was not received by the resident during the last 7 (seven) days. Review of Mosby's (YEAR) Nursing Drug Reference book, found Xarelto listed on page 1,028. The functional class of Xarelto was listed as an anticoagulant. An interview with the RN/MDS Nurse #32 at 9:45 a.m. on [DATE], confirmed Resident #6 was administered Xarelto seven (7) of the seven (7) days during the look back period. She stated she did not count this medication as an anticoagulant because it is not monitored with laboratory testing as most anticoagulant therapies. She indicated this is why she recorded a zero (0) on section N0410 E. Anticoagulant for this MDS. She stated she was not aware it should be counted as an anticoagulant for MDS purposes.",2019-01-01
5483,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2015-07-30,309,E,0,1,ZCVH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to provide the necessary care and services to ensure each resident attained and or maintained the highest practicable physical, mental, and psychosocial well-being for two (2) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey. The facility failed to follow a physician's orders [REDACTED].#40 daily for three days. Additionally, the facility failed to administer Resident #6's insulin according the physician ordered sliding scale. Resident identifiers: #40 and #6. Facility census: 56 Findings include: a) Resident #40 A review of Resident #40's medical record, at 11:24 a.m. on 07/28/15, found a physicians order dated 07/20/15 which read as follows: [MEDICATION NAME] 40 mg (milligrams) po (by mouth) BID (twice daily) X (time) 3 (three) days obtain base weight then daily wt (weight) . Further review of Resident #40's medical record found no indication a base weight was obtained on 07/20/15, nor any indication he was weighed daily thereafter. His most recent weight was obtained on 07/01/15 at which time he weighed 323 pounds. An interview with the Director of Nursing (DON) at 9:38 a.m. on 07/29/15, confirmed Resident #40 did not get weighed on 07/20/15 nor was he weighed daily thereafter. She stated that she reviewed the medical record and could not find these weights anywhere. She indicated Resident #40 likely refused to be weighed, but confirmed she could not find this documented anywhere in the medical record. b) Resident #6 A review of Resident #6's medical record, at 8:41 a.m. on 07/29/15, found a physician's orders [REDACTED]. The following sliding scale was established in the physician order: -- For a blood sugar between 150 - 200 administer 3 units of insulin. -- For a blood sugar between 201 - 250 administer 6 units of insulin. -- For a blood sugar between 251 - 300 administer 9 units of insulin. -- For a blood sugar between 301 - 350 administer 12 units of insulin. -- For a blood sugar between 351 - 400 administer 15 units of insulin. Review of Resident #6's medication administration record (MAR) and his diabetic monitoring sheet which was kept with the MAR found the following dates, times, and blood sugars when Resident #6 had no documented units of insulin administered. However; based on the blood sugars obtained he should have been administered insulin as directed by the sliding scale. -- 07/07/15 at 4:00 p.m., blood sugar (BS) was 259, and the ordered nine (9) units of insulin was not given -- 07/19/15 at 4:45 p.m., BS was 175, and the ordered three (3) units of insuliln was not given -- 07/20/15 at 4:30 p.m., BS was 196, and the ordered three (3) units of insuliln was not given -- 07/25/15 at 4:30 p.m., BS was 162, and the ordered three (3) units of insuliln was not given -- 07/26/15 at 11:30 a.m., BS was 189, and the ordered three (3) units of insuliln was not given -- 07/26/15 at 4:30 p.m., BS was 165, and the ordered three (3) units of insuliln was not given An interview with Registered Nurse (RN) #78, at 8:51 a.m. on 07/30/15, confirmed she was the nurse who obtained the blood sugars mentioned above. When asked why no units of coverage was documented on the MAR or the Diabetic Monitoring sheet she stated, I think it is a mental thing. I just forget to go back and put the number of units I gave him. She stated, she comes out of the room with the glucometer and writes down the blood sugar then draws up the insulin and returns to the room and administers the insulin and then forgets to write in the number of units she gave him. She confirmed for the above dates and time she had no units of coverage documented. Therefore, there is no indication Resident #6 received his sliding scale insulin coverage as directed by the physician's orders [REDACTED].>",2019-01-01
5484,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2015-07-30,311,D,0,1,ZCVH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the restorative participation log, and staff interview, the facility failed to provide restorative nursing services to maintain or to improve a resident's activities of daily living (ADLs) for one (1) of three (3) residents reviewed for the care area of activities of daily living. Resident #69 did not receive restorative services as ordered to maintain or improve their self-performance of ADLs. Resident identifier: #69. Facility census: 56 Findings include: a) Resident #69 A review of Resident #69's medical record, completed on 07/28/15 at 3:20 p.m., found physician's orders [REDACTED]. 6x week for 12 weeks (8/31/15). RNP for SFL ( strength for life) 3x weeks for 12 weeks Mon (Monday), Wed (Wednesday), Fri (Friday). A review of the restorative participation log, on 07/28/15 at 3:25 p.m., for the period of time from 06/08/15 through 06/13/15, revealed Resident #69 received no restorative therapy to assist with ambulation. For the week of 06/15/15 through 06/21/15, and 06/29/15 through 07/05/15, the resident received restorative services five (5) days. From 07/20/15 through 07/26/15, the resident received restorative services four (4) times this week. In addition, the resident did not receive SFL at all from 06/08/15 through 06/14/15. The resident did not receive SFL on 06/15/15. An interview with registered nurse (RN) #16, on 07/28/15 at 3:30 p.m., revealed the staff provided restorative services from Monday through Sunday. The RN stated, The restorative nurse had quit and therefore she had taken the restorative nursing position over and during the above time frame no one was monitoring whether the restorative therapy was provided.",2019-01-01
5485,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2015-07-30,514,D,0,1,ZCVH11,"Based on record review and staff interview, the facility failed to maintain an accurate and complete medical record for one (1) of 13 medical records reviewed during Stage 2 of the Quality Indicator Survey (QIS). The amount of sliding scale insulin administered to Resident #6 was not documented in the resident's medical record. The number of units administered to Resident #6 was contained on another facility document, which was not part of the medical record. Resident identifier: #6. Facility census: 56. Findings include: a) Resident #6 A medical record review, at 8:41 a.m. on 07/29/15, revealed Resident #6 received a sliding scale dose of insulin. The insulin was scheduled to be administered with meals and at bedtime. The resident's blood sugar and the amount of insulin administered should be documented in the clinical record. The medication administration record (MAR), Resident #6's diabetic monitoring sheet, and nursing notes were reviewed. This review found, on 07/04/15 at 7:30 a.m., 11:30 a.m. and 4:00 p.m., there was no documentation to indicate how much insulin Resident #6 received. The following blood sugars were documented respectively on the diabetic monitoring sheet, 244, 162, and 153. However, the amount of insulin administered was not documented in the medical record. An interview with the director of nursing (DON), at 4:28 p.m. on 07/29/15, confirmed the nurse working on 07/04/15 documented the number of units administered on her report sheet. The report sheet was reviewed and contained the missing documentation. The report sheet contained multiple residents' names and information. The DON confirmed this form was not part of the medical record because it contained multiple resident names. It could not be filed in any one particular record. She also confirmed when a resident receives a sliding scale dosage of insulin the number units administered as well as the blood sugar of the resident should be documented on the MAR or the diabetic monitoring sheet. She confirmed the information needed to be in the medical record and was not.",2019-01-01
6595,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2014-04-24,161,E,0,1,LCKP11,"Based on review of residents' funds accounts, review of the facility's current surety bond, and staff interview, the facility failed to ensure the amount of the surety bond was sufficient to cover the residents' funds. This had the potential to affect each of the 28 residents for whom the facility managed personal funds. Facility census: 51. Findings include: a) Review of the surety bond, at 11:00 a.m. on 04/23/14, revealed it was in the amount of $35,000.00. b) On 04/23/14, the business office manager, Employee #59, provided the daily balances of the 28 residents for whom the facility managed funds. Review of this information revealed a balance of $36,032.40 on 02/03/14. On 03/03/14 the resident funds balance was $36,456.57. c) On 04/23/14 at 1:03 p.m., an interview was conducted with the administrator, Employee #1, regarding the surety bond. She was shown the surety bond did not cover the full amount of residents' personal funds managed by the facility for the dates of 02/03/14 and 03/03/14. The administrator said, Okay.",2018-01-01
6596,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2014-04-24,280,D,0,1,LCKP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to revise care plans for two (2) of twenty-two (22) residents reviewed during Stage 2 of the Quality Indicator Survey. Resident #64's care plan was not revised to reflect the resident's current enteral feeding orders. Resident #27's nutritional care plan was not revised to include extra portions of the entree for all three (3) meals. Resident Identifiers: #64 and #27. Facility Census: 51. Findings Include: a) Resident #64 Review of Resident #64's medical record, at 12:26 p.m. on 04/22/14, found the resident's nutritional needs and hydration needs were met via a PE[DEVICE] (percutaneous endoscopic gastrostomy tube). The resident's current enteral feeding orders, written on 04/17/14, were, Glucerna 1.2 to 80 cc/hr (cubic centimeters per hour) continuous. 2. Increase H20 (water) flushes via pe[DEVICE] 250 ml (milliliters) Q (every) 4 hours. The previous order, written on Resident #64's readmission to the facility on [DATE], was for, Glucerna 1.2 @ (at) 70 cc/hr. via feeding tube pump continuously. Review of the resident's current care plan found an intervention of, (typed as written) Provide glucerna 1.2 at 70 mls/hour times 20 hours to provide 1680 calories and 84 gram protein and a total of 1767 mls of H2O per day. This intervention was related to the goal of, (typed as written) Resident will receive adequate nutritional intake through tube feeding thru (through) the forcoming quarter. This intervention reflected the physician order, written on 03/05/14, (typed as written), Increase glucerna 1.2 to 70 mls/hour and decrease hours to 20 hours. 1400 mls, 1680 cals, and 23 cal.kg (calories per kilogram) 84 grams protein 16 pro.kg. (protein per kilogram) 1127 mls free h2o (water). Increase flush to 100 mls q4 hours 600 mls total h20 =1767 mls. Employee #4, Registered Nurse Minimum Data Set Nurse, was interviewed at 3:03 p.m. on 04/22/14. Employee #4 confirmed Resident #64's care plan did not accurately reflect his current enteral feedings. She confirmed his care plan had not been updated to reflect the previous two (2) enteral feeding orders. The nurse agreed the resident's care plan should have been updated with each new order. b) Resident #27 In an interview with Resident #27, during Stage 1 of the Quality Indicator Survey (QIS), at 1:55 p.m. on 04/21/14, the resident stated, I need more to eat, they don't give me enough food. The facility's dietary manager, Employee #70, was interviewed at 2:20 p.m. on 04/22/14 regarding the resident's statement of not getting enough to eat. She stated the resident had been ordered double portions of the main entree served for all three (3) daily meals on 04/08/14, due to his comments about not getting enough to eat. Further review of the medical record found an order, signed by the physician on 04/08/14, for double portions of the entree with all three (3) meals. Review of the resident's care plan, on 02/22/14, found a dietary care plan addressing the resident's mechanically altered therapeutic diet. The care plan was not updated with the new order to serve double portions for all three (3) meals. The dietary manager, Employee #70, was interviewed again on 04/24/14 at 8:47 a.m. She verified the care plan had not been updated to reflect the order of 04/08/14 for double portions.",2018-01-01
6597,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2014-04-24,329,D,0,1,LCKP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, physician interview, and staff interview, the facility failed to ensure three (3) of eight (8) resident's reviewed for unnecessary medications had drug regimens free from unnecessary medications. Resident #39's antipsychotic medication was increased without evidence of an indication for the increase. Resident #39 also was receiving [MEDICATION NAME] without adequate monitoring of his [MEDICATION NAME] time/international normalized ratio (PT/INR). Resident #64 was receiving an antidepressant medication without adequate monitoring of targeted behaviors. The dosage of Resident #54's antianxiety medication was reduced, then resumed without evidence of an increase in behaviors or of attempts to implement nonpharmalogic interventions. Resident Identifiers: #39, #64, and #54. Facility Census: 51. Findings Include: a) Resident #39 1) Review of the resident's medical record, at 10:12 a.m. on 04/23/14, revealed three (3) telephone physician's orders [REDACTED]. Those were: -- On 03/28/14, (typed as written) . [MEDICATION NAME] 100 mg (milligrams) 1 at bedtime (d/c (discontinue) previous). -- On 04/15/14, (typed as written) Clarification: [MEDICATION NAME] 200 mg po (by mouth) daily for DX (diagnosis) of unspecified episodic mood d/o (disorder) r/t (related to) target behaviors as evidenced by hitting, slapping and biting etc. (Although this was written as a clarification order, it actually changed the dose from 100 mg to 200 mg.) -- On 04/17/14, (typed as written) . 2) D/C current [MEDICATION NAME] order. 4) [MEDICATION NAME] 200 mg PO q day (every day). (This order only changed the time of administration of the medication.) Resident #39's medication administration records (MAR) for the month of March 2014 and the month of April 2014 were reviewed. [MEDICATION NAME] 100 mg was started on 03/28/14 and was discontinued on 04/17/14 on the MAR. The resident refused this medication all but three (3) of the twenty (20) days it was offered to him. On 04/18/14 the resident began receiving a 200 mg dose of [MEDICATION NAME]. (The order for the dose of 100 mg of [MEDICATION NAME] was not discontinued on the April 2014 MAR until 04/17/14, even though the order for a dosage increase to 200 mg was obtained on 04/15/14.) Review of Resident #39's progress notes revealed the following in regards to his use of [MEDICATION NAME] and behaviors: -- A note dated 03/28/14, included, Resident with new order for [MEDICATION NAME] increase and decrease in [MEDICATION NAME] after consult with (Psychiatrist Name). -- A note dated 04/02/14, included, Resident became verbally abusive with staff this morning when he was encouraged to stay in room due to stomach virus in facility. Resident stated, 'You [***] es ain't going to run my life. I'll do what I want when I want.' -- An entry dated 04/04/14, noted, Resident with behaviors this am (morning). This LPN entered rsd (resident) room with AM (morning) medications, rsd immediately stated, 'Don't bring that crap in here, I don't need it.' Attempted redirect without success. -- On 04/15/14, it was noted, Resident continues to receive [MEDICATION NAME] and [MEDICATION NAME] for dx of mood disorder. Behaviors have improved with one episode of threatening behaviors, rejection of care and refusing care. No side effects noted to medication use. -- A note dated 04/17/14 included, Resident continues to refuse meds at bedtime. New orders to give all meds at one time during the day. -- An entry dated 04/21/14 included, (Attending Physician's name) saw resident today and ordered follow-up with psychiatry due to behaviors and to review meds. The point of care documentation was reviewed from 03/30/14 through 04/19/14. It was found the resident had eight (8) episodes of rejection of care documented in the point of care documentation. He had an additional two (2) episodes of verbally abusive behavior documented. The medical record review also revealed Resident #39 was readmitted to the facility on [DATE] after an in-patient psychiatric hospitalization . Further medical record review revealed the pharmacist had recommended Resident #39's [MEDICATION NAME] dose of 200 mg by mouth one (1) time a day be considered for a gradual dose reduction. Employee #82, Resident #39's attending physician and the facility's medical director, addressed the recommendation on 04/21/14. Employee #82 disagreed with this recommendation. She provided the following justification, Resident just back from in-pt (in-patient) psych. Followed closely with psychiatry. Employee #7, Licensed Practical Nurse (LPN) was interviewed at 04/23/14 at 12:44 p.m., and again at 10:16 a.m. on 04/24/14. She stated Resident #39's behaviors have improved dramatically since his in-patient hospital stay. Employee #7 confirmed she had taken the verbal order from Resident #39's physician on 04/15/14 to increase his [MEDICATION NAME] from 100 mg to 200 mg. She stated she had told the doctor the resident was having some behaviors and the doctor had told her to increase the medication on 04/15/14. Employee #7 was not able to state what behaviors the resident was demonstrating. Employee #7 reviewed Resident #39's medical record and confirmed the documentation contained in the medical record did not suggest his behaviors were getting worse. She was unable to state why Resident #39's dose of [MEDICATION NAME] was increased based on the documentation in the resident's record. She confirmed the resident had only taken a few doses of the 100 mg dose since 03/28/14. She commented that for the most part, he refused this medication. Employee #7 added, once this resident started having behaviors, they escalated and he threatened to kill people and threw things. However, she was unable to state if that was the reason his [MEDICATION NAME] was increased. Employee #7 could not explain why the note on 04/15/14 indicated the resident's behaviors were improving, but on the same day of the note, his dose of [MEDICATION NAME] was doubled. Employee #7 further confirmed the dose of [MEDICATION NAME] should have been changed on 04/15/14, and she did not know why he did not start receiving the 200 mg dose until 04/18/14. Employee #57, Social Services Director, was interviewed at 3:33 p.m. on 04/23/14. She stated for the last month she had not noticed any increase in Resident #39's behaviors. She stated since the resident returned from the hospital in January 2014, his behaviors had been good. Employee #82, Resident #39's attending physician was interviewed at 8:43 a.m. on 04/24/14. The physician stated she remembered telling the staff to increase Resident #39's [MEDICATION NAME] back to 200 mg when she was told by the staff Resident #39 was threatening other residents and threatening violence. She was afraid his behaviors would escalate. She stated she did not write a note about this because she had given the order by telephone. She could not recall what date she had given the order. She stated on 04/21/14, she had referred him back to see the psychiatrist because the pharmacist had recommended the dose reduction and she would rather the psychiatrist make the call in regards to reducing his [MEDICATION NAME]. Employee #82 reviewed Resident #39's MAR for the month of April 2014 and saw the resident had only taken the [MEDICATION NAME] once for the entire month prior to 04/18/14. She stated, Wow I was not aware he had only taken it one time. She stated she knew he was refusing it some, but did not know he had refused it almost every day. After reviewing the progress notes written by nursing for the time period of 03/28/14 until 04/15/14, the physician stated what was contained in the notes and what she was told did not match. She stated they did not document what they had told her over the telephone. She confirmed that based on what was put into the notes, she would not have increased Resident #39's [MEDICATION NAME]. She stated if he could not get back into see the psychiatrist soon, she would certainly try a dose reduction of the medication. Employee #14, Licensed Practical Nurse (LPN) was interviewed at 9:10 a.m. on 04/24/14. She stated she had written the order for the [MEDICATION NAME] on 04/17/14. She stated the only order the physician had given her on that date was to change the time in which the [MEDICATION NAME] was to be administered. She stated the doctor did not change the dosage on that date, it was changed on 04/15/14. She stated the time of administration was changed because Resident #39 always refused his evening medications, so they started giving them all at one time. She stated since they had changed the time, he had been taking his [MEDICATION NAME]. She stated the resident's behaviors had been better since he came back from the hospital. She stated over the last month his behaviors had been good. She stated the only thing she ever observed him do was refuse medications. 2. [MEDICATION NAME] Resident #39's medical record was reviewed at 10:12 a.m. on 04/23/2014. This review revealed the following physician orders: -- Physician order [REDACTED]. -- Physician order [REDACTED]. - PRN (as needed) (Some antibiotics are known to have an impact on the effectiveness of [MEDICATION NAME].) -- Physician order [REDACTED]. ([MEDICATION NAME] is an antibiotic.) -- Physician order [REDACTED]. ([MEDICATION NAME] is an antibiotic.) The MAR for the month of March 2014 revealed Resident #39 received one (1) dose of [MEDICATION NAME] on 03/13/14 and then received [MEDICATION NAME] on 03/13/14, 03/14/14, 03/15/14, 03/16/14, and 03/18/14. Resident #39 refused his dose of [MEDICATION NAME] on 03/17/14 and 03/19/14. Review of Resident #39's [MEDICATION NAME] Flowsheet revealed his PT/INR was checked on 03/13/14. The results were a PT of 20.2 and an INR of 2.0. Resident #39's PT/INR was not checked again until 03/20/14 with the results being a PT of 12.1 and INR of 1.2. (Typically a therapeutic INR is between 2.0 and 3.0.) An interview with Employee #6, Registered Nurse (RN), was completed at 11:05 a.m. on 04/23/14. She reviewed Resident #39's medical record and confirmed the facility did not obtain the PT/INR as ordered by the physician. She confirmed they obtained the weekly PT/INR, but did not obtain a PT/INR on 03/15/14 as they should have since he began antibiotic therapy on 03/13/14. Employee #6 stated the facility had a finger stick machine they use to obtain the PT/INRs and they must have missed this one. Employee #82, Resident #39's attending physician was interviewed at 9:00 a.m. on 04/24/2014. She stated it was her expectation that a PT/INR be obtained two (2) days after the start of antibiotic therapy. She stated the facility had an order from her to do it and she did not know why Resident #39's was missed. b) Resident #64 Review of this resident's medical at 3:35 p.m. on 04/22/14, revealed Resident #64 received [MEDICATION NAME] 10 mg daily since 01/27/14. Review of the resident's care plan revealed staff were to Observe for and record episodes of sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/eating habits, change in sleep patterns, diminished ability to concentrate, change in psychomotor skills. If noted contact MD promptly. This intervention was added to Resident #39's care plan on 01/27/14. Further review of the medical record, including the point of care (P(NAME)) documentation, found no evidence staff were recording episodes of the identified behaviors. Employee #14, a licensed practical nurse (LPN), was interviewed at 9:30 a.m. on 04/23/14. She stated behavior monitoring was completed in point of care (P(NAME)). She stated there was a section under P(NAME) which would indicate what the targeted behaviors were and the behaviors exhibited would be documented there. She stated she would sometimes write a nurse's note to go along with the documentation in P(NAME), but every behavior should be documented in P(NAME). In an interview with Employee #15, LPN, at 9:35 a.m. on 04/23/14, she stated all behaviors were documented in P(NAME). She stated the nurses and nurse aides could document behaviors in this system. She reported if behavior monitoring was needed for any resident, It will be in P(NAME) and we will know what we are observing for. Employee #81, Registered Nurse (RN), Corporate Clinical Projects, was interviewed at 9:53 a.m. on 04/23/14. She reported staff documented all behaviors in P(NAME). She stated Resident #64 should have some behavior monitoring showing up in P(NAME), but she was unable to locate where this task was linked to this resident. She confirmed it did not appear the staff were monitoring/documenting Resident #64's targeted behaviors. She stated they might write a progress note about a behavior, but the primary place they documented behaviors was in P(NAME). c) Resident #54 Medical record review found the resident was currently receiving the antianxiety medication, [MEDICATION NAME] 2.5 milligrams (mg) at nighttime. On 02/21/14, the facility pharmacist conducted a drug regimen review and recommended a gradual dose reduction (GDR) of the [MEDICATION NAME]. On 03/06/14, the physician reviewed the pharmacist's recommendation and discontinued the [MEDICATION NAME]. On 03/12/14, the physician signed an order to re-start the [MEDICATION NAME] 2.5 mg. at nighttime. Further review of the medical record on 04/23/14 found no evidence the resident had exhibited any behaviors between 03/06/14 and 03/12/14, when the [MEDICATION NAME] was discontinued and re-started. There was no evidence any nonpharmacologic interventions were implemented before re-starting the [MEDICATION NAME] on 03/12/14. An interview with a corporate registered nurse, Employee #81, was conducted at 10:56 a.m. on 04/23/14. Employee #81 was unable to provide any documentation of any resident behavior from 03/06/14 to 03/12/14. She stated, They just aren't there. She added the physician had re-started the [MEDICATION NAME] because the resident said she was nervous. Employee #14, the resident's licensed practical nurse, was interviewed at 10:46 a.m. on 04/23/14. Employee #14 stated the doctor put the resident back on her [MEDICATION NAME] because she (the resident) told the doctor she was nervous and needed her medication. Further review of the resident's medical record found an eighty (80) year old female resident admitted to the facility on [DATE]. On 08/09/2012, the physician had deemed the resident to lack capacity to make medical decisions. On 04/24/14, the resident's physician was interviewed at the facility. The physician said she ordered the [MEDICATION NAME] because the resident said she needed the medication because she (the resident) was nervous especially at nighttime. The physician stated the facility may not have any recorded behaviors. The administrator and Employee #81 were again interviewed on 04/24/14 at 12:11 a.m. At the close of the survey, on 04/24/14, no evidence had been presented to verify the resident experienced / displayed any behaviors during the time frame the medication was discontinued and no evidence was provided to verify nonpharmacologic interventions were provided before resuming the medication on 03/12/14.",2018-01-01
6598,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2014-04-24,371,F,0,1,LCKP11,"Based on observation and staff interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions. Items were found to be unlabeled, undated, and/or expired in both the kitchen and the pantry areas. All equipment was not clean and a staff member allowed dishes to come in contact with her clothing. This had the potential to affect all residents who consume food by oral means. Facility Census: 51. Findings include: a) On the initial tour of the dietary department, on 04/21/14 at 11:10 a.m., accompanied by Employee #80, a member of the dietary staff, the following issues were noted: 1) The walk-in refrigerator had a carton of liquid eggs which were opened with no date to identify when the product had been opened. A plastic glass containing V-8 juice was on a counter in a preparation room. The glass of juice was dated 4/17 to 4/20 and should have been discarded by 04/21/14. 2) Observations in the dry storage area found a large canister containing bags of different types of mixes. The canister contained a bag of biscuit mix that did not have a date of when it was opened. 3) The convection oven was in need of cleaning. There was baked on food debris on the inside and outside of the doors. 4) The side of the reach-in refrigerator sitting beside the steamer had splashes of foods from the steamer. The splashed on food did not appear fresh. 5) A plastic container was under the counter where the steam table was located. It held utensils such as scoops which were not stored in a manner which would prevent the staff from touching the serving portion of one (1) utensil while retrieving the handle of another utensil. 6) During tray line observations, a dietary employee (Employee #79) was observed to carry small dishes next to her body which put the dishes in contact with her uniform creating a potential for cross contamination. b) Nutrition Pantry An observation of the nutrition pantry refrigerator was conducted during the initial tour of the facility on 04/21/14 at 11:00 a.m. The following sanitation issues were identified: -- One (1) open bottle of strawberry Hershey's syrup with no date or resident's name. -- Two (2) containers with Resident #76's name with no date on the containers. One (1) contained a toasted cheese sandwich, French toast, and an egg. The second one contained ground beef and cheese on a bun and squash. -- A container with Resident #76's name, and dated 04/14/14, contained beef stroganoff, a piece of cheese toast and 1/2 of a ground cheeseburger. -- Three (3) containers were found with Resident #38's name and no dates noted. One (1) container had turkey, dressing, a dinner roll, mashed potatoes with gravy, green beans and fried apples. The second one contained cole slaw, potato salad, and cranberry sauce. The third one contained layered pumpkin pie. -- A chocolate cake, labeled with a Use by sticker from the bakery dated 03/27/14. There was no name or other date. Printed on the cake was Happy Birthday and a resident's first name. Employee #3 thought it must be Resident #73's cake. Resident #73's birthday was on 03/21/14. -- An opened thirty-two (32) ounce bottle of frost Gatorade with no name or date. -- An opened quart jar of homemade apple butter with no name or date. -- A gallon jug of apple cider was found with Activity written on the container but no date; the container had large pieces of brown sediment noted. -- A container containing melon with Resident #42's name, but no date. -- Two (2) cups of milk with the dates of 04/16/14 (which indicated the date prepared) and 04/19/14 (which was the discard date). -- Two (2) open containers of cream cheese (one strawberry and one plain) with Resident #25's name on them, but no date to indicate when the items had been opened. -- An undated container of chicken and dumplings with Resident #3's name. -- An opened container of beef bologna with Resident #16's name, but no date. -- An opened container of Smucker's pineapple topping with no date or name. -- An opened jar of dill hamburger pickles with Resident #51's name, but no date. -- Opened bottles of sweet and sour mustard, ranch dressing, and Mountain Dew with no name or date. -- An opened container of spinach dip with no name or date. -- An unopened complete dinner tray with Resident #53 tray tag on the tray. The tray tag was labeled, Dinner, Wednesday, 04/16/14. Employee #3, registered nurse (RN), the infection control nurse was present during the observations of the nutrition pantry refrigerator and confirmed the listed items were not appropriately labeled, and/or were not discarded timely.",2018-01-01
6599,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2014-04-24,411,D,0,1,LCKP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, physician interview, medical record review, and staff interview, the facility failed to complete an accurate dental assessment which should have identified the resident's need for emergency dental services. This was true for one (1) of three (3) residents who triggered the care area of dental services during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #27. Facility census: 51. Findings include: a) Resident #27 During Stage 1 of the QIS, on 04/21/14 at 1:56 p.m., the resident stated his gum was sore due to problems with his teeth. He said he believed he needed to see a dentist. Further observation of the resident's teeth found approximately four (4) to five (5) teeth on the lower gum which were rotted, decayed, black, and worn down to the gum. The gum appeared to be red and inflamed. Further medical record review found the resident's last visit to the dentist occurred on 10/24/12 for a routine cleaning. The dentist had noted the teeth were non restorable and asymptomatic and would be maintained as long as no infection / symptoms occurred. According to the resident's medical record, he had returned from a hospitalization on [DATE]. The nursing re-admission assessment, completed on 04/21/14 at 2:36 p.m., Section B, Oral / Dental / Nutritional, reflected the resident's teeth were healthy, no decay, no broken teeth and no pain. This assessment was completed after the surveyor's interview with the resident on 04/21/14 at 1:56 p.m. On 4/23/14 at 11:15 a.m., during an observation of the resident's oral cavity with the resident's licensed practical nurse, Employee #15, the resident told Employee #15 he had a sore place in his mouth. The resident pulled his lower lip down, pointed to his teeth, and said I can't eat on this side of my mouth, it hurts to chew. Employee #15 examined the resident's oral cavity and verified the teeth were broken down to his gum. She stated the teeth were, Real black and he will need an antibiotic. At 11:32 a.m., on 04/23/14, Employee #7, the unit manager / licensed practical nurse stated she had already called the dentist and made a dental appointment for the resident. She said she had not had time to call the doctor yet, but she made the dental appointment earlier this morning when the resident told her his teeth were hurting. At 12:05 p.m. on 04/23/14, the facility provided a copy of a nursing note, dated 04/23/14 at 11:30 a.m., Resident c/o (complained) mouth pain at breakfast time. Gums noted swollen, with [DIAGNOSES REDACTED], teeth broken, left message for (name of physician) at 9:30 a.m. (Name of physician) returned call at this time, new orders for dental consult and antibiotics. (Name of physician) will see on Thursday for sick call. The resident's physician was interviewed at the facility on 04/24/14 at 9:00 a.m. She stated she had examined the resident today and he definitely had an infection in probably more than one of his lower teeth. She confirmed she had ordered an antibiotic and a dental consult had been made.",2018-01-01
6600,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2014-04-24,502,D,0,1,LCKP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, physician interview, and staff interview, the facility failed to obtain laboratory (lab) services as ordered by the resident's attending physician. Resident #39 had lab orders to obtain a [MEDICATION NAME] time/international normalized ratio (PT/INR) two (2) days after starting an antibiotic. This lab was not obtained as ordered. This was true for one (1) of eight (8) residents who were reviewed for unnecessary medications. Resident Identifier: #39. Facility Census: 51. Findings Include: a) Resident #39 Review of the resident's medical record, at 10:12 a.m. on 04/23/2014, found the following physician orders: -- Physician order [REDACTED]. -- Physician order [REDACTED]. - PRN (as needed) -- Physician order [REDACTED]. -- Physician order [REDACTED]. The Medication Administration Record [REDACTED]. (Resident #39 refused his dose of [MEDICATION NAME] on 03/17/14 and 03/19/14.) Review of Resident #39's [MEDICATION NAME] Flowsheet revealed his PT/INR was checked on 03/13/14, which resulted in a PT of 20.2 and an INR of 2.0. Resident #39's PT/INR was not checked again until 03/20/14 with the results being PT of 12.1 and INR of 1.2. During an interview with Employee #6, Registered Nurse (RN), at 11:05 a.m. on 04/23/14, she reviewed Resident #39's medical record and confirmed the facility did not obtain the PT/INR as ordered by the physician. She confirmed they obtained the weekly PT/INR, but did not obtain a PT/INR on 03/15/14 as they should have since he began antibiotic therapy on 03/13/14. Employee #6 stated the facility has a finger stick machine they use to obtain the PT/INRs and they must have missed this one. Employee #82, Resident #39's attending physician was interviewed at 9:00 a.m. on 04/24/2014. She stated it was her expectation that a PT/INR be obtained two (2) days after the start of antibiotic therapy. She stated the facility had an order from her to do it and she did not know why Resident #39's was missed.",2018-01-01
8119,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2013-10-31,170,D,1,0,H12K11,"Based on record review, resident interview, and staff interview, the facility failed to allow one (1) resident to promptly receive mail that was unopened. A box of items Resident #3 had ordered was opened before it was given to the resident. One (1) of three (3) residents reviewed was affected. Resident identifier: #3. Facility census: 59. Findings include: a) Resident #3 During an interview with Resident #3, on 10/29/13 at 4:00 p.m., the resident said that on 10/15/13 he had received a box in the mail. The resident said the administrator had opened this box and had removed his knives, then retaped the box. He stated he knew he had received the knives due to the information listed on the package insert. The resident stated he was upset because his mail was opened and he had not given the facility permission to open his mail. Resident #3 also stated he did not get to look at the knives he had ordered through the mail until a couple of days later when Employee #57, the business office manager, and Employee #52, the activity director, brought him the knives. An interview was conducted on 10/31/13 at 12:20 p.m., with Employee #56, the admission coordinator. She was asked whether Resident #3 had given the facility permission to open his mail. She stated no, he had only signed the information on admission that he could send and receive mail. She confirmed that Resident #3 opened his own mail. In an interview on 10/29/13 at 3:30 p.m., Employee #1, the administrator, stated she had discovered this resident was keeping knives and a stun gun in his room. She said she and the resident had a verbal agreement that he would review the items that he ordered through the mail, then give her anything that she felt was a danger to him or other residents. She stated this resident received a box the same day this had happened and she felt like she needed to open the box in order to know what was in the box that could be harmful to others residents. She stated there were knives in the box, and she had removed the knives and re-taped the box. The box was then taken to the resident so he could review what was left in the box that he had ordered. On 10/29/13 at 4:45 p.m., Employee # 57, the business office manager (BOM), was asked about the package Resident #3 had received on 10/15/13. She stated earlier that day several knives and a stun gun were found in the resident's room. The items were taken by the administrator to be placed in the safe. She confirmed since this had just happened, Employee #1 did open the box and remove the knives. The box was retaped prior to Resident #3 receiving his package. She stated a couple days later Employee #1 told her to take the resident his knives back so he could look at the knives. She stated she and the activities director had taken the knives back to the resident.",2016-10-01
8165,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2012-11-15,157,D,0,1,M8CD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to notify the physician timely with recommendations from the dietitian for a change in a dietary intervention to prevent further weight loss. This affected one resident (#19) of the 3 residents reviewed out of the 5 residents identified with weight loss. Findings include: Resident #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent Minimum Data Set, dated dated dated [DATE], indicated the resident received set up help with her meal and was supervised when eating, had dysphagia, and had no weight loss. The resident's plan of care dated June 13, 2012, indicated the resident was new to the facility. Body Mass Index was 27%, present weight was 165 pounds, and resident was above her Ideal Body Weight of 120-140 pounds. The goal was that resident would maintain an adequate nutrition status as evidenced by maintaining a stable weight within five pounds with an intervention that the dietitian would review as recommended or as needed. Additional interventions included: May have resident choice menu one time per month, regular diet daily at meals as ordered, record food and fluid intake daily at meals, and record weight weekly for four weeks and then monthly. The resident's medical record was reviewed and included the following dates and weights: -6/12/12 165 pounds -6/13/12 161 pounds -6/20/12 161 pounds -7/1/12 157.5 pounds -7/4/12 157 pounds -7/11/12 156 pounds -7/18/12 157 pounds -8/1/12 154.5 pounds -9/1/12 153 pounds A dietary assessment was completed by the dietitian on June 27, 2012. The dietitian documented the resident's height 66 inches and that she weighed 161 pounds. The resident was on a regular diet with an average intake of 62% of meals. The resident had an oral intake of 1410 calories and 61 grams of protein, had no skin breakdown, no [MEDICAL CONDITION], and there were no recommendations made at this time by the dietitian. On July 25, 2012, the dietitian did an assessment on the resident. The dietitian documented the resident acquired a new Stage 1 pressure ulcer to the left heel. The resident had an oral intake of 1115 calories and 48 grams of protein and the oral intake needed to improve to promote wound healing. Documentation included that when the dietitian met with the resident she told the dietitian she didn't want to get fat and did not want foods between meals. The dietitian documented that she encouraged the resident to increase her oral intake to promote the healing of the pressure ulcer on her heel. The dietitian documented her plan to recommend Super Cereal at breakfast to increase protein and calories and would continue to monitor oral intakes, weights, and pressure ulcer healing. The dietitian completed a Registered dietitian to Physician Recommendation Form on July 25, 2012. The form included the resident's name, physician name, and room number. The form listed a Summary of Nutritional Concern and indicated that the resident had a new Stage 1 pressure ulcer on heel. Oral intakes were documented at 49%. The Recommendation of dietitian was for the resident to receive Super Cereal at breakfast. The form was signed and dated July 25, 2012, by the dietitian. On July 30, 2012, the physician wrote an order for [REDACTED]. On November 15, 2012, at 11:45 a.m., the Unit Manager, a Registered Nurse, staff #7 was interviewed. Staff #7 stated the dietitian comes to the facility every two weeks. If recommendations are made by the dietitian, the recommendations are kept until the physician comes to the facility on Mondays and Thursdays. The physician would then review the recommendations and write physician orders [REDACTED]. Staff #7 verified the physician was in the facility on the morning of July 25, 2012, the same day the dietitian made the recommendation for Super Cereal. Staff #7 stated the physician was not in the facility on July 26, 2012, which was a Thursday, so she did not see the dietitian's recommendations until July 30, 2012, which was the following Monday. The physician wrote an order based on the dietitian's recommendation five days after the dietitian assessed the resident and identified a nutritional concern due to the development of a Stage 1 pressure ulcer. On November, 15, 2012, at 1:10 p.m., the Director of Nursing (DON), Staff #2, was interviewed. Staff #2 verified the dietitian comes to the facility twice a month and the physician comes twice a week. She stated the dietitian gives the recommendations to the unit managers and they give them to the physician on the days that the physician is in the facility. The DON stated there was no specific policy and stated it was the facility's procedure for notifying the physician of the dietitian's recommendations.",2016-09-01
8166,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2012-11-15,225,D,0,1,M8CD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review the facility failed to thoroughly investigate 2 of 4 alleged violations of mistreatment of [REDACTED]. Findings include: 1. Review of investigation #1 revealed resident #60 reported she heard CNA (certified nurse's aide), staff #24, having sex with her roommate, resident #59, on June 25, 2012. The facility provided evidence that they reported the allegation to all the proper authorities and had witness statements from the nurse who was responsible for the care of the residents on the hall on that night. There were also a witness statements from the alleged perpetrator and the Social Service Director (SSD), staff #55. Based on the above interviews and witness statements the facility did not substantiate the allegation. However, the facility could not provide evidence that other residents in the building had been interviewed regarding staff treatment or the care and services provided by staff # 24. Further review of the investigation revealed that both the resident alleging the incident and the alleged victim had been diagnosed by the physician as lacking capacity, increasing the importance of extending the investigation to residents with capacity who could have given accurate accounts of staff treatment and behavior. 2. Review of investigation #3 revealed on June 26, 2012, staff #24 alleged that a CNA was rough while changing resident #25, who was a demented resident. The facility provided evidence of reporting to the proper authorities. The alleged perpetrator was suspended pending the investigation. Witness statements included 2 CNAs and the Licensed Practical Nurse (LPN) working on that hall. However, there was no evidence that other residents were questioned about staff treatment, specifically staff being rough with them. The Nursing Home Administrator (NHA), staff #1, concluded the investigation by substantiating the allegation of rough treatment and terminating the CNA. However, there was no evidence the facility interviewed other residents, who had been in the care of the CNA, to determine how many other residents might have also received rough treatment from the CNA. The Social Service Director (SSD), staff #55, was interviewed on November 15, 2012, at 10:12 a.m She was asked about the investigation process. She responded, When an allegation is made most of the time the nurses report it to me. I complete the necessary forms. Then we have 5 days to complete an investigation. Suspension depends on the allegation. If it is an allegation of abuse, we suspend the alleged perpetrator. The SSD stated the investigation consisted of talking to the staff, and resident, if appropriate, and getting written statements from the staff. She further stated, Then we make our determination from those statements. The SSD was asked if she talked to the residents. She stated, Oh yes and I document it in the investigation. When asked specifically about the above investigations, the SSD stated, I didn't do much with the investigations, just the forms. With regard to the sex allegation, the SSD stated she talked to the alleged victim. I asked her if CNA (staff #24), or any other CNA, touched her inappropriately. She denied it. I didn't ask other residents at that time. The Director of Nursing (DON), staff #2, was interviewed at 10:50 a.m., on November 15, 2012. She stated, I can't remember talking to other residents related to CNA (staff #24) being inappropriate. The DON stated she remembered the CNA being terminated for treating resident #25 roughly. She further stated, I can't remember talking to other residents about rough treatment from staff. The Nursing Home Administrator (NHA), staff #1, was interviewed on November 15, 2012, at 11:43 a.m She was asked about the investigation process. She stated, In an abuse allegation we always remove the alleged perpetrator and start getting witness statements from staff and residents as well, if they have capacity and are involved in the situation. With regard to the allegation related to the CNA #24 having sexual relations with resident #59, the NHA stated, We did talk to other residents asking if there were concerns with CNA #24 caring for them, but we didn't document it. The NHA continued that the CNA accused of rough treatment was terminated as a result of the investigation on June 29, 2012. When asked if other residents were interviewed about rough treatment by staff, the NHA responded, If the investigation was unsubstantiated, I wouldn't want anyone to come back with that stigma. If a resident was involved in someway, we would want to know if others were affected, but we knew at the onset we going to terminate the CNA. If we weren't sure of what happened we would have interviewed other residents to determine if the allegation was pertinent to them. If the CNA wasn't going to be here again, it didn't matter if there was 1 or 2 (victims) she wasn't coming back in my building. There was no question--she was gone. No one else complained.",2016-09-01
8167,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2012-11-15,371,D,0,1,M8CD11,"Based on observations, interviews and policy review the facility failed to date opened foods for proper storage in the refrigerator. This had the potential to affect all residents who consumed oral nutrition. Findings include: On November 12, at 9:00 a.m., observations were of the refrigerator made during the initial tour of the kitchen. Observations included foods that were opened and not dated. There were twelve hamburger patties in a container and covered loosely with foil that were not dated. One five pound container of shredded chicken salad and one five pound container of cottage cheese, that had approximately a half pound left in each container, had been opened but was not dated. The Dietary Manager, staff #68, stated they had been opened on the previous Thursday, November 8, 2012. There were also two boiled eggs in a container that was not dated. The Dietary Manager #68 stated the eggs were boiled that morning and were intended to be used for the birds and not the residents. The Dietary Manager verified foods should be dated after opening and put back in refrigerator for storage. Two policies were provided regarding Food Preparation and Service and Food Storage. The Food Preparation and Service Policy listed procedures. Item #10 indicated leftovers will be stored immediately after meals are served; leftovers will be stored in appropriate containers and labeled with contents and date of storage. The Food Storage Policy had a policy statement that read: It is the policy of this facility that food storage areas be maintained in a clean, safe, and sanitary manner. The policy listed seven procedures, but specific procedures regarding dating and storing previously opened foods in the refrigerator was absent. On November 15, 2012, at 1:20 p.m., the Administrator verified the facility only had the two policies and there was no specific policy on the storage of refrigerated foods that had been opened and not dated.",2016-09-01
8168,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2012-11-15,502,D,0,1,M8CD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** , Based on interviews and record review, the facility failed to obtain a physician ordered lab test for 1 resident (#35) out of 10 residents reviewed for unnecessary medications. Findings include: Resident #35 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the most recent recapitulation of physician orders, signed by the physician on November 1, 2012, included orders for a lipid panel every six months in February and in August. Review of the clinical record failed to reveal results for the lipid panel that was ordered to be obtained in August 2012. Staff interviews were conducted with the Director of Nurses, staff #2, on November 14, 2012. Staff #2 claimed that the lab was not obtained in August because the physician had intended to discontinue the lab test in September 2011, however, the current physician orders did not reflect this. Staff #2 verified that the lipid panel still appeared as a current order on the most recent recapitulation of physician orders.",2016-09-01
8169,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2012-11-15,504,D,0,1,M8CD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility obtained a lab test without a physician's order for 1 resident (#45) out of 10 residents reviewed for unnecessary medications. Findings include: Resident #45 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the most recent recapitulation of physician orders, signed by the physician on November 1, 2012, included orders for lab testing in April. The lab tests that were ordered to be obtained in April were [MEDICATION NAME] level, CMP (complete metabolic panel), and TSH ([MEDICAL CONDITION] stimulating hormone). Review of the clinical record revealed that the lab tests were obtained on April 16, 2012, and then again on April 19, 2012. There was no physician order for [REDACTED]. Staff interviews were conducted with the Director of Nurses (DON), staff #2, on November 15, 2012. Staff #2 stated that there was a miscommunication between the nurses who requested that the lab tests be obtained. Staff #2 stated that the nurse who requested the lab tests on April 19, 2012, was unaware that the lab tests had already been obtained on April 16, 2012. Staff #2 verified that there was no physician order to obtain a second set of labs in April.",2016-09-01
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
9979,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2012-06-14,280,D,1,0,18U511,"**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 ensure the care plan was revised to reflect the resident's status and level of care for two (2) of five (5) residents reviewed. The facility had knowledge of changes in the plan of care for Resident #54 and Resident #25; however, the care plan did not reflect these changes. Resident identifiers: #54 and #25. Facility census: 52. Findings include: a) Resident #54 On 06/13/12, at approximately 10:00 a.m., medical record review for Resident #54 revealed a nursing note dated 05/05/12 at 11:30 a.m. The note stated, ""BP (blood pressure) - 145/81 p (pulse) - 87 R (respiration) - 10 T (temperature) 97.3 Res. (resident) alert 02 (oxygen) sat (saturation) 94 % on O2 via nc (nasal cannula). Resp (respiration) shallow, non-labored. Res slid out of Geri-chair onto buttock; she did not hit her head. No apparent injury noted."" The care plan review revealed the facility had care planned the resident's risk for falls. Resident #54 was at risk for falls due to impaired mobility, cognitive loss, [MEDICAL CONDITION] medication use, and intermittent confusion. This facility initiated care planning this problem on 04/11/12. The goal for the resident was for the resident to be free of serious injury related to falls as evidenced by no fracture, or no cerebral bleed. The interventions included ""Assess cause, pattern of previous falls and act upon resolvable factors. Encourage and remind (Resident #54) to request assistance with needed transfers. PT/OT (physical/occupational therapy) consult as indicated. Keep frequently used items on bedside table or within reach (water pitcher, cup, tissues, hairbrush, etc.) Be sure call light is within reach and encourage using it for assistance as needed. Respond promptly to all request for assistance. Ensure that resident is wearing appropriate footwear (shoes, bedroom slippers, non-skid socks) when ambulating or up in w/c (wheelchair). Follow fall protocol. "" The director of nursing (Employee #2) provided a copy of the occupational therapy screening completed on 05/05/12. The occupational therapy assistant documented ""05/05/12 Res. fell slid out of Geri Chair. Res. currently on Hospice Care. Low bed with mats."" The director of nursing said the resident did have a low bed with mats to her bedside. However, the resident's care plan for falls did not contain this fall safety precaution as an intervention. b) Resident #25 The medical record review for Resident #25, conducted on 06/13/12, at approximately 2:00 p.m., revealed a seventy (70) year old female admitted to the facility on [DATE]. On 06/13/12, at approximately 2:30 p.m., Employee #14 (licensed practical nurse) indicated the resident often refused medications, particularly medications given for constipation. She provided a copy of the resident's Medication Administration Record [REDACTED]. The resident had refused this medication nineteen (19) times in the month of June 2012. The LPN stated the physician had recently discontinued Peri [MEDICATION NAME] because the resident kept refusing the medication. The physician knew the resident refused the [MEDICATION NAME], but did not wish to discontinue the medication because at times the resident would agree to take it. The care plan review for Resident #25 revealed the facility had care planned the resident's issue with constipation. One of the interventions stated, ""give laxatives per order."" The remainder of the care plan did not mention the resident's resistance at taking medications, particularly laxatives. On 06/13/12 at approximately 4:00 p.m., the administrator (Employee #1) and the director of nursing (Employee #2) both reviewed the care plan and agreed it did not address the resident's refusal to take medications particularly those for constipation. .",2015-08-01
9980,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2012-06-14,428,D,1,0,18U511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility did not ensure the physician provided a rationale for the decision to decline a reduction in an antipsychotic medication recommended by the pharmacist. One (1) of five (5) residents on the sample had a drug regimen review in which the pharmacist recommended a gradual dose reduction for Risperdal. The physician declined the gradual dose reduction, but did not provide any rationale as to why she declined the reduction. Resident identifier: #24. Facility census: 52. Findings include: a) Resident #24 Medical record review for this resident, conducted on 06/13/12, at approximately 3:00 p.m., revealed the pharmacist had identified an irregularity for an antipsychotic medication. A communication from the pharmacist to the attending physician, dated 03/20/12, indicated a request for a reduction of Risperdal. The pharmacist recommended attempting a gradual dose reduction (GDR) for the antipsychotic medication, Risperdal 0.5 mg hs (at night). The physician had disagreed with the pharmacist and signed the ""note to the attending physician/prescriber"" on 04/07/11. The physician provided no clinical rationale stating why she did not wish to reduce the dosage of Risperdal. On 06/13/12, at approximately 4:00 p.m., Employee #8 (licensed practical nurse) indicated the physician normally documented the information related to her rejection of a pharmacist's recommendation on the ""note to the attending physician/prescriber"" or in the physician progress notes [REDACTED]. .",2015-08-01
11139,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2011-04-15,246,E,1,0,DRNI11,". Based on observation, resident interview, record review, and staff interview, the facility failed to ensure each resident received reasonable accommodations of needs. During the initial tour of the facility, many residents were up in chairs or ambulating about the facility. Four (4) residents were observed in bed without access to their call light buttons. Another resident, who needed assistance, was found later that evening to be unable to reach his call light to summon assistance. Resident identifiers: #31, #34, #9, #40, and #20. Facility census: 51. Findings include: a) Resident #31 During the initial tour of the facility at approximately 4:50 p.m. on 04/13/11, observation found this resident's call light to be out of reach. The resident was in bed with the head of the bed elevated at approximately 75 degrees. His call light was on the handle of his bedside table, which was to his left and behind the head of the bed. When asked if he could reach his call light, he said he could not. -- b) Resident #34 At approximately 5:00 p.m. on 04/13/11, this resident's call light was noted to be on the floor beneath his bed. -- c) Resident #9 At 5:07 p.m. on 04/13/11, the resident was lying in his low bed on his back. His call light button was beneath the bed on the floor. When asked if he used his call light, he said he did but he could not reach it. He put his hand on the controller for his bed; when asked if that was what he used to call for help, he said it was just for the bed. At 7:30 p.m. on the same evening, his call bell button was again observed on the floor beneath his bed. -- d) Resident #40 At approximately 5:30 p.m. on 0413/11, observation found this resident sitting in a recliner next to her bed. Her call light was next to her, but it was underneath the cover on her bed. When asked where her call light was, she felt around for the button. It took her several minutes to locate the right cord. According to her quarterly minimum data set assessment, with an assessment reference date of 01/27/11, her vision was severely impaired. -- e) Resident #20 On 04/13/11 at 6:38 p.m., this resident motioned as though needing assistance. He said he was tired, did not feel well, and needed to go back to bed. When asked if he had rung his call bell, he said he had not - that he could not reach it. The resident was sitting up in a wheelchair with his overbed table in front of him. His call bell button was lying on his bed, several feet away. The overbed table was between the resident and the call button. The resident was handed his call button, which he rang at 6:40 p.m. -- f) On 04/15/11 at 1:55 p.m., a licensed practical nurse (Employee #15) was asked whether these five (5) residents were able to use their call bells. She said they could. .",2014-08-01
11140,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2011-04-15,274,D,1,0,DRNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, review of medical records, staff interview, and resident interview, the facility had failed to conduct a comprehensive assessment within fourteen (14) days after a significant change in the resident's condition should have been identified. Review of medical records found one (1) of six (6) residents on the sample had declines in more than two (2) areas of activities of daily living (ADLs), continued weight loss, and a decline in continence. A significant change in status assessment had not been conducted in an attempt to identify possible causal factors. Resident identifier: #9. Facility census: 51. Findings include: a) Resident #9 Resident #9's most recent minimum data set assessments 3.0 (MDS) were reviewed. A quarterly assessment with an assessment reference date (ARD) of 10/29/10 was compared to a quarterly assessment with an ARD of 01/26/11. The following changes were noted between the 10/29/10 and 01/26/11 assessments: - Bed mobility improved from extensive assistance of two (2) to limited assistance of one (1); - Transfer abilities declined from limited assistance of two (2) to extensive assistance of two (2); - Walk in room and walk in corridor declined from extensive assistance of two (2) to did not occur; - Toilet use declined from limited assistance of two (2) to total dependence with the assistance of two (2); - Personal hygiene declined from limited assistance of one (1) to extensive assistance of two (2); - He had been coded as requiring human assistance to balance when moving from a sitting to standing position, walking, turning, and moving on and off of the toilet in October 2010, but the January 2011 assessment indicated these activities did not occur; - Bowel continence declined from continent to always incontinent - In October, the assessment was coded for significant weight loss with his weight entered as 164 pounds. In January, his weight had continued to decline and was listed as 154 pounds. Additionally, between the two (2) quarterly assessments, the resident had been hospitalized from [DATE] to 12/11/10 and again 12/17/10 to 12/26/10. These changes indicated a comprehensive assessment needed to be completed with the additional care area assessments (CAAs) completed. The CAAs would help identify causal factors and possible interventions to restore the resident to his previous ability levels or to prevent further declines. An interview with the MDS nurse (Employee #6), in mid morning on 04/15/11, found she had not done a significant change assessment. The criteria in the interpretive guidelines for F274 were briefly reviewed with the nurse, as it offered better guidance than the current RAI manual (which has been acknowledged by the Centers for Medicare and Medicaid). She acknowledged the need for a significant change assessment and began the assessment later that morning. A nursing assistant (Employee #36) was interviewed in the afternoon on 04/14/11, regarding this resident. She said she had tried to get him out of bed, but he refused. The last time she could remember him agreeing to get up in a chair had been about a month ago. She said he has had increased confusion. Also in the afternoon of 04/14/11, a nursing assistant (Employee #37) said the resident had been refusing to go take a shower for about four (4) to six (6) months. He would take a bed bath but refused to take a bath or shower. She said, at one time, they would get him up, but he would ""throw himself onto the floor so he could go back to bed."" The resident was interviewed at 10:00 a.m. on 04/15/11. He said he was feeling ""some better"" today. When asked if he ever got up in a chair, he said, ""No, I can't walk."" He was aware staff would get him up in a chair if he wanted - he said he knew that. Then he said he did not get up because his ""hind end is sore."" When asked if he would get up if his hind end was not sore, he quickly said, ""No."" The resident said he preferred to stay in bed and to be by himself. When asked about moving around in bed, he stated he would turn sometimes, but preferred to stay on his back. Due to Resident #9's refusal to get out of bed and to participate in any activities, it could not be determined that his decline was clinically avoidable. However, his declines did meet the criteria for a significant change in condition assessment. .",2014-08-01
11141,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2011-04-15,279,D,1,0,DRNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of medical records, the facility had failed to develop and implement a care plan to address a resident's fluid restriction. The care plan was not developed to provide sufficient guidance to the nursing staff to ensure compliance with the physician's orders [REDACTED]. Additionally, the care plan included monitoring of the resident's intakes and outputs, but no method for this monitoring was implemented. One (1) of six (6) residents on the sample was affected. Resident identifier: #26. Facility census: 51. Findings include: a) Resident #26 Review of the resident's medical record, on 04/15/11, revealed a physician's orders [REDACTED].@ 10 AM and 2 PM @ snack pass."" 1. Review of the resident's care plan found it included: ""Fluid Restriction: 1200 ml Dietary and 300 ml Nursing - Serve 120 ml liquid @ 10 AM and 2 PM @ snack pass."" The plan was not developed to provide further guidance to nursing staff as to how much fluid could be given on a given shift, especially with consideration given to medication passes and other activities. 2. The care plan also had an intervention to monitor fluid intake and output. Further review of her record found there was inconsistent recordation of her intakes. When two (2) licensed practical nurses (LPNs - Employees #15 and #21) were asked where her fluid intakes were tracked, they said they would be on the appetite records and the hydration records. When asked if these were recorded in her medical record, they said there were no intake and output sheets for the individual resident. There was no effective method to allow for monitoring the resident's fluid intake and her output, to determine whether the fluid restriction was being implemented as ordered or to monitor her intake and output as identified in the care plan. .",2014-08-01
11142,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2011-04-15,309,E,1,0,DRNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, resident interview, staff interview, and observation, the facility failed to ensure each resident received the care and services to maintain his or her highest practicable levels of well-being in accordance with the plan of care. A resident experienced an acute episode of gastrointestinal (GI) bleeding, but his blood pressure was not checked for more than thirty (30) minutes after the staff was made aware he was ill. Another resident had an order for [REDACTED]. A resident who had recently begun to gain weight after having experienced a significant weight loss. He had also had declines in his abilities to perform activities of daily living. This resident was observed to not be positioned to facilitate feeding himself. Six (6) residents were found to have orders for nutritional supplements. The orders included instructions to record the percentage of the supplements the resident consumed. These percentages were not consistently recorded as ordered for six (6) of six (6) residents. Resident identifiers: #20, #26, #47, #9, #6, #26, #32 and #50. Facility census: 51. Findings include: a) Resident #20 On 04/13/11 at 6:38 p.m., this resident motioned as though needing assistance. He said he was tired, did not feel well, and needed to go back to bed. When asked if he had rung his call bell, he said he had not - that he could not reach it. The resident was sitting up in a wheelchair with his overbed table in front of him. His call bell button was lying on his bed, several feet away. The overbed table was between the resident and the call button. The resident rang his call bell at 6:40 p.m. after being handed his call bell. At 6:43 p.m., a nursing assistant came to the door to see what he needed. He told her he needed to go to bed because he did not feel well. The nursing assistant had a bag of soiled linen in her hand, so she could not enter the room. She summoned another nursing assistant and said she would be back as soon as she disposed of the linens. She returned at approximately 6:44 p.m., and the two (2) nursing assistants began to get ready to transfer him to his bed. The resident again said he felt like he was having trouble breathing and felt like he was going to pass out. One (1) of the nursing assistants checked to make sure the resident's oxygen was running as the other summoned the nurse. A licensed practical nurse (LPN - Employee #16) came to the room promptly. After speaking with the resident, checking his heart rate and respirations, she went to get the pulse oximeter with which to check his oxygen saturation. As the nurse re-entered the room, it was noted there was approximately 120 cc of a reddish fluid beneath the resident's wheelchair. This was pointed out to the staff. Initially it was thought to possibly be spilled juice, but closer inspection found it was not juice. The nurse attempted to obtain a reading of the resident's oxygen saturation level but was unable to do so. A registered nurse (RN - Employee #4) came to the resident's room to speak with Employee #16. She was informed of the resident's condition and that the fluid under his wheelchair appeared to be bloody. Employee #4 was advised the resident's oxygen saturation could not be obtained and she attempted to check several times before obtaining a reading. A stethoscope was obtained, and Employee #4 listened to the resident's lungs. She commented he was not moving much air. The stool was tested and found to be positive for blood. Employee #4 asked Employee #16 to contact the physician to transfer the resident to the hospital. The resident was returned to bed. It was noted the back of his pants, and the posterior-medial aspect of his pants were saturated. As the nursing assistants removed his pants and incontinence brief, it was found he had passed loose bloody stool. When they turned him to his left side to provide care, more bloody liquid was expelled. This occurred again when he was turned to his right side. At 7:10 p.m., Employee #4 was asked about the resident's blood pressure. This was thirty (30) minutes after staff had become aware of the resident's condition. She was advised it had not been checked, and she immediately went to obtain a blood pressure cuff. At 7:20 p.m., the RN went to the resident's room to start intravenous fluids in preparation for his transfer to the hospital Review of the resident's medical record, on the morning of 04/14/11, found a ""Nursing Transfer / Discharge Summary"" form had been completed. The form noted he was having profuse rectal bleeding with positive hemoccult. His pulse was noted to have been 65 and his blood pressure 90/50. The form included a section ""admitting [DIAGNOSES REDACTED]."" The section had been signed at 1:20 a.m. by Employee #14 (an LPN). -- b) Resident #26 Review of the resident's medical record, on 04/15/11, found she had orders for a 1200 cc fluid restriction. Further investigation found there was inconsistent recordation of her intakes. When staff were asked about where her intakes were tracked, they said they would be on the appetite records and the hydration records. An effort was made to determine her daily intakes. Two LPNs (Employees #15 and #21) pulled the available records for a two (2) week period. The following results were obtained: Date - Brkfst - Lunch - Dinner - 10 a.m. - 2 p.m. - 4 p.m. - 8 p.m. 04/14/11 - 480 - 480 - 480 - 120 - snack - 0 - 120 (total 1,680) 04/13/11 - NPO - NPO - 480 - R - R - R - 120 04/12/11 - 240 - 180 - 120 - 240 - blank - blank - blank 04/11/11 - 480 - LOA - 240 - blank - 240 - 240 - R 04/10/11 - 360 - 360 - 240 - 120 - snack - 120 - R (total 1,200) 04/09/11 - 480 - 240 - 120 - sleep - 120 - R - snack 04/08/11 - missed getting the forms for this date 04/07/11 - 360 - 240 - 0 (There were two (2) sheets for the same date with different amounts recorded.) 04/06/11 - 480 - NPO - 480 - 120 - R - R - R 04/05/11 - 720 - 120 - 120 - LOA - 120 - R - R 04/04/11 - 360 - 240 - 240 - blank - 240 - 240 - blank 04/03/11 - 480 - 480 - 240 - blank - 240 - 240 - blank (total 1,440) 04/02/11 - 480 - 480 - 120 - 240 - 240 - blank - blank (total 1,680) 04/01/11 - 480 - 480 - 480 - 120 - R - R - snack (total 1,560) This information was collected from the appetite sheets, the hydration sheets, and the nursing assistant sheets. The LPN who took care of filing the appetite and hydration sheets (Employee #21) and the unit nurse (Employee #15) said they did not use intake and output sheets. It was also learned the information was not recorded in the individual's medical record. This did not allow for chronicling the resident's intakes in order to determine whether the fluid restriction was being implemented as ordered. At the time of the exit conference at approximately 3:30 p.m. on 04/15/11, the director of nursing stated they had initiated using an intake sheet that had been used in the past. -- c) Resident #9 Observations, at lunch time (12:28 p.m.) on 04/14/11, found the resident lying in bed. His lunch tray sat on the overbed table which had been placed across the bed. The head of his bed had been elevated to approximately 50 degrees, and he had slid down in the bed. This resulted in his lunch tray being slightly above the height of his mouth. When asked if he could see what was on his tray, he said, ""Not really."" This resident had experienced weight losses in the recent pass, although he had gained weight in the last two (2) months. He had also had declines in his activities of daily living in the last six (6) months. The positioning of the resident for his meal did not facilitate the ease in which he could feed himself. -- d) Residents #47, #32, #9, #6, #26, and #50 Review of residents' medical records found physician's orders [REDACTED]. Review of the treatment records found the amount of the supplements ingested were not consistently recorded for six (6) of six (6) residents whose records were reviewed. This information would be needed to ascertain the individual resident's acceptance and the effectiveness of the ordered supplement. During mid-morning on 04/15/11, the treatment records were reviewed for the period from 04/01/11 through 04/14/11. The following were noted: 1. Resident #47 - An order had been written on 07/06/10 for ""Glucerna Shake 8 oz at lunch & dinner; Record % consumed."" The record showed the percentage of intake had not been recorded seventeen (17) of twenty-eight (28) times the supplement should have been provided. 2. Resident #32 - The treatment record included places to record the percentage of snacks consumed. The snacks were to be given twice a day. The order was implemented on 3-11 shift on 04/07/11 and 100% had been recorded at that time. The next fourteen (14) times the percentage should have been recorded had been omitted. This resident had experienced a significant weight loss. On 04/14/11, super cereal at breakfast had been ordered. 3. Resident #50 - On 02/28/11, [MEDICATION NAME] 8 ounces had been ordered to be given at 1000 (10:00 a.m.) and 1400 (2:00 p.m.). The order included to record the percentage consumed. From 04/01/11 through 04/14/11, this supplement should have been provided twenty-eight (28) times. The supplement was initialed as given seven (7) times. The percentage of intake was not recorded twenty-three (23) of twenty-eight (28) times it should have been recorded. This resident had experienced gradual progressive weight loss. 4. Resident #26 - This resident was also on a fluid restriction of 1200 cc / day. Her treatment record reflected an order, dated 03/31/11, for recording the percentage of her intake of Ensure 240 cc with each meal. Of the forty-two (42) times the Ensure should have been recorded, there were twenty-seven (27) omissions. The resident's weight had been recorded as 145 pounds in March 2011 and as 134.5 pounds in April 2011. 5. Resident #6 - This resident was to have the percentage of intake of Two-Cal HN recorded three (3) times a day. It was not recorded thirty-two (32) of forty-two (42) times it should have been recorded. 6. Resident #9 - On 03/08/11, an order had been written for Glucerna Shakes 8 oz to be given at 1000 (10:00 a.m.), 1400 (2:00 p.m.), and 2100 (9:00 p.m.) with the percentage of the supplement consumed. The percentage consumed was not recorded twenty-two (22) of forty-two (42) times. In a conversation with the registered dietitian on 04/15/11 at approximately 12:50 p.m., she agreed the residents' consumption of the nutritional supplements was needed when attempting to evaluate their effectiveness as weight loss interventions. .",2014-08-01
3180,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2018-03-08,559,D,1,0,OH3K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to notify a resident's representative concerning a change in room assignment. This was evident for two (2) of three (3) sampled residents reviewed for room change notifications. Resident identifiers: #13, #8. Facility census: 66. Findings included: a) Resident #13 The medical record and the room transfer/new roommate change forms were reviewed on 03/06/18 .There were discrepancies in the details of a room change for this incapacitated resident as follows: --A physician wrote orders on 07/01/17 to try to place the resident in a different room with a different room-mate. --A nurse progress note dated 07/04/17 at 2:10 p.m. addressed that the resident was moved to another room today. --A nurse progress note dated. 07/04/17 at 9:28 p.m. addressed that the resident moved recently to a private room. The medical record was silent related to family notification of the room change prior to the move. --A room transfer/new roommate change form addressed that the resident transferred from her semi-private room to a private room on 07/06/17, and that the patient and responsible party was notified. However, the resident did not have a room change on 07/06/17. Further review of the medical record found [DIAGNOSES REDACTED]. An assessment of her cognitive functioning, with assessment reference date (ARD ) 07/03/17, found she had a score of 04 on the brief interview for mental status (BIMS) assessment. A score between 0-7 indicates severely impaired cognitive functioning. An interview was conducted with registered nurse Employee #3 on 03/06/18 at 3:45 p.m. She said the only information she found was that a room change occurred on 07/06/18 and the family was all right with the room change. An interview was conducted with the administrator and the director of nursing (DON) on 03/07/18 at 3:00 p.m., at which time it was discussed that it is still not known the actual date of her move from one (1) room to another room in (MONTH) (YEAR). They were informed that there has still been no evidence provided by the facility that the family was notified of the impending room change and the location of the new room. An interview was conducted with the licensed social worker (LSW) on 03/08/18 at 1:00 p.m. She said there was no evidence to show the facility notified the family of the impending move from room B 14 to B 15. She said the physician was at the facility on 07/01/17, and she said perhaps the physician notified the family of an impending room change somewhere else in the building. No evidence was provided by the facility prior to exit that the family was notified in advance of the impending room change and its location , and the family was in agreement with the room change and its location prior to the move b) Resident #8 The medical record was reviewed on 03/06/18. [DIAGNOSES REDACTED]. An assessment of his cognitive functioning, with assessment reference date (ARD ) 07/03/17, found he had a score of 05 on the brief interview for mental status (BIMS) assessment. A score between 0-7 indicates severely impaired cognitive functioning. The medical record and the room transfer/new roommate change forms were reviewed on 03/06/18. There was a discrepancy in the details of a room change for this resident. On 02/01/18 at 11:26 a.m., the resident moved from his private room on the D Hall, into a semi-private room on the B hall. According to the room transfer change form, the patient, responsible party, and roommate were notified, and the patient did not refuse the transfer. Observation found this resident does not currently reside on the B Hall. Rather, he resides in a private room on the D Hall. The medical record was silent regarding when he moved back to the D hall. The medical record was silent regarding whether the family and patient were notified and agreeable with the room transfer and its location before it took place. An interview was conducted with registered nurse Employee #3 on 03/06/18 at 4:00 p.m. She said she would try to find out exactly what day he moved to the D Hall. She said she would try to see if the family was notified timely of the move and its location before it occurred, and if they were in agreement with the transfer of rooms. An interview was conducted with the administrator and the director of nursing (DON) on 03/07/18 at 3:00 p.m., at which time it was discussed that it is still not known the actual date and time of his move from the B Hall to the D Hall where he currently resides. They were informed that there has been no evidence provided by the facility that the family was notified of the impending room change and the location of the new room. No evidence was provided by the facility prior to exit that the family was notified in advance of the impending room change and its location, and that they were in agreement with the room change.",2020-09-01
3181,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2018-03-08,583,D,1,0,OH3K11,"> Based on observation and staff interview, the facility failed to ensure personal privacy for a resident during activities of daily living care provided by staff. Staff wheeled a resident in a shower chair to her room from the common use shower room without ensuring the resident was adequately covered. This was evident for one (1) randomly observed resident. Resident identifier #1. Facility census: 66. Findings included: a) Resident #1 Observation on 03/08/18 at 9:45 a.m. found a nursing assistant wheeling Resident #1 in a shower chair from the community use shower room on the D hall, to the resident's room toward the distal end of the B hall. The resident was covered with a white bed sheet, and her hair was piled beneath a towel on her head. which was worn like a turban. Her bare feet and legs could be seen dangling as she wheeled down the hall. When they passed by, the resident's bare buttocks could be seen, as the sheet did not wrap all the way around her in the back. The administrator was notified, who in turn immediately notified registered nurse Employee #3, who in turn immediately ran up to the resident in the wheelchair and covered the resident's backside with the sheet. At this time, one (1) male resident sat in the B Hall in his wheelchair at the beginning of the B wing hallway. It is not known if he did or did not see the resident's exposed skin. An interview was conducted with the director of nursing on 03/08/18 at 12:30 p.m. She said she was made aware of this incident earlier this morning. She said E#3 said the sheet slipped and caught on the wheel of the wheel chair. She said Employee #3 educated the nursing assistant on providing privacy and dignity to the residents during transport to their room from the shower room.",2020-09-01
3182,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2018-03-08,609,D,1,0,OH3K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of concerns and grievances, staff interview, and the facility's table of abuse/neglect reporting requirements for WV Nursing Homes and Nursing Facilities, the facility failed to report all allegations of abuse and/or neglect to the appropriate state agencies. This was evident for two (2) grievances/concerns reviewed in the most recent nine (9) months. Allegations of abuse and/or neglect by a licensed nurse was not reported to the state licensing board. Allegations of neglect by two (2) nurse aides were not reported to any of the state agencies following an incident where a resident slid out of a sling to the floor and broke a bone during a transfer with a mechanical lift. Resident identifiers: #14, #2. Facility census: 66. Findings include: a) Resident #14 Review of the grievance/complaint log and the reportable file on 03/06/18 found that on 01/20/18 nurse aide (NA) #7 and NA #8 used a mechanical lift and sling to transfer this resident from the bed to the chair. During the transfer, the resident slid out of the sling and onto the floor. X-ray revealed a right acute mildly displaced [MEDICAL CONDITION] tibia and fibula. Review of the incident report found event summary and investigation, found that no state agencies were faxed about the incident. On 03/07/18 at 11:20 a.m. an interview was conducted with registered nurse (RN) #3 (RN #3). As a note, the incident reports are kept in her office. When asked if a reportable was done, she replied in the negative. According to the report, the two (2) aides reenacted the scenario. RN #3 said the cause of the fall was because the resident leaned forward in the lift. She said this resident tends to lean forward. She said the resident has been re-educated not to lean forward several times. She said nurse aide competency evaluations for mechanical lift transfers were most recently done in October, (YEAR). An interview was conducted with the administrator and the director of nursing on 03/07/18 at 3:00 p.m. They said they discussed reporting to state agencies at that time, but decided that it probably did not meet the reporting requirements. The administrator provided a copy of the abuse/neglect reporting table for nursing homes in WV. It defined neglect as a failure to provide goods and services necessary to avoid physical harm and psychological, harm, even if unintended. This is regardless of whether the perpetrator actually meant or intended to cause harm. They agreed that when the resident accidentally fell on to the floor and broke a bone during a bed to chair transfer by the nursing assistants, that in effect it was an allegation of an unintended failure to provide services necessary to avoid physical harm. The DON said the two (2) aides were experienced employees. She said they re-educated the two (2) nurse aides on 01/24/18 regarding the proper techniques for transferring a resident via a mechanical lift. b) Resident #2 Review of the grievance/complaint log and the reportable file on 03/06/18 found that on 02/05/18 a reportable was faxed to the Office and Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the Ombudsman related to an anonymous allegation of abuse toward this resident by licensed practical nurse (LPN) #6. There was no evidence that the allegation was reported to the nurse's licensing board. An interview was conduced with the administrator on 03/06/18 at 2:00 p.m. A discussion ensued about the grievance/complaint investigation that was done on 02/05/18. When asked if the licensing board was notified of the allegation of abuse by a licensed nurse, he replied in the negative. He then looked on page two (2) of his table of reporting guidelines, and acknowledged that it directed when allegation of abuse or neglect is made and the known alleged perpetrator holds a professional license, then the licensing board would be notified. The administrator said they had a miss on that one as they did not report to the licensed practical nurse board.",2020-09-01
3183,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2018-03-08,655,D,1,0,OH3K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to ensure it identified and developed individualized interventions for a resident initially admitted to the facility with physical behaviors due to cognitive loss and/or dementia. This was evident for Resident #13, who was one (1) of three (3) sampled residents reviewed for behaviors. Resident identifier: #13. Facility census: 66. Findings include: a) Resident #13 Review of the medical record on 03/05/18 found this resident first came to the facility on [DATE]. [DIAGNOSES REDACTED]. A care planned area of focus included this resident exhibited physical behaviors due to cognitive loss/dementia. It identified that she Yells at the girl in the mirror, has pulled the sink off the wall at home, broke the mirror at home. The corresponding interventions were silent as to what non-pharmacological methods might be employed to help decrease her physical behaviors. Care-planned interventions included the following: 1. Staff will administer [MEDICATION NAME] (a medication used in the treatment of [REDACTED]. Notify the doctor as indicated. 2. Monitor medications especially new/changed/discontinues, for side effects and resident's response contributing to physical behaviors, including antipsychotics, [MEDICATION NAME], opiods, benzodiazepines (recent discontinuation, omission or decrease in dose) drug interactions/toxicity/errors. 3. Refer the resident to a behavioral health provider to develop a Behavior Contract, if appropriate. 4. Encourage the resident to seek staff support for distressed mood. The care-planned goal for this problem area stated (name of resident) will demonstrate effective coping skills related to physical behavior by next review. Medication at the time she came to the facility and throughout her short stay included [MEDICATION NAME] (an antipsychotic medication) and [MEDICATION NAME] ( a medication used to treat anxiety). Nurse progress notes included numerous descriptions of behaviors such as the following: --repeating 'I am going home, I am an American, Call the cops, Yelling for help, Stating to staff she was going to 'knock the hell out of them'. --walked the halls trying to get into rooms and take the trash cans --wanted to start a fire in the stove --extremely combative, hitting, kicking, punching and attempting to bite CNA (nursing assistant) --going in and out of other residents' rooms. saying this is her house and she wants everybody out. Struck roommate on upper thigh because she wanted her out of her bed and house. Unable to reason with resident. --going in to other resident's rooms and took pictures off wall and pillows and blankets.staff intervened, resident became agitated, cursing, and hit a staff member --back handed nurse and broker her glasses, then resident attempted to choke nurse with stethoscope and broke her stethoscope. During an interview with the licensed social worker on 03/05/18 at 4:00 p.m., she said this resident had a lot of behaviors. An interview was conducted with the director of nursing (DON) on 03/07/18 at 3:00 p.m. We discussed the care plan for this resident. The DON said she would consider the care plan as the initial, interim care plan as she was in the facility less than three (3) weeks. The DON said this resident entered the facility with known behaviors, and should have been careplanned initially for behaviors. She acknowledged the care plan lacked measurable goals for what they wanted to achieve in her behaviors. She acknowledged the interventions were not individualized and person-centered for that resident. The DON summoned her care plan nurse, who agreed there were no specific goals or specific interventions that suited this resident. For instance, the care plan did not identify her behaviors. The care plan did not identify antecedents that may trigger behaviors. The care plan did not identify non-pharmacological interventions that may be helpful for this residents, or actions for employees to try to soothe and calm her or distract her.",2020-09-01
3184,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2019-07-17,550,D,0,1,4MZG11,"Based on observation, staff interviews and policy review, the facility failed to provide dignity for residents during their breakfast meal. Nurse Aide's (NA) stood over resident while assisting them with their breakfast meal. This was two (2) random observation for discovery. Resident identifers: #25 and #1. Facility census: 67. Findings included: a) Resident #25 Observation on 07/09/19 at 8:31 AM, found NA #15, standing up assisting Resident #25, to consume his breakfast meal. The NA was asked should you be standing up assisting Resident #25, to consume his meal. NA #15 acknowledged that she should be sitting down. b) Resident #1 Observation on 07/09/19 at 8:08 AM, found Nurse Aide (NA) #59 standing over assisting Resident #1 to consume his breakfast meal. When NA #59 was asked should you be standing up assisting Resident #1 to consume his breakfast meal. The NA said it is easier for her to stand and feed the resident. The NA acknowledged that standing over the resident is not the way she should be assisting Resident #1. In an interview on 07/09/19 at 9:00 AM, with the Center Nurse Executive (CNE)#12, when informed about the NA standing up assisting residents to consume their breakfast meal this morning, she stated the staff knows they should sit in a chair and assist the resident's to eat their meals. A review of the facility's considerate and respect policy on 07/11/19 at 8:17 AM, revealed promoting patient independence and dignity in dining such as avoidance of staff standing over the patient while assisting them to eat.",2020-09-01
3185,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2019-07-17,558,D,0,1,4MZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to ensure a resident had a call light within their reach, and a functioning remote television changer for a facility provided television. This was true for a resident identified during a random opportunity for discovery. This practice had the potential to effect more than a limited number. Resident identifier: R#17. Census: 67 Findings included: a) Call light Observations, on 07/09/19 at 03:18 PM, revealed Resident (R#17)'s call light was lying at the head of the resident's bed on the floor. When the resident was asked to press the call light button to test the call light system, the resident looked around and said the call light button is missing again. R#17 was sitting in her wheelchair beside her bed. This surveyor went out into the hall and requested Nurse Aide (NA#41) to come into the room. This surveyor asked NA#41 to help the resident find the resident's call light button. NA#41 found the call light button on the floor tied to the bed rail, out of reach of the resident. NA#41 said, They tied it to the bed rail again and they have been told not to do that. NA#41 confirmed the call light button should always be within the resident's reach, and R#17's was not. Review of records revealed the R#17 needs extensive to depend assistance in all activities of daily living, is incontinent of bowel and bladder, and has a left [MEDICAL CONDITION] (BKA). R#17 gets into her wheelchair with the assistance of staff using a lift and has a history of falls. R#17 does not have a prosthesis for the left BKA and currently does not desire one. b) Remote television changer During an interview, on 07/09/19 at 03:32 PM, Resident (R#17) said she wished she could change the television (TV) channels, that it had been on that same channel (Hallmark) for several days and kept showing the same movies over and over. When Resident (R#17) was asked if it was her (R#17) television or her roommates, R#17 replied it belongs to the facility. The TV was sitting high on top of a wooden wardrobe (at least more than six feet high), out of reach of the resident. R#17 said when she was in another room, she was given a TV changer to change channels but not since she moved to this room. When asked if she had ever asked for a TV changer, she replied Yes, several times, but did not remember who she asked. An interview with Activities Director (AD#44), on 07/09/19 at 03:37 PM, revealed the television in R#17's room does belong to the facility and should have a TV changer with it in the room. AD#44 and this surveyor went into the resident's room to see if a TV changer could be found. A TV changer was found on top of the ward robe beside the TV out of reach. AD#44 checked the TV changer but it did not work the TV in R#17's room. AD#44 said the TV changer did not go with the TV it was sitting beside. AD#44 said she will look to see if they have one for the television R#17 was watching. AD#44 turned to R#17 and asked the resident, Is it important for you to watch TV? R#17 replied Yeah, it's boring with nothing to do, it's nice to watch. AD#44 found R#17 a functional TV changer after Surveyor intervention.",2020-09-01
3186,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2019-07-17,656,D,0,1,4MZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and policy review, the facility failed to implement and complete an AIMS assessment with a significant change of condition of dementia and to develop a care plan for the needs of a Foley catheter. Resident identifiers: #31 and #50. Facility census: 67. Findings included: a) Resident #31 On 07/09/19 at 9:26 AM, catheter was observed at lunch while resident was in dining room. Catheter bag was dragging on the floor. On 07/09/19 at 12:44 PM, at lunch, observed the resident in the dining room with the catheter bag dragging the floor. The catheter bag was directly on the floor and was dirty. The Employee #3 verified the issue and she agreed the catheter bag should not have been on the floor. She escorted the resident to his room to have the cover changed. Current care plan indicated a problem with having sediment buildup in his indwelling catheter bag and bilateral kidney stones. The certified nursing cardex instructions showed the care needed for the catheter was to keep the bag off the floor. b) Resident #32 A review of Resident #32's care plan on 07/15/19 at 11:30 AM, revealed a care plan with a focus that said the resident has a [DIAGNOSES REDACTED]. The intervention in the care plan is to complete an AIMS ( abnormal Involuntary movement scale) assessment on admission, significant change, and every six (6) months. A review of medical record on 07/15/19 at 11:45 AM, revealed Resident #32 had a assessment complete for a significant change in status with an Assessment Reference date (ARD) of 05/14/19 for Resident #32. A review of Resident #32's medical record found no AIMS assessment was completed for the significant change of status with the ARD of 05/14/19. Clinical reimbursement coordinator (CRC) on 07/15/19 at 1:15 PM, was asked for Resident #32's AIMS report for the significant change of status with the ARD of 05/14/19. The CRC looked at the AIMS report and verified the AIMS report was not completed as the care plan said they would do when Resident #32 had a significant change of status on 05/ 14/19.",2020-09-01
3187,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2019-07-17,657,D,0,1,4MZG11,"Based on record review, staff interview, and resident interview the facility failed to ensure the participation of a resident and/or resident's representative, to the extent practicable, by failing to invite and/or notify of scheduled care plan meetings. The facility also failed to revise a resident's care plan concerning oxygen (O2) administration and a resident's care plan concerning bed mobility. This was true for one (1) of one (1) residents reviewed for care planning, and true for two (2) of seventeen (17) resident's care plans reviewed. This practice has the potential to affect more than a limited number of residents. Resident identifier: R#17, R#62, and R#9. Facility Census: 67. Findings included: a) Resident (R#17) An interview with Resident (R#17), on 07/09/19 at 03:20 PM, revealed the resident could not remember ever being invited to a care plan meeting or ever attending one. R#17 could not recall anyone meeting with her or talking with her about her plan of care. Review of the records, on 07/10/19 at 08:36 AM, revealed the last four care plan meeting notes dated 08/01/18, 10/24/18, 2/08/19, and 5/01/19 showed the care plan meetings were not attended by the resident or the resident's representative. Review of the progress notes revealed they all were documented the same; #2. Family/resident in attendance (Yes/No, who): no. Interview with social worker (SW#67), on 07/10/19 at 09:40 AM, revealed residents are to have a care plan meeting every three months and letters of notification are to be sent to family representatives three (3) weeks prior to the day of the scheduled care plan meeting. SW#67 said, I hand deliver the notice to the resident the Monday prior to the meeting and place it in their room on their board, but they never come. The social worker was asked to provide proof notifications were given as she had described. This surveyor asked for any copies of letters sent or provided to Resident (R#17) or her representative. SW#67 stated she used a template to create the letters and printed them off as needed but did not keep them. SW#67 said she did not keep or file any copies of the notices or letters send out to residents or their representatives and asked if she should. SW#67 said, Since (MONTH) (YEAR), a log is kept when care plan meetings are scheduled and who is notified and when. The care plan meeting logs since (MONTH) (YEAR) was requested for review. Review of the care plan meeting log forms used to track all care plan meetings revealed columns designated to record; a resident's name, resident's bed number, whether the resident is cognitively intact, MDS (minimum data set) type, ARD (assessment reference date) due date, meeting scheduled date, date mailed to representative, date resident notified, whether resident plans to attend, and whether representative plans to attend. Review of the care plan meeting logs for the past 10 months, starting from the time they were created and maintained to current, revealed R#17's care plan meetings were listed for only 10/31/18 and 01/30/19. Review of the care plan meeting logs revealed the logs were not completed in their entirety, with all the requested information needed to track and monitor R#17 and other resident's scheduled care plan meetings. Review of the facility's (MONTH) (YEAR) and (MONTH) 2019 care plan meeting logs revealed R#17 had a care plan meeting scheduled on 10/31/18 and 01/30/19. The (MONTH) form was only filled out to show R#17 name, resident's bed number, cognitively a Brief Interview for Mental Status (BIMs) score of 12 was entered, MDS type was second quarter, ARD due date 10/23/18, date the meeting was scheduled was 10/31/18, and the date the notice was mailed to the resident's representative 10/10/18. The rest of the columns were blank, there was no entry designating the date the resident was notified, whether the resident plans to attend, or whether the representative plans to attend. Progress note revealed care plan meeting was not attended by the resident or the resident's representative. The (MONTH) form was only filled out to show R#17 name, resident's bed number, cognitively a Brief Interview for Mental Status (BIMs) score of 8 was entered, MDS type was third quarter, ARD due date 01/22/19, date the meeting was scheduled was 01/30/19. The rest of the columns were blank, there was no entry designating the date the notice was mailed to the resident's representative, a date the resident was notified, whether the resident plans to attend, or whether the representative plans to attend. Progress note revealed care plan meeting was not attended by the resident or the resident's representative. Review of the Care Plan Meeting Note, dated 02/08/19, read as follows: 1. Attendance (list all in attendance): 1/23/19- IDT (Interdisciplinary Team); 2. Family/resident in attendance (Yes/No, who): no; and 3. Summary of meeting . Entry #1 indicated the Interdisciplinary Team (IDT) was in attendance on 01/23/19, but did not indicate what disciplines or who makes up the IDT. Review of progress notes revealed a care plan meeting took place on 05/01/19. The 05/01/19 meeting was not entered on the care plan meeting logs. According to the progress notes the care plan meeting on 05/01/19 was not attended by the resident or the resident's representative. Interview with social worker (SW#67), on 07/10/19 at 01:02 PM, revealed SW#67 could not find any proof the resident was given a notice or the family representative was sent a letter to invite them to R#17's (MONTH) or (MONTH) care plan meetings. b) Resident (R#62) Review of the current care plan, on 07/17/19 at 09:33 AM, revealed the care plan did not reflect the administration of oxygen the resident was presently being given. Review of records revealed an order Oxygen (O2) 2 LPM (liters per minute) via nasal cannula PRN (as needed) for shortness of breath, dated 03/22/19. The current order, dated 05/20/19, is 'Oxygen (O2) 2 LPM (liters per minute) via nasal cannula continuously'. Review of Resident (R#62)'s care plan revealed an intervention resolved on 04/23/19, for oxygen 2 LPM (liters per minute) via nasal cannula PRN (as needed) for shortness of breath. However, the current care plan was not revised to reflect oxygen given continuously as ordered. An interview and review of current care plan with registered nurse (RN#58), on 07/17/19 at 09:48 AM, confirmed R#62's care plan was not revised to reflect and the current O2 administration orders. R#62's care plan was revised after surveyor intervention on 07/17/19 to include oxygen therapy being currently provided to the resident as ordered. c) Resident #9 A review of the quarterly Minimum Data Set (MDS) with a Assessment Reference Date (ARD) of 01/15/19, found Resident #9's bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture is extensive assistance two (2) plus person assist. Resident #9's annual MDS with the ARD of 04/16/19, finds the resident's bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture is total dependent two (2) plus person assist. The clinical reimbursement coordinator (CRC) #33 was showed the care plan related to Resident #9 activity of daily living (ADL) in which the care plan did not have what the intervention are for Resident 's #9's bed mobility. CRC #33 said on 07/10/19 at 3:20 PM, confirmed she did not know why there was no bed mobility on the care plan nor on the Kardex (( It is meant to serve as a quick reference for nurse Aide's when they wanted to know what care a patient needed ). The CRC #33 on 07/10/19 at 3:33 PM, showed surveyor that Resident #9 had a care plan initiated on 04/07/17 that that stated: Provide resident with extensive to dependent assistance of one (1) or two (2) with bed mobility, but the care plan had been resolved which indicates (removed) on 05/05/17 for some reason . CRC #33 said the care plan should have been revised to include what Resident #9's current bed mobility is at this time. CRC stated that, she will revised the care plan and the NA Kardex today.",2020-09-01
3188,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2019-07-17,658,E,0,1,4MZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed meet professional standard of quality related to one (1) resident with a Gastrostomy tube ( [DEVICE]). Resident identifer: #216. Facility census: 67. Findings included: a) Resident # 216 A review of Resident #216's physician order [REDACTED]. The physician wrote an order on 06/21/19, to start administering Resident #216 on [MEDICATION NAME] 20 milligrams (MG), one (1) tablet, two (2) times a day to be administered via the route of his [DEVICE]. Resident #216 physician wrote an order to have nothing by mouth (NPO), diet NPO texture initiated on 04/29/19. The resident was admitted on [DATE]. Resident #216 has a care plan focus that said the resident is at risk for aspiration related to [DEVICE] initiated on 06/21/19. The intervention are to administration medication as ordered. There was a physician order [REDACTED].#216 that stated, Milk of Magnesia 30 ML by G- Tube for no BM in three (3) days whenever needed (PRN). The Medication Administration Record (MAR)revealed that Resident #216 was administered the Milk of Magnesia medication on 05/23/19, and 05/27/19. Nurse #57 wrote her initials on the above dates. Under the reason why Resident #216 was administered the Milk of Magnesia, she wrote the medication was administered by mouth. On 06/24/19 the resident received the Milk of Magnesia by Nurse #57 and again on 07/06/19 by Nurse #71 by mouth and not by [DEVICE]. The MAR and the physician order [REDACTED]. A review of Resident #216 (MONTH) 2019, MAR and physician order [REDACTED]. Resident #216 [MEDICATION NAME] was changed to receive the medication by mouth and not by [DEVICE] on 07/01/19. The Clinical Reimbursement Coordinator (CRC) on 07/10/19 at 9:20 AM, revealed the [MEDICATION NAME] and the Milk of Magnesia medication route to be administer for Resident #216 was inaccurate on the (MAR) and the physician order. The CRC #33 was shown the Milk of Magnesia MAR for (MONTH) 2019. The CRC acknowledged that the MAR was written correctly for the Milk of Magnesia to be given by [DEVICE], and she agreed that Nurse #57 had signed off that she had administered the medication by mouth instead of by G- Tube for the Dates of 05/23/19 and 05/27/19. The CRC also agreed that on 06/24/19 and on 07/06/19 the Milk of Magnesia the Nurses #57 and #71 did sign off they had administered the Milk of Magnesia by mouth and the physician order [REDACTED]. The CRC stated that, The medication had been transcribed wrong on the MAR for (MONTH) and (MONTH) 2019 by the Coordinator Health Information Magament (CHIM) #81 (employee's name). CRC #33 showed where Registered Nurse (RN) #78, RN #58 and the physician had reviewed the physician orders [REDACTED]. CRC #33 confirmed the error had not been identified by facility's staff until surveyor had completed the medication pass on Resident #216. The CRC stated that, I was reviewing the physician orders [REDACTED].#216 (resident's name) should have been receiving his medication. CRC stated that, the resident is NPO and should only receive his medication by [DEVICE] except for the medication [MEDICATION NAME] which is for Gingivitis. The CRC said none of the nurses in the facility who administered theses medication identified the physician order [REDACTED]. CRC #33 stated the facility nurse signed their initals that the Milk of Magnesia and [MEDICATION NAME] medication were given by mouth. The CRC stated I am sure they gave the medication by [DEVICE], but the facility has no evidence of this. The CRC acknowledges the three (3)facility staff and the physician had reviewing the physician order [REDACTED]. The CRC said that according to the standard of practice for nurses, she would of expected the nurses should have identified the medication on the MAR and the physician orders [REDACTED]. Clarification order was written on 07/10/19, stating the route of administration Milk of Magnesia and [MEDICATION NAME] - both medication to be administered by G- Tube. In an interview with the facility's physician on 07/16/19 at 8:06 AM, the physician acknowledged the physician order [REDACTED].#216 his Milk of Magnesia and [MEDICATION NAME] by mouth instead of by G- Tube. The physician stated, I know. The facility's pharmacy policy reveals the staff should verify each time a medication is administered that it is the correct medication, correct dose, at the correct route, at the correct time, for the correct resident. Confirm that the MAR reflects the most recent medication order. Reference from the Nursing 2012 Drug Handbook. (2012). Lippincott[NAME] & Wilkins: Philadelphia, Pennsylvania states under Right route: Again, check the order and appropriateness of the route ordered. Confirm that the patient can take or receive the medication by the ordered route. The employee list provided by the facility identifies nursing staff who initial the MAR they had administered Resident #216 the medication [MEDICATION NAME] 20 MG by mouth twice a day. Licensed Practical Nurse (LPN) #3, initialed the MAR that she administered [MEDICATION NAME] on the following dates at 9:00 AM: 07/01/19; 07/02/19; 07/03/19; 07/07/19; 07/08/19; and 07/09/19. LPN #21, initialed the MAR that she administered [MEDICATION NAME] on the following dates at 9:00 AM: 07/04/19; 07/05/19 and 07/06/19. Nurse #71, initialed the MAR that she administered [MEDICATION NAME] on the following dates at 8:00 PM: 07/06/19 and 07/07/19. LPN #85, initialed the MAR that she administered [MEDICATION NAME] on the following dates at 8:00 PM: 07/01/19; 07/02/19; 07/04/19; 07/05/19; 07/08/19; and 07/09/19. Nurse #57, initialed the MAR that she administered [MEDICATION NAME] on 07/03/19 at 8:00 PM. The employee list provided by the facility identified Nurse #57 (06/24/19) and #71 (07/06/19) who initial the MAR that they had administered Resident #216 the medication Milk of Magnesia by mouth 400 MG, give 30 ML as needed for constipation every three (3) days if no BM, to be administered via the route of the G- Tube. Nurse #57 wrote on the PRN reason for administering the Milk of Magnesia, identified the site was by mouth on 05/23/19 and 05/27/19. The order stated to administer the Milk of magnesia by G- Tube.",2020-09-01
3189,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2019-07-17,689,D,0,1,4MZG11,"Based on observation and staff interview, the facility failed to safely transfer a dependent resident from bed to a Geri- chair for one (1) of one (1) resident with decline activity daily living (ADL). Resident identifer: #9. Facility census 67. Findings included: a) Resident #9 Observation on 07/15/19 at 10:30 AM, revealed Licensed Practical Nurse (LPN ) #45 and Nurse Aide (NA) #9 transfer Resident #9 from her bed to her Geri- chair. When LPN #45 and the NA #9 proceeded to sit Resident #9 down into the Geri- chair, the chair had moved. The Geri- chair back up against the bathroom door, in which prevented the Geri- chair from moving any further. LPN #45 and NA #9 was asked did you have the wheels locked on the Geri chair they both stated, Yes. NA #9 and LPN#45 confirmed the Geri chair moves like this sometimes. The Administrator on 07/15/19 at 10:35 AM, was informed of the locks on the Geri- chair not functioning properly on Resident #9's Geri- chair. The Administrator said on 07/15/19 at 11:00 AM, that the Clinical Reimbursement Coordinator #33 had locked the Geri- chair and he unlocked/locked the chair and the chair did moved. The Administrator said the locks on Resident #9's Geri chair are working intermittent ( intermittent is something that starts and stops or happens irregularly). The administrator said he will fix the locks on Resident #9's Geri- chair.",2020-09-01
3190,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2019-07-17,690,D,0,1,4MZG11,"Based on observation, staff interview, policy and record review, the facility failed to provide care by incorrectly positioning the foley catheter bag while resident was sitting in his wheelchair. This was a random observation for discovery while Resident #31 was in the main dining room. Resident identifier: #31. Facility census: 67. Findings included: a) Resident #31 On 07/09/19 at 9:26 AM, observed the catheter bag dragged on the floor in the dining room during breakfast. On 07/09/19 at 12:44 PM, observed the Resident in the dining room with his catheter bag dragging the floor. The catheter bag was on the floor and was noted to have debris and to be dirty. At the time, Employee #3 verified the issue and she agreed the catheter bag should not have been on the floor. She escorted the resident to his room to have the cover changed. A review of the policy provided by Registered #58 was dated as revised on 02/01/19 regarding the care of the catheter revealed the drainage bag is to be below the level of the bladder and off the floor. Additionally the nurse aide current cardex instructions indicated the resident's catheter bag is to be off the floor. The current care plan did address the resident had a concern with a catheter but the interventions did not specify how the staff was to position the catheter as per the policy.",2020-09-01
3191,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2019-07-17,726,E,0,1,4MZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, pharmacy policy, and professional standard of care, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The nursing staff failed to administer medication the correct route for one (1) resident with a G- Tube. Resident identifer: #216. Facility census: 67. Findings included: a) Resident # 216 A review of Resident #216's physician order [REDACTED]. The physician wrote an order on 06/21/19, to start administering Resident #216 on [MEDICATION NAME] 20 milligrams (MG), one (1) tablet, two (2) times a day to be administered via the route of his [DEVICE]. Resident #216 physician wrote an order to have nothing by mouth (NPO), diet NPO texture initiated on 04/29/19. The resident was admitted on [DATE]. Resident #216 has a care plan focus that said the resident is at risk for aspiration related to [DEVICE] initiated on 06/21/19. The intervention are to administration medication as ordered. There was a physician order [REDACTED].#216 that stated, Milk of Magnesia 30 ML by G- Tube for no BM in three (3) days whenever needed (PRN). The Medication Administration Record (MAR)revealed that Resident #216 was administered the Milk of Magnesia medication on 05/23/19, and 05/27/19. Nurse #57 wrote her initials on the above dates. Under the reason why Resident #216 was administered the Milk of Magnesia, she wrote the medication was administered by mouth. On 06/24/19 the resident received the Milk of Magnesia by Nurse #57 and again on 07/06/19 by Nurse #71 by mouth and not by [DEVICE]. The MAR and the physician order [REDACTED]. A review of Resident #216 (MONTH) 2019, MAR and physician order [REDACTED]. Resident #216 [MEDICATION NAME] was changed to receive the medication by mouth and not by [DEVICE] on 07/01/19. The Clinical Reimbursement Coordinator (CRC) on 07/10/19 at 9:20 AM, revealed the [MEDICATION NAME] and the Milk of Magnesia medication route to be administer for Resident #216 was inaccurate on the (MAR) and the physician order. The CRC #33 was shown the Milk of Magnesia MAR for (MONTH) 2019. The CRC acknowledged that the MAR was written correctly for the Milk of Magnesia to be given by [DEVICE], and she agreed that Nurse #57 had signed off that she had administered the medication by mouth instead of by G- Tube for the Dates of 05/23/19 and 05/27/19. The CRC also agreed that on 06/24/19 and on 07/06/19 the Milk of Magnesia the Nurses #57 and #71 did sign off they had administered the Milk of Magnesia by mouth and the physician order [REDACTED]. The CRC stated that, The medication had been transcribed wrong on the MAR for (MONTH) and (MONTH) 2019 by the Coordinator Health Information Magament (CHIM) #81 (employee's name). CRC #33 showed where Registered Nurse (RN) #78, RN #58 and the physician had reviewed the physician orders [REDACTED]. CRC #33 confirmed the error had not been identified by facility's staff until surveyor had completed the medication pass on Resident #216. The CRC stated that, I was reviewing the physician orders [REDACTED].#216 (resident's name) should have been receiving his medication. CRC stated that, the resident is NPO and should only receive his medication by [DEVICE] except for the medication [MEDICATION NAME] which is for Gingivitis. The CRC said none of the nurses in the facility who administered theses medication identified the physician order [REDACTED]. CRC #33 stated the facility nurse signed their initals that the Milk of Magnesia and [MEDICATION NAME] medication were given by mouth. The CRC stated I am sure they gave the medication by [DEVICE], but the facility has no evidence of this. The CRC acknowledges the three (3)facility staff and the physician had reviewing the physician order [REDACTED]. The CRC said that according to the standard of practice for nurses, she would of expected the nurses should have identified the medication on the MAR and the physician orders [REDACTED]. Clarification order was written on 07/10/19, stating the route of administration Milk of Magnesia and [MEDICATION NAME] - both medication to be administered by G- Tube. In an interview with the facility's physician on 07/16/19 at 8:06 AM, the physician acknowledged the physician order [REDACTED].#216 his Milk of Magnesia and [MEDICATION NAME] by mouth instead of by G- Tube. The physician stated, I know. The facility's pharmacy policy reveals the staff should verify each time a medication is administered that it is the correct medication, correct dose, at the correct route, at the correct time, for the correct resident. Confirm that the MAR reflects the most recent medication order. Reference from the Nursing 2012 Drug Handbook. (2012). Lippincott[NAME] & Wilkins: Philadelphia, Pennsylvania states under Right route: Again, check the order and appropriateness of the route ordered. Confirm that the patient can take or receive the medication by the ordered route. The employee list provided by the facility identifies nursing staff who initial the MAR they had administered Resident #216 the medication [MEDICATION NAME] 20 MG by mouth twice a day. Licensed Practical Nurse (LPN) #3, initialed the MAR that she administered [MEDICATION NAME] on the following dates at 9:00 AM: 07/01/19; 07/02/19; 07/03/19; 07/07/19; 07/08/19; and 07/09/19. LPN #21, initialed the MAR that she administered [MEDICATION NAME] on the following dates at 9:00 AM: 07/04/19; 07/05/19 and 07/06/19. Nurse #71, initialed the MAR that she administered [MEDICATION NAME] on the following dates at 8:00 PM: 07/06/19 and 07/07/19. LPN #85, initialed the MAR that she administered [MEDICATION NAME] on the following dates at 8:00 PM: 07/01/19; 07/02/19; 07/04/19; 07/05/19; 07/08/19; and 07/09/19. Nurse #57, initialed the MAR that she administered [MEDICATION NAME] on 07/03/19 at 8:00 PM. The employee list provided by the facility identified Nurse #57 (06/24/19) and #71 (07/06/19) who initial the MAR that they had administered Resident #216 the medication Milk of Magnesia by mouth 400 MG, give 30 ML as needed for constipation every three (3) days if no BM, to be administered via the route of the G- Tube. Nurse #57 wrote on the PRN reason for administering the Milk of Magnesia, identified the site was by mouth on 05/23/19 and 05/27/19. The order stated to administer the Milk of magnesia by G- Tube.",2020-09-01
3192,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2019-07-17,745,E,0,1,4MZG11,"Based on record review, staff interview, and resident interview the facility failed to provide medically related social services regarding: failure to invite and/or notify residents and/or resident representatives to attend their care plan meetings; and ensure corresponding documentation of the invitations and notifications are in the resident's medical record. This practice has the potential to affect more than a limited number of residents. Resident identifier: #17, #4, #5, #6, #7, #9, #10, #11, #12, #15, #16, #18, #19, #22, #32, #36, #64, 300, #301, #302, #303 and #304. Facility Census: 67. Findings included: An interview with Resident (R#17), on 07/09/19 at 03:20 PM, revealed the resident could not remember ever being invited to a care plan meeting or ever attending one. R#17 could not recall anyone meeting with her or talking with her about her plan of care. Review of the records, on 07/10/19 at 08:36 AM, revealed the last four care plan meeting notes dated 08/01/18, 10/24/18, 2/08/19, and 5/01/19 showed the care plan meetings were not attended by the resident or the resident's representative. Review of the progress notes revealed they all were documented the same; #2. Family/resident in attendance (Yes/No, who): no. Interview with social worker (SW#67), on 07/10/19 at 09:40 AM, revealed residents are to have a care plan meeting every three months and letters of notification are to be sent to family representatives three (3) weeks prior to the day of the scheduled care plan meeting. SW#67 said, I hand deliver the notice to the resident the Monday prior to the meeting and place it in their room on their board, but they never come. The social worker was asked to provide proof notifications were given as she had described. This surveyor asked for any copies of letters sent or provided to Resident (R#17) or her representative. SW#67 stated she used a template to create the letters and printed them off as needed but did not keep them. SW#67 said she did not keep or file any copies of the notices or letters send out to residents or their representatives and asked if she should. SW#67 said, Since (MONTH) (YEAR), a log is kept when care plan meetings are scheduled and who is notified and when. The care plan meeting logs since (MONTH) (YEAR) was requested for review. Review of the care plan meeting log forms used to track all care plan meetings revealed columns designated to record; a resident's name, resident's bed number, whether the resident is cognitively intact, MDS (minimum data set) type, ARD (assessment reference date) due date, meeting scheduled date, date mailed to representative, date resident notified, whether resident plans to attend, and whether representative plans to attend. Review of the care plan meeting logs for the past 10 months, starting from the time they were created and maintained to current, revealed R#17's care plan meetings were listed for only 10/31/18 and 01/30/19. Review of the care plan meeting logs revealed the logs were not completed in their entirety, with all the requested information needed to track and monitor R#17 and other resident's scheduled care plan meetings. Review of the facility's (MONTH) (YEAR) and (MONTH) 2019 care plan meeting logs revealed R#17 had a care plan meeting scheduled on 10/31/18 and 01/30/19. The (MONTH) form was only filled out to show R#17 name, resident's bed number, cognitively a Brief Interview for Mental Status (BIMs) score of 12 was entered, MDS type was second quarter, ARD due date 10/23/18, date the meeting was scheduled was 10/31/18, and the date the notice was mailed to the resident's representative 10/10/18. The rest of the columns were blank, there was no entry designating the date the resident was notified, whether the resident plans to attend, or whether the representative plans to attend. Progress note revealed care plan meeting was not attended by the resident or the resident's representative. The (MONTH) form was only filled out to show R#17 name, resident's bed number, cognitively a Brief Interview for Mental Status (BIMs) score of 8 was entered, MDS type was third quarter, ARD due date 01/22/19, date the meeting was scheduled was 01/30/19. The rest of the columns were blank, there was no entry designating the date the notice was mailed to the resident's representative, a date the resident was notified, whether the resident plans to attend, or whether the representative plans to attend. Progress note revealed care plan meeting was not attended by the resident or the resident's representative. Review of the Care Plan Meeting Note, dated 02/08/19, read as follows: 1. Attendance (list all in attendance): 1/23/19- IDT (Interdisciplinary Team); 2. Family/resident in attendance (Yes/No, who): no; and 3. Summary of meeting . Entry #1 indicated the Interdisciplinary Team (IDT) was in attendance on 01/23/19, but did not indicate what disciplines or who makes up the IDT. Review of progress notes revealed a care plan meeting took place on 05/01/19. The 05/01/19 meeting was not entered on the care plan meeting logs. According to the progress notes the care plan meeting on 05/01/19 was not attended by the resident or the resident's representative. Interview with social worker (SW#67), on 07/10/19 at 01:02 PM, revealed SW#67 could not find any proof the resident was given a notice or the family representative was sent a letter to invite them to R#17's (MONTH) or (MONTH) care plan meetings. The (MONTH) log indicated a letter was mailed to the resident's representative on 10/10/18, however there was no copy of the letter in the resident's record to show what was sent. Review of care plan meeting logs revealed the care plan meeting logs were not completed in their entirety, there were various blank entries noted throughout the logs. A detailed review by this Surveyor of care plan meetings scheduled 01/17/19 through 01/30/19 revealed the following. There were twenty-one (21) residents (Resident #17, #4, #5, #6, #7, #9, #10, #11, #12, #15, #16, #18, #19, #22, #32, #36, #64, 300, #301, #302, #303 and #304) whose care plan meetings were scheduled during 01/17/19 through 01/30/19. There was not any documentation that showed any of the residents or representatives received a letter notifying and/or inviting them to the care plan meetings. The progress notes for Residents #17, #4, #5, #6, #7, #9, #10, #11, #12, #15, #16, #18, #19, #22, #32, #36, #64, 300, #301, #302, #303 and #304 concerning their (MONTH) 2019 care plan meetings were reviewed. All twenty-one (21) residents progress notes revealed no representatives or residents attended their scheduled care plan meetings.",2020-09-01
3193,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2019-07-17,761,D,0,1,4MZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and the facility's policy, the facility failed to check the medication refrigerators temperatures in the medication storage room for the month of (MONTH) and (MONTH) 2019. This had the potential to affect more than a limited number of residents. Facility census: 67. Findings included: a) Medication Refrigerator in the medication storage room. Observation of the medication storage room on 07/08/19 at 1:30 PM, with Licensed Practical Nurse (LPN) #3, found the medication and the vaccination refrigerator temperature were not being checked. The Medication refrigerator for the month of (MONTH) were not checked on PM of 06/16/19, 06/21/19, 06/22/19. (MONTH) the refrigerator temperature were not checked on the PM of 07/06/19, and 07/07/19. Licensed Practical Nurse #3 confirmed the refrigerator temperature had not been checked on the above dates. Inside the Medication Refrigerator in the medication storage room the following items were found: -- Two (2)boxes with 12 in each box of 650 milligram (MG) of Tylenol suppositories. This medication is used for pain. -- One (1) bottle of[NAME]Brandy. Used for anxiety. -- One (1) box of [MEDICATION NAME] 0.005% eye drops. Used for [MEDICAL CONDITION]. -- One (1) [MEDICATION NAME] suppositories. Used to treat constipation. -- One (1) Prevnar 13 immunization. -- five (5) Prevnar 23 immunization. -- two (2) 25 MG dose pack of [MEDICATION NAME], is an intramuscularly injection. Used to treat atypical antipsychotic. They are used to relieve symptoms such as delusions, hearing voices, hallucinations, or paranoid or confused thoughts typically associated with some mental illnesses. -- One (1) vial of [MEDICATION NAME] 100 Units insulin. Used for Diabetics. -- Four (4) [MEDICATION NAME] pens, (three (3) Mlliter (ML)/ pen. Used for Diabetics -- One (1) vial of Levimir, 10 ML. Used for Diabetics -- Two (2) [MEDICATION NAME], three (3) ML. Used for Diabetics --One (1)Humalog pen three, (3) ML. Used for Diabetics -- One (1) [MEDICATION NAME] Flex touch, three (3) ML. Used for Diabetics -- Two (2) [MEDICATION NAME] Kwik Pen. Used for Diabetics. -- 12 [MEDICATION NAME] suppository, 25 MG each. Used to treat nausea and vomiting. A review of the facility's medication and vaccine refrigerator/freezer temperature revealed that refrigerator and freezers used to store medications and vaccines will operate within acceptable temperature range and will be checked twice a day for proper temperatures.",2020-09-01
3194,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2019-07-17,802,D,0,1,4MZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure an employee with a valid and unexpired food handler's card worked in the kitchen. This has the potential to affect more than a limited number of residents who are served from this main dietary department. Employee identifier: #82. Facility census: 67. Findings included: a) Employee #82 By discussion with the dietary staff in the kitchen on [DATE] it was found a staff member #82 helps out in the kitchen at times. He used to perform such things as cooking breakfast but now does more dietary aide duties. His food handler's card expired (MONTH) 17, 2019. According to discussion with the dietary manager #4, the employee has been in the kitchen area within the past two to three weeks. Interview with Employee #82, at 1:00 PM on [DATE], he verified his food handler's card was expired. He indicated he used to do more cooking type duties but now may pour milk or juice and help out with cleaning dishes, if he was needed. He would go to the kitchen first thing and help out then go begin his maintenance duties. Additionally he said he has not attended any of the inservice trainings required by dietary staff.",2020-09-01
3195,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2019-07-17,835,E,0,1,4MZG11,"Based on medical record review, resident interview, review of (YEAR) annual Long-Term Care Survey Process (LTCSP) plan of correction, and staff interview, the facility failed to ensure effective oversight and management of its operations. This was true concerning the facility's failure to ensure residents and resident representatives received notification and invitation to their care plan meetings. This practice had the potential to affect more than limited numbers of residents. Resident identifiers: #17, #4, #5, #6, #7, #9, #10, #11, #12, #15, #16, #18, #19, #22, #32, #36, #64, 300, #301, #302, #303 and #304. Facility census: 67. Findings included: Interview with the administrator concerning issues and deficient practices identified during the annual LTCSP survey, on 07/17/19 at 11:16 AM, revealed a repeated deficient practice from the previous year's annual survey concerning residents and/or representatives not being invited/notified of their care plan meetings; and the lack of corresponding documentation in the residents' medical records. The administrator was aware of the care plan meeting issues and plan of correction to address the care plan meeting issues. Review of the facility's correction plan from the previous annual survey addressing invitation and notification of resident's care plan meetings to residents and/or responsible parties, on 07/17/19 at 12:15 PM, revealed corresponding documentation of the invitations and notifications were to be in the resident's medical record. Residents were to be notified verbally and in writing. All social workers were to be re-educated by the administrator concerning involvement and notification of the resident's care plan meetings, and of invitations and notifications corresponding documentation that was to be placed in the resident's medical record. Social worker was to audit notifications of residents and/or responsible parties weekly for four weeks then randomly thereafter to ensure residents are invited verbally and in writing to attend his/her care plan meetings. Trends identified were to be reported to the administrator and monthly to the quality improvement committee for additional follow-up until the issue was resolved then randomly thereafter as determined by the quality improvement committee. Interview with social worker (SW#67), on 07/10/19 at 09:40 AM, revealed residents are to have a care plan meeting every three months and letters of notification are to be sent to family representatives three (3) weeks prior to the day of the scheduled care plan meeting. SW#67 said, I hand deliver the notice to the resident the Monday prior to the meeting and place it in their room on their board, but they never come. The social worker was asked to provide proof notifications were given as she had described. This surveyor asked for any copies of letters sent or provided to Resident (R#17) or her representative. SW#67 stated she used a template to create the letters and printed them off as needed but did not keep them. SW#67 said she did not keep or file any copies of the notices or letters send out to residents or their representatives and asked if she should. SW#67 said, Since (MONTH) (YEAR), a log is kept when care plan meetings are scheduled and who is notified and when. The care plan meeting logs for (MONTH) (YEAR) forward to (MONTH) 2019 was requested for review. Review of the care plan meeting log forms used to track all care plan meetings revealed columns designated to record; a resident's name, resident's bed number, whether the resident is cognitively intact, MDS (minimum data set) type, ARD (assessment reference date) due date, meeting scheduled date, date mailed to representative, date resident notified, whether resident plans to attend, and whether representative plans to attend. Review of the care plan meeting logs for the past ten (10) months, starting from the time they were created and maintained to current, revealed R#17's care plan meetings were listed for only 10/31/18 and 01/30/19. Review of the care plan meeting logs revealed the logs were not completed in their entirety, with all the requested information needed to track and monitor R#17 and other resident's scheduled care plan meetings. Review of the facility's (MONTH) (YEAR) and (MONTH) 2019 care plan meeting logs revealed R#17 had a care plan meeting scheduled on 10/31/18 and 01/30/19. The (MONTH) form was partially filled out to show R#17 name, resident's bed number, cognitively a Brief Interview for Mental Status (BIMs) score of 12 was entered, MDS type was second quarter, ARD due date 10/23/18, date the meeting was scheduled was 10/31/18, and the date the notice was mailed to the resident's representative 10/10/18. The rest of the columns were blank, there was no entry designating the date the resident was notified, whether the resident plans to attend, or whether the representative plans to attend. Progress note revealed care plan meeting was not attended by the resident or the resident's representative. The (MONTH) form was only filled out to show R#17 name, resident's bed number, cognitively a Brief Interview for Mental Status (BIMs) score of 8 was entered, MDS type was third quarter, ARD due date 01/22/19, date the meeting was scheduled was 01/30/19. The rest of the columns were blank, there was no entry designating the date the notice was mailed to the resident's representative, a date the resident was notified, whether the resident plans to attend, or whether the representative plans to attend. Progress note revealed care plan meeting was not attended by the resident or the resident's representative. Review of the Care Plan Meeting Note, dated 02/08/19, read as follows: 1. Attendance (list all in attendance): 1/23/19- IDT (Interdisciplinary Team); 2. Family/resident in attendance (Yes/No, who): no; and 3. Summary of meeting . Entry #1 indicated the Interdisciplinary Team (IDT) was in attendance on 01/23/19, but did not indicate what disciplines or who makes up the IDT. Review of progress notes revealed a care plan meeting took place on 05/01/19. The 05/01/19 meeting was not entered on the care plan meeting logs. According to the progress notes the care plan meeting on 05/01/19 was not attended by the resident or the resident's representative. Interview with social worker (SW#67), on 07/10/19 at 01:02 PM, revealed SW#67 could not find any proof the resident was given a notice or the family representative was sent a letter to invite them to R#17's (MONTH) or (MONTH) care plan meetings. The (MONTH) log indicated a letter was mailed to the resident's representative on 10/10/18, however there was no copy of the letter in the resident's record to show what was sent. Review of care plan meeting logs revealed the care plan meeting logs were not completed in their entirety, there were various blank entries noted throughout the logs. A detailed review by this Surveyor of care plan meetings scheduled 01/17/19 through 01/30/19 revealed the following. There were twenty-one (21) residents (Resident #17, #4, #5, #6, #7, #9, #10, #11, #12, #15, #16, #18, #19, #22, #32, #36, #64, 300, #301, #302, #303 and #304) whose care plan meetings were scheduled during 01/17/19 through 01/30/19. There was not any documentation that showed any of the residents or representatives received a letter notifying and/or inviting them to the care plan meetings. The progress notes for Residents #17, #4, #5, #6, #7, #9, #10, #11, #12, #15, #16, #18, #19, #22, #32, #36, #64, 300, #301, #302, #303 and #304 concerning their (MONTH) 2019 care plan meetings were reviewed. All twenty-one (21) residents progress notes revealed no representatives or residents attended their scheduled care plan meetings.",2020-09-01
3196,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2019-07-17,842,E,0,1,4MZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, the pharmacy's policy and reference from professional standard of practice from the Nursing 2012 Drug Handbook, the facility failed to accurately document in the medical record related to medications for one (1) of five (5)residents Medication Administration Record (MAR) reviewed during the review of the Medication Administration Pass. Resident identifer: #216. Facility census: 67. Findings included: a) Resident # 216 A review of Resident #216's physician order [REDACTED]. The physician wrote an order on 06/21/19, to start administering Resident #216 on [MEDICATION NAME] 20 milligrams (MG), one (1) tablet, two (2) times a day to be administered via the route of his [DEVICE]. Resident #216 physician wrote an order to have nothing by mouth (NPO), diet NPO texture initiated on 04/29/19. The resident was admitted on [DATE]. Resident #216 has a care plan focus that said the resident is at risk for aspiration related to [DEVICE] initiated on 06/21/19. The intervention are to administration medication as ordered. There was a physician order [REDACTED].#216 that stated, Milk of Magnesia 30 ML by G- Tube for no BM in three (3) days whenever needed (PRN). The Medication Administration Record (MAR)revealed that Resident #216 was administered the Milk of Magnesia medication on 05/23/19, and 05/27/19. Nurse #57 wrote her initials on the above dates. Under the reason why Resident #216 was administered the Milk of Magnesia, she wrote the medication was administered by mouth. On 06/24/19 the resident received the Milk of Magnesia by Nurse #57 and again on 07/06/19 by Nurse #71 by mouth and not by [DEVICE]. The MAR and the physician order [REDACTED]. A review of Resident #216 (MONTH) 2019, MAR and physician order [REDACTED]. Resident #216 [MEDICATION NAME] was changed to receive the medication by mouth and not by [DEVICE] on 07/01/19. The Clinical Reimbursement Coordinator (CRC) on 07/10/19 at 9:20 AM, revealed the [MEDICATION NAME] and the Milk of Magnesia medication route to be administer for Resident #216 was inaccurate on the (MAR) and the physician order. The CRC #33 was shown the Milk of Magnesia MAR for (MONTH) 2019. The CRC acknowledged that the MAR was written correctly for the Milk of Magnesia to be given by [DEVICE], and she agreed that Nurse #57 had signed off that she had administered the medication by mouth instead of by G- Tube for the Dates of 05/23/19 and 05/27/19. The CRC also agreed that on 06/24/19 and on 07/06/19 the Milk of Magnesia the Nurses #57 and #71 did sign off they had administered the Milk of Magnesia by mouth and the physician order [REDACTED]. The CRC stated that, The medication had been transcribed wrong on the MAR for (MONTH) and (MONTH) 2019 by the Coordinator Health Information Magament (CHIM) #81 (employee's name). CRC #33 showed where Registered Nurse (RN) #78, RN #58 and the physician had reviewed the physician orders [REDACTED]. CRC #33 confirmed the error had not been identified by facility's staff until surveyor had completed the medication pass on Resident #216. The CRC stated that, I was reviewing the physician orders [REDACTED].#216 (resident's name) should have been receiving his medication. CRC stated that, the resident is NPO and should only receive his medication by [DEVICE] except for the medication [MEDICATION NAME] which is for Gingivitis. The CRC said none of the nurses in the facility who administered theses medication identified the physician order [REDACTED]. CRC #33 stated the facility nurse signed their initals that the Milk of Magnesia and [MEDICATION NAME] medication were given by mouth. The CRC stated I am sure they gave the medication by [DEVICE], but the facility has no evidence of this. The CRC acknowledges the three (3)facility staff and the physician had reviewing the physician order [REDACTED]. The CRC said that according to the standard of practice for nurses, she would of expected the nurses should have identified the medication on the MAR and the physician orders [REDACTED]. Clarification order was written on 07/10/19, stating the route of administration Milk of Magnesia and [MEDICATION NAME] - both medication to be administered by G- Tube. In an interview with the facility's physician on 07/16/19 at 8:06 AM, the physician acknowledged the physician order [REDACTED].#216 his Milk of Magnesia and [MEDICATION NAME] by mouth instead of by G- Tube. The physician stated, I know. The facility's pharmacy policy reveals the staff should verify each time a medication is administered that it is the correct medication, correct dose, at the correct route, at the correct time, for the correct resident. Confirm that the MAR reflects the most recent medication order. Reference from the Nursing 2012 Drug Handbook. (2012). Lippincott[NAME] & Wilkins: Philadelphia, Pennsylvania states under Right route: Again, check the order and appropriateness of the route ordered. Confirm that the patient can take or receive the medication by the ordered route. The employee list provided by the facility identifies nursing staff who initial the MAR they had administered Resident #216 the medication [MEDICATION NAME] 20 MG by mouth twice a day. Licensed Practical Nurse (LPN) #3, initialed the MAR that she administered [MEDICATION NAME] on the following dates at 9:00 AM: 07/01/19; 07/02/19; 07/03/19; 07/07/19; 07/08/19; and 07/09/19. LPN #21, initialed the MAR that she administered [MEDICATION NAME] on the following dates at 9:00 AM: 07/04/19; 07/05/19 and 07/06/19. Nurse #71, initialed the MAR that she administered [MEDICATION NAME] on the following dates at 8:00 PM: 07/06/19 and 07/07/19. LPN #85, initialed the MAR that she administered [MEDICATION NAME] on the following dates at 8:00 PM: 07/01/19; 07/02/19; 07/04/19; 07/05/19; 07/08/19; and 07/09/19. Nurse #57, initialed the MAR that she administered [MEDICATION NAME] on 07/03/19 at 8:00 PM. The employee list provided by the facility identified Nurse #57 (06/24/19) and #71 (07/06/19) who initial the MAR that they had administered Resident #216 the medication Milk of Magnesia by mouth 400 MG, give 30 ML as needed for constipation every three (3) days if no BM, to be administered via the route of the G- Tube. Nurse #57 wrote on the PRN reason for administering the Milk of Magnesia, identified the site was by mouth on 05/23/19 and 05/27/19. The order stated to administer the Milk of magnesia by G- Tube. b) Resident #66 A nursing progress note on Resident #66 said on 04/13/19 at 10:22 PM, Nurse #57 writes that Residents #66 is complaining of mid-sternal chest pain, non-radiating. Resident #66'S oxygen saturation were found to be in low 60's. [MEDICATION NAME] sublingual 0.4 milligrams (MG) given times one (1) with relief. Resident #66's oxygen saturation improved to 91%. Blood pressure was 185/82, heart rate 88, respiratory rate of 28 before [MEDICATION NAME] was given. The resident's blood pressure five (5) minutes after [MEDICATION NAME] was administered is 139 (sic}(quoted as is). Resident reports relief. The note goes on to say the resident is currently resting in bed with eyes closed. No further complaints. Will continue to monitor. A review of the Medication Administration record (MAR) on 07/17/19 at 8:38 AM, revealed Nurse #57 did not sign off on the MAR that she had administered the [MEDICATION NAME] 0.4 MG sublingual on 04/13/19. In an interview on 07/17/19 at 9:40 AM with Registered Nurse #58 acknowledge the nurse did not sign off on the MAR when she administered Resident #66 [MEDICATION NAME].",2020-09-01
3197,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2019-07-17,867,E,0,1,4MZG11,"Based on the issues identified during the annual Long-Term Care Survey Process, the facility failed to ensure their Quality Assessment and Assurance (QA&A) program identified and corrected quality deficiencies of which they should have been aware. The facility failed to: ensure resident rights and accommodation of resident's needs; ensure residents and/or representatives are invited/notified of care plan meetings; ensure services provided meet professional standards; ensure facility is free of accident hazards; ensure competent nursing staff; ensure medically related social services are provided and administration services; ensure behaviors are effectively monitored; ensure appropriate storage of medications; ensure approved staff has current food handler's card when working in the kitchen; ensure accurate documentation related to medication administration; and ensure an effective infection control program is maintained to the extent possible. This has the potential to affect more than a limited number of residents. Facility census: 67. Findings included: Details of the deficient practices cross-referenced in the Federal citation issued at: a) F550 Resident rights-dignified dining experience b) F558 Reasonable accommodation of needs c) F657 Care plan timing and revision d) F658 Services provided meet professional standards e) F689 Free of accident hazards f) F690 Catheters g) F726 Competent nursing staff h) F745 Provision of medically related social services i) F761 Medication storage/refrigeration j) F802 Dietary support personnel k) F835 Administration l) F842 Resident Record- Medication documentation m) F867 Quality Assessment and Assurance (QA&A) program n) F880 Infection Control and Prevention o) F883 Immunizations On 07/17/19 at 11:16 AM, interview with the administrator concerning the QA&A program revealed the QA&A committee had not identified all the issues, concerns, and deficient practices identified during the annual survey. Issues and deficient practices identified were concerning: resident rights and accommodation of resident's needs; providing services that met professional standards; accident hazards; competent nursing staff regarding medication administration with accurate documentation and effectively monitoring behaviors; ensuring appropriate storage of medication; ensuring approved staff with food handler's card working in the kitchen; failure to provide medically related social services; and identified infection control issues were discussed and acknowledged. Also discussed was the deficient practice repeated from the previous year's annual survey concerning not ensuring residents and/or representatives were invited/notified of their care plan meeting; and the lack of documentation in residents' records. Administrator was aware of the previous annual survey's care plan meeting issues and plan of correction to address the care plan meeting issues. Review of the facility's correction plan from the previous annual survey addressing invitation and notification of resident's care plan meetings to residents and/or responsible parties, on 07/17/19 at 12:15 PM, revealed corresponding documentation of the invitations and notifications was to be in the resident's medical record. Residents were to be notified verbally and in writing. All social workers were to be re-educated by the administrator concerning involvement and notification of the resident's care plan meetings, and of invitations and notifications corresponding documentation that was to be placed in the resident's medical record. Social worker was to audit notifications of residents and/or responsible parties weekly for four weeks then randomly thereafter to ensure residents are invited verbally and in writing to attend his/her care plan meetings. Trends identified were to be reported to the administrator and monthly to the quality improvement committee for additional follow-up until the issue was resolved then randomly thereafter as determined by the quality improvement committee.",2020-09-01
3198,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2019-07-17,880,E,0,1,4MZG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy, competency skills, the facility failed to implement infection control practices and process. Foley catheter care was not performed accurately, two resident Foley catheter bag was allowed to remain in contact with the floor. This had the potential to affect two (2) out of three (3 resident reviewed for the care area of Urinary Catheter/Urinary Tract Infection. Resident identifers: #26, and 31. Facility census: 67. Findings included: a) Resident #26 A review of Resident #26's history and physical identifies the resident has a indwelling Foley catheter related to [MEDICAL CONDITION]. Observation of Resident #26's urinary catheter care being performed by Geriatric Nurse Assistant Specialist (GNAS) #22 on 07/11/19 at 10:25 AM, found the GNAS reached in the covered basket outside of Resident #26's room and donned a pair of gloves, and picked up several wash clothes and towels. The GNAS recovered the basket, opened, closed the door, placed the towel on the over- the -bed tablet, moved the resident's drinking glasses, reached in opened the night stand, pulled out a wash basin, closed the door, placed the wash basin in the sink, turn on/off the water and filled the wash basin, and placed wash basin on the over-the -bed table, picking up the wash clothes and putting them in the wash basin. The GNAS then with these same gloves placed the wash clothes into the water, applied soap on a wash cloth, cleansed Resident #26's urinary catheter, then brought another wash cloth out of the water and rinsed the Foley catheter off, and then picked up a towel and dried Resident #26 Urinary Catheter. The GNAS was informed that she had not washed her hands prior to donning the pair of gloves, and then she had touched multiple objects with the same gloves and continued with providing Foley catheter care to Resident #26. The GNAS said I am nervous. The GNAS acknowledged that she did not wash her hands, and had donned a pair of gloves and touched objects, but did not removed the gloves, wash her hands and then donned a pair of gloves before providing urinary catheter care. The Registered Nurse (RN) #58 who is responsible for the infection control at the facility was informed of the Foley catheter care that was provided by GNAS #22. RN #58 was informed the GNAS did not wash her hands prior to donning a pair of gloves. Then the GNAS removed gloves from a basket outside the room, then donned the gloves touched wash clothes, towels from the covered basket, the outside of the basket, the outer and inside of the resident's entrance door, the resident's water cup, night stand, wash basin, turning on and off the water, placing the wash clothes into the wash basin. The GNAS #22 did not removed the contaminated gloves, nor wash her hand and don another pair of gloves prior to performing Resident #26's urinary catheter care. RN #58 agreed the GNAS provided urinary catheter care incorrectly. The facility's policy for the care of an indwelling Foley catheter finds the nursing staff should gather supplies, introduce yourself to the patient and verify patient identification, explain the procedure and provide privacy, cleanse hands, position the resident in a supine position, put on gloves, then proceed with cleansing the Foley catheter, remove gloves and cleanse hands. b) Resident (R#26) Observation, on 07/08/19 at 1:26PM, revealed R#26 lying in his bed with his urinary catheter drainage bag sitting directly on the floor. Current professional standards of practice for maintenance of Foley Catheters include, Do not let the drainage bag touch or lie on the floor. According to the CDC's (Centers for Disease Control and Prevention) Guideline for Prevention of Catheter-Associated Urinary Tract Infections, a directive listed under 'Proper Techniques for Urinary Catheter Maintenance' is Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. According to Lippincott Nursing Center, an authority for the professional development of nurses providing evidence-based procedure guidance; the principles for managing an indwelling catheter include, The collecting bag should be positioned below the level of bladder at all times and never placed on the floor. c) Resident #31 Observation at lunch in the main dining room on 07/08/19 at breakfast revealed the resident's catheter was in a blue bag and was in direct contact with the floor. It had a brown substance and accumulation of dirt on the bag. On 07/09/19 at 12:44 PM at lunch in the main dining room the same situation was observed again in dining room. The cath bag was on the floor and was dirty. Nursing staff #3 verified the issue and agreed the catheter bag should not have been on the floor. She escorted the resident to his room to have the cover changed. Review of the facility regarding catheter care with a revision date of 2/19 stated the catheter is to be positioned below the level of the resident's bladder and to be off the ground.",2020-09-01
3199,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2019-07-17,883,D,0,1,4MZG11,"Based on medical record review and staff interview, the facility failed to ensure an effective immunization program. The nursing staff failed to obtain the history of one (1) of five ( 5) residents regarding their Pneumococcal vaccinations administration. Resident identifer: #33. Facility census: 67. Findings included: a) Resident #33 A review of Resident #33's Pneumococcal vaccination administration revealed on 07/10/19 at 10:03 AM, a consent that said hereby decline the administration of a pneumococcal vaccine series. The reason for the decline was received in 2008. This form had the date of 08/26/16. The facility's immunization record for Resident #33 finds the facility did not obtain what type of pneumococcal vaccination the resident has received, whether he had received Prevnar 13 or 23. Resident #33's immunization record only contained that the resident had received a pneumococcal vaccination on 11/19/2008 from a nursing home, but the form did not identify which vaccination the resident had received. RN #58 was asked about Resident #33's pneumococcal vaccination history and she stated, I gave you is all of the record I have for (resident's name). RN #58 confirmed that she did not have any documentation on which pneumococcal vaccination Resident #33 received because their was another nurse working here prior to her being given this position and this nurse did not obtain Resident #33's pneumococcal history when Resident #33 came here. RN #58 on 07/10/19, notified the nursing home and they nursing home had faxed the facility a copy of Resident #33's immunization record. The immunization record from the other nursing home only revealed a pneumococcal vaccination was administered, but the form did not identify which pneumococcal vaccination was administered.",2020-09-01
3200,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2018-08-22,568,D,0,1,8YOP11,"Based on record review, resident and staff interview, the facility failed to make available the individual financial records through quarterly statements and upon request. This was true for three (3) of three (3) residents' financial records. Resident identifiers: #28, #7 and #21. Facility census: 68. Findings included: a) Residents #28, #7 and #21 personal funds account review: On 08/20/18 at 11:50 AM, Resident #28 was interviewed and she said, I don't know how much money is in my account. Review of individual financial records on 08/21/18 at 10:15 am, three (3) residents were randomly chosen to review. The three (3) resident's records reviewed was #28 due to her voiced concerns with her account and #7 and #21, which was found to be cognitively intact. It was found that Resident #28, #7 and #21 had not been provided with quarterly statements regarding the balance of their personal funds account. Interview with Employee #20. Business Office Manager (BOM) on 08/21/18 at 11:15 am found Resident #28, #7 and #21 was not provided with a quarterly statement of their personal funds accounts.",2020-09-01
3201,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2018-08-22,637,D,0,1,8YOP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a significant Minimum Data Set (MDS) when Resident #70 was determined to be end of life. Both resident/responsible party refused Hospice care. This was true for one (1) of seventeen (17) residents Minimum Data Sets (MDS) reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier: #70. Facility census: 68. Findings included: a) Resident #70 Review of Resident #70's emergency report dated 04/06/18, found Resident #70 was transported to local emergency room . During her stay at local emergency room , the resident and her responsible party was counseled by the physician of the resident's serious nature of multiple medical problems, [MEDICAL CONDITION], pneumonia,[MEDICAL CONDITION], and heart failure. Resident #70 does not want to be transferred to the Intensive Care Unit (ICU) and patient and family are agreeable to comfort care with antibiotics and diuretic and consult Hospice care. Progress notes for Resident #70 reveals a note written on 04/06/18 at 1:51 pm, read: family and resident was offered Hospice services; both declined and wishes to be kept comfortable . attending physician in agreement with comfort/end of life care due to [MEDICAL CONDITION] with metastasis to bone and end stage heart failure . Review of Resident #70's death certificate date 07/05/18 at 10:40 pm, completed by the attending physician, the cause of death was malignant neoplasm of left lung with metastasis to bones and heart failure. Interview with the Director of Nursing (DON) on 08/21/18 at 2:05 pm, found a significant MDS had not been completed. She confirmed a significant MDS should have been completed for Resident #70 due to on 04/06/18, the resident/family refused Hospice care although requested comfort care/end of life.",2020-09-01
3202,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2018-08-22,641,D,0,1,8YOP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, facility failed to accurately complete the Minimum Data Set (MDS) to reflect Resident # 29's status. This was true for one (1) of seventeen (17) sampled residents. Resident #29 was inaccurate in area of mental status. Resident identifiers: #29. Facility Census: 68. Findings included: a) Resident #29 Review of Resident #29's medical records, found the resident was admitted on [DATE]. [DIAGNOSES REDACTED]. ALS is a progressive neurological disease affecting voluntary muscles. His condition has progressed rapidly and has affected the resident's speech, swallowing, and ambulation. On 05/01/18, speech therapy evaluated and approved the resident for a lingraphragic sight gaze device (SGD) with eye gaze feature. (The Eye gaze Edge is an eye-operated communication and control system that empowers people with disabilities to communicate and interact with the world. By looking at control keys or cells displayed on a screen, a user can generate speech either by typing a message or selecting pre-programmed phrases.) Interview with Resident #29 on 08/20/18 found the resident's speech was hard to understand although a computer with eye gaze feature and a hand-held pad was used to communicate with this surveyor. Further review of records found on 12/29/18, the physician had declared the resident had capacity to make his own medical decisions. Review of Resident #29's significant MDS assessment with an assessment reference date (ARD) of 06/13/18, which found section A - Hearing, Speech and Vision indicates the resident's speech is unclear, usually is understood by others and he usually understands others. Section C- Cognitive Patterns, indicates the resident is rarely/never understood and no Brief Mini-Mental Interview (BIM) was attempted. Resident #29 could participate in the BIM interview using his assistive devices to complete the test. Resident #29 continued to direct his care by refusing to use his feeding tube for nutrition, thickened liquids and doctor appointments. Interview with the Speech Therapist (ST) concerning his cognitive ability to understand and communicate, she said his speech and swallowing ability has deteriorated greatly but he is able to understand and direct his care. Interview with the Director of Nursing (DON) on 04/22/18 at 12:15 p.m., found the resident was alert and oriented but unable to express verbally his needs/requests but he could communicate through his special equipment (computer and writing board. She confirmed the significant MDS with ARD of 06/13/18 was inaccurate. She further confirmed his cognitive ability is intact.",2020-09-01
3203,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2018-08-22,656,D,0,1,8YOP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interview, the facility failed to ensure a resident centered care plan was developed and/or implemented for three (3) of seventeen (17) resident care plans reviewed. Resident #25's care plan was not developed to include the development of a new pressure ulcer. Resident #40's care plan was not implemented for applying a brace to prevent contractures. Resident #43's care plan was not developed to include the use of a diuretic medication. Resident identifiers: #40, #25, and #43. Facility census: 68. Findings included: a) Resident #25 On 08/15/18, the resident returned to the facility, from the hospital, with a new Stage 1 pressure area to the left heel, measuring, 2 centimeters (cm's) x 1 cm. Review of the current care plan on 08/21/18 at 1:00 p.m., found the facility had not addressed the development of the pressure ulcer. At 1:11 PM on 08/21/18, the Clinical Care Reimbursement Coordinator (CRC) #22 confirmed the care plan had not been updated to reflect the resident returned from the hospital with a Stage I pressure area. b) Resident #40 Review of the current care plan found the problem: --I am at risk for contractures related to my [MEDICAL CONDITION] with left side weakness. The goal associated with the problem: --I want to remain free from contractures through next evaluation. Interventions included: --Nursing will apply left hand orthotoic (typed as written) at 8:00 a.m. and remove at 1:00 p.m. This is to prevent contractures. Monitor the surrounding area for redness. Observation of the resident on 08/20/18 at 11:16 AM, found the resident was not wearing a hand splint to the left hand. The resident said no one had put the brace on her hand. She said she was not capable of applying the brace herself. Observation of the resident at 9:20 a.m. on 08/22/18, with Registered Nurse (RN) #53 found the brace was lying on the far end of the over the bed table which was at the foot of the resident's bed. RN #53 said she would ask the nurse why the brace was not on the resident. RN #53 acknowledged the physician orders [REDACTED]. c) Resident #43 Review of resident #43's physician orders [REDACTED]. Review of Resident #43's comprehensive care plan revealed the focus Resident is at risk for respiratory complications related to lung congestion and dx. (diagnosis) of [MEDICAL CONDITION]/[MEDICAL CONDITION] ([MEDICAL CONDITION]/[MEDICAL CONDITION]). An intervention was to Administer [MEDICATION NAME] and [MEDICATION NAME] as per orders, obtain labs, and adjust medication as prescribed by (attending physician's name redacted). The comprehensive care plan did not contain a focus or interventions related to monitoring for side-effects and complications that may be caused by [MEDICATION NAME]. During an interview on 08/22/18 at 08:50 AM, the Coordinator for Clinical Reimbursement (CRC)agreed the comprehensive care plan did not contain a focus or interventions related to monitoring for side-effects and complications that may be caused by [MEDICATION NAME]. She stated she usually puts a focus for potential for dehydration as a focus for residents prescribed [MEDICATION NAME], because dehydration is a potential complication of diuretic therapy. The CRC stated she would update Resident #43's comprehensive care plan to contain a focus related to potential for dehydration.",2020-09-01
3204,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2018-08-22,657,D,0,1,8YOP11,"Based on resident interview, record review and staff interview, the facility failed to ensure Resident #28 and/or her responsible party was involved in developing her comprehensive care plan. This was true for one (1) of one (1) residents reviewed for the care area of care planning during the long term care survey. Resident identifier: 28. Facility census: 68. Findings included: a) Resident #28 An interview with Resident #28 at 11:52 a.m. on 08/20/18 indicated she did not feel as if she was involved in the development of her plan of care. She stated that they do not meet with her and discuss things with her. A review of Resident #28's medical record at 8:53 a.m. on 08/22/18 found Resident #28 had a care plan meeting on the following dates during the last year 06/24/18, 03/14/18, 12/22/17, 12/12/17, and 10/18/17. The record contained a care plan meeting note for each date the care plan meeting was held. Each note contained the following:Family/Resident in attendance (Yes/No, who): No. This indicates the resident nor the responsible party attended a care plan meeting in the past one (1) year. An interview with Social Worker #31 and Employee #42 the Admissions Assistant at 9:12 a.m. on 08/22/18 found they typically send out letters to the resident and to the residents responsible party. They indicated this is not documented in the residents medical record and they have no documentation that this is done. Employee #42 indicated that she just recently started maintaining a tracking log to show that she has sent a letter and on what date. She was asked to provide this information for Resident #28. She stated she only had one list that had Resident #28's name on it and she did not send out letters for this meeting because she did not receive the list until the day of the meeting. This was for the care plan meeting held in (MONTH) (YEAR).",2020-09-01
3205,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2018-08-22,684,D,0,1,8YOP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one (1) of one (1) residents reviewed for the care area of infections. The physician's antibiotic orders were not followed for Resident #33. Resident identifier: #33. Facility census: 68. Findings included: a) Resident #33 Review of Resident #33's medical records revealed an order for [REDACTED]. The Medication Administration Record [REDACTED] - 06/26/18; 2 doses - 06/27/18; 2 doses - 06/28/18; 2 doses - 06/29/18; 2 doses - 06/30/18; 2 doses - 07/01/18; 2 doses - 07/02/18; 1 dose The MAR indicated [REDACTED]. During an interview on 08/22/18 at 8:45 AM, the Director of Nursing (DoN) agreed Resident #33's [MEDICATION NAME] (cefprozil) order was for seven (days) or fourteen (14) doses but the MAR indicated [REDACTED]. The DoN stated she would look into the matter. On 08/22/18 at 11:00 AM, DoN reported she had no further information to provide, and resident #33 had received six (6) and a half days or thirteen (13) doses of [MEDICATION NAME] (cefprozil) instead of the full seven (7) days or fourteen (14) doses ordered by the physician.",2020-09-01
3206,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2018-08-22,688,D,0,1,8YOP11,"**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) of three (3) residents reviewed for position and mobility had physician ordered interventions in place for the prevention of contractures. Resident #40 was not wearing a brace to her left hand to prevent contractures. Resident identifier: #40. Facility census: 68. Findings included: a) Resident #40 Review of the physician's orders [REDACTED]. The resident's [DIAGNOSES REDACTED]. Observation of the resident on 08/20/18 at 11:16 AM, found the resident was not wearing a hand splint to the left hand. The resident said no one had put the brace on her hand. She said she was not capable of applying the brace herself. Review of the current care plan found the problem: --I am at risk for contractures related to my [MEDICAL CONDITION] with left side weakness. The goal associated with the problem: --I want to remain free from contractures through next evaluation. Interventions included: --Nursing will apply left hand orthotoic (typed as written) at 8:00 a.m. and remove at 1:00 p.m. This is to prevent contractures. Monitor the surrounding area for redness. Observation of the resident at 9:20 a.m. on 08/22/18, with Registered Nurse (RN) #53 found the brace was lying on the far end of the over the bed table which was at the foot of the resident's bed. RN #53 said she would ask the nurse why the brace was not on the resident. RN #53 acknowledged the physician orders [REDACTED].",2020-09-01
3207,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2018-08-22,710,D,0,1,8YOP11,"Based on record review, observation, and staff interview the facility failed to ensure the physician was aware of a change in the resident's medical status for one (1) of one (1) resident reviewed for pressure ulcers. Resident #25 returned from the hospital with a Stage I pressure ulcer to the left heel. There was no evidence the physician was aware of the change in condition. Resident identifier: #24. Facility census: 68. Findings included: a) Resident #25 On 08/15/18, the resident returned to the facility, from the hospital, with a new Stage 1 pressure area to the left heel, measuring, 2 centimeters (cm's) x 1 cm. A nursing note dated 08/15/2018 at 1:10 p.m. noted: --Assessment Note: A skin check was performed. The following New skin injury/wound(s) were identified: Bruise(s):Description: scattered bruising to bilateral upper extremities assumed to be from veni puncture while in hospital setting. Skin Tear(s):Location(s): right forearm 0.5x0.1 Pressure Area(s):Location(s): stage 1 left heel 2 x 1. Review of the admitting orders, completed on 08/15/18 at 1:40 p.m., found no mention of a pressure ulcer to the resident's left heel. There was no new treatment orders to the left heel. The resident had a previous order dated, 05/31/17, to wear position cushion boots at bedtime. The admitting orders noted all previous orders would be resumed. The physician approved the orders by telephone on 08/15/18 and later signed the orders on 08/19/18. Review of the current care plan on 08/21/18 at 1:00 p.m., found the facility had not addressed the development of the pressure ulcer. Observation of the left heel with Licensed Practical Nurse (LPN) #62, on 08/21/18 at 1:09 p.m., found the resident came back from the hospital with a pressure ulcer. LPN #62 said, Our policy is to just keep pressure off of the wound. She added, There is no dressing changes or treatments, just keep pressure off the wound. (The heels were floated with a bed pillow at the time of the observation.) At 1:11 PM on 08/21/18, the Clinical Care Reimbursement Coordinator (CRC) #22 confirmed the care plan had not been updated to reflect the resident returned from the hospital with a Stage I pressure area. At 3:03 p.m. on 08/21/18, the director of nursing (DON) said she could find no evidence the physician was aware of the resident's pressure ulcer. She said the physician was contacted and he would see the resident on 08/22/18. The DON further confirmed the facility's only treatment is to float the heels. Review of the facility policy, entitled Skin Integrity Management, revised on 11/28/16, requires, .Notify physician/APP to obtain orders .",2020-09-01
3208,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2018-08-22,756,D,0,1,8YOP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure teh pharmacist identified and reported irregularities in the resident's drug regimen to the attending physician for one (1) of five (5) residents reviewed for unnecessary medications. Resident #27 was receiving the same dose of the antidepressant, [MEDICATION NAME] for the past year without any attempts at a gradual dose reduction (GDR). Resident identifier: #27. Facility census: 68. Findings included: a) Resident #27. Record review found the resident was prescribed [MEDICATION NAME], 100 milligrams, daily, for the treatment of [REDACTED]. Further review of the monthly pharmacy consultation reports for the past year found no indication the pharmacist had suggested a GDR of [MEDICATION NAME]. At 8:25 AM on 08/22/18, Employee #27, the coordinator of health information management, said she could not find any consulting pharmacist reports for the past year referencing a GDR of [MEDICATION NAME]. At 8:43 AM on 08/22/18, the director of nursing (DON) said she could not find any reports from the consulting pharmacist referencing a GDR of [MEDICATION NAME]. On 08/22/18 at 10:02 AM, the DON said she had contacted the pharmacist via email. She provided a copy of the pharmacist's response. The pharmacist said she didn't suggest a GDR, which would have been due in July, (YEAR), because the psychiatrist had seen the resident on 07/16/18 and said to continue with the resident's current medications as the benefits outweigh the risks. The DON provided a copy of the psychiatrists visit to support her statement. The guidance to surveyors requires the pharmacist to report irregularities to the attending physician. The attending physician can then respond to the report and determine if medications are to be continued. Regulations require an attempt at a GRD for [MEDICAL CONDITION] medications at least yearly, after the first year, or documentation as to why the medications should be continued if a GDR is not in the resident's best interest.",2020-09-01
3209,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2018-08-22,808,D,0,1,8YOP11,"**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 three (3) residents reviewed for the care area of nutrition received the therapeutic diet ordered by the physician. Resident identifier: #25. Facility census: 68. Findings included: a) Resident #25 Record review found a physician's orders [REDACTED].>--Regular/Liberalized diet, dysphagia puree texture, large portions at meals, dated 03/07/18. Review of the medical record found the residents weight on 03/01/18 was recorded as 205 pounds. On 08/13/18 the residents weight was 187 pounds. A nursing note dated, 8/13/2018 at 8:16 a.m. found, Weight Change Note: WEIGHT WARNING: --Value: 187.0 --Vital Date: (YEAR)-08-08 11:00:00.0 --MDS (minimum data set): -5.0% change over 30 day(s) ( 5.6% , 11.0 ) --MDS: -10.0% change over 180 day(s) ( 10.1% , 21.0 ) (name of resident) has had a SWL (abbreviation unknown) with multiple medical issues including UTI's (urinary tract infections) requiring IV & PO ABX (antibiotics) During some of this time, PO (by mouth) intake was not good but is now approx. (approximately) 70-80%. POA (power of attorney) & (name of physician) are aware of weight & health status, will continue monitoring weight, intake and proceed as indicated. At 12:45 p.m. on 08/22/18, the resident was observed eating his noon meal in his room. The Dietary Manager (DM) and Licensed Practical Nurse, (LPN) #62 verified the resident did not receive large portions on his noon meal tray as directed by the physician's orders [REDACTED].>",2020-09-01
4624,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2016-03-17,241,D,0,1,NIDP11,"Based on observation and staff interview, the facility failed to ensure Resident #2 was treated with dignity and respect during the noon meal service. Resident #2 was eating in her room and was not served at the same time as her roommate, whom was also eating in the room. Resident identifier: #2. Facility census: 62. Findings include: a) Resident #2 Observation of the noon meal, at 12:30 p.m. on 03/14/16, found Resident #2 and Resident #23 preparing to have the noon meal in their room. The residents did not receive their meals at the same time. Resident #23 received her meal at 12:31 p.m., and Resident #2 did not receive her meal until 12:41 p.m. During this period of time, the staff served other residents on another unit before retrieving Resident #2's tray from the kitchen.At 12:45 p.m. on 03/14/16, this observation was discussed and verified with Employee #47, a licensed nurse who was the charge nurse on the unit. On 03/14/16 at 1:06 p.m., a discussion was held with the administrator and the director of nursing regarding the observations of the facility's failure to promote dignity for Residents #2 on 03/14/16. No additional information was provided.",2019-09-01
4625,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2016-03-17,272,D,0,1,NIDP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure an admission comprehensive Minimum Data Set (MDS) accurately reflected the resident's prognosis. This was true for one (1) of three (3) residents reviewed for the care area of death, during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #74. Facility census: 62. Findings include: a) Resident #74 Record review on [DATE] at 1:30 p.m., found the resident was admitted to the facility on [DATE]. The resident expired at the facility on [DATE]. The resident triggered the care area of death in Stage 2 of the QIS because he died within 30 days of the nursing home admission and did not have an explicit terminal prognosis. Review of a hospital discharge summary, dated [DATE], found the following information: .93 YOM (year old male) admitted to respite care for acute myelogenous [MEDICAL CONDITION], nursing home placement obtained with continued hospice care. Patient declined further [MEDICAL CONDITION] . Review of the facility's admission orders [REDACTED] Resident is certified as Hospice, and his prognosis was listed as Terminal. The admission MDS, with an assessment reference date (ARD) of [DATE], coded the resident as not having a condition or chronic disease that may result in a life expectancy of less than 6 months in section J1400, entitled: prognosis. The Resident Assessment Instrument (RAI) Manuel instructions for the coding of section J1400 includes, Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services . An interview with the Registered Nurse (RN), MDS coordinator, Employee #11, at 2:02 p.m. on [DATE], found the resident was receiving Hospice services while at the facility and his prognosis was listed as terminal. Employee #11 said, I thought the physician had to write a note the resident had 6 months or less to live. The RAI Manuel instructions for completing section J1400 were reviewed with Employee #11. After the review, Employee #11 said she would complete a corrected MDS. At 9:30 a.m. on [DATE], Employee #11 provided a copy of the corrected MDS.",2019-09-01
4626,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2016-03-17,279,D,0,1,NIDP11,"**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 Resident #8's [DIAGNOSES REDACTED]. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident #8's care plan indicated she received [MEDICATION NAME] for a [DIAGNOSES REDACTED]. Resident Identifier: #8. Facility Census: 62. Findings include: a) Resident #8 A review of Resident #8's medical record, at 1:36 p.m. on 03/15/16, found a physician's orders [REDACTED]. This order had a start date of 10/01/15. Resident #8's care plan was reviewed and found the following focus statement, I have a dx (diagnosis) of depression. The goal related to this focus statement was, I will eat in the dining room and visit with my daughter at least 2 times a week. Interventions related to this focus statement included, I will participate in mood assessments quarterly and as needed and will tell staff when I feel depressed. And, I will take [MEDICATION NAME] 20 mg every day. This care plan was initiated on 08/12/12 and was revised on 05/05/15 and 10/02/15 after the [MEDICATION NAME] 20 mg order was obtained from the physician. A review of Resident #8's most recent minimum data set (MDS) with an assessment reference date (ARD) of 02/03/16 found section I5800. Depression was coded no indicating Resident #8 does not have a [DIAGNOSES REDACTED]. An interview with the Registered Nurse Assessment Coordinator (RNAC) at 4:16 p.m. on 03/15/16, confirmed Resident #8's care plan did not address her [DIAGNOSES REDACTED]. She confirmed Resident #8 does not have a [DIAGNOSES REDACTED]. She confirmed the comprehensive care plan was not accurate and should indicate she has a [DIAGNOSES REDACTED].",2019-09-01
4627,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2016-03-17,282,D,0,1,NIDP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interviews, staff interviews, record reviews and policy reviews, the facility failed to implement the care plans for three (3) of three (3) residents reviewed for the care area of skin condition during Stage 2 of the Quality Indicator Survey (QIS). Three (3) of three (3) residents had bruising that was not identified or assessed. Resident identifiers: #3, #63 and #14. Facility Census: 62. Finding include: a) Resident #3 On 03/14/16 at 2:01 p.m., during the Stage 1 interview with Resident #3, a bruise approximately four (4) centimeters (cm) by five (5) cm was observed on her upper right arm. She reported she received the bruise after the blood pressure cuff squeezed her arm. A review of the care plan on 03/14/16 at 3:10 p.m. revealed this resident was at risk for bruises due to fragile skin and bruises easily. The intervention of reporting any complications related to bruising was not implemented for this resident. This intervention was initiated on 03/09/16. A review of the nursing progress notes from 03/03/16 to 03/15/16 had no notes to acknowledge any bruising received by Resident #3. A review of the Skin Care/Bruise Guideline, provided by the facility, stated new bruises are to be documented in the nurses' notes to include initial findings, location and size. On 03/16/16 at 11:28 a.m., the (DON) verified the care plan had not been implemented in regards to reporting any skin complications or bruising for Resident #3. b) Resident #63 On 03/15/16 at 9:21 a.m., during the Stage 1 interview with Resident #63, a bruise approximately one (1) centimeter (cm) by two (2) cm was observed on her right forearm. She reported she gets bruises and doesn't know how she gets them. A review of the care plan on 03/15/16 at 3:00 p.m. revealed this resident was at risk for skin breakdown. The intervention to monitor and report any changes in skin condition was not implemented for this resident. During an interview on 03/15/16 at 3:20 p.m., with Registered Nurse (RN) #67, she verified there were no nursing notes regarding any bruising for Resident #63. A review of the Skin Care/Bruise Guideline, provided by facility, stated new bruises are to be documented in the nurses' notes to include initial findings, location and size. On 03/16/16 at 4:15 p.m., the (DON) verified the care plan had not been implemented in regards to reporting any changes in skin condition for Resident #63. c) Resident #14 On 03/14/16 at 2:44 p.m., observation of Resident #14 revealed the resident had bruising on the top of both of her hands. The bruising was dark purple in color, covering seventy five percent (75%) of the top of both hands. On 03/15/16 at 2:00 p.m. Resident #14's progress notes were reviewed. There was no information documented in the progress notes referring to the bruising on the top of her hands. On 03/15/16 at 2:15 p.m. in an interview with License Practical Nurse (LPN) #47, she stated the resident had a [MEDICAL CONDITION] about a week earlier. LPN #47 stated the resident slung her hands during the [MEDICAL CONDITION]. LPN #47 was unable to provide any information on the bruising to the top of both hands. A review of the medical record detailed the resident's last [MEDICAL CONDITION] was on 03/02/16. Review of Accidents/Incidents policy on 03/16/16 at 11:50 a.m. revealed the following: An incident is defined as any occurrence not consistent with the routine operation of the Center or normal care of the patient. An observation of incident can involve a visitor or staff member, malfunctioning equipment, or observation of situation that poses a threat to safety or security. The nurse will notify the physician/mid-level provider of the accident/incident, report the physical findings and extent of injuries, and obtain orders if indicated. Document the accident/incident in the patient's chart; Documentation will include all pertinent information,date, time, place, notifications, and initial and ongoing assessments. All accidents/incidents, witnessed or unwitnessed, will be reported to the supervisor. The Administrator, DON, or designee will review all accidents/incidents to determine if: Required documentation has been completed; and interventions to prevent further accidents/incidents have been identified and implemented. A review of accidents/incident reports for January, February, and (MONTH) (YEAR) revealed that no accident/incident report was done related to the bruising to the top of the resident's hands. The care plan for Resident #14 was reviewed on 03/16/16 at 2:45 p.m. and revealed that on 12/11/14 Resident #14 was noted at risk for abnormal bleeding due to receiving [MEDICATION NAME] (anticoagulant-high risk for bleeding) every day. The intervention included monitoring for signs and symptoms including abnormal bleeding, bleeding gums, blood in urine, blood in stool, or abnormal bruising. The care plan indicated to notify the doctor if signs and symptoms of abnormal bleeding were present. During an interview with Nursing Assistant (NA) #27 on 03/16/16 at 2:50 p.m. NA #27 stated that Resident #14 gets blood draws. Medical record review on 03/16/16 at 2:55 p.m. revealed Resident #14's last lab work was completed on 03/10/16. In an interview on 03/16/16 at 3:00 p.m. with Registered Nurse (RN) #2, the RN could not confirm the site used for the lab draw for Resident #14. During an interview, with the Director of Nursing (DON) on 03/16/16 at 4:50 p.m., the DON confirmed the facility did not investigate or identify the origin of the resident's bruising to the top of the hands. She stated she would have expected her staff to have completed an incident/accident report to investigate the cause of the bruises. The DON agreed the care plan for monitoring signs and symptoms of abnormal bruising and notifying the physician was not implemented. A final medical record review, on 03/17/16 at 10:00 a.m., showed a Skin Check Performed on 03/15/16, a day after the surveyor identified the bruising on top of Resident #14's hands. The skin check did not identify any injuries or wounds. No further information was provided regarding why the facility had not identified the bruising.",2019-09-01
4628,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2016-03-17,309,E,0,1,NIDP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, policy review, resident interview, and staff interview, the facility failed to ensure four (4) of 26 Stage 2 sampled residents received the care and services needed to maintain and/or attain the highest practicable physical, mental and psychosocial well-being. The facility failed to promptly obtain a clarification order from Resident #8's Nephrologist in regards to the usage of antibiotics. For Resident #3, #63, and #14 the facility failed to identify and investigate the causative factors, and monitor new bruising to each of the three (3) residents reviewed for the care area of skin conditions, non-pressure related during Stage 2 of the quality indicator survey (QIS). Resident identifiers: #8, #3, #63, and #14. Facility census: 62. Findings include: a) Resident #8 A review of Resident #8's medical record at 1:36 p.m. on 03/15/16, found the resident had a Urine Analysis with a culture and sensitivity (UA C & S) completed on 03/09/16. The results were received by the facility on 03/11/16. Review of Resident #80's physician telephone orders found an order dated 03/11/16 at 3:00 p.m. This order read as follows, [MEDICATION NAME] (PCN) 500 milligrams (MG) twice a day for five (5) days. This medication was ordered for a [DIAGNOSES REDACTED]. Further review of the physician's telephone orders found an additional order dated 03/11/16 at 7:15 p.m. which read as follows, D/C (discontinue) PCN pending clarification with (Name of Resident #8's nephrology doctor). At the time of this medical record review there was no indication the facility followed up with Nephrologist to clarify if the resident needed to receive the antibiotic to treat her UTI. During an interview with the Director of Nursing (DON) at 3:13 p.m. on 03/15/16, she indicated that she would have to look into this situation to see if clarification was ever obtained. An additional interview, with the DON at 4:06 p.m. on 03/15/16, found after the earlier conversation with the Surveyor, she called Resident #8's Nephrologist and they did not want to treat the UTI. She stated that the Nephrologist ordered the UA C&S because they were looking for protein in the urine and if Resident #8 was not showing any clinical symptoms of a UTI that they did not want her to receive an antibiotic. The DON further indicated that they had faxed the lab results to the Nephrologist on Sunday, 03/13/16. She stated that she did not get a chance to follow up on it on 03/14/16 because of the survey. She was then asked when she followed up with the Nephrologist and she stated, I called them after we talked earlier today. Prior to surveyor intervention the facility had failed to obtain clarification from Resident #8's Nephrologist in regards to the need for the antibiotic as instructed by the physician on 03/11/16 at 7:15 p.m. b) Resident #3 On 03/14/16 at 2:01 p.m., during the Stage 1 interview with Resident #3, a bruise approximately four (4) centimeters (cm) by five (5) cm was observed on her upper right arm. The resident reported she received the bruise after the blood pressure cuff squeezed her arm. A review of the care plan on 03/14/16 at 3:10 p.m., reveale this resident was at risk for bruises due to fragile skin. The intervention of reporting any complications related to bruising for this resident was not completed. During a review of the Incident and Accident reports for January, (MONTH) and (MONTH) (YEAR), there was no evidence this incident was reported or investigated. A review of the Skin Care/Bruise Guideline, provided by the facility, stated new bruises are to be documented in the nurses' notes to include initial findings, location, size, description and initiate investigation. There was no evidence the bruise for this resident was reported or assessed. On 03/16/16 at 11:28 a.m., the (DON) verified the bruise for Resident #3 was not identified or assessed for possible complications. She further agreed the incident was not reported or investigated. c) Resident #63 On 03/15/16 at 9:21 a.m., during the Stage 1 interview with Resident #63, a bruise approximately one (1) centimeter (cm) by two (2) cm was observed on her right forearm. The resident reported she gets bruises and doesn't know how she gets them. A review of the care plan on 03/15/16 at 3:00 p.m. revealed this resident is at risk for skin breakdown. There was no evidence the intervention to monitor and report any changes in skin condition was completed for this resident. A review of the Skin Care/Bruise Guideline, provided by the facility, stated new bruises are to be documented in the nurses' notes to include initial findings, location, size, description and initiate investigation. There was no evidence the bruise for this resident was reported or assessed. During a review of the Incident and Accident reports for January, (MONTH) and (MONTH) (YEAR), there was no evidence this incident was reported or investigated. On 03/16/16 at 4:15 p.m., the (DON) verified the bruise for Resident #63 was not identified or assessed for possible complications she further agreed the incident was not reported or investigated. d) Resident #14 On 03/14/16 at 2:44 p.m. observation of Resident #14 revealed the resident had bruising on the top of both of her hands. The bruising was dark purple in color, covering seventy five percent (75%) of the top of both hands. On 03/15/16 at 2:00 p.m. Resident #14's progress notes were reviewed. There was no information documented in the progress notes referring to the bruising on the top of the resident's hands. On 03/15/16 at 2:15 p.m. in an interview with License Practical Nurse (LPN) #47, the LPN stated the resident had a [MEDICAL CONDITION] about a week earlier. LPN #47 stated the resident slung her hands during the [MEDICAL CONDITION]. LPN #47 was unable to provide any information about the bruising to the top of both of the resident's hands. A review of the medical record detailed the resident's last [MEDICAL CONDITION] was on 03/02/16. Review of Accidents/Incidents policy on 03/16/16 at 11:50 a.m. revealed the following: An incident is defined as any occurrence not consistent with the routine operation of the Center or normal care of the patient. An observation of incident can involve a visitor or staff member, malfunctioning equipment, or observation of situation that poses a threat to safety or security. The nurse will notify the physician/mid-level provider of the accident/incident, report the physical findings and extent of injuries, and obtain orders if indicated. Document the accident/incident in the patient's chart; Documentation will include all pertinent information, date, time, place, notifications, and initial and ongoing assessments. All accidents/incidents, witnessed or unwitnessed, will be reported to the supervisor. The Administrator, DON, or designee will review all accidents/incidents to determine if: Required documentation has been completed; and interventions to prevent further accidents/incidents have been identified and implemented. A review of the accidents/incidents for January, February, and (MONTH) (YEAR) revealed that no accident/incident report was done regarding the bruising to the top of Resident #14's hands. The care plan for Resident #14 was reviewed on 03/16/16 at 2:45 p.m. and revealed that on 12/11/14 Resident #14 was noted to be at risk for abnormal bleeding due to receiving [MEDICATION NAME] (anticoagulant-high risk for bleeding) every day. The intervention included monitoring for signs and symptoms including abnormal bleeding, bleeding gums, blood in urine, blood in stool, or abnormal bruising. The care plan indicated to notify the doctor if signs and symptoms of abnormal bleeding were present. During an interview with Nursing Assistant (NA) #27 on 03/16/16 at 2:50 p.m. NA #27 stated that Resident #14 gets blood draws. Medical record review on 03/16/16 at 2:55 p.m. revealed Resident #14's last lab work was on 03/10/16. In an interview on 03/16/16 at 3:00 p.m. with Registered Nurse (RN) #2 she could not confirm the site used for the lab draw for Resident #14. During an interview with the Director of Nursing (DON) on 03/16/16 at 4:50 p.m., she confirmed the facility did not investigate or identify the origin of the bruising to the top of the resident's hands. She stated she would have expected her staff to have completed an incident/accident report to investigate the cause of the bruises. The DON agreed the care plan for monitoring signs and symptoms of abnormal bruising and notifying the physician was not implemented. She further agreed the monitoring for abnormal bruising and bleeding was important due to Resident #14 receiving [MEDICATION NAME]. A final medical record review, on 03/17/16 at 10:00 a.m., showed a skin check was performed on 03/15/16. This was one (1) day after the surveyor identified the bruising on top of the Resident #14's hands. The skin check did not identify any injuries or wounds. No further information was provided as to why the facility had not identified the bruising to the top of both of the resident's hands.",2019-09-01
4629,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2016-03-17,315,D,0,1,NIDP11,"Based on observation, record review, and staff interview, the facility failed to ensure a resident, who had a decline in bladder functioning, received a thorough assessment to determine if any services could be provided to restore or improve bladder functioning. This was true for one (1) of one (1) resident reviewed for the care area of urinary incontinency during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #46. Facility census: 62. Findings include: a) Resident #46 Observation of the resident, at 9:08 a.m. on 03/15/16, during a Stage 1 interview, found the presence of a strong urine odor. The resident was in his room, in bed. An adult brief could be seen protruding from the waistband of his pants. The resident's clothing and bedding appeared to be dry. Review of the most recent minimum data set (MDS), on 03/16/16 at 1:00 p.m., an annual assessment, with an assessment reference date (ARD) of 02/16/16 found the resident was coded as always being continent of urine in section H0300. He was also coded as always continent of bowel. Review of the activities of daily living (ADL) record, completed by the nursing assistants, found the resident was coded as always continent of urine and bowel in the seven (7) day assessment period, (02/10/16 - 02/16/16) used to completed the MDS. Therefore, the MDS was coded correctly according to the documentation present in the resident's medical record. Review of the shower schedule with Licensed Practical Nurse (LPN) #16, on 03/16/16 at 2:00 p.m., found the resident received a shower on the afternoon shifts of 03/11/16 and 03/15/16. LPN#16 was informed the resident currently had a urine odor. She said she had never noticed an odor but she would investigate and have his nursing assistant, clean him up. She confirmed the resident does wear briefs and he occasionally uses the urinal by himself. Continued review of the ADL flowsheets with the director of nursing (DON) at 2:26 p.m. on 03/16/16, found the following documentation on the ADL flow sheets: --The resident had at three (3) episodes of urinary incontinence and one (1) episode of bowel incontinence in (MONTH) (YEAR). --He had one (1) episode of urinary incontinence and one (1) episode of bowel incontinence in (MONTH) (YEAR). --After the completion of the MDS on 02/16/16, the resident had daily episodes of urinary incontinence on the afternoon shifts of 02/22/16; 02/23/16; 02/24/16; 02/25/16; 02/26/16; 02/27/16; 02/28/16; and 02/29/16. He remained continent of bowel during this time frame. --In (MONTH) (YEAR), the resident was incontinent of urine on every day from 03/01/16 through 03/16/16. Following the review of the ADL flowsheets with the DON at 2:26 p.m. on 03/16/16, the DON confirmed the resident had experienced a decline in urinary incontinence after completion of the 02/16/16, MDS. She said she could not explain the reason but would call the doctor to see if he wanted to order a urinalysis. She confirmed the resident was not on a toileting program and facility staff had been using adult briefs for the resident. An interview with LPN #16 and Nursing Assistant (NA) #52, at 2:53 p.m. on 03/16/16, found the resident was, a little wet, when incontinence care was provided. NA #52 stated, His urine always has an odor. NA #52 said she thought the resident had been wearing briefs for, a long time now. At 10:34 a.m. on 03/17/2016, the DON said, We did a UA (urinalysis) and everything was good. I had a meeting with the girls and told them they have to tell us when there is a change in the resident. We are going to put him on a toileting schedule.",2019-09-01
4630,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2016-03-17,325,D,0,1,NIDP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and resident interview, the facility failed to ensure two (2) of three (3) residents reviewed for the care area of nutrition during Stage 2 of the Quality Indicator Survey (QIS) maintained acceptable parameters of nutritional status. The facility discontinued Resident #65's health shakes citing he was not drinking them when in fact he was consuming them three (3) times a day, as ordered by the physician. Additionally, the facility failed to weigh Resident #65 when he returned from the hospital on [DATE]. They did not weigh him until 02/25/16, at which time a severe weight loss of 13 pounds (lbs.) was discovered. Resident #6 had suffered a weight loss and upon investigation it was discovered the facility was not tracking supplements provided to the resident to prevent weight loss. The resident received a sandwich twice a day to promote weight gain. He had not been consuming the sandwiches, however; staff indicated that with his meal intakes and the sandwiches he was getting twice a day that weight loss should not be a problem for him. Resident identifiers: #65 and #6. Facility census: 62. Findings include: a) Resident #65. A review of Resident #65's medical record at 9:11 a.m. on 03/16/16, found the following recorded weights (All weight loss/gain Percentages calculated using the following formula % of body weight loss = (usual weight - actual weight) / (usual weight) x 100.): Date of admission 05/27/15 - 141 pounds 06/08/15 - 143 lbs. 06/14/15 - 144 lbs. 06/26/15 - 144 lbs. 07/20/15 - 140 lbs . 08/02/15 - 136 lbs. 08/10/15 - 133 lbs. 08/17/15 - 130 lbs. 08/24/15 - 127 lbs. 09/03/15 - 130 lbs. 09/10/15 - 130 lbs. 09/20/15 - 137 lbs. 09/25/15 - 140 lbs. 10/01/15 - 137 lbs. 10/15/15 - 136 lbs. 10/20/15 - 137 lbs. 11/02/15 - 136 lbs. 12/01/15 - 135 lbs. 12/15/15 - 139 lbs. 01/02/16 - 140 lbs. 01/20/16 - 147 lbs. 01/24/16 - 151 lbs. 02/01/16 - 149 lbs. 02/02/16 - 149 lbs. 02/25/16 - 136 lbs. 03/02/16 - 135 lbs. 03/08/16 - 136 lbs. 03/14/16 - 142.3 lbs. From 05/27/15 the resident's date of admission until 08/24/15 a total of 90 days Resident #65 lost 9.9 % of his entire body weight this represents a severe weight loss. As a result of this weight loss, the dietician assessed the resident and recommended a house supplement three times a day. The physician agreed with the recommendation and Resident #65 was started on a house supplement three times a day on 08/28/15. {Guidance to Surveyors related to suggested parameters for evaluating significance and unplanned and undesired weight loss, found in Appendix PP of the CMS (Centers for Medicare and Medicaid Services) State Operations Manual contained the following: Interval Significant Loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5% Greater than 7.5% 6 months 10% Greater than 10 %} Review of the Medication Administration Record [REDACTED]. Resident #65 weighed 127 lbs. on 08/24/15 and on 09/25/15 he weighed 140 pounds which represents a 9% weight gain during the time Resident #65 was receiving his house supplement three (3) times a day. Further review of the record found a nutritional progress note dated 09/23/15, which read as follows: wt. (weight) gain 7.9% in 30 days after wt. loss. PO (by mouth intake) = 72%. Improved PO intake. Res. (resident) is not taking supplements. No skin breakdown. Rec (recommend) d/c (discontinue) supplements. (Please note since the supplements were ordered on [DATE] Resident #65 has consumed 100 % of the supplement three (3) times a day.) The record also contained the following nursing progress note dated 09/24/15, which read as follows: New order per (name of Residents attending physician) #1 D/C supplements. #2 d/c yogurt at meals. Resident not eating yogurt, is not drinking supplements . Resident #65 stopped receiving his house supplement on 10/01/15. Resident #65 continued to gain weight despite his supplement being discontinued but he remained under his ideal body weight of 170 lbs. as indicated by the licensed dietician on her assessments dated 02/25/16 and 1/25/16. Additional review of the record found Resident #65 was discharged to the hospital on [DATE] and was readmitted on [DATE]. Resident #65 was not weighed upon his readmission to the facility and was not weighed again until 02/25/16 six (6) days after his readmission at which time he weighed 136 lbs. This was an 8.7% weight loss compared to his weight on 02/02/16. This represents another severe weight loss. Review of the facility's Weights and Heights policy found the following, Patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the interdisciplinary team care team. Hospital weight will not serve as admission or re- admission weight. He was evaluated by the dietician on 02/25/16, and she recommended a house supplement three (3) times a day. This recommendation was agreed upon by the physician and Resident #65 continues to receive his house supplement three (3) times a day. Since the house supplement was ordered on [DATE] Resident #65 has gained 6.3 lbs. or 4.4 % of his body weight. Interviews with the Registered Nurse Assessment Coordinator (RNAC) at 10:30 a.m. and 11:09 a.m. on 03/16/16 confirmed it was the facility's policy/practice to weigh residents on the day of readmission to determine if there was any weight loss while at the hospital and to determine if interventions need to be added to prevent further weight loss. She confirmed, Resident #65 was not weighed upon his readmission to the facility on [DATE]. She agreed this was a missed opportunity to possibly identify his weight loss sooner. She also confirmed that Resident #65 never refused his house supplement in (MONTH) (YEAR) so she was unsure why the dietician recommended that it be discontinued due to his refusals. . b) Resident #6 Record review on 03/15/16 at 1:30 p.m. found Resident #6 triggered the care area of nutrition because his Body Mass Index (BMI) was less than 22 and he was not receiving nutritional supplements. This sixty-six (66) year old male resident was admitted to the facility on [DATE]. At the time of admission the resident weight was recorded as 123 pounds. The most recent weight obtained by the facility was on 03/02/16, at which time the resident weighed 117 pounds. (A six (6) pound weight loss.) His height is 5' 8 and his BMI was 18.7. The resident experienced a 4.8% weight loss from 10/19/15 to 03/02/16. On 10/22/15, the registered dietitian completed a nutritional assessment. The assessment noted the resident received a normal diet and had no swallowing issues. According to the assessment, the resident required 1788 calories and 1677 cc (cubic centimeters) of fluid per day. His usual body weight was listed as unknown. The nutrition plan was: With PO (by mouth) at 94% of regular diet Resident is taking 2256 calories and 78 grams of pro. (Protein). Very good PO intake at this time. No skin breakdown, . Res (resident) may gain wt. (weight) with current intake . The dietitian did not recommend any nutritional supplements. A second nutritional assessment was completed by the registered dietitian on 01/22/16 with no concerns identified. The resident's weight was 120 pounds at the time of the assessment. The assessment noted the resident ate his meals in the dining room, had a low body mass index (BMI) and was below his ideal body weight. Intake was good at 50-100%, and he received a sandwich at 10:00 a.m. and 2:00 p.m. Review of the current care plan found a problem: Resident is at nutritional risk due to BMI (body mass index) 18.7, UTI (urinary tract infection) and MR (mental [MEDICAL CONDITION]) PO (by mouth) 94%. The goal associated with this problem was, Resident will consume 75-100% of at least 3 meals q (every) day x 90 days. Interventions included: Encourage 100% consumption of all fluids provided, Offer fluids of choice, Provide diet as ordered, Offer snacks, Encourage patient to come for dining room for meals, and Monitor intake at all meals, offer alternative choices as needed, alert dietitian and physician to any decline in intake, etc. A nursing note, dated 10/19/15, found, I am at nutritional risk d/t (due to) Low BMI of 18.2 and IBW (ideal body weight) dx (diagnosis) of MR. I am able to make some of my needs known. My BMI is 18.2 IBW 154. My intake is good 50-100%. I receive a sandwich at 10 and 2 p An interview with Dietary Manager (DM) #45, at 3:33 p.m. on 03/15/16, found the resident received a sandwich at 10:00 a.m. and 2:00 p.m. She stated the facility did not record the percentage of the sandwich consumed by the resident. When asked if the resident ate his sandwiches, she replied, I don't know, they aren't coming back to the kitchen so I guess he is eating them. Review of the percentages of meals consumed for (MONTH) (YEAR) with DM #45 found the resident was not consuming 75-100% of all meals. On four (4) occasions from 03/01/16 to 03/15/16, the resident consumed only 25% of his meals. On five (5) occasions from 03/01/16 to 03/15/16, he consumed only 50% of the meal served. At 4:08 p.m. on 03/15/16, the resident's Licensed Practical Nurse (LPN) #47 said, He doesn't eat those sandwiches. At 5:01 p.m. on 03/15/16, the DM said, I have discontinued the sandwiches and called the doctor who ordered a health shake at 10:00 a.m. and 2:00 p.m. to replace the sandwich. I will re-evaluate this in three (3) days to see if he is drinking the health shake. The DM confirmed the facility had not explored or assessed the reason for the resident's weight loss before surveyor intervention.",2019-09-01
4631,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2016-03-17,371,F,0,1,NIDP11,"Based on observation and staff interview, the facility failed to ensure food was stored and served in a sanitary manner. During the tour of the kitchen, opened food was discovered in the walk-in freezer without a date, an oven had a dirty control panel and a two (2) gallon plastic container was stored with the rim directly on a rusted shelf. This had the potential to affect all residents receiving nourishment from the kitchen. Facility census: 62. Findings include: a) Kitchen area On a tour of the kitchen, on 03/14/16 at 11:30 a.m., a (40) ounce bag of Brussel sprouts was discovered in the walk-in freezer. The bag of Brussel sprouts were not labeled with a date to show when they had been opened. The control panel on the convection oven had dirty on/off pivot switches, and a two (2) gallon container used for making tea was stored with the rim facing down directly on a rusted shelf. During an interview with the Dietary Manager, on 03/14/16 at 11:45 a.m., she verified the Brussel sprouts in the freezer were not dated to show when they were opened, the control panel on the oven needed to be cleaned and the tea container was stored directly on the rusted shelf.",2019-09-01
4632,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2016-03-17,514,D,0,1,NIDP11,"**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 twenty-three (23) medical records reviewed during Stage 2 contained accurate documentation. The death certificate for Resident #26 had the incorrect date of death . Resident identifier: #26. Facility census: 62. Findings include: a) Resident #26 A review of the medical record, on [DATE] at 1:49 p.m., revealed the nursing notes documented Resident #26 had died in the facility on [DATE] at 8:05 a.m. Upon further review, it was discovered the death certificate had the recorded date and time of death as [DATE] at 8:05 a.m. An interview with the Health Information Management Coordinator on [DATE] at 11:18 a.m., verified she recorded the incorrect date of death on the death certificate for Resident #26.",2019-09-01
4633,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2016-03-17,520,E,0,1,NIDP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record reviews, the quality assessment and assurance (QA&A) committee failed to identity and address quality deficiencies of which they were aware or should have been aware. A systemic breakdown was identified relating to the assessment of skin conditions, (non pressure areas) and resident nutritional changes. This affected Resident's #3, #63, #14, #65 and #6. Facility census: 62. Findings include: a) Resident #3 On 03/14/16 at 2:01 p.m., during the Stage 1 interview with Resident #3, a bruise approximately four (4) centimeters (cm) by five (5) cm was observed on her upper right arm. The resident reported she received the bruise after the blood pressure cuff squeezed her arm. A review of the medical record on 03/14/16 at 3:10 p.m., revealed the care plan indicated this resident was at risk for bruises due to fragile skin. The intervention of reporting any complications related to bruising for this resident was not completed. During a review of the Incident and Accident reports for January, (MONTH) and (MONTH) (YEAR), there was no evidence this incident was reported or investigated. A review of the Skin Care/Bruise Guideline, provided by the facility, stated new bruises are to be documented in the nurses' notes to include initial findings, location, size, description and initiate investigation. There was no evidence the bruise for this resident was reported or assessed. On 03/16/16 at 11:28 a.m., the (DON) verified the bruise for Resident #3 was not identified or assessed for possible complications. She further agreed the incident was not reported or investigated. b) Resident #63 On 03/15/16 at 9:21 a.m., during the Stage 1 interview with Resident #63, a bruise approximately one (1) centimeter (cm) by two (2) cm was observed on her right forearm. The resident reported she gets bruises and doesn't know how she gets them. A review of the care plan on 03/15/16 at 3:00 p.m. revealed this resident is at risk for skin breakdown. There was no evidence the intervention to monitor and report any changes in skin condition was completed for this resident. A review of the Skin Care/Bruise Guideline, provided by the facility, stated new bruises are to be documented in the nurses' notes to include initial findings, location, size, description and initiate investigation. There was no evidence the bruise for this resident was reported or assessed. During a review of the Incident and Accident reports for January, (MONTH) and (MONTH) (YEAR), there was no evidence this incident was reported or investigated. On 03/16/16 at 4:15 p.m., the (DON) verified the bruise for Resident #63 was not identified or assessed for possible complications She further agreed the incident was not reported or investigated. c) Resident #14 On 03/14/16 at 2:44 p.m. observation of Resident #14 revealed the resident had bruising on the top of both of her hands. The bruising was dark purple in color, covering seventy five percent (75%) of the top of both hands. On 03/15/16 at 2:00 p.m. Resident #14's progress notes were reviewed. There was no information documented in the progress notes referring to the bruising on the top of the resident's hands. On 03/15/16 at 2:15 p.m. in an interview with License Practical Nurse (LPN) #47, she stated the resident had a [MEDICAL CONDITION] about a week earlier. LPN #47 stated the resident slings her hands during the [MEDICAL CONDITION]. LPN #47 was unable to provide any information on the bruising to the top of both hands. A review of the medical record detailed the resident's last [MEDICAL CONDITION] was on 03/02/16. Review of Accidents/Incidents policy on 03/16/16 at 11:50 a.m. revealed the following: An incident is defined as any occurrence not consistent with the routine operation of the Center or normal care of the patient. An observation of incident can involve a visitor or staff member, malfunctioning equipment, or observation of situation that poses a threat to safety or security. The nurse will notify the physician/mid-level provider of the accident/incident, report the physical findings and extent of injuries, and obtain orders if indicated. Document the accident/incident in the patient's chart; Documentation will include all pertinent information,date, time, place, notifications, and initial and ongoing assessments. All accidents/incidents, witnessed or unwitnessed, will be reported to the supervisor. The Administrator, DON, or designee will review all accidents/incidents to determine if: Required documentation has been completed; and interventions to prevent further accidents/incidents have been identified and implemented. Reviewed accidents/incidents for January, February, and (MONTH) (YEAR) revealed that no accident/incident report was done regarding the bruising. The care plan for Resident #14 was reviewed on 03/16/16 at 2:45 p.m. and revealed that on 12/11/14 Resident #14 was noted at risk for abnormal bleeding due to receiving [MEDICATION NAME] (anticoagulant-high risk for bleeding) every day. The interventions in the care plan included monitoring for signs and symptoms included abnormal bleeding, bleeding gums, blood in urine, blood in stool, or abnormal bruising. The care plan indicated to notify the doctor if signs and symptoms of abnormal bleeding were present. During an interview with Nursing Assistant (NA) #27 on 03/16/16 at 2:50 p.m. NA #27 stated that Resident #14 gets blood draws. Medical record review on 03/16/16 at 2:55 p.m. revealed Resident #14's last lab work scheduled was on 03/10/16. In an interview on 03/16/16 at 3:00 p.m. with Registered Nurse (RN) #2 she could not confirm the site used for the lab draw for Resident #14. During an interview with the Director of Nursing (DON) on 03/16/16 at 4:50 p.m., she confirmed the facility did not investigate or identify the origin of the resident's bruising to the top of the hands. She stated she would have expected her staff to have completed an incident/accident report to investigate the cause of the bruises. The DON agreed the care plan for monitoring signs and symptoms of abnormal bruising and notifying the physician was not implemented. She further agreed the monitoring for abnormal bruising and bleeding was important due to Resident #14 recieving [MEDICATION NAME]. A final medical record review on 03/17/16 at 10:00 a.m. showed a Skin Check Performed on 03/15/16, a day after the surveyor identified the bruising on top of the Resident #14's hands. The skin check did not identify any injuries or wounds. d) Resident #65 A review of Resident #65's medical record at 9:11 a.m. on 03/16/16, found the following recorded weights (All weight loss/gain Percentages calculated using the following formula % of body weight loss = (usual weight - actual weight) / (usual weight) x 100.): Date of admission 05/27/15 - 141 pounds 06/08/15 - 143 lbs. 06/14/15 - 144 lbs. 06/26/15 - 144 lbs. 07/20/15 - 140 lbs 08/02/15 - 136 lbs. 08/10/15 - 133 lbs. 08/17/15 - 130 lbs. 08/24/15 - 127 lbs. 09/03/15 - 130 lbs. 09/10/15 - 130 lbs. 09/20/15 - 137 lbs. 09/25/15 - 140 lbs. 10/01/15 - 137 lbs. 10/15/15 - 136 lbs. 10/20/15 - 137 lbs. 11/02/15 - 136 lbs. 12/01/15 - 135 lbs. 12/15/15 - 139 lbs. 01/02/16 - 140 lbs. 01/20/16 - 147 lbs. 01/24/16 - 151 lbs. 02/01/16 - 149 lbs. 02/02/16 - 149 lbs. 02/25/16 - 136 lbs. 03/02/16 - 135 lbs. 03/08/16 - 136 lbs. 03/14/16 - 142.3 lbs. From 05/27/15 the residents date of admission, until 08/24/15 a total of 90 days Resident #65 lost 9.9 % of his entire body weight. This represents a severe weight loss. As a result of this weight loss, the dietician assessed the resident and recommended a house supplement three (3) times a day. The physician agreed with the recommendation and Resident #65 was started on a house supplement three times a day on 08/28/15. {Guidance to Surveyors related to suggested parameters for evaluating significance and unplanned and undesired weight loss, found in Appendix PP of the CMS (Centers for Medicare and Medicaid Services) State Operations Manual contained the following: Interval Significant Loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5% Greater than 7.5% 6 months 10% Greater than 10%.} Review of the Medication Administration Record [REDACTED]. Resident #65 weighed 127 lbs. on 08/24/15 and on 09/25/15 he weighed 140 pounds which represents a 9% weight gain during the time Resident #65 was receiving his house supplement three (3) times a day. Further review of the record found a nutritional progress note dated 09/23/15, which read as follows: wt. (weight) gain 7.9% in 30 days after wt. loss. PO (by mouth intake) = 72%. Improved PO intake. Res. (resident) is not taking supplements. No skin breakdown. Rec (recommend) d/c (discontinue) supplements. (Please note since the supplements were ordered on [DATE] Resident #65 has consumed 100 % of the supplement three (3) times a day.) The record also contained the following nursing progress note dated 09/24/15, which read as follows: New order per (name of Residents attending physician) #1 D/C supplements. #2 d/c yogurt at meals. Resident not eating yogurt, is not drinking supplements . Resident #65 stopped receiving his house supplement on 10/01/15. Resident #65 continued to gain weight despite his supplement being discontinued but he remained under his ideal body weight of 170 lbs. as indicated by the licensed dietician on her assessments dated 02/25/16 and 1/25/16. Additional review of the record found Resident #65 was discharged to the hospital on [DATE] and was readmitted on [DATE]. Resident #65 was not weighed upon his readmission to the facility and was not weighed again until 02/25/16 six (6) days after his readmission at which time he weighed 136 lbs. This was a 8.7% weight loss compared to his weight on 02/02/16. This represents another severe weight loss. Review of the facility's Weights and Heights policy found the following, Patients are weighed upon admission and/or re-admission, then weekly for four weeks and monthly thereafter. Additional weights may be obtained at the discretion of the interdisciplinary team care team. Hospital weight will not serve as admission or re- admission weight. He was evaluated by the dietician on 02/25/16, and she recommended a house supplement three (3) times a day. This recommendation was agreed upon by the physician and Resident #65 continues to receive his house supplement three (3)times a day. Since the house supplement was ordered on [DATE] Resident #65 has gained 6.3 lbs. or 4.4 % of his body weight. Interviews with the Registered Nurse Assessment Coordinator (RNAC) at 10:30 a.m. and 11:09 a.m. on 03/16/16 confirmed it was the facility's policy/practice to weigh residents on the day of readmission to determine if there was any weight loss while at the hospital and to determine if interventions need to be added to prevent further weight loss. She confirmed, Resident #65 was not weighed upon his readmission to the facility on [DATE]. She agreed this was a missed opportunity to possibly identify his weight loss sooner. She also confirmed that Resident #65 never refused his house supplement in (MONTH) (YEAR) so she was unsure why the dietician recommended that it be discontinued due to his refusals. e) Resident #6 Record review on 03/15/16 at 1:30 p.m. found Resident #6 triggered the care area of nutrition because his Body Mass Index (BMI) was less than 22 and he was not receiving nutritional supplements. This sixty-six (66) year old male resident was admitted to the facility on [DATE]. At the time of admission the resident weight was recorded as 123 pounds. The most recent weight obtained by the facility was on 03/02/16, at which time the resident weighed 117 pounds. (A six (6) pound weight loss.) His height is 5' 8 and his BMI was 18.7. The resident experienced a 4.8% weight loss from 10/19/15 to 03/02/16. On 10/22/15, the registered dietitian completed a nutritional assessment. The assessment noted the resident received a normal diet and had no swallowing issues. According to the assessment, the resident required 1788 calories and 1677 cc (cubic centimeters) of fluid per day. His usual body weight was listed as unknown. The nutrition plan was: With PO (by mouth) at 94% of regular diet Resident is taking 2256 calories and 78 grams of pro. (protein). Very good PO intake at this time. No skin breakdown, . Res (resident) may gain wt. (weight) with current intake . The dietitian did not recommend any nutritional supplements. A second nutritional assessment was completed by the registered dietitian on 01/22/16 with no concerns identified. The resident's weight was 120 pounds at the time of the assessment. The assessment noted the resident ate his meals in the dining room, had a low BMI and was below his ideal body weight. Intake was good at 50-100%, and he received a sandwich at 10:00 a.m. and 2:00 p.m. Review of the current care plan found a problem: Resident is at nutritional risk due to BMI 18.7, UTI (urinary tract infection) and MR (mental [MEDICAL CONDITION]) PO (by mouth) 94%. The goal associated with this problem was, Resident will consume 75-100% of at least 3 meals q (every) day x 90 days. Interventions included: Encourage 100% consumption of all fluids provided, Offer fluids of choice, Provide diet as ordered, Offer snacks, Encourage patient to come for dining room for meals, and Monitor intake at all meals, offer alternative choices as needed, alert dietitian and physician to any decline in intake, etc. A nursing note, dated 10/19/15, found, I am at nutritional risk d/t (due to) Low BMI of 18.2 and IBW (ideal body weight) dx (diagnosis) of MR. I am able to make some of my needs known. My BMI is 18.2 IBW 154. My intake is good 50-100%. I receive a sandwich at 10 and 2 p An interview with Dietary Manager (DM) #45, at 3:33 p.m. on 03/15/16, found the resident received a sandwich at 10:00 a.m. and 2:00 p.m. She stated the facility did not record the percentage of the sandwich consumed by the resident. When asked if the resident ate his sandwiches, she replied, I don't know, they aren't coming back to the kitchen so I guess he is eating them. Review of the percentages of meals consumed for (MONTH) (YEAR) with DM #45 found the resident was not consuming 75-100% of all meals. On four (4) occasions from 03/01/16 to 03/15/16, the resident consumed only 25% of his meals. On five (5) occasions from 03/01/16 to 03/15/16, he consumed only 50% of the meal served. At 4:08 p.m. on 03/15/16, the resident's Licensed Practical Nurse (LPN) #47 said, He doesn't eat those sandwiches. At 5:01 p.m. on 03/15/16, the DM said, I have discontinued the sandwiches and called the doctor who ordered a health shake at 10:00 a.m. and 2:00 p.m. to replace the sandwich. I will re-evaluate this in three (3) days to see if he is drinking the health shake. The DM confirmed the facility had not explored or assessed the reason for the resident's weight loss before surveyor intervention. f) Interviews with QA&A committee members. At 10:50 a.m. on 03/17/16, the administrator and the director of nursing (DON) were interviewed regarding Resident's #3, #63, and #14 who had bruising not identified by the facility prior to surveyor intervention. The DON was unaware incident reports were not being completed to identify non-pressure area skin conditions. The DON confirmed the QA&A committee had failed to identify this was an issue and no action plan was put in place prior to the discovery during the survey. For resident's #65 and #6, the DON confirmed the quality assessment and assurance (QA&A) committee failed to recognize the facility did not maintain acceptable parameters of nutritional status. No action plan had been implemented prior to the discovery during the survey. The DON was unaware of the discrepancies regarding the consumption for the snacks ordered for resident #65 and the nutritional supplement ordered for Resident #6.",2019-09-01
5565,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2015-02-11,225,C,0,1,II7711,"Based on personnel record review, review of the requirements for criminal background checks in West Virginia, review of the Affordable Healthcare Act, and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law. The facility failed to ensure the results of the fingerprint based statewide and/or federal criminal background checks were received and/or reviewed prior to employees working in the facility longer than sixty (60) days. This was true for three (3) of five (5) new hire personnel records reviewed. Employee identifiers: #69, #22, and #31. Facility Census: 65. Findings Include: a) Employee #69 A review of Employee #69's personnel record at 12:30 p.m. on 02/10/15, found Employee #69 was hired as a Laundry Aide on 10/29/14. Her sixtieth (60th) day of employment was 12/27/14. Review of her application found she had lived outside of the state of West Virginia in the previous five (5) years. Further review of the personnel record found no results of a fingerprint based federal background check. Additional review found the facility had mailed Employee #69's fingerprints to the company completing the federal criminal background check on 10/29/14. An interview with Employee #36, bookkeeper, at 12:45 p.m. on 02/10/15, revealed the facility identified Employee #69 had lived out of state and needed a fingerprint based federal background check. She indicated she mailed the fingerprints to the company completing the background check on 10/29/14. When asked if she had called to see why the results had not been returned she stated, No, because they told me it could take up to twelve (12) weeks to get the results back She said they advised her not to call until after twelve (12) weeks. Employee #36 was asked if Employee #69 was still actively working at the facility. She replied, Yes she is. Review of Employee #69's timecard on 02/11/15 at 1:25 p.m., for the previous thirty (30) days, found she had worked on 01/11/15 through 01/13/15, 01/16/15 through 01/20/15, 01/22/15, 01/23/15, 01/26/15 through 01/28/15, 01/30/15 through 02/02/15, 02/04/15 through 02/06/15, 02/09/15 through 02/11/15. Which was twenty-three (23) of thirty (30) days. b) Employee #22 A review of Employee #22's personnel record, at 12:50 p.m. on 02/10/15, found Employee #22 was hired as a Dietary Aide on 11/20/14. Her sixtieth (60th) day of employment was 01/18/15. Further review of the personnel record found no results of a fingerprint based statewide background check. Additional review found the facility had mailed Employee #22's fingerprints to the company completing the statewide criminal background check on 11/19/14. An interview with Employee #36, bookkeeper, at 1:00 p.m. on 02/10/15, revealed the she was aware the employee needed a fingerprint based statewide background check only. She indicated she mailed the fingerprints to the company completing the background check on 11/20/14. When asked if she had called to see why the results had not been returned she stated, No, because they told me it could take up to twelve (12) weeks to get the results back. When asked if Employee #22 was still actively working at the facility, she replied, Yes she is. Review of Employee #22's timecard on 02/11/15 at 1:25 p.m., from her sixtieth (60th ) day of employment, 01/18/15 to present, found she had worked on 01/19/15, 01/22/15, 01/24/15 through 01/27/15, 01/30/15 through 02/02/15, 02/05/15 through 02/09/15, which was fifteen (15) of twenty-four (24) days. c) Employee #31 A review of Employee #31's personnel record at 1:07 p.m. on 02/10/15, found Employee #31 was hired as a Registered Nurse on 08/18/14. Her sixtieth (60th) day of employment was 10/16/14. Further review of the personnel record found no results of a fingerprint based statewide background check. Additional review found the facility had mailed Employee #22's fingerprints to the company completing the statewide criminal background check on 08/29/14. An interview with Employee #36, bookkeeper, at 1:15 p.m. on 02/10/15, revealed the employee needed a fingerprint based statewide background check only. She indicated she mailed the fingerprints to the company completing the background check on 08/29/14. She further stated the company rejected Employee #31's fingerprints on 12/05/14. Employee #36 indicated the letter notifying them the fingerprints had been rejected was mailed to Employee #31 and not to the facility. Employee #36 stated Employee #31 did not bring in the rejection letter until two (2) weeks ago. Employee #36 stated she sent Employee #31 to have her fingerprints re-done today (02/10/15). Employee #36 was asked if Employee #31 was still actively working at the facility, and she replied, Yes she is. Review of Employee #31's timecard on 02/11/15 at 1:25 p.m., for the previous thirty (30) days found she had worked on 01/13/15, 01/14/15, 01/18/15, 01/21/15, 01/22/15, 01/29/15 through 01/31/15, 02/03/15, 02/04/15, 02/07/15, 02/08/15, and 02/11/15. Which was thirteen (13) of thirty (30) days. d) Review of Affordable Care Act Section 6201 Section 6201 (a)(3)(A) requires that long-term care facilities and providers obtain state and national criminal history background checks on prospective employees that utilize: a search of state-based abuse and neglect registries, state criminal history records, and national fingerprint-based criminal history record checks. Section 6201 (a)(3)(B) requires that participating states describe and test methods that reduce duplicative fingerprinting, including providing for the development of rap back capability by the State Section 6201 (a)(3)(C) requires that the background checks conducted under the nationwide program remain valid for a period of time as specified by the Secretary (not yet determined). Under section 6201 (a)(4)(A) and (B), participating states must also monitor compliance with the requirements of the nationwide program and have procedures in place to: - Conduct screening and criminal history background checks; - Monitor compliance by facilities and providers; - Provide for up to 60 days of provisional employment by the long term care facility/provider for a direct patient access employee, pending completion of the required criminal history background check or appeals process; . e) Review of Bureau of Medical Services (Medicaid) Services Manual The Bureau for Medical Services (Medicaid) manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). It is the responsibility of the employer to assure that the exclusion lists are checked monthly. The facility may employ an individual for a maximum of 60 days if a preliminary check is completed. The facility may choose to contract with a company that completes internet background checks use these results until the fingerprint results are received.",2018-10-01
5566,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2015-02-11,309,D,0,1,II7711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the provision of care and services to attain or maintain each resident's well-being for one (1) of five (5) residents reviewed during Stage 2 for the care area of unnecessary medications. Resident #71 was not provided medications in accordance with physician's orders [REDACTED]. Resident identifier: #71. Facility census: 65. Findings include: a) Resident #71 Medical record review, on 02/10/15 at 2:00 p.m., found a physician's orders [REDACTED]. The order included to notify the doctor if the systolic blood pressure was less than 100 or pulse was less than 50. The medication was prescribed for hypertension. ([MEDICATION NAME] is a beta blocker used to treat high blood pressure.) Review of the Medication Administration Record [REDACTED] -- 01/18/15 - 96/58, -- 01/19/15 - 84/52, -- 01/20/15 - 94/50, -- 01/24/15 - 82/38, -- 01/29/15 - 96/62. Documentation present on the MAR found the [MEDICATION NAME] was held on all of the these days. Further review of the nurses' notes and MAR found no evidence the physician was notified when the resident's blood pressure fell below the specified parameters. An interview with the director of nursing (DON) and Employee #16, a registered nurse, at 3:29 p.m. on 02/10/15, confirmed there was no evidence to support the physician was contacted regarding the resident's blood pressure and no evidence the physician ordered the medication to be held.",2018-10-01
5567,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2015-02-11,329,D,0,1,II7711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of medication administration, medical record review, and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary medications. Resident #18's physician did not provide a clinical rationale for not reducing the resident's dose of [MEDICATION NAME] as recommended by the consulting psychiatrist. This was identified, during a random opportunity for discovery, for one (1) of four (4) residents observed for medication administration. Resident identifier: #18. Facility census: 65. Findings include: a) Resident #18 During the observation of medication pass on 02/11/15 at 8:45 a.m., Registered Nurse (RN) #18 administered [MEDICATION NAME] 10 milligram (mg) by mouth to Resident #18. Medical record review on 02/11/15 at 10:00 a.m., found a physician's orders [REDACTED]. urea nitrogen (BUN) and creatinine (CR) (laboratory tests used to monitor the resident's kidney function). Further medical record review on 02/11/15, revealed a nursing entry, written on 02/04/15 by RN #69, noting, . (Psychiatrist's name) consult on 01/31/15 recommends decreasing her [MEDICATION NAME] and starting [MEDICATION NAME] due to her elevated BUN level . Notified (name of attending physician) and at this time we will not make any medication changes In an interview with the Director of Nursing on 02/11/15 at 12:00 p.m., she verified there was no order and/or clinical rationale provided by the attending physician for not reducing the [MEDICATION NAME] as ordered/recommended by the specialist after a consultation at the facility.",2018-10-01
5568,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2015-02-11,332,D,0,1,II7711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, review of Centers for Medicare and Medicaid Services (CMS) guidance to surveyors, and information from the National Institutes of Health (NIH), the facility failed to ensure it was free of a medication error rate of five (5) percent or greater. Two (2) errors were identified during twenty-eight (28) observed opportunities, making the facility's medication error rate 7%. Resident #21 received [MEDICATION NAME] without an apical pulse prior to administration. Resident #18 was administered [MEDICATION NAME] 10 milligrams (mg) at 9:00 a.m., when the medication had been reduced to at night only. Resident identifiers: #21 and #18. Facility census: 65. Findings include: a) Observation of medication administration pass, on 02/11/15 at 9:00 a.m., identified twenty-eight (28) opportunities for medication errors. There were two (2) medication errors observed in the twenty-eight (28) opportunities for error. b) Resident #21 On 02/11/15 at 9:09 a.m., Licensed Practical Nurse (LPN) #20, was observed as she administered one tablet of a cardiac glycoside ([MEDICATION NAME]) by mouth. She administered the medication with only a thirty (30) second radial (wrist) pulse prior to the administration. An interview with LPN #20, on 02/11/15 at 9:30 a.m., revealed an apical (chest) pulse should be obtained using a stethoscope for a full minute prior to the administration of [MEDICATION NAME]. She further stated, I am supposed to do an apical pulse for a full minute prior to giving the [MEDICATION NAME], but the resident just keeps talking when a stethoscope is placed on her chest. She further confirmed she had obtained a radial pulse for thirty (30) seconds instead of an apical pulse. Patient education compiled by the National Institutes of Health (NIH), related to how to administer [MEDICATION NAME], was reviewed on 02/11/15 at 9:45 a.m. The NIH recommends to monitor the apical pulse for one (1) full minute before administering. The CMS guidance directs medications be given in accordance with current commonly accepted health standards established by national organizations, boards, and councils. Interview with the director of nursing (DON) on 02/11/15 at 12:30 p.m., confirmed an apical pulse should be obtained for one (1) minute prior to the administration of [MEDICATION NAME]. c) Resident #18 Registered Nurse (RN) #55 was observed on 02/11/15 at 8:45 a.m. as she administered a dementia medication ([MEDICATION NAME]) to Resident #18. Medical record review, on 02/11/15 at 11:00 a.m., revealed an order written [REDACTED]. Interview with the director of nursing (DON) on 02/11/15 at 12:30 p.m., confirmed the order to reduce the [MEDICATION NAME] remained on the current physician orders. She further confirmed that although the [MEDICATION NAME] reduction was not approved by the attending physician, the licensed nurses had failed to discontinue the order to reduce the medication and thus the reduction should have been implemented as directed by the physician orders.",2018-10-01
5569,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2015-02-11,371,F,0,1,II7711,"Based on observation, staff interview, and policy review, the facility failed to ensure food was stored under sanitary conditions. Foods in the freezer were open, exposing them to potential contamination, unlabeled and undated. In addition, dry storage foods were not labeled and dated after they were opened. This had the potential to affect all residents who consumed food served from the kitchen. Facility census: 65. Findings include: a) Kitchen Observation of the freezer section and the dry storage room on 02/09/15 at 10:27 a.m., with Dietary Manager (DM) #65, found the walk-in freezer had a large clear plastic bag of chicken patties that was opened, undated and exposed to the freezer air. One (1) package each of Rice Krispies, toasted oat and corn flake cereal, and one (1) packages of hard marshmallows were opened with no date to identify when the products had been opened. The dietary manager (DM) stated the chicken patties were opened last Thursday. She said the bag must have come untied, and the toasted oats were just opened that morning. The DM stated, These marshmallows are hard, and I will throw these away. She agreed her staff should have put a date on the dry storage items when they were opened. The DM confirmed the chicken patties should have been labeled, properly tied, and should have contained the date of when they were opened. During an observation and interview in the dry storage room with the DM, on 02/11/15 at 10:45 a.m., there were cereals (Rice Krispies, and corn flakes) that were removed from the original packages. They were on a storage shelf in two (2) clear plastic containers which were unlabeled and undated. When asked if the containers should be labeled and dated, the DM confirmed they the containers of cereal should have been labeled and dated. A review of the facility's policy was conducted with the DM on 02/12/15 at 2:00 p.m. The policy directed frozen foods stored in the freezer were to be properly closed and have a use-by date of 45 days after opening. Dry food items were to be properly closed and have a use-by date of 60 days after opened. The DM confirmed staff should have indicated when each of the the food items was opened, so any dietary staff member would know when to discard the food items. The policy also stated items that were removed from the original box were to be individually dated. The containers which contained the dry bulk items were not clearly labeled with the product name or the date opened.",2018-10-01
7309,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2013-10-31,272,D,0,1,DOBF11,"Based on medical record review, staff interview, and observations, the facility failed to ensure the minimum data set (MDS) assessment accurately reflected the current condition of the resident. The facility incorrectly coded Resident #15 had contractures of the hand, wrist, and elbow. This was true for one (1) of fifteen (15) residents sampled in Stage 2 of the quality indicator survey. Resident identifier: #15. Facility census: 68. Findings include: a) Resident #15 Medical record review on 10/29/13 found the most recent MDS, with an assessment reference date (ARD) of 08/13/13, was coded in Section S (SC100) to indicate the resident had contractures of the hand, wrist, and elbow. During an interview with Employee #6, the registered nurse clinical reimbursement coordinator, at 2:46 p.m. on 10/29/13, she stated this was a mistake. She said the resident did not have contractures of the hand, wrist, or elbow. Observation of Resident #15 with Employee #6, at 2:55 p.m. on 10/29/13, found the resident could flex her hand, elbow and wrist with the assistance of Employee #6. The occupational therapist, Employee #84, also assessed the resident at 3:00 p.m. on 10/29/13. Employee #84 stated, the resident was flaccid and not contracted. Employee #84 further added, A contracture is an immovable joint, and according to his assessment this was not true for Resident #15. Both Employees #6 and #84 verified the MDS was incorrectly coded after their assessments on 10/29/13.",2017-06-01
7310,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2013-10-31,278,D,0,1,DOBF11,"Based on medical record review, staff interview, and observations, the facility failed to ensure the minimum data set (MDS) assessment for one (1) of fifteen (15) residents reviewed in Stage 2 of the quality indicator survey accurately reflected the resident's status. The MDS was certified as being accurate by the registered nurse clinical reimbursement coordinator; however, Section (S), entitled functional status / contractures was coded incorrectly. Resident identifier: #15. Facility census: 68. Findings include: a) Resident #15 Medical record review, on 10/29/13, found the most recent MDS, with an assessment reference date (ARD) of 08/13/13, Section S (SC100) was coded to indicate the resident had contractures of the hand, wrist, and elbow. The accuracy of the MDS was verified by Employee #6 on 08/15/13. During an interview with Employee #6, the registered nurse clinical reimbursement coordinator, at 2:46 p.m. on 10/29/13, she stated this was a mistake and the resident did not have contractures of the hand, wrist, or elbow. Observation of Resident #15 with Employee #6, at 2:55 p.m. on 10/29/13, found the resident could flex her hand, elbow and wrist with the assistance of Employee #6. The occupational therapist, Employee #84 also assessed the resident at 3:00 p.m. on 10/29/13. Employee #84 stated the resident was flaccid and not contracted. Employee #84 further added, A contracture is an immovable joint, and according to his assessment, this was not true for Resident #15. Both Employees #6 and #84 verified the MDS was incorrectly coded after their assessments on 10/29/13. At 3:15 p.m. on 10/29/13, Employee #6 stated she would submit a corrected MDS.",2017-06-01
7311,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2013-10-31,371,F,0,1,DOBF11,"Based on observation and staff interview, the facility failed to ensure food items were stored and dated properly after opening. The unused portions of biscuit mix and granulated brown sugar were not dated after they were opened. Due to this practice, the staff was not able to verify if these foods were safe to use. This had the potential to affect more than an isolated number of residents receiving nourishment from the dietary kitchen. Census: 68 Findings include: a) On 10/28/13 at 11:50 a.m., during the tour of the kitchen storage room, it was discovered the remaining, unused portion of a five (5) pound bag of biscuit mix and a two (2) pound bag of granulated brown sugar was not dated after opening. This practice did not inform the staff these food items were safe to use. A staff interview was conducted on 10/29/13 at 10:05 a.m., with Employee #79, Food Service Director. She verified the biscuit mix and the brown sugar was not dated after being opened. She also reported she knew all unused food items were to be dated after opening.",2017-06-01
8727,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2012-05-10,272,D,0,1,B5IX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interviews, the facility failed to ensure the minimum data sets (MDS) for two (2) of twenty-six (26) residents were completed accurately. Resident #21's assessment did not accurately reflect the resident's dental status, and Resident #77's weight loss was not reflected on her assessment. Resident identifiers: #21 and #77. Facility census: 68. Findings include: a) Resident #21 Observation of the resident's oral cavity during Stage I of the quality indicator survey (QIS) found the resident had some broken natural teeth. Review of the minimum data set (MDS), with an assessment reference date (ARD) of 09/24/11, Section (L) - Oral/dental status, item (d) found the facility documented the resident had no Obvious or likely cavity or broken natural teeth. Observation of the resident's oral cavity with Employee #75, a licensed practical nurse, at 2:30 p.m. on 05/08/12, found the resident had at least one broken tooth on the top upper right side of her gum. Further review of the medical record found the facility had referred the resident for a dental consult on 11/04/11 for, . two teeth decayed and broke off on the upper right side leaving a snag. The results of the dental consult found documentation from the dentist, Resident's (#6) tooth was broken to gingival margin, patient said the tooth was not hurting and she did not want an extraction at this time. That is ok as long as it does not hurt. Review of oral assessments, completed by the nursing staff, found only one assessment completed on 02/08/11, before the 09/24/11 MDS. The oral assessment indicated, Has several own teeth. A few small caries maybe present but no large areas. During an interview with the with dietary manager, on 05/08/12 at 3:20 p.m., she verified the resident's diet was changed from a regular diet to a mechanically soft diet on 11/02/11 due to, loosing some teeth. The dietary manager was unsure of any further details regarding the resident's dental issues. An interview with Employee #8, the registered nurse unit manager, at 3:30 p.m. on 05/08/12, revealed the resident did not received any dental consults between 02/08/11 (the completion of the oral assessment), and the completion of the 09/24/11 annual MDS. Employee #8 verified the 09/24/11 MDS was incorrectly coded under Section (L) question (d). Employee #29, a registered nurse, was also interviewed with Employee #8. Employee #29 stated she had completed the oral assessment. She verified the resident had a few small caries when she examined the oral cavity. She said she should have written a nursing note so the dental issues were identified before completion of the 09/24/12 MDS. b) Resident #77 This resident was admitted to the facility on [DATE]. Her weight was listed as 361 lbs. (pounds) on the five (5) day Medicare admission MDS assessment, with an ARD of 04/03/12. The next MDS assessment, with an ARD of 04/13/12, which was a Medicare 14 day assessment, indicated the weight was 328 lbs. This was a loss of 33 lbs in ten (10) days. If a resident loses more than than 5% in 30 days, the MDS should have been coded as a significant weight change having occurred. A 5% weight change for this resident would have been 18 lbs. The weight was coded as a 0 which indicated no change. The next MDS significant change assessment, with an ARD of 04/27/12, revealed the resident's weight was now 312 pounds. This assessment had been coded as a significant change for other areas, but not the weight loss. The weight on this assessment represented an additional loss of 16 pounds in 14 days. This was also a significant weight loss. Again the MDS assessment was coded as a 0 which meant no weight change or none known. Interview with Employee #8, the RN (registered nurse) unit charge nurse, on 05/08/12 in the afternoon, revealed she had reviewed the definition of the weight loss. According to the MDS criteria it should have been coded as a Yes or 1 (one) which would indicate a significant weight loss on both MDS assessments. She stated it was a human error in coding. The MDS had been coded as a 0 which meant there was no weight loss or gain or it was unknown.",2016-04-01
8728,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2012-05-10,280,D,0,1,B5IX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, it was determined the facility had not revised the care plan for one (1) of twenty-six (26) sampled residents. Upon admission to the facility, Resident #73 had planned to return home after discharge from the facility. Her plans later changed and she decided to become a long-term resident of the facility. Her care plan was not revised to reflect the change in her discharge plans. Resident identifier: #73. Facility census: 68. Findings include: a) Resident #73 Resident #73 was admitted to the facility on [DATE]. Her initial discharge plans were to return home. Review of the medical record found, on 04/13/12 at 9:25 a.m., Resident #73 told Employee #54 (social worker) her plans had changed, and she wanted to reside in the facility long term. Review of the care plan, on 05/08/12, identified the care plan had not been revised to reflect the resident's change in discharge plans. During an interview with Employee #54, on 05/09/12, she confirmed she had not made revisions to the care plan to reflect the changes in Resident #73's discharge plans.",2016-04-01
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
2318,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2017-10-04,272,D,0,1,JGSV11,"Based on observation, staff interview, and record review the facility failed to ensure a comprehensive Minimum Data Set (MDS) was accurate and complete for one (1) of three (3) residents reviewed for the care area of dental status and services. Resident identifier: #11. Facility census: 78. Findings include: a) Resident #11 Observation of the resident during Stage 1 of the Quality Indicator Survey (QIS) at 8:15 a.m. on 10/03/17, found the resident had upper dentures. The resident had some natural teeth and a partial on the lower jaw. Several of the resident's teeth were missing, some were broken, and some appeared to be discolored possibly indicating a cavity. Review of the resident's admission MDS, with an assessment reference date (ARD) of 09/21/17, found the dental section coded the resident as having no obvious or likely cavity or broken natural teeth. At 3:49 p.m. on 10/03/17, observation of Resident #11's oral cavity with Employee #5, the Registered Nurse (RN) MDS coordinator, confirmed the resident has broken natural teeth and likely some cavities. RN #5 said she would complete a corrected MDS.",2020-09-01
2319,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2017-10-04,278,E,0,1,JGSV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the Minimum Data Set's (MDS's) were accurately completed to represent the resident's status for four (4) of eleven (11) resident's whose's MDS's were reviewed during Stage 2 of the Quality Indicator survey (QIS). Resident's #118, #31 and #33's MDS's were inaccurate in the care area of behavioral and emotional status. In addition, Resident #33's MDS was inaccurate in the care area of activities of daily living (ADL's). Resident #34's MDS was inaccurate in the care area of accidents. Resident identifiers: #118, #31, #34, and #33. Facility census: 78. Findings include: a) Resident #118 Record review at 1:30 p.m. on 10/03/17, found the resident was admitted to the facility on [DATE]. The resident discharged to his home on 07/18/17. The resident triggered the care area of behavioral and emotional status during Stage 2 of the Quality Indicator Survey (QIS). The 14 day minimum data set (MDS) with an assessment reference date (ARD) of 07/04/17, coded the resident as rejecting care 1 to 3 days (e.g. blood work, taking medications, activities of daily living (ADL) assistance) that is necessary to achieve the resident's goals for health and well-being. On 10/03/17 at 2:34 p.m., Employee #5, the Registered Nurse (RN) MDS coordinator confirmed the MDS was coded incorrectly. RN #5 said she could find no evidence in the chart the resident resisted care during the look back period for competition of the 14 day MDS. b) Resident #31 Resident #31 triggered the care area of behavioral and emotional status during Stage 2 of the Quality Indicator Survey (QIS The quarterly Minimum Data Set (MDS) for Resident # 31 with Assessment Reference Date (ARD) 06/03/17, Section E, Behavior, Rejection of Care, stated the behavior was not exhibited. The Brief Interview for Mental Status (BIMS) score was 13. The quarterly MDS for Resident #31 with ARD 08/24/17, Section E, Behavior, Rejection of Care, stated behavior of this this type occurred one (1) to three (3) days. A Nurses Note written on 08/22/17 at 9:21 p.m. stated, Resident refused shower this evening. Resident stated he would rather have his shower at a different time. During an interview on 10/04/17 10:00 a.m., the Director of Nursing (DoN) stated she was not aware of any refusal of care other than the refusal of the shower during the look-back period for the MDS with ARD 08/24/17. During an interview on 10/04/2017 at 10:52 a.m., the DoN was shown the Resident Assessment Instrument (RAI) Manual page E-15 which stated, The intent of this item (E ) is to identify potential behavioral problems, not situations in which care has been rejected based on a choice that is consistent with the resident's preference or goals for health well-being or a choice made on behalf of the resident by a family member or other proxy decision maker. The DoN agreed showering schedule is a resident preference. The DoN stated some education needed to be done with the MDS staff. On 10/04/17, the quarterly MDS for Resident #31 with ARD 08/24/17, Section E, Behavior, Rejection of Care, was corrected to state that the behavior was not exhibited. c) Resident #34 A review of Resident #34's medical record at 9:12 a.m. on 10/04/17 found a Quarterly Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 03/16/17. Review of this MDS found section J1800. Any falls since admission/entry or Reentry or Prior Assessment, whichever is more recent was responded to with a number one (1) which indicated the resident had fallen since her prior assessment which had an ARD of 12/19/16. Further review of the MDS found Section J1900. Number falls Since Admission/entry reentry or Prior Assessment, whichever is more recent was marked to indicate resident #34 had only sustained one (1) fall with no injury since the previous MDS with an ARD of 12/19/16 Review of Resident #34's medical record found Resident #34 fell on [DATE] and 02/27/17. This was two (2) falls with no injury between the MDS assessment on 12/19/16 and the MDS assessment on 03/16/17. An interview with Registered Nurse (RN) MDS Coordinator #5 at 1:27 p.m. on 10/04/17 confirmed the MDS with an ARD of 03/16/17 was not completed to accurately reflect the number of falls Resident #34 sustained between the assessment completed on 12/19/16 and the assessment completed on 03/16/17. She indicated that she would submit a correction to correct the mistake. d) Resident #33 During Stage 2 of the Quality Indicator Survey (QIS), Resident triggered for a decline in Activities of Daily Living (ADL). This decline was in the area of locomotion off of the unit. The 14 day MDS with an assessment reference date (ARD) of 07/31/17 indicated Resident #33 required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance) with locomotion and the 30 day MDS with ARD of 08/14/17, Resident #33 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with locomotion. Additionally the resident triggered the care area of behavioral and emotional status during Stage 2 of the Quality Indicator Survey (QIS). The 30 day minimum data set (MDS) with an assessment reference date (ARD) of 08/14/17 noted the resident rejected care 1 to 3 days (e.g. blood work, taking medications, activities of daily living (ADL) assistance) that is necessary to achieve the resident's goals for health and well-being. On 10/03/17 at 3:30 p.m., the Director of Nursing (DON) reviewed the look back period of the MDS with ARD of 08/14/17 was inaccurate. She confirmed Resident #33 did not have a decline in locomotion off the unit. She required limited assistance in locomotion off the unit. Additionally, she confirmed the resident did refused one (1) shower but this was her choice and not a rejection of care in which would prevent the resident's goals for health and well-being.",2020-09-01
2320,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2017-10-04,282,E,0,1,JGSV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement one (1) of eleven (11) resident's care plans reviewed during Stage 2 of the Quality Indicator Survey (QIS). Staff continued to weight Resident #100 after the care plan directed staff to discontinue weights. Resident identifier: #100. Facility census: 78. Findings include: a) Resident #100 Review of the resident's care plan on 10/03/17 at 10:00 a.m., found the current problem: Risk of altered nutrition/hydration status related to disease [DIAGNOSES REDACTED]. Resident is comfort care with no weights. The problem was initiated on 12/20/16 and revised on 07/06/17. Interventions included: Discontinue weights as ordered, dated 12/20/16. Review of the resident's weights and vitals summary found weights were obtained on the following dates after the care plan directed discontinuing the weights on 12/20/17: --12/28/17 --01/02/17 --01/08/17 --01/15/17 --01/22/17 --01/29/17 --02/07/17 --03/02/17 --04/06/17 --05/02/17 --06/05/17 --07/02/17 --08/02/17 --08/13/17 An interview with the director of nursing (DON) at 11:11 on 10/03/17, confirmed the facility should have discontinued weights after 12/20/17, as directed by the care plan.",2020-09-01
2321,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2017-10-04,371,E,0,1,JGSV11,"Based on observations and staff interview, the facility failed to store foods under sanitary conditions. Food items were stored unlabeled and undated, food equipment was found soiled and in need of cleaning (gasket to chest type freezer had a mold like substance) and debris, the drip pan had accumulated food debris. This procedure has the potential to affect all residents who consume foods by oral means that are served from this central location. Census: 78. Findings include: a) During the initial tour after entrance at 11:15 a.m. on 10/02/17 the following issues were noted: 1. In the walkin refrigerator a container of syrup was unlabeled and dated which would ensure dietary staff knew when it was opened and if still safe for consumption. 2. A chest type cooler for milk cartons was found to have the gasket soiled with debris and in need of cleaning; 3. The drip pan under the range top was heavily soiled with food debris and needed cleaning; These issued were verified with the assistant dietary manager at the time of the observations.",2020-09-01
2322,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2018-10-19,558,D,0,1,6SIG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview and staff interview, the facility failed to ensure accommodations for Resident #336 to have an appropriately fitted wheelchair. Resident identifier: #336. Facility census 85. Findings included: a) Resident #336 During an interview on 10/15/18 at 10:45 AM, Resident #336 stated the his wheelchair was to small and Physical Therapist (FT) #119 told him on Friday (10/12/18) he thinks there is a wheelchair that would fit him. However, it is locked up, and he told Resident #36 he would get it for him first think on Monday morning (10/15/18). Resident #336 stated he was still waiting for the wheelchair. During an interview on 10/18/18 at 2:56 PM, Resident #336 stated he still does not have a wheelchair to fit him. He also stated he has to hold his legs up to use his current wheelchair. He said, By the time I get to the other side of the building for therapy, I am worn out. Then by the time I have therapy and holds my legs up to get back to my room I'm in so much pain. Resident #336 stated they (the Physical therapy staff) stuck some kind of a board under him and removed the footrest to try to help him, but that was not very good. He went on to say, I can't beleive I'm the only 61 man that has ever been here. On 10/18/18 at 3:00 PM, Physical Therapy Assistant (PTA) # 111 said that, they have tried to rig up a chair for his height, today they tried to raise up the seat and placed a board under him to help him support his legs. During an interview on 10/18/18 at 3:10 PM, Director of Rehab #122 was asked about providing a wheelchair that fits this resident. She said she was unware of what this surveyor was talking about. It was explained to her that this resident was admitted on [DATE] and was told by PT #119 on 10/12/18, he would find him a wheelchair that fits him on Monday, and as of today he still does not have one. She was asked what was her plan to accommadate the needs of this resident. She answered, Well I guess we can order one, she was asked how long will that take, and she shrugged her shoulders and replied a week or so. On 10/18/18 at 3:09 PM, the Administrator was informed of the situation with Resident #336. Corporate Vice President #125 was present with the interview with the Administrator. She asked if I reported this to the facility on Monday. This surveyor informed her that PT #119 has known about this since 10/12/18. She said they will go and talk to the resident to see what he needs. On 10/18/18 at 3:33 PM, PT #119 said he and others looked in the storage area, could not find a chair. He adjusted his chair yesterday. He said that he will try to find him in another chair when they locate one. He said that ordering a special chair to accomadate his height and that would cost a $1000.00 or more. On 10/18/18 at 3:40 PM, Administrator said he is ordering this resident a taller wheelchair.",2020-09-01
2323,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2018-10-19,580,D,1,1,6SIG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, the facility failed to notify Resident #186's family/responsible party when there were changes in his condition and/or his plan of care. On multiple occasions, Resident #186's family was not notified of medication changes or changes in his condition. Resident #186 lacked capacity to make informed medical decisions effective on [DATE]. This was a random opportunity for discovery. Resident identifier: #186. Facility census: 85. Findings included: a) Resident #186 A review of Resident #186's medical record found a physician's determination of capacity dated [DATE] which indicated the resident did not have the capacity to make health care decisions. Further review of the record found the following notes: 1. Note dated [DATE] at 3:30 p.m. read as follows, Resident found walking by self in the room by physical therapy. Resident stated, I am not feeling well. Resident was in the bathroom stating, I don't feel well. Skin clammy. Blood sugar: 243, blood pressure ,[DATE], pulse 50, respirations 18 and oxygen (O2) saturation (sat) was 88 % (percent). Resident had a large diarrhea stool, the resident stating, It is the second one today. Resident assisted back to bed. O2 sat still 88% and pulse 50. States, I am feeling better. Review of the facility's standing orders found, Shortness of breath or low O2 saturation less than 90%: Initiate oxygen at two (2) liters/minute (2 L/M) via nasal cannula and notify the physician. No documentation the family/responsible party and/or physician when the above change in condition occurred. 2. Note dated [DATE] at 4:23 pm read as follows: Resident sitting up in wheelchair, pulse now 57 and O2 sat 83%. Oxygen placed at 2 L/M via nasal cannula. Resident states, I feel okay. No documentation the family/responsible party and/or physician when the above change in condition occurred. 3. Note dated [DATE] at 5:15 pm read as follows: Resident with complaints of nausea, chest discomfort, and fell ing sweaty. Upon observation resident noted to have [MEDICAL CONDITION], diaphoresis, and nausea. The resident has orders for the following advance directives: CPR (cardiopulmonary resuscitation). Resident had complaints of nausea, sweatiness, and mild chest discomfort to daughter. Upon assessment, resident very diaphoretic, nauseated, and heart rate of 48. Resident had an episode earlier in the shift with some loose stool. O2 sat was low and resident was placed on O2 at 2 L/M via nasal cannula. Now resident denies chest pain to nurse. Vital signs stable. The next note dated [DATE] at 11:05 pm read as follows: Resident returned from (Name of Hospital) now via ambulance. [DIAGNOSES REDACTED]. Denies chest pain now. Vital signs (VS) blood pressure- ,[DATE], pulse- 77, SPO2 100% on room air., temperature 97.7 and blood sugar (BS) 236. Assisted in bed. Snack given. Call bell in reach. New orders to change [MEDICATION NAME] to 10 milligrams (MG) and to stop [MEDICATION NAME] per (Physician's Name). Will monitor for changes. No documentation the family/responsible party when the above change in condition occurred. 4. Progress note dated [DATE] at 7:13 am read as follows: Lab results received. Blood urea nitrogen (BUN), potassium 5.7, and creatinine 1.5. (Name of Physician) contacted. Received new orders for 0.45 Sodium Chloride solution at 60 ML per hour times two (2) liters (2,000 ml) subcutaneous (SQ) via hypodermocysis and [MEDICATION NAME] (potassium reducing medication) now and second dose in 24 hours, repeat the Basic Metabolic Panel (BMP) in 24 hours. No documentation the family/responsible party when the above change in condition occurred. 5. Note dated [DATE] at 10:30 am read as follows: Urine culture results received. No significant growth in 24 hours. Doctor notified. Resident aware. No documentation the family/responsible party when the above change in condition occurred. 6. Note dated [DATE] at 3:29 pm read as follows: New order to discontinue [MEDICATION NAME] due to urine culture having no growth. Resident aware. No documentation the family/responsible party when the above change in condition occurred. 7. Progress note dated [DATE] at 5:08 am read as follows: [MEDICATION NAME] 15 units subcutaneously (SQ) held due to blood sugar of 82. Review of physician's orders [REDACTED]. No documentation the family/responsible party and/or physician when the above change in condition occurred. Interview with the Director of Nursing (DON) on [DATE] at 11:10 am. During this review, Resident #186's medical record was reviewed: physician orders, progress notes, and standing orders found on the seven (7) occasions the physician and/or responsible party was not notified of a change in Resident #186's medical condition. DON confirmed the responsibility party was not notified. She also confirmed Resident #186 did not have capacity to make medical decisions.",2020-09-01
2324,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2018-10-19,583,D,0,1,6SIG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview with the Hospice nurse (contracted by the facility to provide care), policy review and staff interview, the facility failed to ensure residents had the right to privacy during personal care. Resident #29, was assessed by a Hospice Nurse beside the nurses station. Resident #71 was not afforded privacy during perineal care. This was a random opportunity for discovery. Resident identifiers: #29 and #71. Facility census: 85. Findings included: a) Resident #29 Observation of the resident at 11:28 AM on 10/16/18, found the resident was seated in a wheelchair beside a wall directly across from the nurses station. A female was observed to be squatting in the floor beside the resident. Further observation found the female was obtaining blood pressure and pulse. The female asked the resident if she was in any pain and asking how the resident was feeling. The resident did not respond to her questions. The surveyor asked the female who she was and she identified herself as the resident's Hospice Nurse, Contracted Employee (CE) #140. When asked if she should be assessing the resident in the hallway, she said the resident wanted her to perform the assessment in the hallway. CE #140 stopped the assessment. Nursing assistant, NA #2 came down the hallway and asked Resident #29 if she was ready to go to lunch. The resident acknowledged with a smile and NA #2 took the resident to the dining room with CE #140 following the resident and the NA down the hallway to the dining room. Record review found the physician certified the resident for Hospice services on 05/22/18. The [DIAGNOSES REDACTED]. Review of several assessments by the Hospice nurse found the following documentation: 06/12/18, .When I call her name she responds, Yes. Pt. (patient) does not respond to any of my other questions at this time . 07/25/18, .She is easily roused but does not open her eyes and verbiage is difficult to understand. Baby is understood . Her mental status was described as lethargic and confused. Receptive to assessment: not able to follow commands. 08/01/18 .She doesn't follow commands and doesn't open her eyes states only, Whatever Review of the resident's most recent minimum data set (MDS), a quarterly, with an assessment reference date (ARD) of 08/24/18 found the facility was unable to complete a brief interview for mental status (BIMS) with the resident. The facility coded the resident as being rarely/never understood as the reason not to complete the BIMS. The staff assessment of the residents' mental status on the MDS, coded the resident as having long and short term memory problems, unable to recall the current season, location of room, staff names and faces, and unable to recall she is residing in a nursing home. The MDS indicated a mood assessment/interview was unable to be conducted as the resident is rarely/never understood. The observation of the Hospice nurses assessment in the hallway was discussed with the director of nursing at 11:45 AM on 10/15/18. At 3:13 PM on 10/18/18, the above situation was again discussed with the DON and a corporate Registered Nurse, RN #124. No further information was provided by these employees by the close of the survey on 10/19/18 at 3:15 PM. b) Resident #71 During an observation of incontinence care, on 10/18/18 at 9:16 AM, Nurse Aide (NA) #130, did not close the door to the resident's room. During interview with NA #130, she had no comment about the door being open. On 10/18/18 at 10:02 AM, DON was informed for the observation of NA #130 not ensuring Resident #71 had privacy during peri-care. She said that, she was surpised because NA #130 was one of the best nurse aides at the facility.",2020-09-01
2325,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2018-10-19,641,E,0,1,6SIG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview and staff interview, facility failed to accurately complete the Minimum Data Set (MDS) to reflect each resident's status. This was true for five (5) of twenty-three (23) sampled residents. Resident identifiers: #47, #76, #183, #17, and #14. Facility census: 85. Findings included: a) Resident #47 Observation and interview on 10/15/18 at 3:04 pm, found Resident #47, had lower teeth broken off at gum level, he stated, I had my upper teeth extracted, but not my lower. Resident states, These teeth don't hurt me. I was going to get them pulled years ago but could not afford to have them removed. Observation and interview with Employee #65, Registered Nurse (RN) Unit Manager (UM) on 10/19/18 at 11:10 am, found the resident had multiple lower teeth which were broken off at gum level and some was partially covered by the gum. Review of the annual MDS with assessment reference date (ARD) of 08/14/18, found Section L Oral/Dental Status indicated the resident had no natural teeth or tooth fragment (s) (edentulous). The Director of Nursing (DON) was notified of the inaccurate MDS with ARD of 08/14/18 on 10/19/18 at 1:05 pm. No further information was provided. b) Resident #76 Medical record review for Resident #76 receives [MEDICATION NAME] 75 milligrams (mg) daily. On 08/21/18, the consultant pharmacist requested a gradual dose reduction (GDR) for the [MEDICATION NAME]. On 08/29/18, Resident #76's physician responded on 08/29/18, the resident had a failed GDR of [MEDICATION NAME] in (MONTH) (YEAR) and she indicated the recommendation above ([MEDICATION NAME]) is clinically contraindicated for this individual as indicated below. (severe anxiety and agitation). Review of the MDS with an ARD of 09/28/18, Section N 0450 D, Antipschotic Medication Review, this review indicated No, GDR has not been documented by a physician as clinically contraindicated. Section N0450 E- Date physician documented GDR as clinically contraindicated. Section [NAME] was blank. Interview with the DON on 10/16/18 at 11:00 am, she confirmed the MDS with ARD of 09/28/18 was inaccurate. The physician had documented on 08/26/18 a GDR of [MEDICATION NAME] was clinically contraindicated. No further information was provided. c) Resident #186 History and Physical (H&P) completed on 07/18/18 at hospital reveals the resident has complaints of right knee pain, decreased ROM, and inability to bear weight on the right leg. Resident #186 was admitted to the facility on [DATE] for rehabilitation for fractured right side of pelvis. Review of Resident #186's admission assessment and care plan, found the resident had upper and lower dentures, hard of hearing and wears bilateral hearing aids, limited mobility in lower extremities due to fracture on right side of pelvis without dislocation and increased pain especially on right side (hip and leg) with transfers and ambulation. Review of the progress notes found a note dated 07/24/18 at 1:11 pm which read: .Resident at this time refusing medications, refusing to start antibiotic and hyodermaclysis Further review of the capacity form dated 07/22/18, which indicates Resident #186 is incapacitated due to [MEDICAL CONDITION]. Review of the admission MDS with an ARD of07/28/18 found the following section inaccurate: --B 0200- Hearing marked 0- no hearing aids --E 0800- Rejection of Care marked 0- no rejection of care. --G 0400- Functional limitation in range of motion (ROM) marked 0- no limitations --I 4800- Neurological left blank --J 1700- C- Did the resident have any fracture related to fall in the 6 months prior to admission/entry or reentry - marked 0- no falls. --L 0200- Dental Marked none of above were present. Interview with the DON on 10/18/18 at 2:15 pm. Review of Resident #186's medical records found the MDS with ARD of 07/28/18 was inaccurate in all of the above areas. She confirmed the resident wears bilateral hearing aids, edentulous with full upper and lower dentures, did reject care (medications and fluids) on 07/24/18, resident has ROM limitation of lower extremities due to a recent fall with a fractured pelvis and pain when standing or ambulating, he was diagnosied with vascular demnetia on 07/22/18 and also had a fracture of pelvis within 6 months of admission due to a fall. d) Resident #14 Resident #14's Minimum Data Set (MDS) with Assessment Reference Date (ARD) 05/03/18 indicated the resident had no falls since admission or reentry or prior assessment, whichever is more recent. According to Resident #14's medical records, the resident had a fall on 05/04/18. She was sent to the emergency room and diagnosed with [REDACTED]. Resident #14's MDS with ARD 05/17/18 indicated the resident had no falls since admission or reentry or prior assessment, whichever is more recent. During an interview on 10/17/18 at 1:45 PM, Registered Nurse (RN) MDS Coordinator #88stated Resident #14's MDS with ARD 05/17/18 should have documented the resident had a fall since the previous MDS with ARD 05/03/18. The RN MDS Coordinator stated she would review the resident's records to determine if an injury had been sustained in the fall and then correct the information. e) Resident #17 On 10/15/18 at 1:17 PM, observation and interview with the resident found he was unable to move his right arm upon command. The resident demonstrated by taking his left hand, grasping his right arm by the wrist, and moving the right arm up and down with his left hand. He said he couldn't move his arm, wrist or fingers on his own. The arm did not appear to be contracted, just flaccid, (soft and hanging loosely or limply.) Review of the resident's most recent minimum data set (MDS), an annual, with a reference assessment date of 08/01/18, found the MDS coded the residents right side as being dominant side in Section S, entitled functional status. The MDS further coded the resident has having full use of his dominant hand/arm. At 11:56 AM on 10/18/18, Employee #88, a Registered Nurse, MDS coordinator confirmed the MDS was coded incorrectly. She said the resident does not have full use of his right hand/arm. [NAME] #88 said she would do a corrected MDS. On 10/18/18 at 03:25 PM, the above issue was discussed with the director of nursing and a corporate Registered Nurse, RN #124. No further information was provided by these two employees before the close of the survey on 10/19/18 at 3:15 PM.",2020-09-01
2326,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2018-10-19,656,E,0,1,6SIG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff interview and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident. This practice affected five (5) of the twenty-three (23) residents reviewed in the survey sample. Resident identifiers: #39, 317, #29, #51, #64. Facility census: 85. Findings included: a) Resident #39 1. Nonpharmacological interventions for pain Resident #39 had [DIAGNOSES REDACTED]. The resident had an order for [REDACTED]. Resident #39's comprehensive care plan contained the following focus, Resident is at risk for pain related to history of falls, [MEDICAL CONDITION], gout, hemorrhoids, dry eyes, nausea,[MEDICAL CONDITION] constipation. Resident c/o of right shoulder/arm pain. Resident frequently sits on toilet for extended period of time. The interventions included, Pain assessments every shift. Attempt non-pharmacological interventions prior to administering PRN [MEDICATION NAME]. Specific resident-centered nonpharmacological interventions were not documented. On [DATE] at 2:20 PM, Resident #39 told the Director of Nursing (DoN) and this surveyor that she had pain in her hands because she had been exercising them. The DoN stated the resident had an order for [REDACTED]. A nurse's note written on [DATE] at 14:35 stated, Nurse assessed resident's pain. Resident stated that she was experiencing pain, when asked where she was hurting she stated that her hand was hurting when she uses it for exercise. Resident stated that she was having a ,[DATE] pain, resident has orders for [MEDICATION NAME] 50mg BID (twice a day). Standing order for Tylenol initiated. Will continue to observe. The medication was noted to be effective on the Medication Administration Record [REDACTED] 2. Range of motion During an interview with Resident #39 on [DATE] at 2:29 PM, the resident stated she exercised her hands and legs. Upon command, she was able to straighten the palm of her left hand, but she was not able to fully the fingers on her left hand. The Director of Nursing (DoN) was present during the interview with the resident. During an interview on [DATE] at 8:28 AM, Physical Therapy Assistant (PTA) #114 stated Resident #39 was currently receiving physical therapy. PTA #114 stated physical therapy was working with resident's lower extremities while the resident was in bed because she was no longer able to go to the physical therapy department. During an interview on [DATE] at 8:32 AM, Occupational Therapy Assistant (OTA) #117 stated Resident #39 had declined occupational therapy after her last screening. The Occupational Therapy Screening Form dated [DATE] stated, Patient would like physical therapy not OT (occupational therapy). Review of Resident #39's comprehensive care plan revealed the care plan did not contain a focus related to range of motion. During an interview on [DATE] at 9:44 AM, the DoN stated that it was new that Resident #39 wanted to exercise. She stated she would review Resident #39's comprehensive care plan for information relating to range of motion. On [DATE] at 10:51 AM, the DoN demonstrated Resident #39's Comprehensive Care Plan included the intervention, Encourage activity and exercise during the day. This intervention was included with the focus, Resident has episodes of difficulty sleeping. No further information regarding range of motion was documented on the comprehensive care plan. 3. TED ([MEDICAL CONDITION]-Embolic Deterrent) Hose Resident #39's comprehensive care plan contained the intervention, Knee high ted hose ON AM OFF PM. This intervention was contained in the focus, Resident is at risk for ADL decline related to muscle weakness, fatigue, diabetes, and depression. TED hose is used to prevent blood clots. On [DATE] at 10:00 AM, Wound Nurse Licensed Practical Nurse (LPN) #24 was observed performing wound care to a diabetic ulcer and two (2) deep tissue injuries on Resident #39's right foot. Resident was noted to not have TED hose on at this time. On [DATE] at 3:25 PM, Resident #39 was again observed not to have TED hose on. LPN #36 was present during this observation. She stated she would check to see if Resident #39's physician wanted to continue the order. On [DATE] at 3:31 PM, the Director of Nursing (DoN) was informed Resident #39 had an intervention on her comprehensive care plan for TED hose to be applied in the morning and removed at night. The DoN was also informed Resident #39 did not have her TED hose on when observed on two occasions that day. The DoN had no further information regarding the matter. On [DATE], an order was written to Discontinue TED hose due to resident not getting out of bed at this time. b) Resident #17 During an interview with the resident at 1:22 PM on [DATE], the resident said, I got my teeth pulled now I need dentures. They told me Medicaid doesn't pay for them. Review of the resident's care plan found the following focus/problem: The resident has oral/dental health problems or is at risk for oral/dental health problems. The goal associated with the problem: The resident will be free from infection, pain, or bleeding in the oral cavity (mouth) and resident will comply with mouth care at least daily through next review. Interventions included: Resident has natural teeth. Oral hygiene twice daily and as needed. Observation of the resident's oral cavity with Registered Nurse, minimum data set coordinator, (RN #88), at 12:03 PM on [DATE], found the resident does not have his own natural teeth. At 1:38 PM on [DATE], RN #88 confirmed the resident's care plan was not accurate and he does not have his own natural teeth. c) Resident #29 Record review found an order for [REDACTED].>Review of the resident's care plan addressing Hospice services found the following focus: (Name of Resident) will also be receiving Hospice due to end stage Alzheimer' disease; post and plan of care have been reviewed with responsible party and (Name of Resident) does not want CPR, requests not to be transferred to the hospital, does not want enter al/tube feeding, requests no antibiotics, no labs, no weights. The goals associated with the focus are: Advanced directives will be honored by staff through next review period. (Name of resident) will maintain optimal quality of life, dignity and comfort within limitations imposed by disease and dying process, as evidenced by no signs or symptoms of distress and needs met by staff through review date. Interventions included: (Name of Hospice agency and telephone number) Call Hospice care when: Resident condition changes, before transport to hospital, physician gives any orders, medications are needed or ineffective, resident has pain or any other symptom, resident/family requests a visit, Schedule MDS/care plan meeting, resident expires, any questions, concerns or information needed. A nurses note, dated [DATE], Noted thick yellow drainage to left eye, attempted to clean. Notified the doctor. New order for [MEDICATION NAME] eye drops to affected eye four times a day for 5 days for [MEDICAL CONDITION]. The resident's responsible party was notified. The nurses note did not indicated the Hospice agency was notified. On [DATE], a nurses note documented the doctor was at bedside, due to congestion. New order for [MEDICATION NAME] two times a day for 7 days. Again the responsible party was notified. The nurses note did not indicate the Hospice agency was notified. On [DATE] 11:18 AM, the director of nursing verified Hospice should be notified of changes in the residents condition and new medication orders-according to the directive given to the facility by the Hospice agency. The DON confirmed the antibiotic eye drops ordered on [DATE] and the [MEDICATION NAME] ordered on [DATE] did constitute a change in condition and new physicians orders. The DON was unable to provide evidence the Hospice agency was notified of the changes in the resident's condition resulting in new physician's orders [REDACTED]. At 3:45 PM on [DATE], the DON was still unable to provide evidence the Hospice agency was aware of the changes in the residents condition on [DATE] and [DATE] and the new physician's orders [REDACTED]. The DON confirmed the resident's care pan directed to contact the Hospice agency with changes in condition and medications. No further evidence was presented before the close of the survey on [DATE] at 3:15 PM. d) Resident #51 During an observation on [DATE] at 3:46 PM, Medical Records Director #14 witnessed there was not an anchor device accordance with professional standards, catheters are securely anchored to prevent excessive tension on the catheter and how are interventions (such as avoiding tugging on the catheter during transfer and care delivery) used to prevent inadvertent catheter removal or tissue injury from dislodging the catheter, on leg for indwelling Foley Catheter. During a brief interview on [DATE] at 1:46 PM, DON was informed of findings. She had no response. Review of care plan found no evidence the facility addressed the resident having a foley catheter with appropriate goals and interventions. On ,[DATE] at 10:59 AM, MDS Coordinator #88 agreed the care plan did not address the foley catherter for this resident. e) Resident #64 During an observation on [DATE] at 3:42 PM, Nurse Aide #123 witnessed there was not an anchor secure device on leg for indwelling Foley catheter accordance with professional standards, catheters are securely anchored to prevent excessive tension on the catheter and how are interventions (such as avoiding tugging on the catheter during transfer and care delivery) used to prevent inadvertent catheter removal or tissue injury from dislodging the catheter. She said she would report it to the nurse. During a brief interview on [DATE] at 1:46 PM, DON was informed of findings. She had no response. On ,[DATE] at 10:59 AM, MDS Coordinator #88 agreed the care plan for this resident was not developed to have direction to have an anchor or secure device to be placed on the leg of the resident.",2020-09-01
2327,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2018-10-19,657,D,0,1,6SIG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility's interdisciplinary staff failed to revise the care plans of two (2) of twenty-three (23) residents reviewed. Resident #56's care plan was not revised when the resident was no longer receiving a diuretic. Resident #14's care plan was not revised to reflect current dental status. Resident #186's care plan was not revised to reflect his discharge status. Resident identifiers: #56 and #14. Facility census: 85. Findings included: a) Resident #56 Review of the resident's care plan on 10/18/18 08:09 AM found a focus/problem, revised on 04/18/18: (Name of Resident) has a history of [MEDICAL CONDITION] and is at risk for dehydration and [DIAGNOSES REDACTED] related to diuretic medication. Review of the current physician's orders [REDACTED]. On 10/18/18 at 10:23 AM, Registered Nurse, minimum data set (MDS) coordinator, RN #88 said the resident was no longer on a diuretic medication. The care plan should have been revised when the diuretic was discontinued. b) Resident #14 During an interview on 10/15/18 at 10:16 AM, Resident #14 stated she had been having some trouble with her lower denture plate not fitting well. Resident #14's comprehensive care plan contained the focus, Potential for oral/dental problems with inability to consume diet and risk for choking, difficulty chewing r/t (related to) dysphagia d/t (due to)[MEDICAL CONDITION]([MEDICAL CONDITION].). Resident wears upper denture plate. 8/25/17 Resident is in the process of getting a new lower denture plate. This focus was last revised on 08/25/17. According to the Nurses Note on 01/09/18, Resident received her bottom dentures. Additionally, Resident #14 had some difficulty with loosening of her lower denture plate. On 07/02/18, the consulting dentist report stated, Gave pt. (patient) a tube of adhesive to use as needed. The comprehensive care plan did not contain an intervention related to using dental adhesive to facilitate the fit of Resident #14's lower denture plate. . During an interview on 10/17/18 at 2:31 PM, the Director of Nursing (DoN) was informed Resident #14's comprehensive care plan was not revised when the resident received her lower denture plate and did not contain an intervention to use denture paste to facilitate denture fit. The DoN had no additional information regarding the matter.",2020-09-01
2328,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2018-10-19,660,D,1,1,6SIG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interview and policy review, the facility failed to develop and implement an effective discharge process for Resident #186. This was true for one (1) of four (4) reviewed for discharge. Resident identifier: #186. Facility census: 85. Findings included: a) Resident #186 Review of Resident #186's medical records, found a History and Physical (H&P) dated 07/18/18, this H&P was completed by the discharging hospital. This H&P found the resident had fallen at home on 07/15/18, which resulted in a right ischial pubic fracture without displacement. Patient's baseline is active, walks without assistance, lives alone and has family support. Patient was admitted to the hospital for pain management and physical therapy treatment. Patient's goals are to be able to walk with minimal amount of help and return to baseline and home. Review of the Pre-admission Screening dated 07/19/18, this assessment recommended short-term placement of three (3) to six (6) months. Resident #186 was admitted to the facility on [DATE] at 1:55 p.m., the admission assessment completed on 07/21/18 found the assessment information was provided by the resident and his goals on admission was short term for therapy and to return home with home health services. Family present in the room during the assessment and in agreement of short term admission for therapy. Review of the baseline care plan and the comprehensive care plan found the following: Focus- Resident does show potential for discharge. Date initiated 07/29/18. Goal- Resident care needs will be met at facility throughout stay. Date initiated 07/29/18. Interventions- Support resident, family and/or representive as needed. Date initiated 07/29/18. Review of progress notes found on 07/24/18, the resident wanted to go home. On 07/29/18 at 10:51 am the social worker entered a note which read as follows: The resident is here for rehabilitation. The resident will be going home after his stay here. On 08/06/18, the attending physician, wrote a progress note which read as follows: Family needs to know, physical therapy feels he is not ready to go home and he will need 24 hour a day care. On 08/01/18 at 9:12 pm, the social worker's progress note read as follows: The resident had care plan held on 07/31/18 with the resident's son and daughter attended. MDS, social worker and physical therapy present. The resident will be going home after rehabilitation stay. The resident will have home health for physical and occupational therapy and nursing. Pharmacy chosen. On 08/14/18at 4:12 pm, the social worker's progress note read as follows: The resident had a care plan today and his son and daughter attended. Review of the facility's discharge planning process policy included: The Center will support each resident in the exercise of his or her right to participate in his or her care and treatment, including planning for discharge. The Center will support each resident's expected goals and outcomes regarding discharge upon admission, routinely in accordance with the MDS assessment cycle, and as needed. a) Initial information and discharge goals will be included in the resident's baseline care plan. b) Subsequent assessment information and discharge goals will be included in the resident's comprehensive plan of care. Review of an effective discharge planning process should include the following: --The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. --Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. --The discharge plan must be updated, as needed, to reflect these changes. Involve the interdisciplinary team in the ongoing process of developing the discharge plan. Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. --Address the resident's goals of care and treatment preferences. Document that a resident has been asked about their interest in receiving information regarding returning to the community. If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. --Update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. --Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge. Interview with Employee # 91, Social worker, on 10/18/18 at 11:45 am, she verified she had not initiated an effective discharge plan for Resident #186. She verified the first contact with the resident and family was not until 07/29/18 (eight days after admission). She verified the interdisciplinary team had not participate in the discharge planning process. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) was notified on 10/18/18 at 12:00 pm of the lack of an effective discharge plan for Resident #186. No further information provided.",2020-09-01
2329,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2018-10-19,661,D,1,1,6SIG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, resident interview and staff interview the facility failed to complete and accurate discharge summary to reflect the current condition for one (1) of four (4) residents reviewed for discharge. Resident identifier: #186. Facility census: 85. Findings included: a) Resident #186 Review of Resident #186's discharge summary dated 08/16/18, found the following inaccurate information: -- Code status: Do Not Resuscitate --List medications that have been discontinued during stay with rationale and are not to be continued: N/A (not applicable) --Essential information regarding illnesses or problems: Resident has capacity. -- Overall prognosis- description; 07/24/18 through 07/27/18- administered hypodermoclysis to right lower quadrant (RLQ) of abdomen, 0.45% Sodium Chloride (NACL) at 60 cc/hour related to elevated BUN (blood urea nitrogen). Interview with the DON on 10/18/18 at 2:10 pm. Resident #186's medical record reviewed. She confirmed Resident #186's advance directives indicates the resident is Full code (cardiopulmonary resuscitation), the resident had [MEDICATION NAME] discontinued during the stay due to low blood pressure, Resident #186 did not have capacity and the resident actually was ordered Normal saline 0.9% at rate of 50cc for 1,000 ml/cc and Sodium chloride 0.4 % at rate of 60 cc/hr. for 2,000 ml/cc. She confirmed the above-mentioned areas of the discharge summary was inaccurate.",2020-09-01
2330,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2018-10-19,684,E,1,1,6SIG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, resident interview, record review and staff interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for six (6) of 23 resident reviewed. Resident identifiers: #337, #51, #186, #47, #39 and #31. Facility census: 85. Findings included: a) Resident #337 On [DATE] at 11:12 AM, Resident #337 and her daughter that was at bedside, said Resident # 337 was very upset when she got here today. She said she was up all night with awful leg spasms' and she did not sleep all night. Her daughter said she was not notified. Resident #337 stated that the nurse aide and the nurse was aware that she did not get any rest all night. She did not know their names she has not been here very long. Nurses notes from the electronic chart: -[DATE] 09:59 Daily Skilled Note Text: resident alert and oriented resident has therapy for weakness resident 2 person assist with transfers resident has bruising and [MEDICAL CONDITION] to right arm and hand dryness to bilateral feet resident is no bp or sticks in left arm no c/o pain at this time -[DATE] 09:59 Daily Skilled Note Text: Skilled for therapy. Alert and oriented x's 3. Mood pleasant. Cooperative with care. Able to make needs known. Moves all extremities with weakness. One assist with ADL's. Transfers with two assists. Self feeds in room with good oral intake. Continent of bowel. Incontinent of bladder. Clinical N Y -[DATE] 10:43 Nurses Note Text: Refused shower this shift. Clinical Y -[DATE] 11:21 Social Service Note Text: The Social Worker provided emotional support to resident and her daughter due to her daughter today telling her she would be making her home at The Brier. The resident stated that she knew this would be coming and she was fine with this. The Social Worker will continue to provide emotional support to resident and her daughter. Social Services Y -[DATE] 14:54 Nurses Note Text: Resident c/o spasms in legs Doctor notified New order [MEDICATION NAME] 10mg HS, arterial Doppler for resting claudication Resident aware Clinical Y During an interview on [DATE] at 12:56 PM, DON was about Resident #337's complaint of leg spasms that prevented her from sleeping on Sunday night, DON states she spoke to the resident Monday morning and she did not say anything about that to her. It was pointed out that the leg spasms (pain) was not addressed until 3:00 PM. Asked DON to go back in the resident's room and ask her about her legs keeping her up all night, in the presents of the surveyor and ask her again about how her night was on Sunday. On [DATE] at 12:59 PM, DON asked Resident # 337 about how she did Sunday night and what happened, Resident states she did not sleep a wink that night. DON asked if she let the NA's and Nurse know? She said yes, they just did not know what do for her, DON in room agreed that the nurse should have documented any intervention done for the resident and called the doctor and family member. b) Resident #51 On [DATE] at 10:10 AM, Licensed Practical Nurse (LPN) #24 treatment nurse going to wait until Resident # 51 receives medication for pain. Resident # 51 had hip surgery in (MONTH) has bloody drainage coming from the right hip [DATE] 11:51 AM LPN treatment nurse in to put a patch on hip to help contain the drainage. Large plate size place on the top sheet had bloody drainage and the under pad was saturated with the same drainage from her right hip. On [DATE] at11:40 AM, Resident # 51 tearful tilted to the right was tilted to the right earlier. On [DATE] at 12:01 PM, LPN #24 said that about two weeks ago a boil like place was on the right hip it drained a bit then heeled over. Then on Saturday the same place it popped open and has been draining a lot ever since. She also said she this did a culture of the wound on [DATE] in the AM. Review of nurses notes and medical records there is not any skin wound assessment about this wound. On [DATE] at 8:12 AM, DON looking right hip with LPN #24 dressing was just changed and had a small amount of bloody drainage on it. On [DATE] at 2:10 PM, DON in for brief interview asked if there was any wound/skin assessment done for the wound on her hip. She stated that it happened 2 days after the day the skin assessment was done, so it would not be done until her next scheduled day to do the skin assessments. She was asked are you saying that the wound will not be measured and/or assessed and documented for nine days after it was noticed? She said, now that I've heard you say that out loud, you are right. Nurses Notes copied from the electronic chart: -[DATE] 14:52 Nurses Note Note Text: Wound culture Providencia stuartii,[MEDICAL CONDITION]+Staph Doctor reviewed New order Bactrim DS x 10 days, contact precautions Resident aware Clinical Y -[DATE] 16:31 Nurses Note Note Text: Resident did not want to be turned to be assisted to be cleaned up d/t pain. This nurse administered Resident scheduled pain medication, explained to CNA to give Resident 45 min to allow pain medication to work, then to try to assist Resident again. Educated Resident. Resident stated understanding. Clinical Y -[DATE] 17:25 Nurses Note Note Text: Resident started on ABT [MEDICAL CONDITION]+ Staph wound to right hip with no adverse reactions noted or reported. Resident continues to c/o pain to the right hip area which is exacerbated by movement. PCP is aware. Resident has bandage in place to right hip. VS WNL. Resident is afebrile. Resident on Contact precautions [MEDICAL CONDITION]+ staph wound to right hip. Clinical Y Y -[DATE] 01:48 Nurses Note Note Text: 6p-6a: ABT continues [MEDICAL CONDITION] + Staph. Right hip wound. No adverse reactions noted. Vital signs within normal limits. Resident alert and oriented. Dressing clean, dry, intact. Slight redness to peri-wound. Monitoring ongoing. Receives pain medication as ordered. Resident appears to be resting comfortably and voices no concerns. Clinical Y Y On [DATE] at 9:39 AM, DON was asked what the wound on her is being called, she said that it an abscess. and a skin assessment was done. c) Resident #31 Review of the medication administration record (MAR) on [DATE] at 9:45 AM, found the physician ordered [MEDICATION NAME] Solution, 100 unit/ML, on [DATE]. Inject 3 units subcutaneously before meals for diabetes type II. Hold if blood sugar is less than 160. The order was discontinued on [DATE]. On [DATE] the residents blood sugar was recorded on the MAR as being 147, at 5:00 PM. The nurse initialed the MAR indicating 3 units of [MEDICATION NAME] solution was administered. The directions on the MAR directed nurses to use a code-5, if the medication was held and to see the nurses notes. The MAR did not indicate the insulin was held. Review of the nurses notes found no indication the insulin was held. At 9:45 AM on [DATE], the director of nursing was unable to provide any documentation the insulin was held per the physician's orders [REDACTED].> d) Resident #186 A review of Resident #186's medical record found a physician's determination of capacity dated [DATE] which indicated the resident did not have the capacity to make health care decisions. Further review of the record found the following notes: 1. Assessment of Change in condition: Note dated [DATE] at 3:30 p.m. read as follows, Resident found walking by self in the room by physical therapy. Resident stated, I am not feeling well. Resident was in the bathroom stating, I don't feel well. Skin clammy. Blood sugar: 243, blood pressure ,[DATE], pulse 50, respirations 18 and oxygen (O2) saturation (sat) was 88 % (percent). Resident had a large diarrhea stool, the resident stating, It is the second one today. Resident assisted back to bed. O2 sat still 88% and pulse 50. States, I am feeling better. Review of the facility's standing orders found, Shortness of breath or low O2 saturation less than 90%: Initiate oxygen at two (2) liters/minute (2 L/M) via nasal cannula and notify the physician. No documentation the family/responsible party and/or physician when the above change in condition occurred. Note dated [DATE] at 4:23 pm read as follows: Resident sitting up in wheelchair, pulse now 57 and O2 sat 83%. Oxygen placed at 2 L/M via nasal cannula. Resident states, I feel okay. No documentation the family/responsible party and/or physician when the above change in condition occurred. Note dated [DATE] at 5:15 pm read as follows: Resident with complaints of nausea, chest discomfort, and fell ing sweaty. Upon observation resident noted to have [MEDICAL CONDITION], diaphoresis, and nausea. The resident has orders for the following advance directives: CPR (cardiopulmonary resuscitation). Resident had complaints of nausea, sweatiness, and mild chest discomfort to daughter. Upon assessment, resident very diaphoretic, nauseated, and heart rate of 48. Resident had an episode earlier in the shift with some loose stool. O2 sat was low and resident was placed on O2 at 2 L/M via nasal cannula. Now resident denies chest pain to nurse. Vital signs stable. The next note dated [DATE] at 11:05 pm read as follows: Resident returned from (Name of Hospital) now via ambulance. [DIAGNOSES REDACTED]. Denies chest pain now. Vital signs (VS) blood pressure- ,[DATE], pulse- 77, SPO2 100% on room air., temperature 97.7 and blood sugar (BS) 236. Assisted in bed. Snack given. Call bell in reach. New orders to change [MEDICATION NAME] to 10 milligrams (MG) and to stop [MEDICATION NAME] per (Physician's Name). Will monitor for changes. No documentation the family/responsible party when the above change in condition occurred. 2. [MEDICATION NAME] Progress note dated [DATE] at 5:08 am read as follows: [MEDICATION NAME] 15 units subcutaneously (SQ) held due to blood sugar of 82. Review of physician's orders [REDACTED]. No documentation the family/responsible party and/or physician when the above change in condition occurred. 3. Hypodermoclysis Review of Resident #186's physician order [REDACTED]. Review of the Medication Administration Record (MAR) found the NS was started at 2:28 pm on [DATE]. The amount of ml infused over shift documented: --evening shift on [DATE]- 200 cc/ml infused --night shift on [DATE]- 200 cc/ml infused --day shift on [DATE]- 300 cc infused -- evening shift and night shift on [DATE] coded 9 which indicates to see nurse's notes. Review of Nurse's notes found no notes to explain the Hypodermoclysis was stopped prior to the completion of the 1000 cc/ml. Total amount of fluids infused was 700 cc/m Review of Resident #186's physician order [REDACTED]. Review of the Medication Administration Record (MAR) found the Sodium Chloride was started at 7:54 am on [DATE]. The amount of ml infused over shift documented: --day shift on [DATE]- 200 cc/ml infused --evening shift on [DATE]- 200 cc/ml infused --night shift on [DATE]- 260 cc/ml infused --day shift on [DATE]- 400 cc/ml infused --evening shift on [DATE]- 300 cc/ml infused --night shift on [DATE] - 250 cc/ml infused Total amount of fluids infused 1610 cc/ml Interview with the DON on [DATE] at 2:10 pm. Resident #186's medical record reviewed. She confirmed on [DATE] at 3:30 pm, the nurse failed to follow the standing order for oxygen at 2 l/m via nasal cannula for an oxygen sat for 88%, she confirmed the order for [MEDICATION NAME] was not followed (held on [DATE]) and the resident did not receive Hypodermoclysis fluids on two separate occasion. The first order on [DATE] for 1000 cc/ml; the resident received 700 cc/ml of the 1,000 cc/ml ordered. The second order on [DATE] for 2,000 cc/ml; the resident received 1610 cc/ml of 2,000 cc/ml ordered. She confirmed the orders for Hypodermoclysis. d) Resident #47 Observation and interview on [DATE] at 3:04 pm, found Resident #47, had lower teeth which was broken off at gum level, he stated, I had my upper teeth extracted, but not my lower. Resident states, These teeth don't hurt me. I was going to get them pulled years ago but could not afford to have them removed. Observation and interview with Employee #65, Registered Nurse (RN) Unit Manager (UM) on [DATE] at 11:10 am, found the resident had multiple lower teeth which were broken off at gum level and some was partially covered with gum. Review of the annual MDS with assessment reference date (ARD) of [DATE], found Section L Oral/Dental Status indicated the resident had no natural teeth or tooth fragment (s) (edentulous). The Director of Nursing (DON) was notified of the inaccurate MDS with ARD of [DATE] on [DATE] at 1:05 pm. No further information was provided. e) Resident #39 Resident #39 had a physician's orders [REDACTED]. TED hose is used to prevent blood clots. On [DATE] at 10:00 AM, Wound Nurse Licensed Practical Nurse (LPN) #24 was observed performing wound care to a diabetic ulcer and two (2) deep tissue injuries on Resident #39's right foot. Resident was noted to not have TED hose on at this time. On [DATE] at 3:25 PM, Resident #39 was again observed not to have TED hose on. LPN #36 was present during this observation. She stated she would check to see if Resident #39's physician wanted to continue the order. On [DATE] at 3:31 PM, the Director of Nursing (DoN) was informed Resident #39 had an physician's orders [REDACTED]. The DoN was also informed Resident #39 did not have her TED hose on when observed on two occasions that day. The DoN had no further information regarding the matter. On [DATE], an order was written to Discontinue TED hose due to resident not getting out of bed at this time.",2020-09-01
2331,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2018-10-19,761,E,0,1,6SIG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to properly label and store insulin vials according to professional standards of practice. The medications were located in the 100 hallway medication cart, the 500 hallway medication cart, and the medication cart. The residents affected were #2, #70, #21, and #12. Resident identifiers: #2, #70, #21, and #12. Facility census: 85. Findings include: a) 100 hallway medication cart On 10/17/18 at 8:12 AM, the 100 hallway medication cart was inspected for medication labeling and storage. Licensed Practical Nurse (LPN) #36 was in attendance. The [MEDICATION NAME] vial for Resident #2 was dated as opened 09/18/18, or twenty-nine (29) or thirty (30) days ago, depending on when the first day was counted. This was verified by LPN #36. LPN #36 stated she did not know if facility policy counted the day the vial was opened as the first day, or the day after the vial was opened as the first day. The instructions on the label stated to discard the vial in 28 days after opening. Additionally, the [MEDICATION NAME] vial for Resident #70 was not dated when opened. Neither the bag containing the insulin vial nor the insulin vial itself was dated. LPN #36 verified the insulin was not dated when opened. On 10/17/18 at 8:17 AM, Corporate Registered Nurse (RN) #124 was shown Resident #2's vial of insulin. Corporate RN #124 also stated she did not know if facility policy counted the day the vial was opened as the first day, or the day after the vial was opened as the first day. She stated the vial should have been discarded before now regardless of when the first day was counted. On 10/17/18 at 8:17 AM, Corporate RN #124 was also shown Resident #70's undated insulin. She had no comment on the matter. b) 500 hallway medication cart On 10/17/18 at 8:40 AM, the 500 hallway was inspected for medication labeling and storage. Licensed Practical Nurse (LPN) #42 was in attendance. The [MEDICATION NAME] vial for Resident #21 was not dated on the vial when opened. The bag containing the vial was dated. This was verified by LPN #42. The Director of Nursing (DoN) was shown Resident #21's insulin vial and bag on 10/17/18 at 8:45 AM. The DoN stated the facility's policy was to date both the bag containing the vial and the insulin vial itself when the vial was opened. Review of the facility's policy for insulin administration demonstrated the policy stated, Ensure that the opened date is documented on the vial or pen . c) Medication Room On 10/17/18 at 9:33 AM, the medication room was inspected for medication labeling and storage. Registered Nurse (RN) #40 was in attendance. In the medication room refrigerator, the Novalog insulin vial prescribed for Resident #12 did not have a date when opened. Neither the medication box containing the vial nor vial the vial itself were dated. The cap had been removed from the vial. RN #40 agreed the insulin had not been dated when opened. On 10/17/18 at 9:53 AM, RN #40 stated the insulin was a one-time order for Resident #12, and that the insulin should have been dated when opened or discarded after use.",2020-09-01
2332,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2018-10-19,791,D,0,1,6SIG11,"Based on resident interview, observation, record review, and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for the care area of dental services received assistance with obtaining dentures. Resident identifier: #17. Facility census: 85. Findings included: a) Resident #17 During an interview with the resident at 1:22 PM on 10/15/18, the resident said, I got my teeth pulled now I need dentures. They told me Medicaid doesn't pay for them. Observation of the resident's oral cavity with Registered Nurse, minimum data set coordinator, (RN #88), at 12:03 PM on 10/16/18, found the resident does not have his own natural teeth. At 1:38 PM on 10/16/18, the residents dental consult, dated 12/05/17 was provided by RN #88. The dental consult found the resident had 3 teeth extracted on 12/05/17. Attached to the consult was pricing for upper and lower dentures. RN #88 said social services usually takes care of assisting residents with obtaining dentures and working out the payment system. At 4:23 PM on 10/16/18, social services employee, SS #41, reviewed the dental consult with pricing for dentures. SS #41 she did not know the resident needed dentures. She said, if she would have received a copy of the consult, she could have contacted the local Department of Health and Human Resource (DHHR) for a, remedial. She explained a remedial as the local DHHR can adjust the monthly resource amount owed by the resident to the facility to allow for payment of dentures. At 4:57 PM on 10/16/18, SS #41 said she had medical records employee (MR #14) call the dentist office. She said, MR #14 told her the resident and his brother told the dentist they would have to wait for dentures because of the cost. At 3:35 PM on 10/18/18, the above issue was discussed with the Director of Nursing and a corporate Registered Nurse, #124. At the close of the survey, on 10/19/18 at 3:15 PM, no further information was provided to substantiate the facility made any attempts to assist with exploring the payment options and assisting with obtaining dentures for Resident #17.",2020-09-01
2333,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2018-10-19,842,D,0,1,6SIG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the medical records of two (2)of twenty-three (23) residents were complete and accurate. Resident identifiers: #31 and #39. Facility census: 85. Findings included: a) Resident #31 At 12:59 PM on 10/16/18, the closed medical record of Resident #31 was reviewed. The resident was admitted to the facility on [DATE] and was discharged to home on 09/04/18. The closed medical record did not contain copies of the notes indicating the care and services provided by the therapy department. At 2:29 PM on 10/16/18, the corporate Registered Nurse (RN) #124, was asked where the therapy notes were located. RN #124 confirmed the surveyors were not able to access the electronic medical record with therapy documentation. At 2:46 PM on 10/16/18, RN #124 verified the therapy notes should have been in the closed medical records [REDACTED] The director of rehabilitation services, [NAME] #122 was interviewed at 1:04 PM on 10/17/18. [NAME] #122 said, We are to print them out and get the doctor to sign them. We give the notes to the unit manager who then sees that the copy gets placed in the hard chart. [NAME] #122 did not know why a copy of Resident #31's therapy notes were not in the medical record. b) Resident #39 Resident #39 had an order for [REDACTED]. Review of the progress notes demonstrated Resident #39's buttock wound care had been performed every Monday, Wednesday, and Friday as ordered. However, review of the Weekly Wound Evaluation for Resident #39 dated 10/15/18 stated, Treatment: Clean area. Skin prep peri wound. Apply honey wound gel to wound bed, and cover with BF (acronym unknown) q (every) Monday and Thursday. The Weekly Skin Wound evaluation dated 10/15/18 had been completed by Licensed Practical Nurse (LPN) #24. During an interview on 10/17/18 at 11:30 AM, LPN #24 stated Resident #39's Weekly Wound Evaluation dated 10/15/18 was incorrect when it stated to provide wound care on Monday and Thursday. LPN #24 stated Resident #39's wound treatment was Monday, Wednesday, and Friday. She stated she would strike the inaccurate information from Resident #39's Weekly Wound Evaluation dated 10/15/18.",2020-09-01
2334,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2018-10-19,849,D,0,1,6SIG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to communicate changes in care with the Hospice agency for one (1) of one (1) resident reviewed for Hospice care. The Hospice agency was not notified when medications were added to the resident's medication regime due to changes in the resident's condition. Resident identifier: #29. Facility census: 85. Findings included: a) Resident #29 Record review found an order for [REDACTED].>In the front of the resident's medical record was direction, provided by Hospice agency instructing the facility to contact the Hospice agency when: Resident's condition changes, Before transport to hospital, Physician gives any orders, Medications are needed or ineffective, Resident has pain or any other symptom, Resident/Family wants a visit, Schedule Minimum Data Set (MDS) care plan meeting, Resident dies, Any questions, concerns or info needed. Review of the facility's policy entitled, Hospice Services Center Agreement, dated 11/27/17, directed: 3. The written agreement must also include a written stipulation that the center immediately notifies the hospice regarding the following: a. A significant change in the resident's physical, mental, social, or emotional status. b. Clinical complications that suggest a need to alter the plan of care. c. A need to transfer the resident from the center for any condition. d. The resident's death. A nurses note, dated 07/05/18, Noted thick yellow drainage to left eye, attempted to clean. Notified the doctor. New order for [MEDICATION NAME] eye drops to affected eye four times a day for 5 days for [MEDICAL CONDITION]. The resident's responsible party was notified. The nurses note did not indicated the Hospice agency was notified. On 10/11/18, a nurses note documented the doctor was at bedside, due to congestion. New order for [MEDICATION NAME] two times a day for 7 days. Again the responsible party was notified. The nurses note did not indicate the Hospice agency was notified. On 10/16/18 11:18 AM, the director of nursing verified Hospice should be notified of changes in the residents condition and new medication orders-according to the directive given to the facility by the Hospice agency. The DON confirmed the antibiotic eye drops ordered on [DATE] and the [MEDICATION NAME] ordered on [DATE] did constitute a change in condition and new physicians orders. The DON was unable to provide evidence the Hospice agency was notified of the changes in the resident's condition resulting in new physician's orders [REDACTED]. At 3:45 PM on 10/18/18, the DON was still unable to provide evidence the Hospice agency was aware of the changes in the residents condition on 07/05/18 and 10/11/18 and the new physician's orders [REDACTED].",2020-09-01
2335,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2018-10-19,880,D,0,1,6SIG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of the Medication Administration and staff interview, the facility failed to maintain effective infection control during observation of the medication administration. This was true for two (2) of three (3) observed during medication administration. This had the potential to affect all resides residing in the facility receiving medication. Resident identifiers: #43 and #14. Facility census: 85. Findings include: a) Resident #43 During the medication administration, on 10/17/18 at 9:10 am, Employee #81, licensed practical nurse (LPN) was observed administering Resident #43 her medication. Upon entering Resident #43's room the LPN #81, sat the resident's medication on the bedside table Natural tears (eye drops) and [MEDICATION NAME] nasal spray without a barrier and then proceeded to place them back on the medication cart. Additionally, LPN #81 when entering the room donned a pair of gloves. She then proceeded to place a topical pain patch ([MEDICATION NAME] 4% patch) to the resident's lower back, instill one (1) drop of Natural tears in both eyes and one spray of nasal spray to each nostril ([MEDICATION NAME]) and then she removed her glove from her right hand and poured Resident #43's oral medication in the gloved left hand. LPN #81 did not at any time change her gloves and/or wash her hands. She then placed the eye drops and nasal spray on the medication cart. Interview with LPN #81, immediately following this observation was asked if she should have changed gloves and/or washed her hands and should you place a barrier when placing multi dose medications (eye drops and nasal spray) on the resident's table. She said, I should have changed gloves and wash hands after the topical patch placement, the eye drops and the nasal spray, and I should have placed a barrier on the table before sitting the eye drops and the nasal spray. Infection control issues, by LPN #81, during the medication administration of Resident #43, was addressed with the Director of Nursing (DON) on 10/19/18 at 10:05 am. She confirmed a barrier should have been used and LPN#81 should have changed gloves and was her hands between the topical patch, eye drops and nasal spray. b) Resident #14 On 10/17/18 at 8:00 AM, Licensed Practical Nurse (LPN) #36 was observed preparing medications for administration to Resident #14. When opening the potassium pill for Resident #14, LPN #36 dropped the tablet onto the top of the medication cart. LPN #36 picked up the tablet from the top of the medication cart, placed it in the medication administration cup with Resident #14's other medications, and administered the medication. On 10/17/18 at 8:10 AM, LPN #36 was informed she had potentially contaminated Resident #14 with infectious agents by administering medication that had been dropped onto the top of the medication cart. LPN #36 had no information regarding the matter. During an interview on 10/17/18 at 8:17 AM, Corporate Registered Nurse (RN) #124 was informed Resident # 14's medication had been dropped onto the top of the medication cart prior to administration. Corporate RN #124 had no additional information regarding the matter.",2020-09-01
2336,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2019-12-04,609,D,0,1,V0DD11,"Based on record review and staff interview, the facility failed to report alleged violation related to mistreatment exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and report the results of all investigation to the proper authorities within prescribe timeframes. This failed practice had the potential to affect a limited number of residents. Resident identifier: #66. Facility census: 81. Findings include: a) Review of facility policy A review of the facility's policy entitled, Abuse, Neglect, and Exploitation revised on 02/01/2019, noted the following: Policy Explanation and Compliance Guidelines: 1. The center will establish policies and procedures on abuse, neglect, exploitation or misappropriation of resident property pertaining to the following components: b. Investigation and staff identification of allegations d. Reporting and response. 2. The center will have an Abuse Coordinator in the center (i.e., Director of Nursing, CEO/Administrator, or center appointed designee). The Abuse Coordinator will report allegations or suspected abuse, neglect, or exploitation immediately to: - CEO / Administrator - Other Officials in accordance with State Law - State Survey and Certification agency through established procedures 3. The center will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. The components of the center abuse prohibition plan are discussed herein: VII. Reporting / Response of Abuse, Neglect, and Exploitation When abuse, neglect or exploitation is suspected: - Immediately report all alleged violations to the CEO/Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes . The CEO/Administrator should follow up with government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. b) Resident #66 A review of Resident #66's medical record, revealed the following: -- 9/15/2019 5:50 PM Nurses Note Late Entry: Resident was going down to her room and was grabbed by another resident. She grabbed her left arm and wouldn't let go. Staff had to reinterate. The other resident stated she just wanted her purple bracelet. No redness or bruising was noted to wrist. Resident stated it hurts. (PHYSICIAN NAME) was notified. -- 9/15/2019 6:00 PM Nurses Note: 6a-6p I checked resident's left arm and noted no injuries. -- 9/15/2019 7:04 PM Nurses Note: Weekly note-Resident is alert and oriented and able to relate needs to staff. Takes meds whole. Assist of one with ADLs (Activities of Daily Living). Appetite is poor to fair. Feeds self and eats in the dining room. Ambulates with wheeled walker. Attends activities of choice. Goes in wheelchair most of the day. Is continent of bowel and bladder. -- 9/15/2019 10:42 PM Nurses Note Late Entry: resident left arm checked no injuries noted. -- 9/15/2019 10:43 PM Nurses Note: weekly 6p-6a; resident alert and oriented, ambulates self with wheel chair, skin warm and intact, lung sound clear, bowel sound present x4 quadrants, no complain of pain or discomfort noted so far during the shift, sleeping quality in bed at this time, call bel in reach. will continue to monitor. -- 9/16/2019 10:23 AM Nurses Note Resident's left hand/wrist assessed- no redness, swelling. Resident moves hand/wrist without difficulty. Resident c/o slight pain with movement. DO (physician) notified. Resident capacitated. -- 9/16/2019 1:30 PM Nurses Note: New orders received for left hand/wrist x-ray. Resident aware. American Quality Imaging notified. -- 9/16/2019 3:48 PM Nurses Note: XRAY results received and noted, Negative left wrist, Negative Left hand. DR (physician). aware, resident aware. -- 9/16/2019 3:49 PM Social Service Note: Spoke with Resident this AM and she stated that another Resident had held on to wrist on her left hand and it hurt. Wrist had already been assessed by staff when incident occurred but the LPN (Licensed Practical Nurse) reassessed the wrist and an X-Ray was ordered which showed no issues. Continue to offer support. Resident has had no further concerns to Social Worker. Resident stated she was not afraid and knew that staff were there to make sure that she was O.K. She then went to talk with Social Worker about her craft activities. -- 9/16/2019 9:45 PM Nurses Note Late Entry: Resident left hand/ wrist assessed- no redness or swelling noted during this shift resident complain of no pain or discomfort noted well monitor resident during shift On 12/03/19 at 11:26 AM, during an interview with Employee #13, Social Worker (SW), was asked who submitted the reportable incidents. SW #13 stated that Employee #70, Social Worker, as well as SW #13 were responsible for the facility's reportable incidents. SW #13 stated that she did not report the incident for Resident #66, since there was no injury. On 12/03/19 at 2:48 PM, the findings were discussed with the Administrator. No further information was provided prior to the close of the annual survey on 12/04/19 at 3:30 PM.",2020-09-01
2337,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2019-12-04,640,D,0,1,V0DD11,"Based on record review and staff interview, the facility failed to complete a discharge Minimum Data Set (MDS) assessment for one (1) of two (2) residents reviewed for the care area of discharge. Resident identifier: #42. Facility census: 81. Findings included: Review of Resident #42's medical records revealed he was discharged to the community on 10/25/19. Further review of Resident #42's medical records revealed no discharge Minimum Data Set (MDS) assessment. On, 12/04/19 at 10:41 AM, Registered Nurse Minimum Data Set Coordinator #74 confirmed Resident #42 did not have a discharge MDS completed. No further information was provided through the completion of the survey.",2020-09-01
2338,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2019-12-04,656,E,0,1,V0DD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident interview, the facility failed to develop and/or implement the comprehensive care plan for three (3) of 21 residents reviewed during the long-term care survey process. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #47, #67, #66. Facility census: 81. Findings included: a) Resident # 47 On 12/03/19 at 9:25 AM, Resident #47 stated he was having pain. On 12/03/19 at 9:30 AM, Licensed Practical Nurse (LPN) #10 administered Tylenol 650 mg to Resident #47 via his Percutaneous endoscopic gastrostomy (PEG) tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications. Because a PEG tube can become dislodged from the stomach, the placement of the PEG tube should be checked before medications or feedings are administered through it. Placement can be checked by injecting a small amount of air through the tube with a syringe and listening for the air in the stomach with a stethoscope. This is called auscultation. Placement can also be checked by aspirating stomach contents from the tube using a syringe. LPN #10 administered Tylenol through Resident #47's PEG tube by crushing Tylenol tablets and dissolving them in water. The water containing the Tylenol was then infused by allowing it to flow through the PEG tube by gravity through the barrel of the syringe. LPN #10 did not check the PEG tube for placement before administering the medication to Resident #47. Resident #47's comprehensive care plan contained the focus, Resident has need for use of feeding tube. Interventions included, Check tube placement by aspiration and auscultation (listening) prior to administering any medication and/or feeding. During an interview on 12/03/19 at 12:33 PM, Corporate Registered Nurse (RN) #137 was informed LPN #10 did not implement Resident #47's comprehensive care plan regarding checking PEG tube placement prior to administering medication. Corporate RN #137 had no additional information regarding the matter. No further information was provided through the completion of the survey. b) Resident #67 During a record review it revealed nursing notes that Resident #67 was on a fluid restriction. This was mentioned on: - 10/03/19 at 10:17 AM, Resident continues to be on fluid restriction and is non-compliant at this time. - 12/02/19 at 11:10 PM, Resident continues to be on fluid restriction and is non-compliant at this time. -12/02/19 at 9:57 AM, Resident continues to be on fluid restriction and is non-compliant at this time. -12/01/19 at 10:45 PM, Resident continues to be on fluid restriction and is non-compliant at this time. -12/01/19 at 10:24 AM, Resident continues to be on fluid restriction and is non-compliant at this time . act. The physician order [REDACTED]. (There was no measurable amount or goals, for the amount of fluids she should receive). The care plan, date of initiated, 11/25/19 was as follows: Focus; Resident #67 has a [DIAGNOSES REDACTED]. Goals; Resident will be free from complications. Interventions; Fluid as ordered. Restrict or give as ordered. Focus: Risk of altered nutrition/hydration status related to [DIAGNOSES REDACTED]. Interventi0ons; Fluid with meals and medication pass only. During an interview on 12/03/19 at 10:27 AM, Corporate Registered Nurse #137 states, that she did see the care, and it looked as though it was not personalized, and it was right out of a care plan book. She said, she has looked into the fluid restriction and this resident was not on a fluid restriction. She did not comment on why the nursing notes repeatedly referred to this resident was on a fluid restriction when she was not. c) Resident #66 A review of Resident #66's medical record, revealed the following: -- 1/7/2019 5:15 PM Social Service Note: The Social worker talked with the resident about not using inappropriate language and she stated that will not be using this anymore. -- 1/7/2019 5:18 PM Social Service Note: The Social Worker talked with the resident about how she treated her friend this past weekend who lives at the center. The resident knows that she should not cuss or be hurtful in any way to him. The resident stated that she apologized and she is very sorry for this. The resident stated that she did not feel good and she took her frustration out on her friend. The resident stated that she will no longer due this. -- 1/11/2019 09:53 AM Social Service Note: The Social Worker talked with the resident yesterday about the resident calling one of the staff members a cuss word and she stated that she never called her this. The Social Worker talked to the resident about using appropriate vocabulary. -- 1/11/2019 4:42 PM Social Service Note: The Social Worker talked with resident due to resident stating to assistant last night at sleep study that she was not given anything to drink when she was here at the center. The resident stated that she was given something to drink at the center and she denied ever saying anything like this. -- 2/27/2019 8:01 PM Social Service Note: The Social Worker talked with the resident about not helping her roommate and to always use the call bell if her roommate needs assistance. The resident stated that she would use the call bell for assistance. -- 7/1/2019 09:47 AM Social Service Note: It was reported by staff that Resident had been attempting to take Resident's to the porch area, asking visitors for food and making other comments, such as don't go in there there's warm death in there,saying she has hairs in her food in order to get more food to share with her friend, another Resident. The Resident denied all this and stated she has not done any of things noted above. When it was explained to her that these issues were reported by numerous visitors and staff she had nothing to say. It was explained to her that she is not to take any of the other Resident's outside. Staff will take Resident's outside because they are aware of who can be on the porch area without staff being present. It was also explained that asking visitors for food is unacceptable. If Resident wants more food she is to ask staff of the facility. When asked about the comment about warm death she stated that she had not said that. It was explained that comments of that nature are unacceptable. Resident then stated that she had said that the building was cold and her room was cold. It was explained that Social Services would speak with staff about keeping her heat on 70 in order that she would not be cold. The Resident has stated for several days she finds hair in her food; however, she does not want staff to take the food with the hair in it back to the kitchen and yet wants more food, which she shares with her friend. On numerous occasions she has been requested not to give food to her friend. He has digestive issues and his Resp. Party feels that extra food is not good for him. He has also been told if he is still hungry after meals to ask staff for food, so they can give him food that will not hurt his stomach. The staff will specifically check her tray in order to ensue that their is no hair in her food. She stated that she would stop the behaviors which she previously said she was not engaging in. She was also informed that if these behaviors continue her brother would be requested to meet with team members to discuss interventions/options for the Resident. Resident verbalized understanding. -- 7/2/2019 4:07 PM Social Service Note: Spoke with Resident about making remarks about not liking certain people. Suggested that she leave the room, activity, etc. without comment if there is someone present she has an issue with. She verbalized understanding. -- 7/9/2019 09:39 AM Social Service Note: Spoke with the Resident x2 (2 times) regarding report from weekend. It was reported that the Resident was asking visitors to take her out to buy beads and also that she was standing in the doorway of her room with only her bras and panties on. Resident stated and it was later confirmed that the visitor had offered to take her on an outing. Suggested and Resident agreed that a call to her brother would be acceptable in order to ensure that he had no concerns regarding her going on the outing. Reminded Resident that she is not to ask visitors to bring her in food or take her places and she stated she would not. Resident stated that she cannot sleep good with clothing on and it was suggested that she keep a robe by her bed and when she gets up put the robe on due to families visiting other Residents on her hall. She stated she understood and that was a good idea. Also, spoke with her about talking and being disruptive during activities and suggested if she needed to leave the activity quietly get up and leave. She agreed with this also. When Resident is observed engaged in a good activity she is reinforced/ verbally praised by staff. She is offered activities to keep her engaged in acceptable activities. -- 7/20/2019 2:49 PM Social Service Note Late Entry: Was informed by staff members that Resident had been acting in an unacceptable manner. She had made false reports about a C.N.[NAME] (certified nursing assistant), had been acting in an unacceptable manner with her boyfriend and talks with visitors coming in to facility and tells them much inaccurate information. The Resident also became upset because she asked for a salad and the kitchen told her it would take a few minutes to prepare. Spoke with Resident in the 500 hall library and she had received her salad. Spoke about the need not to accuse people or tell untruths on staff. She stated that she had told a lie on one staff member but did tell her she was sorry. Explained the seriousness of making false accusations and Resident verbalized understanding. Also, explained that if Resident does not call ahead and ask for a food substitute she may have to wait a few minutes while the kitchen makes her request. She also verbalized understanding regarding this. Also spoke with her regarding her Resident friend and the acceptable behaviors she may engage in with him. She also verbalized understanding. She was very irritated but did state that she would stop the behaviors which she verbalized back to the Social Worker in order to ensure that she understood what behaviors had been talked about. -- 8/2/2019 12:50 PM Social Service Note: Resident has been exhibiting attention seeking behaviors; such as gagging, saying she is sick and making it difficult for other Residents to enjoy the activity due to this; she also continues to make up stories and telling visitors she is not being treated fairly by activities-- she later recants these allegations. When asked about these statements she states that she should not be engaging in these behaviors and she will stop. Staff continue to praise Resident for conducting herself in an acceptable manner. Her brother has also spoken with her regarding these issues. The Resident was encouraged to quietly leave the activities if she becomes ill and let the LPN (licensed practical nurse) know in order to be assessed and treated. She was also encouraged to be sure that information she gives regarding staff are accurate as this could lead to serious consequences for them. Continue to meet with Resident on a regular basis. -- 8/13/2019 09:17 AM Social Service Note: The Social Worker talked with the resident about modesty and also about not asking people who visit the center to take her shopping. The resident knows that Activities Department is available to shop for her. -- 8/29/2019 1:59 PM Social Service Note: Resident was asked about an issue that occurred in therapy with another Resident in which she kissed the Resident. Resident stated that the lady was very special and she just wanted her to know that she respected and liked her. Explained that kissing was not the best way to show that and suggested she just tell the Resident; she stated that she would from now on. Also talked with her about personal space and the fact that some people do not like to be hugged, etc. She stated that she understood. -- 11/7/2019 1:29 PM Social Service Note: Staff have approached Social Worker on several occasions this week to report that Resident has been going in to visit other Residents very early (6AM), has been asking staff for money, and has also been asking visitors for personal possessions. Have spoken with her about these behaviors and she initially denies them and admits to doing what she has been asked not to. Offer Resident praise for acceptable behavior but she continues to engage in the above behaviors. Have also asked staff to re-direct Resident to acceptable activities if they observe her engaging in behaviors noted above. The Resident would benefit from being re-directed while behavior is occurring due to the fact that when asked about behaviors she denies them. -- 11/15/2019 11:00 AM Care Plan Note: The Resident is alert and oriented x 3 (three times). She is able to make wants and needs known and is up daily in her wheel chair. She receives assistance with ADL (activities of daily living) care and eats independently in the dining room. Her intake is 85%. She is continent of bowel and bladder and has not had any falls this review period. She attends activities of choice and she and her friend do individual activities such as making beads and coloring together. The Resident is very intrusive at times and wants to give candy to Residents and wants to enter their rooms and water their flowers and just visit. Have explained that some Residents would prefer her not to go into their rooms and water their plants etc. Have also explained on several occasions that she is not to give food to others due to special diets. She expresses understanding but continues to engage in the same behaviors at times. Offer her praise for acceptable behavior and make sure she understands what is unacceptable. She exhibits poor judgement and limited insight. The Resident is long term due to level of care required. She is carried for her attention seeking/unacceptable behaviors. Continue to offer support and encouragement. Attendees: Social Worker, Resident Information obtained from: CCM/RN, Dietary, Activities and C.N.[NAME] A review of Resident #66's behavior documentation noted the following: -- 6/11/19 11:47 - yelling/screaming -- 6/11/19 11:47 - threatening behavior -- 6/11/19 11:47 - rejection of care -- 6/11/19 11:57 - abusive language -- 7/20/19 13:17 - rejection of care -- 7/20/19 13:17 - threatening behavior -- 7/20/19 13:17 - yelling / screaming -- 7/20/19 13:17 - abusive language -- 10/10/19 12:25 - abusive language -- 10/20/19 19:99 - yelling/screaming -- 11/18/19 14:03 - yelling/screaming -- 11/24/19 13:56 - yelling/screaming A review of Resident #66's care plan did note the following: Focus: Although the Resident is deemed to have capacity she is very childlike and her judgement is impaired and her insight is poor. She continues at times to display episodes of agitation, anxiety, depression, anger most likely r/t (related to) intellectual disability. Goal: Resident will have improved mood and behaviors as evidenced by complying with requests without yelling, screaming, etc. and will verbalize no statements of self harm thru next review. Interventions include: Observe/document/report to MD (physician) new or increased s/sx (signs and symptoms) of depression: Sad, irritable, angry, never satisfied, crying, shame, worthlessness, guilt, [MEDICAL CONDITION], negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, needing constant reassurance. On 12/03/19 at 11:30 AM, during an interview with Employee #13, Social Worker, SW #13 was asked about Resident #66's behaviors. SW #13 stated Resident #66 likes to visit other residents, but does so in the middle of the night, in the morning before the other resident(s) wake up, or while other residents are getting dressed and / or receiving care. SW #13 noted Resident #66 is intrusive with others and into their personal space. SW #13 also stated Resident #66 does make false statements to staff and visitors. Resident #66 has attempt to solicit money and / or craft supplies from visitors. SW #13 stated that Resident #66 has yelling, cursed, and screamed at staff at times. Resident #66 has used inappropriate language to other residents. SW #13 stated Resident #66 does exhibit attention seeking behaviors. SW #13 stated she has discussed appropriate visiting times with Resident #66 on multiple occasions. SW #13 stated Resident #66 has exhibited behaviors of a sexual nature as well as removing clothing, or being seen in public in just her underwear. During an interview on 12/04/19 at 11:49 AM, SW #13 was asked if Resident #66's behaviors were contained in Resident #66's care plan. SW #13 stated Resident #66's behaviors should have been care planned; however, they were not care planned. SW #13 stated she did not care plan Resident #66's behaviors since SW #13 meets with Resident #66 and discusses resident's behavior. SW #13 stated interventions should be on the care plan, so that staff will know how to assist Resident #66 and how to address her behaviors. On 12/04/19 at 12:34 PM, the findings were discussed with the Administrator. No additional information was provided at the end of the survey on 12/04/19 at 3:30 PM.",2020-09-01
2339,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2019-12-04,684,D,0,1,V0DD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to administer medication after a gradual dose reduction was completed. This failed practice had the potential to affect one (1) of five (5) Residents reviewed in the care area of unnecessary medications. Resident identifier: #11. Facility census: 81. Findings included: a) Resident #11 Review of the Medication Regimen Review (MRR) for (MONTH) of 2019 revealed request from the pharmacist to evaluate and document the continued use of [MEDICATION NAME] (antidepressant) at the current dose of 10 milligrams (mg) daily. Documentation reflects the attending physician ordered dose reduction of 5 mg daily for four (4) weeks then discontinue medication, with sign date of 07/11/19 by the physician. Printed date on the MRR was 07/08/19. Review of the Medication Administration Record [REDACTED]. The reduced dose of [MEDICATION NAME] 5 mg daily was not started and administered until 07/12/19 at 8:00 AM. During an interview on 12/03/19 at 2:45 PM the Assistant Director of Nursing (ADON) verified the [MEDICATION NAME] antidepressant medication was not administered on 07/11/19, resulting in a missed dose. The ADON stated, I'm sure it was an order entry error that caused the missed administration when we changed the order over to the lower dose.",2020-09-01
2340,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2019-12-04,693,D,0,1,V0DD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident interview, the facility failed to ensure a resident receiving enteral (tube) feeding received appropriate care and services. This was true for one (1) of one (1) residents with enteral feeding in the long-term care survey sample. Resident identifier: #47. Facility census: 81. Findings included: a) Policy Review The facility's policy entitled Care and treatment of [REDACTED]. b) Resident # 47 On 12/03/19 at 9:25 AM, Resident #47 stated he was having pain. On 12/03/19 at 9:30 AM, Licensed Practical Nurse (LPN) #10 administered Tylenol 650 mg to Resident #47 via his Percutaneous endoscopic gastrostomy (PEG) tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications. Because a PEG tube can become dislodged from the stomach, the placement of the PEG tube should be checked before medications or feedings are administered through it. Placement can be checked by injecting a small amount of air through the tube with a syringe and listening for the air in the stomach with a stethoscope. This is called auscultation. Placement can also be checked by aspirating stomach contents from the tube using a syringe. LPN #10 administered Tylenol through Resident #47's PEG tube by crushing Tylenol tablets and dissolving them in water. The water containing the Tylenol was then infused by allowing it to flow through the PEG tube by gravity through the barrel of the syringe. LPN #10 did not check the PEG tube for placement before administering the medication to Resident #47. Resident #47 had an order written [REDACTED]. During an interview on 12/03/19 at 12:33 PM, Corporate Registered Nurse (RN) #137 was informed LPN #10 did not check Resident #47's PEG tube placement prior to administering medication. Corporate RN #137 had no additional information regarding the matter. No further information was provided through the completion of the survey.",2020-09-01
2341,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2019-12-04,730,D,0,1,V0DD11,"Based on record review and staff interview, the facility failed to ensure that nursing assistants (NA's) received annual performance appraisals. This was true for two (2) of five (5) employee files that were reviewed. Employee Identifiers: #2 and #44. Facility census: 81. Findings include: a) Employee #2 A review of Employee #2, nursing assistant (NA), personnel record found she was hired 06/28/04. Further review of her personnel record found her last performance evaluation was dated 02/26/15. On 12/04/19 at 10:09 AM, during an interview with Employee #47, Human Resource Director (HR), HR #47 was asked if all employee evaluations were contained within their employee file. HR #47 stated that the employee file is the only place that the performance evaluation would be located. On 12/04/19 at 12:38 PM, the findings were discussed with the Administrator. No further information was provided at the end of the survey on 12/04/19 at 3:30 PM. b) Employee #44 A review of Employee #44, nursing assistant (NA), personnel record found she was hired 02/08/90. Further review of her personnel record noted that her last performance evaluation was dated 10/04/19. NA #44's performance evaluation was due to be completed on 02/08/19. NA #44's employee evaluation was completed approximately eight (8) months past her annual date. Moreover, NA #44's employee file noted that prior to the performance evaluation that was completed on 10/04/18, NA #44's previous employee evaluation had not been completed since 02/26/15. On 12/04/19 at 10:09 AM, during an interview with Employee #47, Human Resource Director (HR), HR #47 was asked if all employee evaluations were contained within their employee file. HR #47 stated that the employee file is the only place that the performance evaluation would be located. On 12/04/19 at 12:38 PM, the findings were discussed with the Administrator. No further information was provided at the end of the survey on 12/04/19 at 3:30 PM. c) Policy Review A review of the facility's policy entitled, Nurse Aide Education / Program noted the following: --Additional training will be provided to each nurse aide based on any areas of weakness as determined in the nurse aide's performance reviews. --The Director of Nursing shall communicate the educational needs of the employee to the Staff Development Coordinator upon final review of the annual performance appraisal. --Education that is needed based on the performance appraisal will be completed within 90 days of the appraisal, unless otherwise specified in the appraisal.",2020-09-01
2342,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2019-12-04,756,D,0,1,V0DD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the attending physician failed to appropriately respond to the medication regimen recommendations made by the pharmacist during monthly medication regimens reviews. This failed practice had the potential to affect two (2) of five (5) Residents reviewed for the care area of unnecessary medications. Resident identifiers: #8, #11. Facility census: 81 Findings included: a) Resident #8 Record review of Medication Regimen Review (MRR) dated 04/05/19 revealed the Resident had a consult with the psychiatrist in (MONTH) of 2019, and the Psychiatrist noted continued confusion with no reported physical aggression with staff on increased dose [MEDICATION NAME] 50 mg (antipsychotic medication) twice daily. The Pharmacist requested documentation to be provided for continued need of [MEDICATION NAME] as per noted in Psychiatric consult. The MRR was not signed or dated by the attending physician until 11/6/19 at which time the physician noted [MEDICATION NAME] was decreased on 09/04/19. During an interview on 12/03/19 at 3:10 PM the Assistant Director of Nursing (ADON) verified and agreed MRR dated 04/05/19 was not addressed appropriately by the attending physician, and the physician should have responded to the pharmacist's recommendations in a timelier manner. b) Resident #11 Record review of Medication Regimen Review (MRR) dated 04/04/19 revealed recommendation from the pharmacist to discontinue [MEDICATION NAME] (ACE inhibitor used to treat high blood pressure) due to Resident's increased serum Potassium levels. The MRR was not signed or dated by the attending physician to indicate any acknowledgment or action to be taken for the recommendation. During an interview on 12/03/19 at 3:00 PM the Assistant Director of Nursing (ADON) verified and agreed MRR dated 04/04/19 was not completed appropriately by the attending physician to document acknowledgement of the recommendations and what action was to be taken. c) Administrator Interview During an interview on 12/04/19 at 1:35 PM the Administrator stated, We (the facility) identified an issue with those (Medication Regimen Review) in (MONTH) (2019), so we (the facility) went all the way back to (MONTH) 1st of 2019 to see what was missed. The pharmacist done her part. What happened is those (Medication Regimen Review) made it up to nursing and from there they never got looked at. The Administrator further stated the issues identified with the monthly Medication Regimen Reviews were added into the Quality assurance and performance improvement (QAPI) program agenda in (MONTH) 2019.",2020-09-01
2343,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2019-12-04,842,E,0,1,V0DD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview the facility failed to ensure medical record were complete and accurate. This was true for four (4) of 21 sampled residents. Resident identifiers: #83, #47, #33 and #60 . Facility Census: 81. Findings included: a) Resident #83 Observations of Resident #83 on 12/02/19 at 11:13 a.m. found she had missing teeth and her remaining teeth appeared to be in poor condition. A review of Resident #83's medical record found the following three (3) dental assessments: -- Dental assessment dated [DATE] indicated the resident had no natural teeth or tooth fragment(s) (edentulous). -- Dental assessment dated [DATE] indicated the resident had obvious or likely cavity or broken natural teeth. Resident with natural teeth, some broken and caries noted. Denies any pain or discomfort or difficulty eating/drinking. Oral mucosa is pink, moist. -- Dental assessment dated [DATE] indicated the resident had obvious or likely cavity or broken natural teeth. Resident with natural teeth, some broken and caries noted. Denies any pain or discomfort or difficulty eating/drinking. Oral mucosa is pink, moist. An interview with Registered Nurse (RN) #16 at 12/03/19 at 8:53 a.m. confirmed Resident #83 had some natural teeth and the assessment completed on 08/20/19 was inaccurate. b) Resident #47 1. On 12/03/19 at 9:30 AM, Licensed Practical Nurse (LPN) #10 administered [MEDICATION NAME] (Tylenol) 650 mg to Resident #47 via his Percutaneous endoscopic gastrostomy (PEG) tube, a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications. Review of Resident #47's medical records on 12/03/19 at 9:40 AM revealed an order for [REDACTED].#47's other medications were ordered to be given by PEG tube. During an interview on 12/03/19 at 12:33 PM, Corporate Registered Nurse (RN) #137 was informed Resident #47's [MEDICATION NAME] was ordered orally but was administered through his PEG tube. Corporate RN #137 stated she would clarify the order with the physician. Review of Resident #47's medical records on 12/04/19 at 8:00 AM revealed the order had been changed to [MEDICATION NAME] 325 mg, give 2 tablets via PEG tube every 6 hours as needed for pain. 2. Review of Resident #47's medical records on 12/03/19 at 9:40 AM revealed an order written [REDACTED]. The order did not give the dosage of modular protein to be given. During an interview on 12/03/19 at 12:33 PM, Corporate Registered Nurse (RN) #137 was informed Resident #47's modular protein order did not contain the dosage. Corporate RN #137 stated she would clarify the order with the physician. Review of Resident #47's medical records on 12/04/19 at 8:00 AM revealed the modular protein order was rewritten for 30 ml (milliliters) twice a day. c) Resident #33 A review of Resident #33's care plan noted the care plan had been updated on 10/22/19. In Resident #33's medical record, the following note was revealed: -- 11/6/2019 5:45 PM Social Service Note: The Social Worker had quarterly care plan with the residents representative. The Social Worker went over all appointments and medications. The Social Worker also talked with the residents representative about the resident continuing to be non-complaint with his fluid restrictions. The Social Worker went over the Psychiatrist [NAME] progress note with the representative. The Social went over the residents Code Status, BIM, PHQ-9 and the behaviors the resident has had. The Social Worker went over his nutritional status. The resident continues to people watch and he likes to self propel in his wheelchair. The resident will continue to make his home here at the center. No concerns voiced in care plan. On 12/03/19 at 1:07 PM , Employee #70, Social Worker, the 11/6/19 social services note was reviewed. SW #70 reviewed the medical record for documentation on the care plan meeting. SW #70 stated for quarterly care plans, the interdisciplinary team, consisting of nursing, activities, dietary, therapy, and social services does not document nor review the care plan as a group. SW #70 stated that she contacts the resident and / or resident representative to review the quarterly care plan. On 12/04/19 at 11:30 AM, the findings related to the quarterly care plans was discussed with the Administrator. On 12/04/19 at 11:50 AM, during an interview with SW #70 provided a paper document entitled, DOM Treatment Plan Conference Record. SW #70 stated that this form is completed every quarter with the inter-disciplinary team. When asked why this form could not be located in the electronic medical record, SW #70 stated that this form is not scanned into the medical record. SW #70 stated that this form is competed for every quarterly care plan, rather than a note placed in the resident's electronic medical record. On 12/04/19 at 12:48 PM, the findings related to components of Resident #33's medical record not being contained in the electronic medical record was discussed with Employee #137, Corporate Registered Nurse (RN). No further information was provided at the end of the survey on 12/04/19 at 3:30 PM. d) Resident #60 A review of Resident #60's care plan noted the care plan had been updated on 10/22/19. In Resident #60's medical record, the following note was revealed: -- 1/4/2019 8:25 PM Care Plan Note: The resident had care plan on (MONTH) 3, 2019 and she has capacity and she scored a 15 on her BIM. The resident scored a 0 on her PHQ-9. The resident is a DNR. the resident is currently in restorative and her meal intake was 91%. The resident loves to attend church here at the center. She also enjoys Toss The Dice and Bingo. The resident I happy with her roommate and she will continue to make her home long term here at the center. Attendees: [NAME], Social Services [NAME], Director Of Rehab [NAME], Food Service Director Assistant -- 1/23/2018 12:11 PM Care Plan Note Late Entry : Admission MDS Assessment and Care Plan Conference. CPT met. Face sheet, advance directives, capacity, dx & med lists, consults, lab, MDS, CAAs, P[NAME] Task lists, Kardex, and care plan reviewed. Resident and son attended. She is A/O x 3, has capacity, and is a DNR, limited interventions, feeding tube & IVF trials. She is able to communicate her needs without difficulty. She needs extensive assist of x 2 staff for mobility, transfer, dressing, bathing, and toileting. She has been participating well with her therapy programs and can walk using a hemi-walker up to 100 ft with limited assist but still needs help with sit to stand. She is occasionally incontinent of bladder but always continent of bowel. She has not fallen and skin integrity is currently intact. Her pain regimen includes [MEDICATION NAME] routinely and Tylenol PRN. She denied pain. She is taking [MEDICATION NAME] for [MEDICAL CONDITION] without exhibiting adverse effects. She takes a NAS regular diet and weight is 162#. Dietary will address her Nutritional Status care plan. Social Services will address her discharge plans when appropriate. Nursing will care plan for ADLs, Urinary Incontinence, Falls, Dehydration, and PU. Attendees: [NAME], RN; [NAME] MSW/LGSW,Social Services; [NAME], Activities Director; [NAME], PT -- 1/2/2018 12:46 PM Care Plan Note Late Entry: Admission MDS Assessment and Care Plan Conference. CPT met. Face sheet, advance directives, capacity, dx & med lists, consults, lab, MDS, CAAs, P[NAME] Task lists, Kardex, and care plan reviewed. Resident and family attended. She is A/O x 3, has capacity, and is a DNR, limited interventions, Feeding tube trial and IVF trial x 2 weeks. She is able to communicate her needs without difficulty. She needs extensive assist of x 2 staff for mobility, transfer, dressing, bathing, and toileting. She has been participating well with her therapy programs. She is always continent of B&B. She has not fallen. skin integrity-has stage II PU to her right buttock on admission. Her pain regimen includes [MEDICATION NAME] 300mg TID. She denied pain when interviewed. She is taking antibiotics for [MEDICAL CONDITION] of RLE and pneumonia without exhibiting adverse effects. She takes a NAS regular diet, average intake is 51-75% and weight is 162#. Dietary will address her Nutritional Status care plan. Social Services will address her potential forCognitive Loss/Dementia in a care plan and assist with discharge plans. Nursing will care plan for ADLs, Urinary Incontinence, Falls, Dehydration, and PU. Attendees: [NAME], RN; [NAME] MSW/LGSW, Social Services; [NAME] [NAME], Activities Director; [NAME], PT; [NAME], COT[NAME] A review of Resident #60's medical record noted the resident's care plan was last updated on 10/29/19. A further review of the medical record noted the following social service note: -- 11/22/2019 4:00 PM Social Service Note: The resident had quarterly care plan with the resident and she went over BIM, PHQ-9, Code Status with resident. The Social Worker went over all medications, appointments and the residents diet. The resident is on a regular diet regular texture and the residents meal intake is 76% -100% on (MONTH) 30, 2019. The Social Worker went over the residents low potassium diet which includes no baked potatoes, orange juice tomatoes or bananas. The resident is given one slice of tomato when on menu for sandwiches. The resident was well aware of her low potassium diet. The resident is alert and oriented times three and she has capacity. The resident currently has completed occupational therapy and she is in the restorative Nursing Program for Strengthening ambulation 5X a week for 8 weeks. The resident is assist of one for ADLS and she is assist of Two for staff transfers and she is continent of bowel and bladder. The resident currently participates in the following activities such as spiritual programs, exercise,special events, crafts family visits and reading. The resident has close friend on her hall who she visits with frequently. The resident will continue to make her home long term here at the center. No concerns voiced in care plan. On 12/03/19 at 1:07 PM , Employee #70, Social Worker, the 11/22/19 social services note was reviewed. SW #70 reviewed the medical record for documentation on the care plan meeting. SW #70 stated for quarterly care plans, the interdisciplinary team, consisting of nursing, activities, dietary, therapy, and social services does not document nor review the care plan as a group. SW #70 stated that she contacts the resident and / or resident representative to review the quarterly care plan. On 12/04/19 at 11:30 AM, the findings related to the quarterly care plans was discussed with the Administrator. On 12/04/19 at 11:50 AM, during an interview with SW #70 provided a paper document entitled, DOM Treatment Plan Conference Record. SW #70 stated that this form is completed every quarter with the inter-disciplinary team. When asked why this form could not be located in the electronic medical record, SW #70 stated that this form is not scanned into the medical record. SW #70 stated that this form is competed for every quarterly care plan, rather than a note placed in the resident's electronic medical record. On 12/04/19 at 12:48 PM, the findings related to components of Resident #60's medical record not being contained in the electronic medical record was discussed with Employee #137, Corporate Registered Nurse (RN). No further information was provided at the end of the survey on 12/04/19 at 3:30 PM.",2020-09-01
2344,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2019-12-04,880,F,0,1,V0DD11,"Based on observation, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. This failed practice had the potential to affect more than a limited number of residents residing at the facility. Resident identifiers: Resident #3 and #60. Facility census 81. Findings included: a) Laundry Room During an observation and tour of the laundry rooms on 12/04/19 at 8:39 AM, Laundry Staff #24 was witness to the airflow being pulled from the soiled laundry room into the clean laundry room. This was verified by using a piece of tissue paper along the door dividing the two rooms. The paper was being pulled into the clean laundry room, while standing in the soiled room. On 12/04/19 at 8:41 AM, Housekeeping supervisor #93 also verified that the tissue paper was being pulled into the clean laundry room from the soiled laundry room. He stated that he would find a fix for that as soon as possible. b) Resident #3 During the initial tour on 12/02/19 at 10:57 AM, Resident #3's Bilevel Positive Airway Pressure (bi-pap) mask was observed to be lying on the bedside table, not in a bag. A bag was observed to be hanging near Resident #3's bed, empty. On 12/02/19 at 10:59 AM, Employee #62, Licensed Practical Nurse (LPN) was asked to enter Resident #3's room. LPN #62 observed the bi-pap mask sitting out on Resident #3's bedside table. LPN #62 stated that the mask should have been wiped off and placed in a bag when not in use. On 12/04/19 at 11:30 AM, the findings were discussed with the Administrator. No further information was provided prior to the end of the survey on 12/04/19 at 3:30 PM. c) Resident #60 During the initial tour on 12/02/19 at 11:07 AM, the surveyor observed Resident #60's nebulizer was not in a bag, still connected to machine, unit fully assembled, and not in use. On 12/02/19 at 11:12 AM , Employee #49, LPN, was asked to enter Resident #60's room. LPN #49 observed the nebulizer sitting out on Resident #60's bedside table. LPN #49 stated that the nebulizer was supposed to be in a bag. A bag was noted beside the resident's bed, empty. On 12/03/19 at 8:30 AM, Resident #60's nebulizer was out on the bedside table. LPN #49 stated that the nebulizer was supposed to be in the bag. LPN #49 further noted that night shift must have left it out. LPN #49 stated that she would put the nebulizer in the appropriate bag after Resident #60 completed her nebulizer treatment. Resident #60 refused to use the nebulizer. A review of the facility's policy entitled, Small Volume Nebulizer revealed the following: V. Cleaning and Replacement Schedule: [NAME] The Nebulizer Circuit should be disassembled after each treatment, rinsed with water and let to air dry. Place the nebulizer circuit in the equipment bag for infection control purposes. B. Daily, the nebulizer circuit should be washed with warm, soapy water, rinsed with water and let to air dry. C. The Nebulizer Circuit should be wiped clean with a damp cloth as necessary to avoid accumulation of dust. D. The air inlet filter should be checked and changed as needed. E. Replace disposable supplies every ten (10) days and as needed. F. Date each supply item (e.g., nebulizer circuit) or supply bag for documentation purposes and indication of the next scheduled replacement, as applicable. On 12/04/19 at 11:30 AM, the findings were discussed with the Administrator. No further information was provided prior to the end of the survey on 12/04/19 at 3:30 PM.",2020-09-01
4218,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2016-08-11,157,E,0,1,1GMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the physician was notified when two (2) of five (5) residents, reviewed for the care area of unnecessary medications, experienced episodes of [MEDICAL CONDITION]. Resident identifiers: #8 and #85. Facility census: 84. Findings include: a) Resident #8 Medical record review, at 2:00 p.m. on 08/09/16 found Resident #8 found current physician's orders for treatment of [REDACTED]. --Blood sugar check, two (2) times a day; --[MEDICATION NAME] Solution 100 unit/ (milliliter) ML, inject 40 units subcutaneously in the evening; and --[MEDICATION NAME] solution 100 unit/ML, inject 53 units subcutaneously in the morning. On 03/18/16, the physician signed standing orders for this resident directing the implementation of the facility's hyper/[DIAGNOSES REDACTED] protocols unless parameters otherwise ordered by the physician. The current physician's orders did not contain any parameters. Review of the [DIAGNOSES REDACTED]/[MEDICAL CONDITION] management policy found the following: --Notify the physician, if blood sugars are greater than 300 mg/dl during all or part of 2 consecutive days (unless this represents an improvement from a recently measured value or existing orders specify how the patient's [MEDICAL CONDITION] should be managed). --Notify the physician if the patient with diabetes has not eaten well or not consumed sufficient fluids for 2 or more days and has one or more of the following additional symptoms: abdominal pain, fever, [MEDICAL CONDITION], lethargy or confusion, or respiratory distress. --Document action, resident condition and response and the physician response in the Nurse's notes. The resident's medication administration records (MAR's), were reviewed with the Director of Nursing (DON) at 3:00 p.m. on 08/09/16. Review of the (MONTH) (YEAR) MAR found the following occasions when the resident's blood sugars were over 300 on 2 consecutive days: --04/06/16: blood sugar was 360 --04/07/16: blood sugar was 332 --04/09/16: blood sugar was 324 --04/10/16: blood sugar was 301 --04/11/16: blood sugar was 361 --04/13/16: blood sugar was 332 --04/14/16: blood sugar was 327 --04/16/16: blood sugar was 342 --04/17/16: blood sugar was 325 --04/22/16: blood sugar was 301 --04/23/16: blood sugar was 346 Review of the (MONTH) (YEAR) MAR found the following occasions when the resident's blood sugar was over 300 on two consecutive days: --05/04/16: blood sugar was 318 --05/05/16: blood sugar was 314 --05/07/16: blood sugar was 326 --05/08/16: blood sugar was 326 --05/09/16: blood sugar was 388 --05/25/16: blood sugar was 312 --05/26/16: blood sugar was 377 Review of (MONTH) the (YEAR) MAR found the following occasions when the resident's blood sugar was over 300 on two (2) consecutive days: --06/06/16: blood sugar was 349 --06/07/16: blood sugar was 320 --06/18/16: blood sugar was 329 --06/19/16: blood sugar was 334 --06/20/16: blood sugar was 338 --06/21/16: blood sugar was 313 --06/22/16: blood sugar was 341 Review of the (MONTH) (YEAR) MAR found the following occasions when the resident's blood sugar was over 300 on two (2) consecutive days: --07/04/16: blood sugar was 306 --07/05/16: blood sugar was 368 --07/07/16: blood sugar was 302 --07/08/16: blood sugar was 305 --07/10/16: blood sugar was 323 --07/11/16: blood sugar was 362 --07/12/16: blood sugar was 325 --07/13/16: blood sugar was 305 --07/19/16: blood sugar was 321 --07/20/16: blood sugar was 315 --07/27/16: blood sugar was 361 --07/28/16: blood sugar was 315 At 4:00 p.m. on 08/09/16, the DON confirmed the physician was not contacted each time the resident's blood sugars were over 300 on two consecutive days. b) Resident #85 Medical record review, at 9:11 a.m. on 08/10/16, found Resident #85 received the following medications for the treatment of [REDACTED].>--[MEDICATION NAME] Solution 100 units three times a day (TID) --[MEDICATION NAME] Solution, inject per sliding scale: if blood sugar is 200-299 give 6 units, if blood sugar is 300-399 give 8 units, and if blood sugar is 400-499 give 10 units. On 07/09/16 at 11:30 a.m. the resident's blood sugar was 548. The nurse did not administer any sliding scale insulin. The physician was not notified. The order contained no parameters as to what the nurse should do if the blood sugar was over 499. On 08/10/16 at 11:00 a.m. the DON said she would have expected the nurse to call the physician when the blood sugar was 548. The DON confirmed she could find no evidence the physician was contacted for direction. The resident's physician was interviewed by telephone at 1:50 p.m. on 08/11/16. She stated she would have expected the nurse to call her when the resident's blood sugar was 548.",2020-02-01
4219,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2016-08-11,166,E,0,1,1GMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and resident interview the facility failed to ensure social services addressed all grievances to the residents' satisfaction for three (3) of three (3) residents reviewed. This failed practice had the potential to affect more than a limited number of people and over repeated occurrences. Resident identifiers: # 93, #85 and #83. Facility census: 84. Findings include: a) Resident #93 During an interview with Maintenance Supervisor #72, on 08/10/16 at 8:25 a.m., he stated the resident had light bulbs for daylight and/or soft light. He was aware the resident was concerned with the lighting and would check with Resident #93 to see which he preferred. Resident had expressed concern to the surveyor during Stage I interviews the light was too bright in his eyes when he was lying in bed. He indicated he had informed the social worker (SW) and maintenance staff but it had not been corrected. Spoke with Maintenance Personnel #78, at 1:10 p.m. on 08/10/16, he stated the resident expressed concern with the light being too bright above his bed but was unsure of how long ago it was brought up. Maintenance Personnel #78 said they were going to try to get 40 watt bulbs or order new hospital type lights that go at the head of the bed so the brightest part of the light does not shine in the residents' eyes. According to the SW #40 at 2:50 p.m. the resident had not informed her of the light issue in his room. She stated the maintenance director had talked to him and he would address it. During an interview with Resident #83 on 08/10/16 at 3:40 p.m., he stated he had told several people about the lights being too bright in his eyes. Resident #83 said it had been an ongoing issue for months. He said he had told told everybody. He also said the maintenance staff came in today and changed out the lightbulbs. He said it did make a difference. b) Resident #85 1. Grievance #1 Review of the concern/grievance forms, completed during the past year, at 10:00 a.m. on 08/10/16, found Resident #85 voiced a concern on 04/12/16. The resident stated she was not assisted to the bathroom. The concern/grievance form had the following description of the action(s) taken to investigate, Spoke with resident regarding her allegations and she related it may have seemed like a long time and she stated it was O.K. Attached to the grievance/concern form were three (3) statements from staff: --Statement #1 written by a licensed practical nurse who wrote, On Tuesday 04/12/16 on night shift (name of resident) was assisted to bathroom via Hoyer lift 3 times by staff. --Statement #2 written by a nurse aide who wrote she did not assist the resident on 04/12/16. --Statement #3, dated 04/13/16, completed by a restorative licensed practical nurse (LPN) who wrote: At 6:50 a.m. resident observed lying in bed with lift pad under her. She was crying and saying help me dear lord please. Dressed in gown with brief on and wet with urine. Complained of lying on back and not being able to get up. This nurse and restorative CNA (certified nursing assistant) transferred resident to shower chair then proceeded to complete shower, dressed and transported to dining room via wheelchair no voiced complaints of pain discomfort and no further mention of morning care before restorative arrived. At 2:15 p.m. on 08/10/16, Social Worker (SW) #40 was interviewed regarding Resident #85's concern/grievance form. When asked why the form did not contain when the alleged incident occurred, SW #40 stated the resident did not know, then she said the incident occurred on 04/12/16. SW #40 was asked why she did not interview the resident's nurse aides who provided care on 04/12/16. She confirmed the Hoyer lift required two (2) staff members when used; therefore, two staff members must have assisted the resident to the bathroom if she went to the bathroom [ROOM NUMBER] times during the night shift of 04/12/16. According to statement #3, the resident was found to be wet at 6:50 a.m. SW #40 confirmed the statement was dated 04/13/16 but the writer was referring to 04/12/16. SW #40 said she was going to do a better job in the future when completing the concern/grievance forms and she would be more thorough when investigating. 2. Grievance #2 During Stage 1 of the Quality Indicator Survey (QIS), at 1:41 p.m. on 08/08/16, the resident stated someone had taken $20.00 from her. She said she had two (2) $20.00 bills which she thought she were well hidden in her room, but she guessed she didn't hide it good enough. This was about six months ago. She stated she told many staff members but the social worker told her the facility, Is not responsible for missing items. Review of the grievance/concern forms on 08/10/16, at 10:00 a.m., found no evidence the facility had investigated the resident's allegation of missing money. At 2:49 p.m. on 08/10/16, the Social Worker (SW) #40 said the facility usually doesn't write anything down concerning missing items. She said, It seems like I remember something about missing money and I told her she needed to keep her money up front. We don't replace missing money. Review of the resident's most recent minimum data set (MDS), a quarterly MDS, with an assessment reference date (ARD) of 06/20/16, found the resident's brief interview for mental status (BIMS) score was 15, indicating the resident was cognitively intact. c) Resident # 83 During Stage 1 of the Quality Indicator Survey (QIS) interview with Resident #83, at 2:12 p.m. on 08/08/16, found he had some missing money and clothes. When asked if he had told staff about the missing items he indicated he had, but it did not do any good and they basically said, sorry about your luck. During Stage 2 of the QIS interview with Resident #83, at 1:51 p.m. on 08/10/16, revealed he was missing eight (8) to ten (10) shirts and pairs of pants. He stated, They say they will tell (name of Social Worker (SW) #40), but nothing is ever found. He further stated around this time of the year that he always has money come up missing. Resident #83 stated, When it is fair (state fair) time they know my parents send me extra cash and when I go to the shower and come back someone has taken my money. He stated that last year they took $40.00. When asked if the staff ever addressed the concern related to his missing money he stated, you tell them but it does not do any good nothing ever changes. Resident #83 stated, the only time I have ever got anything back was last week when I had four (4) pairs of pants missing and the new girl (referring to SW #112) found them for me. He stated, she found them because she looked for them no one else has ever looked for anything that has been missing. d) Staff interviews An interview with SW # 40 and SW # 112, at 12:53 p.m. on 08/10/16, revealed they had no knowledge of Resident #83's complaints of missing money and/or clothes. SW # 112 indicated that last week he had reported four (4) pairs of pants were missing, but she found those in laundry and returned them to him. SW #40 and SW #112 had no other knowledge of any missing items for Resident #83. When asked what the process was for missing items, SW #40 indicated they will just look for the item and if they find it they will return it. If they don't find it they will replace it. She stated, We will replace anything except money and jewelry. When asked if they keep a written record of what has been reported missing and the results of the investigation and/or search for the item, they both indicated that was something that they needed to work on. SW #40 stated, we will usually just talk about it and we have not been writing it down. She continued, That is a process we are changing and will improve our record keeping. SW #40 stated, I do have a paper and it has a few things wrote down that we either found or replaced. She was asked to provide a copy of this paper. When provided the form was reviewed and had five entries none of which were dated. The residents were identified by number on the form. When SW #40 was asked to identify each resident by name she did so, but none of the missing items belonged to Resident #83. She again stated, Our record keeping on missing items has been lacking. SW #40 and SW #112 indicated that the facility provides information to each resident or responsible party about what is and is not replaced when missing upon admission to the facility. An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON), at 10:12 a.m. on 08/11/16, confirmed they did not have any knowledge about Resident #83's missing money or clothing. When asked about the process for missing items they both indicated that missing items were discussed daily during stand up meeting and they never really wrote anything down about them. When asked what kinds of things that do or do not replace they indicated it was really just dependent on the circumstances. The NHA stated, I know we replace items I can show you some receipts for things we have replaced. They both indicated that usually what they talk about is found and no follow up is needed. Later in the afternoon the NHA provided four (4) receipts which showed items replaced since (MONTH) of (YEAR). The items included socks, hair products, shampoo, and toothpaste. When asked about the admission paperwork and the facility's policy the NHA agreed they did not read the same. When asked which the facility follows he stated, We pretty much just follow the admissions information. He stated, If we replace something or not really just depends on the investigation and what we find out during the investigation. However; he was unable to provide any evidence that missing items including clothes and/or money were ever investigated by the facility. e) Review of Admission Booklet and Facility Policy Review of the Admission Booklet on 08/10/16 at 4:30 p.m. found the following noted under the heading, Personal Property: --Resident, and not the center, shall be responsible for the provision of all personal comfort items, including footwear, clothing, and petty cash to be utilized for the Resident's incidental expenses. --All clothing and other personal items shall be clearly marked by the Resident or the Representative to indicate ownership by Resident. --The center strongly discourages the keeping within the center valuable jewelry, papers, electronic equipment, large sums of money or other items considered of value. Should the resident choose to bring the aforementioned items, i.e. items of great value, the center shall not be responsible for loss, theft or destruction. Review of the facility's policy titled, Resident and Visitor Incident Policy and Procedure found the following for missing items greater than or equal to $50.00 (clothing, dentures, glasses, etc.): --The employee will immediately report the incident to the immediate Supervisor, DON, or Administrator. --The Supervisor, DON or administrator will conduct a timely investigation of the incident and complete the Incident Report Form. --If the company is found to be at fault, the item reported missing will be replaced with a duplicate item or a similar item of the same approximate function and value. --The Supervisor, DON or Administrator will continue communication with the resident and/or family throughout the investigation up to and including replacement of the missing item. --Follow up after receipt of the replacement is essential to resident satisfaction and company quality assurance and will be documented on the Incident report form, as appropriate. --If the company is not found to be at fault, an investigation will pursue in order to identify the root cause and attempt prevention of future occurrence. Actions taken will be documented on the Incident Report Form, as applicable.",2020-02-01
4220,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2016-08-11,225,D,0,1,1GMW11,"Based on resident interview, record review, staff interview, and facility policy review, the facility failed to report and investigate an allegation of abuse for (1) of one (1) resident reviewed. The failed practice had the potential to affect a limited number of residents reviewed for abuse prohibition. Resident identifiers: 73. Facility census: 84. Findings include: a) Resident #73 1. Resident interview During Stage 1 of the Quality Indicator Survey (QIS), on 08/09/16 at 8:25 a.m., Resident #73 replied, Yes when asked, Has staff, a resident or anyone else here abused you - this includes verbal, physical, or sexual abuse? Resident #73 also replied, Yes when asked, Did you tell staff? Resident #73, appeared extremely emotionally upset as she described an incident where she had been accused by staff of hitting another resident. Resident #73 stated, I was walking out of my door as another resident was being pushed in a wheelchair in the hall outside of my room, when I accidentally hit the ring on my finger against the wall rail and it made a noise. The next thing I know I got jumped by a nurse about hitting and smacking other residents. The whole time I was telling them I didn't hit anyone and I would never. But they never listened to me. They should have known better than that as long as I've been here. They made me feel awful yelling at me about it and thinking I would actually hit someone. I talked to Social Worker (SW) #40, and other staff a couple times but no one has ever told me they were sorry for falsely accusing me, or that they even believe me. Resident #73 appeared alert and oriented during the entire interview. 2. Record review On 08/09/16 at 12:54 p.m., review of records revealed Resident #73 was admitted to the facility in early (YEAR). Review of recent quarterly minimum data set (MDS), with an assessment reference date (ARD) 06/30/16, revealed the resident scored 15 on her brief interview for mental status (BIMS). A person who scores from 13 -15 on the BIMS is considered to be cognitively intact. On 08/09/16 at 3:08 p.m., review of records revealed a physician deemed Resident #73 to have capacity on 04/07/15. Review of facilities reporting forms and reports, on 08/09/16 at 1:43 p.m., revealed there were no reports for this resident. On 08/09/16 at 2:13 p.m., review of progress note dated 08/07/16 revealed .not demonstrate any worrisome behaviors. Progress note dated 08/05/16 revealed no behaviors. Review of progress notes for the prior six (6) month showed there were frequent documentation about the resident not having any behaviors. However, one (1) progress note dated 08/01/16 revealed, (typed as written) Resident was standing outside her room door and the other resident was being pushed up the hallway and this resident smacked the other resident on the arm (102A). Resident was ask about smacking the other resident and she stated she didn't smack her she hit her hand on the hand rail. Resident was educated on not smack other resident 3. Policy review Review of facility's abuse policy on 08/10/16 at 2:47 p.m., revealed All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. 4. Staff interviews An interview with Nurse Aide (NA) #93, revealed NA #93 had always found Resident #73 cooperative, easy going, and easy to get along with. Denied ever seeing or hearing about resident having hit another resident. On 08/09/16 at 4:18 p.m., an interview with SW #40, revealed the SW talked to Resident #73 yesterday (08/08/16) for the first time about the issue of being accused of hitting a resident. Resident #73 reported to SW #40 that she did not hit the other resident. SW #40 stated Resident #73 was upset and was sensitive and her feelings could be hurt easily at times. When SW #40 was asked when she was aware of the incident occurring concerning Resident #73, the SW replied, Sometime last week when it happened, I knew Resident #73 was upset about being accused of hitting a resident. When asked the date the incident happened, the SW said she wasn't sure exactly, but she stated she knew about it before she went off work. SW stated she was off Thursday and Friday (08/04/16 and 08/05/16), so therefore she said she had to have at least known about it before 08/03/16 (Wednesday). SW #40, said she planned to take care of it when she returned back to work on Monday. The SW said she did not want to pass the incident onto the other SW, because they had been recently hired. SW stated she had interviewed Resident #73 yesterday, but had not yet written the resident's statement to be able to provide a copy to the surveyor. An interview with the director of nursing (DON) concerning the incident, on 08/10/16 at 12:27 p.m., revealed the DON was made aware of the incident at a clinical morning meeting. The incident was discussed as a side conversation and someone said Resident #73 didn't hit the resident (DON did not know who said it), therefore the DON stated she didn't go talk to Resident #73. The DON said she went and looked at the other resident and did not see any evidence the resident had been hit. On 08/11/16 at 2:54 p.m. interview with SW #40, revealed the SW agreed Resident #73 was deeply upset about being accused. The SW also revealed Resident #73 had previously been a nurse aid for a little while. SW #40 stated abuse was to be reported immediately, and abuse/neglect trainings and patient rights in-service were provided to all staff yearly or as needed, and when staff was hired. SW #40 agreed the incident had not been handled promptly. During an interview, on 08/11/16 at 3:45 p.m., the administrator stated the incident should have been reported to him immediately or his designee, which was the DON. At the time the incident occurred the administrator was on vacation.",2020-02-01
4221,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2016-08-11,226,D,0,1,1GMW11,"Based on record review, staff interview, resident interview, and review of the facility's abuse investigation policy, the facility failed to operationalize its policies and procedures for identification, investigation, and reporting promptly an allegation of verbal abuse for one (1) of one(1) residents reviewed. The failed practice had the potential to affect a limited number of residents reviewed for abuse prohibition. Resident identifier: #73. Facility census: 84 Findings include: a. Resident #73 1. Resident interview During Stage 1 of the Quality Indicator Survey (QIS), on 08/09/16 at 8:25 a.m., Resident #73 replied, Yes when asked, Has staff, a resident or anyone else here abused you - this includes verbal, physical, or sexual abuse? Resident #73 also replied, Yes when asked, Did you tell staff? Resident #73, appeared extremely emotionally upset as she described an incident where she had been accused by staff of hitting another resident. Resident #73 stated, I was walking out of my door as another resident was being pushed in a wheelchair in the hall outside of my room, when I accidentally hit the ring on my finger against the wall rail and it made a noise. The next thing I know I got jumped by a nurse about hitting and smacking other residents. The whole time I was telling them I didn't hit anyone and I would never. But they never listened to me. They should have known better than that as long as I've been here. They made me feel awful yelling at me about it and thinking I would actually hit someone. I talked to Social Worker (SW) #40, and other staff a couple times but no one has ever told me they were sorry for falsely accusing me, or that they even believe me. Resident #73 appeared alert and oriented during the entire interview. 2. Record review On 08/09/16 at 12:54 p.m., review of records revealed Resident #73 was admitted to the facility in early (YEAR). Review of recent quarterly minimum data set (MDS), with an assessment reference date (ARD) 06/30/16, revealed the resident scored 15 on her brief interview for mental status (BIMS). A person who scores from 13 -15 on the BIMS is considered to be cognitively intact. On 08/09/16 at 3:08 p.m., review of records revealed a physician deemed Resident #73 to have capacity on 04/07/15. Review of facilities reporting forms and reports, on 08/09/16 at 1:43 p.m., revealed there were no reports for this resident. On 08/09/16 at 2:13 p.m., review of progress note dated 08/07/16 revealed .not demonstrate any worrisome behaviors. Progress note dated 08/05/16 revealed no behaviors. Review of progress notes for the prior six (6) month showed there were frequent documentation about the resident not having any behaviors. However, one (1) progress note dated 08/01/16 revealed, (typed as written) Resident was standing outside her room door and the other resident was being pushed up the hallway and this resident smacked the other resident on the arm (102A). Resident was ask about smacking the other resident and she stated she didn't smack her she hit her hand on the hand rail. Resident was educated on not smack other resident 3. Policy review Review of facility's abuse policy on 08/10/16 at 2:47 p.m., revealed All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. 4. Staff interviews On 08/09/16 at 4:18 p.m., an interview with SW #40, revealed the SW talked to Resident #73 yesterday (08/08/16) for the first time about the issue of being accused of hitting a resident. Resident #73 reported to SW #40 that she did not hit the other resident. SW #40 stated Resident #73 was upset and was sensitive and her feelings could be hurt easily at times. When SW #40 was asked when she was aware of the incident occurring concerning Resident #73, the SW replied, Sometime last week when it happened, I knew Resident #73 was upset about being accused of hitting a resident. When asked the date the incident happened, the SW said she wasn't sure exactly, but she stated she knew about it before she went off work. SW stated she was off Thursday and Friday (08/04/16 and 08/05/16), so therefore she said she had to have at least known about it before 08/03/16 (Wednesday). SW #40, said she planned to take care of it when she returned back to work on Monday. The SW said she did not want to pass the incident onto the other SW, because they had been recently hired. SW stated she had interviewed Resident #73 yesterday, but had not yet written the resident's statement to be able to provide a copy to the surveyor. An interview with the director of nursing (DON) concerning the incident, on 08/10/16 at 12:27 p.m., revealed the DON was made aware of the incident at a clinical morning meeting. The incident was discussed as a side conversation and someone said Resident #73 didn't hit the resident (DON did not know who said it), therefore the DON stated she didn't go talk to Resident #73. The DON said she went and looked at the other resident and did not see any evidence the resident had been hit. On 08/11/16 at 2:54 p.m. interview with SW #40, revealed the SW agreed Resident #73 was deeply upset about being accused. The SW also revealed Resident #73 had previously been a nurse aid for a little while. SW #40 stated abuse was to be reported immediately, and abuse/neglect trainings and patient rights in-service were provided to all staff yearly or as needed, and when staff was hired. SW #40 agreed the incident had not been handled promptly. During an interview, on 08/11/16 at 3:45 p.m., the administrator stated the incident should have been reported to him immediately or his designee, which was the DON. At the time the incident occurred the administrator was on vacation.",2020-02-01
4222,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2016-08-11,253,E,0,1,1GMW11,"Based on observations and staff interview, the facility failed to ensure furnishings in resident rooms were clean, comfortable, and in good repair for four (4) out of 29 rooms evaluated during Stage 1 of the Quality Indicator Survey (QIS). This failed practice had the potential to affect more than a limited number of people. Room Numbers: #301, #103, #105, #109[NAME] Facility census: 84. Findings include: a) Room #301, on 08/09/16 at 8:01 a.m., had scuff marks around the hand sink. Also an area by the door frame was noted to be marred. b) Room #103, at 1:44 p.m. and 3:31 p.m. on 08/08/16, had scuff marks on both wardrobes. c) Room #105, on 08/08/16 at 1:30 p.m., had scuff marks on the wardrobes. d) Room #109, at 2:08 p.m. on 08/08/16, had scuffed areas on the wardrobe. During an interview with the maintenance director, on 08/10/16 at 8:45 a.m., he confirmed the areas needed repaired. Furthermore, he verified for issues such as these there was no formal method of reporting and recording them. He said the nursing staff would stop him in the hall and tell him of things that needed repaired. He said would see it was taken care of, however, there was not any documentation available to show what was reported or what was repaired.",2020-02-01
4223,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2016-08-11,278,D,0,1,1GMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately record the resident's status on the quarterly minimum data set ( MDS) related to the care area of behavior for one (1) of twenty MDS assessments reviewed during Stage 2 of the quality indicator survey. Resident #51 was identified as having behavior, such as scratching. The scratching was related to a medical problem, not a behavioral problem. The failed practice had the potential to affect a limited number of residents reviewed during State 2 of the QIS. Resident identifier: 51. Facility census: 84. Findings include: a) Resident #51 A review of Resident #51's quarterly MDS with an assessment reference date (ARD) of 05/16/16, found the resident was identified as having behaviors (physical symptoms directed toward others, hitting, kicking, pushing, scratching, grabbing, abusing other sexually). These behaviors were coded as accruing one (1) to three (3) days. During a review of the behavior monitor flow record on 05/12/16, licensed practical nurse (LPN) #79 identified Resident #51 as having a behavior of pinching/scratching/spitting. Resident #51 had a [DIAGNOSES REDACTED]. In an interview on 08/11/16 at 11:15 a.m., the Director of Nursing (DON) was asked why the quarterly MDS with the ARD of 05/16/16 identified the resident as having physical symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing, abusing other sexually). The DON said the resident at times will scratch herself. During that time the staff was applying Sarna (anti-itch)lotion to her arms, legs, chest, and back. The DON said the scratching that is documented on the behavior monitor flow record is not a behavior, but a medical problem. The resident had a [DIAGNOSES REDACTED]. During this look back period revealed the resident did receive Sarna lotion applied to her arms, legs, chest, and back one time a day for itching. This medication was started on 02/09/16.",2020-02-01
4224,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2016-08-11,334,D,0,1,1GMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review the facility failed to educate and/or obtain consent or refusal for an influenza and pneumococcal vaccine for one (1) of five (5) sampled residents reviewed for influenza and pneumococcal immunizations. This failed practice had the potential to affect a limited number of residents reviewed. Resident identifier: #83. Facility census: 84 Findings include: a) Resident #83 Interview with Infection Control Nurse and DON, on 08/11/16 at 4:15 p.m., revealed the facility could not find a signed consent or refusal for Resident #83 for the influenza and pneumococcal vaccines for the current flu season. The only signed consent or refusal was dated 2013 when the resident was first admitted . Review of the immunization acknowledgment sheet for the year 2013 revealed the sheet applied only to the year 2013. The box for influenza and the box for pneumococcal were both marked, and hand written on the form was Do not want if needed. This form was signed 10/09/13. The Infection Control Nurse and DON agreed the vaccines should be offered annually and the resident given the right to refuse after first being provided the education on the vaccine. On 08/11/16 at 3:30 p.m., review of policy and procedure for Immunizations for Residents revealed, Inform resident or legal representative each year when the influenza vaccinations will be given and provide the Vaccination Information Statement from the CDC (Centers for Disease Control and Prevention) for the current year. The Vaccination Information Statement contains educational information about the benefits and potential side effects of influenza vaccination. According to the Centers for Disease Control and Prevention (CDC), the primary option for reducing the effect of influenza is immuno-[MEDICATION NAME] with vaccine. Vaccinating persons at high risk for complications and their contacts each year before seasonal increases in [MEDICAL CONDITION] circulation is the most effective means of reducing the effect of influenza . achieving increased vaccination rates among persons living in closed settings (e.g., nursing homes and other chronic care facilities) and among staff can reduce the risk for outbreaks . Review of records revealed the facility could not provide any evidence the resident had been informed about the benefits and risks of an influenza immunization or pneumococcal immunization, or whether the resident had been given the opportunity to receive or to refuse the influenza vaccine or pneumococcal immunization since he was first admitted in 2013. No documentation of any information or education was found in the resident's medical records; regarding the benefits or risks of immunization, and/or the administration or the refusal of these vaccines, or any medical contraindications to the vaccines for 2014, (YEAR), or the current (YEAR).",2020-02-01
4225,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2016-08-11,371,B,0,1,1GMW11,"Based on observations and staff interview it was revealed the dietary staff had not ensured foods were stored in accordance with acceptable sanitation practices. Refrigeration storage areas had containers of items which were not labeled or dated as required. This practice has the potential to affect more than a limited number of residents as all residents who consume foods by oral means are served from this central location. Facility census: 84. Findings include a) The kitchen tour was completed shortly after entrance, on 08/08/16 at 11:15 a.m. The tour was completed with the assistant dietary manager. The following items were noted in the walk-in refrigerator during the observations: --Two (2) large containers of sweet BBQ (barbeque) sauce were not labeled or dated of when they were opened. --A sheet pan containing saucers which had desserts on them were not labeled nor dated indicating when they were prepared or to be used. --Four (4) plastic containers were not labeled and dated identifying what the content inside was or when it was opened. These were identified with assistant dietary manager and the dietary manager at the time of the observations and the items were immediately removed from the unit.",2020-02-01
4226,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2016-08-11,514,E,0,1,1GMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to ensure a complete an accurate medical record for four (4) of twenty (20) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). For resident #70, the facility failed to provide a correct [DIAGNOSES REDACTED]. For Resident #11, the medical record contained inconsistent documentation related to pain management and failed to contain the resident's reason for refusal of a pneumococcal vaccine. For Resident #128, the medical record contained conflicting documentation related to [MEDICAL CONDITION]. For Resident #119, the medical record was inaccurate related to pressure ulcers. Resident identifiers: #70, #11, #128, and #119. Facility census: 84. Findings include: a) Resident #70 Medical record review for the care area of unnecessary medications, on 08/11/16 at 9:00 a.m., found Resident #70 was prescribed Cipro, an antibiotic medication, on 07/31/16, for a [DIAGNOSES REDACTED]. At 10:38 a.m. on 08/11/16, the Director of Nursing (DON) [MEDICATION NAME] prescribed for extended-spectrum beta lactamase (ESBL) in the urine and not for a lack of coordination. Beta-lactamases are enzymes produced by bacteria and are treated with antibiotics. b) Resident #11 1. Medical record review, on 08/10/16 at 10:00 a.m., found resident receiving Hospice services for a terminal [DIAGNOSES REDACTED]. The physician prescribed comfort measures and no hospitalization . On 03/04/16 the resident was prescribed [MEDICATION NAME] .25 milligram/milliliter (mg/ml) by mouth every 4 hours as needed for pain. Further review of the medical record and the Medication Administration Record [REDACTED]. --05/09/16 at 8:00 p.m. --07/25/16 at 8:00 a.m. --08/09/16 at 4:30 p.m. The resident's pain was not rated, and there was no follow-up documentation regarding the effectiveness of the medication. The Director of Nursing (DON) was interviewed at 12:59 p.m. on 08/11/16. She stated the facility used a paper MAR indicated [REDACTED]. The DON stated, The nurses had to answer so many questions in so many places that it's confusing. We didn't have these problems when everything was paper because the pain rating and the follow up on the medication's effectiveness was on the MAR, right beside of the medication. It is just to confusing for the staff. The DON stated before administering an as needed pain medication, staff are to try non-pharmacological interventions. The resident's pain was to be rated and the effectiveness of the medication was also to be rated. The DON said, We just had an in-service about pain and the nursing staff know this, it's just the electronic record that has created the problem. The DON printed Resident #11's electronic medical record which showed documentation where the nursing staff document on each shift regarding the resident's pain. The DON said that once this question was asked, the resident may have pain later in the shift and then it is too late to enter anything in the electronic medical record. b) Resident #119 A review of the weekly licensed practical nurse skin evaluation for Resident #119, for the dates of 06/05/16, 06/19/16, 06/27/16 , and 07/15/16 revealed the resident is identified as not having an existing previously identified ulcer. A review of the weekly wound evaluation sheet revealed the resident had an suspected deep tissue injury (SDTI) of the left heel identified on 06/03/16. The weekly wound evaluation sheet identify the STDI was present up to 06/27/16. The wound on 06/27/16 is then identified as a unstageable pressure ulcer. The DON, on 08/10/2016 11:24 a.m., reviewed the skin evaluation form for the dates of: 06/05/16, 06/19/16, 06/27/16 and 07/15/16. The DON confirmed the nurses answered the question wrong. It should be yes, but her staff wrote no. The resident had a SDTI to her left heel, then it changed to an unstageable pressure ulcer. The DON confirmed the nurses inaccurately documented the resident's actual status on the weekly skin evaluation forms. c) Resident #128 A review of Resident #128's medical record revealed the resident weighed 138 pounds on 07/05/16. On 07/18/16, the last weight obtained before discharge, Resident #128 weighed 128.8 pounds. Further review of the record found a handwritten note signed by Resident #128's attending physician which read as follows, Anticipated weight loss secondary to diuresis r/t (related to) [MEDICAL CONDITION]. This note was dated 07/20/16. Peripheral [MEDICAL CONDITION] can be defined as, [MEDICAL CONDITION] (accumulation of fluid causing swelling) in tissues perfused by the peripheral vascular system, usually in the lower limbs. In the most dependent parts of the body (those hanging distally), it may be called dependent [MEDICAL CONDITION]. Review of the physicians progress notes dated 07/08/16, 07/13/16, and 07/20/16 found no mention of [MEDICAL CONDITION]. In fact the section titled [MEDICAL CONDITION] both for pedal and scaral [MEDICAL CONDITION] the physician had circled no. The physician progress notes [REDACTED]. The comprehensive nutritional assessment dated [DATE] indicated Resident #128 had no [MEDICAL CONDITION]. Review of the facility's daily skilled evaluation assessments beginning on 07/06/16 through 07/21/16 found no documentation that indicated Resident #128 had [MEDICAL CONDITION]. Under the heading cardiovascular the form had a place to mark if [MEDICAL CONDITION] was present. This was not marked on any of the daily skilled evaluations. An interview with the Director of Nursing (DON) at 1:04 p.m. on 08/10/16 revealed the residents weight loss was because of [MEDICAL CONDITION] and history of alcoholism and increased physical activity with therapy. She stated she realized the [MEDICAL CONDITION] was not represented in the notes but it was present. An interview with the attending physician at 1:23 p.m. on 08/10/16 found she was familiar with the resident. She stated Resident #128 was an alcoholic and was admitted with a pelvic fracture. She indicated, Resident #128's weight loss was mostly due her [MEDICAL CONDITION], but also related to the increased physical activity and due to her fall and decreased calorie intake. She reviewed her physician progress notes [REDACTED].#128 had [MEDICAL CONDITION] upon admission she was receiving two (2) diuretics and the weight loss was [MEDICAL CONDITION] related. d) Resident #11 On 08/11/16 at 4:05 p.m., review of the pneumococcal vaccination informed consent/declination form for (YEAR) revealed no reason for the refusal of the pneumococcal vaccine. The facility's form was revised (MONTH) (YEAR) with instructions that a signed and completed copy must be filed in the resident's medical record. On the form there were two (2) separate designated areas with boxes stating Vaccination/Revaccination Refused and two (2) lines were under the boxes to document the reason for the refusal. Both boxes were marked indicating refusal of the vaccine, however there was no reason documented in either areas designated to document the reason for the refusal. Interview with Infection Control Nurse and DON, on 08/11/16 at 4:15 p.m., revealed the Infection Control Nurse and DON agreed the form was to have been completed in its entirety.",2020-02-01
4498,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2016-10-13,166,D,1,0,HHR811,"> Based on staff interview, resident interview and medical record review, the facilty failed to ensure resident grievances were resolved for one (1) of eight (8) residents who had expressed concern with loud noises in the facility. A resident had expressed concern the roommate would play the television too loud at times which disturbed her. There was no evidence the staff had followed up and resolved this issue. This failed practice had the potential to affect a limited number of people. Resident identifier: #12. Census: 80. Findings include: a) Resident #12 (re: #73 roommate #73) A review of concern files revealed resident #12 expressed concern the roommate played the television too loud at times which disturbed her. The concern form, dated 09/13/16, said the roommate's (Resident #73) television was too loud. The concern form further stated the resolution to obtain ear phones for the roommate to use with her TV by 09/21/16 . Interview with resident #12, on 10/12/16 at 9:45 a.m., revealed she was under the impression the facility was going to get the roommate ear phones back in (MONTH) (2016), but they have not been purchased for the resident's use. Interview with the administrator and social worker, on 10/12/16 at 1:45 p.m., verified they had not obtained any type of headphone device for the roommate as yet. They had checked at several locations for ear phones but it was still not decided where to get them and who would pay to get them, the facility or the individual. On 10/16/16 at 2:00 p.m., the administrator after discussion with the surveyor, instructed the social worker to speak with Resident #73 about the headphones immediately. The social worker returned later that day and said at this time the resident did not wish to get them. The social worker said in September, Resident #73 had been agreeable to purchase and use headphones, but now had changed her mind. The facility staff had not followed up with either resident to ultimately get the issue resolved after it had been expressed about a month ago.",2019-10-01
4499,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2016-10-13,309,D,1,0,HHR811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interviews, and record review, the facility failed to follow physician's orders for two (2) residents who did not receive medication according to their physician orders. Resident #17 and #36 were to receive [MEDICATION NAME] 15 milligram (mg) in the evening of 10/11/16, and medication count revealed the medication was not administered as prescribed. Resident identifiers: #17 and #36. Facility census 80. Findings include: a) Resident #17 Observation of the medication cart on the 200 hallway, on 10/12/16 at 8:20 a.m., with LPN #83 found one (1) medication packet with resident #17's name on the packet. The medication stated, [MEDICATION NAME] 15 mg for Tuesday 10/11/16 evening. Surveyor and LPN #83, at that time, counted the medication in the cart for Resident #17. No other medication packets were found for this resident as not administered. Review of the Medication Administration Record [REDACTED]. Review of the emergency and narcotic box sheet with LPN #83 revealed there were no [MEDICATION NAME] signed out of the emergency or narcotic box for Tuesday evening for resident #17. LPN #83 was asked why is there one (1) [MEDICATION NAME] 15 mg for Tuesday evening with the date of 10/11/16 on the packet remaining in the medication cart for Resident #17, and LPN #83 replied, The medication [MEDICATION NAME] was not given on Tuesday evening that is why the medication is still in the cart. A review of the physician order found Resident #17 started on [MEDICATION NAME] 15 mg by mouth in the evening for appetite on 10/04/16. A review of Resident #17's pharmacy delivery sheets found the pharmacy delivered seven (7) [MEDICATION NAME] 15 mg to the facility on [DATE]. The MAR indicated [REDACTED]. Further review revealed the pharmacy delivered one (1) [MEDICATION NAME] for Resident #17 on 10/11/16, in which this dose should have been given on 10/11/16. b) Resident #36 Observation of the medication cart on the 200 hallway, on 10/12/16 at 8:27 a.m., with LPN #83 found a packet of [MEDICATION NAME] 15 mg for Tuesday evening (10/11/16) with resident #36's name on the medication packet. Review of the Medication Administration Record [REDACTED]. Surveyor and LPN #83, at that time, counted the medication [MEDICATION NAME] in the medication cart for Resident #36. No other [MEDICATION NAME] was found. The nurse was asked whether the Resident #36 received her medication [MEDICATION NAME] 15 mg on 10/11/16, and the nurse replied, No, because there should not be this one (1) extra [MEDICATION NAME] packet in the medication cart, if the nurse administered the medication. A reviewed of the emergency and narcotic box sheet found there were no [MEDICATION NAME] signed out of the emergency or narcotic box for Tuesday evening for Resident #36. A review of Resident #36's pharmacy delivery sheets found the pharmacy delivered seven (7) [MEDICATION NAME] 15 mg to the facility on [DATE]. The MAR indicated [REDACTED]. The pharmacy delivered one (1) [MEDICATION NAME] for Resident #36 on 10/11/16, in which this dose should have been given on 10/11/16. A review of the physician order found the Resident #36 started on [MEDICATION NAME] 15 mg by mouth in the evening for depression as evidenced by decreased appetite on 10/04/16. c) Interviews with Nursing Staff Interview and review of the pharmacy delivery sheet with the the Director of Nursing (DON), on 10/12/16 at 10:30 a.m., revealed there were seven (7) doses of [MEDICATION NAME] 15 mg were delivered to the facility on [DATE] for both resident. The residents were started on the [MEDICATION NAME] on 10/04/16 to receive one (1) tablet daily from 7:00 p.m. to 10:00 p.m. The residents received the medication from 10/04/16 -10/10/16 for a total of seven (7) doses. The pharmacy brought one (1) dose of [MEDICATION NAME] on 10/11/16 for each resident in which this dose should have been given on 10/11/16. There was one (1) dose of [MEDICATION NAME] for Resident #17 and #36 remaining in the medication cart, on 10/12/16 that was available to be administered. The DON confirmed the [MEDICATION NAME] was not administered on 10/11/16 to Resident #17 and #36. The DON also revealed that she even called the pharmacy to see if somehow an extra dose of [MEDICATION NAME] was delivered for resident #17 and #36, but the pharmacist said there were no more [MEDICATION NAME] delivered to the facility to say there were one (1) extra dose given to us by the pharmacy is the reason why the 10/11/16 [MEDICATION NAME] remains in the medication cart. In an interview, on 10/13/16 at 10:21 p.m., with LPN #121, who worked on 10/11/16, was asked if she administered Resident #17 and #36 their [MEDICATION NAME] on the Tuesday (10/11/16) evening. The LPN revealed that she could not really confirm whether she administered Resident #17 and #36 their [MEDICATION NAME] medication on the evening of 10/11/16.",2019-10-01
5397,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2015-06-11,156,D,0,1,3Y2511,"Based on review of liability notices and staff interview, the facility failed to provide the correct notice of termination of Medicare services, required by the Centers for Medicare and Medicaid Services (CMS), for one (1) of three (3) residents reviewed for the care area of liability notices and beneficiary appeal. Resident #32 did not receive the appropriate notice when skilled care services were terminated with skilled days remaining, and the resident remained in the facility. Resident identifier: #32. Facility census: 81. Findings include: a) Resident #32 At 2:18 p.m. on 06/10/15, Bookkeeper #44 provided a copy of the Medicare non-coverage form given to Resident #32 when Medicare services were terminated. The facility issued CMS form # to Resident #32, on 01/16/15, to notify him Medicare services were being terminated on 01/18/15. Bookkeeper #44 verified Resident #32 began receiving skilled care services on 01/02/14, and was discharged from skilled care services on 01/18/15. She further verified the resident had skilled days remaining and the resident continued to remain at the facility after the termination of skilled care services. According to a memorandum issued by CMS on 01/09/09, The Notice of Medicare Provider Non-coverage (form CMS- is issued when all covered services end for coverage reasons. If after issuing the Notice of Medicare Provider Non-coverage, the SNF (skilled nursing facility) expects the beneficiary to remain in the facility in a non-covered stay, either the SNFABN (skilled nursing facility advanced beneficiary notice) (form CMS- ) or a denial Letter must be issued to inform the beneficiary of potential liability for the non-covered stay. During this evaluation of liability notices and beneficiary appeal rights, Bookkeeper #44 confirmed the facility did not issue the correct notice of Medicare non-coverage form to Resident #32.",2019-01-01
5398,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2015-06-11,280,D,0,1,3Y2511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the care plan for one (1) of two (2) residents whose care plans were reviewed for the care area of accidents, and one (1) of five (5) residents reviewed for unnecessary medications during Stage 2 of the Quality Indicator Survey were revised to reflect current interventions. Resident #24's care plan was not revised after the resident experienced a fall. Resident #44's care plan was not revised after [MEDICATION NAME] was discontinued. Resident identifiers: #24 and #44. Facility census: 81. Findings include: a) Resident #24 Medical record review, on 06/10/15 at 1:00 p.m., revealed a nurse's note dated 05/14/15. This note stated Resident #24 experienced a fall at 11:02 p.m. in her room. Review of the resident's care plan for falls, with a target date of 07/28/15, revealed a problem statement which indicated Resident #24 had, . a potential of falls The care plan was not revised to reflect the resident had an actual fall on 05/14/15.An interview with Employee #13, registered nurse, Minimum Data Sets (MDS) coordinator, on 06/11/15 at 9:30 a.m., confirmed she failed to update the care plan after Resident #24 fell . b) Resident #44 The resident's current care plan, last edited by the facility on 02/27/15, was reviewed on 06/10/15 at 3:00 p.m. It indicated a potential problem for mood disturbance related to a [DIAGNOSES REDACTED]. According to the care plan, the resident was taking [MEDICATION NAME] and [MEDICATION NAME]. Review of the physician's orders [REDACTED]. As of the date of the review, on 06/10/14, the care plan was not revised to reflect the discontinuation of [MEDICATION NAME]. This was discussed with Corporate Nurse (CC) #45 on 06/10/15 at 3:00 p.m She verified the resident's care plan continued to show the resident was receiving [MEDICATION NAME] and had not been revised. At that time she acknowledged awareness of this problem with the facility's care planning process.",2019-01-01
5399,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2015-06-11,282,D,0,1,3Y2511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, observation, and staff interview, the facility failed to implement the care plans for one (1) of three (3) residents reviewed for the care area of dental status, and one (1) of two (2) residents reviewed for the care area of accidents. Resident #48 did not receive dental services according to her care plan. Resident #24 did not receive the services outlined in his care plan to prevent falls. Resident identifiers: #48 and #24. Facility census: 81. Findings include: a) Resident #48 At 3:30 p.m. on 06/08/15, during Stage 1 of the Quality Indicator Survey (QIS), the resident reported her upper partial was broken and she was unable to wear the partial. She said she had been waiting about two (2) months for the facility to get it fixed. Medical record review on 06/09/15 at 1:30 p.m., found the resident was admitted to the facility on [DATE]. The admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/10/14, identified the resident had dental/oral needs in Section L. The admission MDS, Section C, entitled Cognitive Patterns, showed the resident had a brief interview for mental status (BIMS) score of 15, indicating she was cognitively intact. (A score of 15 is the highest possible score for the BIMS evaluation.) The care plan, revised on 05/04/15, included the problem, The resident has potential for oral/dental health problems such as cavities, broken teeth, abscessed teeth r/t (related to) she has her natural teeth. An intervention related to this problem, created on 05/04/15 was, Coordinate arrangements for dental care, transportation as needed/as ordered. At 4:00 p.m. on 06/09/15, MDS Coordinator #13, the author of the care plan, was interviewed regarding the resident's dental issues. She said she was unaware of the broken partial. The MDS coordinator stated she coded the admission MDS for dental issues because, I figured any resident with their natural teeth had problems. At 4:47 p.m. on 06/09/15, Licensed Practical Nurse #93, the resident's LPN, stated she thought the resident talked to the physician a few months ago about her partial. The LPN said, Maybe someone wrote an order for [REDACTED].>At 4:55 p.m. on 06/09/15, the resident's nurse aide (NA), NA #18, stated, I remember they were going to order her a new denture, that was about a month or so ago. The interviews with LPN #93 and NA #18 confirmed the facility was aware the resident's partial was broken. At 9:30 a.m. on 06/10/15, Medical Record Clerk #8, confirmed Resident #48 did not have a dental appointment scheduled before intervention during the survey on 06/09/15. b) Resident #24 Review of Resident #24's medical record on 06/11/15 at 9:15 a.m., found the resident fell on [DATE]. The resident was found on the floor in front of her bathroom door. Review of the POS [REDACTED]. Review of the care plan, on 06/11/15 at 9:45 a.m., revealed an intervention initiated on 09/30/14 for Bed/chair alarm to alert staff of need of assistance. The Kardex (communication sheets for the nursing assistants), as well as the electronic Kiosk, each contained: Bed and chair alarm to alert staff of need of assistance.At 10:00 a.m. on 06/11/15, the resident was observed sitting in her chair. Observation with Registered Nurse (RN) #45, a corporate registered nurse, found the resident did not have a bed and/or a chair alarm. At that time, RN #45 confirmed the alarm was lying on the resident's table.On 06/11/15 at 10:10 a.m., RN #45 and RN #13, reviewed Resident #24's care plan. They confirmed the care plan intervention for the alarm was not implemented.",2019-01-01
5400,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2015-06-11,412,D,0,1,3Y2511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to obtain dental services to meet the needs of one (1) of three (3) residents reviewed for the care area of dental status and services. Resident #48, whose payer status was identified as Medicaid, had a broken upper partial. The facility failed to promptly arrange for dental services. Resident identifier: #48. Facility census: 81. Findings include: a) Resident #48 At 3:30 p.m. on 06/08/15, during Stage 1 of the Quality Indicator Survey (QIS), the resident reported her upper partial was broken and she was unable to wear the partial. She said she had been waiting about two (2) months for the facility to get it fixed. Medical record review on 06/09/15 at 1:30 p.m., found the resident was admitted to the facility on [DATE]. The admission, minimum data set (MDS), with an assessment reference date (ARD) of 10/10/14, identified the resident had dental/oral needs in Section L. The admission MDS, Section C, entitled Cognitive Patterns, showed the resident had a brief interview for mental status (BIMS) score of 15, indicating she was cognitively intact. (A score of 15 is the highest possible score for the BIMS evaluation.) The care plan, revised on 05/04/15, included the problem, The resident has potential for oral/dental health problems such as cavities, broken teeth, abscessed teeth r/t (related to) she has her natural teeth. An intervention related to this problem, created on 05/04/15 was, Coordinate arrangements for dental care, transportation as needed/as ordered. At 4:00 p.m. on 06/09/15, MDS Coordinator #13, the author of the care plan, was interviewed regarding the resident's dental issues. She said she was unaware of the broken partial. The MDS coordinator stated she coded the admission MDS for dental issues because, I figured any resident with their natural teeth had problems. At 4:47 p.m. on 06/09/15, Licensed Practical Nurse #93, the resident's LPN, stated she thought the resident talked to the physician a few months ago about her partial. The LPN said, Maybe someone wrote an order for [REDACTED].>At 4:55 p.m. on 06/09/15, the resident's nurse aide (NA), NA #18, stated, I remember they were going to order her a new denture, that was about a month or so ago. The interviews with LPN #93 and NA #18 confirmed the facility was aware the resident's partial was broken. At 9:30 a.m. on 06/10/15, Medical Record Clerk #8 confirmed Resident #48 did not have a dental appointment scheduled before intervention during the survey on 06/09/15.",2019-01-01
5401,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2015-06-11,431,D,0,1,3Y2511,"Based on observation, staff interview, and review of the guidelines in Appendix PP of the Centers for Medicare and Medicaid Services (CMS) State Operations Manual (SOM), the facility, in coordination with the consultant pharmacist, failed to ensure the safe storage of controlled medications which were subject to abuse. Refrigerated medications subject to abuse were stored in a black Sentry security lock box, which was not permanently affixed to the refrigerator. This practice had the potential to affect a limited number of residents. Facility census: 81 Findings include: a) Observation of the medication storage room on 06/08/15 at 11:48 a.m., with Licensed Practical Nurse (LPN) #26, revealed the medication refrigerator contained one (1) black Sentry security lock box. The box was freely moveable in the refrigerator, and there was no lock on the outside of the refrigerator. The lock box contained one (1) package of Marinol 2.5 milligrams (mg) which contained 26 pills for Resident #32. There was also a package of 10 Marinol 5 mg pills for Resident #39. In an interview on 06/08/15 at 11:50 a.m., LPN #26 agreed since Marinol was a medication subject to abuse, the black Sentry security lock box should have been permanently affixed to the refrigerator. The SOM, Appendix PP includes: The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse . Observation of the medication room with LPN #26, on 06/10/15 at 1:00 p.m., found the black Sentry security box affixed to the refrigerator. The LPN said they . permanently affixed the box in the refrigerator for securing the storage of drugs subject to abuse.",2019-01-01
5402,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2015-06-11,520,C,0,1,3Y2511,"Based on record review and staff interview, the facility's Quality Assessment and Assurance (QA&A) Committee failed to meet quarterly to determine if a defined standard of quality was being achieved to ensure care practices were consistently applied to ensure the facility met, or exceeded, an expected standard of quality, and/or to implement principles of continuous quality improvement. In addition, the facility failed to ensure a designated physician was present at each meeting. This had the potential to affect all residents residing at the facility. Facility census: 81. Findings include: a) At 8:30 a.m. on 06/11/15, Corporate Consultant (CC) #45, a registered nurse, provided copies of the facility's employee sign-in sheets for the previous four (4) QA&A meetings. Review of the sign-in sheets revealed the QA&A committee was not meeting quarterly as required: -- On 05/09/14, a meeting entitled 1st Quarter Report was held. -- There was not another QA&A meeting for over five (5) months, on 10/20/14. -- The next meeting was held in 3.5 months, on 02/03/15. -- There was not another QA&A meeting for four (4) months, on 06/05/15. b) At 9:10 a.m. on 06/11/15, upon inquiry regarding the participation of a physician at the QA&A meetings, CC #45 confirmed she had no evidence to substantiate the attendance of a physician at the 05/09/14 meeting as required by the regulation.",2019-01-01
6561,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2015-01-09,241,D,1,0,DMOO11,"Based on observation and staff interview, the facility failed to maintain resident dignity. A urinary catheter bag was not covered for one (1) of ten (10) residents observed who had catheters. Resident identifier #33. Facility census 80. Findings include: a) Resident #33. Resident #33 was observed on 01/08/15 at 7:55 a.m. This resident was resting in a recliner chair on the 200 hallway. Observation revealed the resident's urinary catheter drainage bag was not covered. An interview with licensed practical nurse(LPN) #3 was conducted at that time. The LPN stated all resident urinary catheter bags were to be covered at all times.",2018-01-01
6562,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2015-01-09,431,E,1,0,DMOO11,"Based on observation, staff interview, and review of the facility's policy, the facility failed to safeguard medications. Medications were observed on top of a medication cart which was unattended. This was observed during one (1) random observation. This practice had the potential to affect more than an isolated number of residents. Facility census: 80. Findings include: a) Observation of a medication cart on the end of the 600 hall revealed, on 01/08/15 at 8:15 a.m., one (1) bottle of Nystatin suspension (used to treat fungal infection) and a bottle of Miralax (a laxative) were on top of the medication cart. The medication cart was not in the sight of Licensed practical nurse (LPN) #4, as she was a few feet down the hall inside a resident's room. This cart was observed unattended for five (5) minutes. The LPN came out of the resident's room and walked to the medication cart at 8:20 a.m. When asked if she normally left medications on the top of the medication cart, she said she was supposed to but the medication back inside the cart after administering the medication. She stated she left them out accidentally. The LPN picked up the medication and placed them in the medication cart. A review of the medication administration policy, on 01/08/15 at 4:00 p.m., revealed, No medications are kept on top of the cart. The policy also stated the medication cart must be clearly visible to the person administering medications.",2018-01-01
6563,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2015-01-09,441,E,1,0,DMOO11,"Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Personal protective equipment (PPE) was stored on the front of the doors of two (2) residents' rooms. These doors were open into the room. The residents in each of these rooms were on isolation precautions for Influenza A. In addition, there were no containers for staff to dispose of their masks when leaving the room. The facility also failed to ensure test results were promptly obtained when a resident was tested for Influenza. This had the potential to affect more than a limited number of residents. Resident Identifiers: #22 and #42. Facility census: 80. Findings include: a) Resident #22 and #42 Observation, on 01/08/15 at 8:00 a.m., of these resident's rooms, revealed a sign by the doors stating droplet transmission precautions. Personal protective equipment (PPE) was observed on the front of the doors, which were open into the rooms. In addition, there were no containers for staff to dispose of their masks when leaving the room. On 01/08/15 at 8:02 a.m., licensed practical nurse (LPN) #3 was asked why Residents #22 and #42 were on droplet transmission precautions. She revealed both residents had Influenza A. The LPN was asked if this was how PPE was always stored, as it was on the door opening to the inside of the room. She replied yes. When asked why the PPE was inside the room, the LPN stated the facility had a three foot rule. She said if the resident was three (3) feet away from the PPE, the PPE could be placed on the inside of the room. When asked if either of the residents was capable of getting near the PPE, she said Resident #42 could walk up to the PPE. When asked about the resident's ability to ambulate throughout the facility, LPN #3 said he routinely wandered throughout the facility. The LPN also stated when Resident #22 was taken around her bed in her wheelchair, she was within one (1)foot of the PPE. Upon inquiry, she confirmed Resident #22 could wheel herself to the door and touch the PPE. The LPN was asked how staff removed their PPE. She said they went into the bathroom, removed their gloves and mask, placed them in the isolation container in the bathroom, and then washed their hands. When asked if the mask should be worn while walking past the resident, the LPN confirmed staff should not be walking past the resident without wearing the mask. Observation revealed there was no isolation container in which to dispose of the mask as staff were leaving the room. The LPN confirmed there was not an isolation container to use upon leaving the room, as someone was always removing them. b) Resident #22 Medical record review, on 01/08/15 at 8:30 a.m., revealed Resident #22 was sent to the nearest emergency room for evaluation of upper respiratory symptoms and tested positive for Influenza A at a acute care hospital. c) Resident #42 Medical record review, on 01/08/15 at 8:35 a.m., revealed the resident had a flu swab performed on 01/05/15. The test was sent to an acute care hospital laboratory (lab) to be tested . The facility did not check on the results of the flu swab until 01/07/15, two (2) days later. In an interview with RN #1, on 01/08/15 at 9:00 a.m., she said the results would have been available from the lab on 01/05/15, the day the nasal swab was sent to the hospital. The resident tested positive for Influenza A. RN #1 said the results should have been obtained by the nursing facility on the same day the swab was sent to be tested for Influenza. The resident continued in his everyday routines, which included going to the dining room, walking down the halls, and visiting other residents in their rooms. A failure to promptly obtain the test results created a potential for the spread of infection to other residents in the facility. d) On 01/08/15 at 9:00 a.m., an interview was conducted with RN #1 and RN #2. When asked about the isolation precautions for Residents #22 and #42, both confirmed they followed a three (3) foot rule. When asked if either resident could come in close contact with the PPE, they both agreed both residents were capable of coming closer than three (3) feet from the PPE. During the interview, the nurses said since the resident can come in contact with the PPE, the PPE should be stored on the outside of the room. RNs #1 and #2 said there should be an isolation container and antibacterial sanitizer at the door. This would prevent staff from removing the PPE in the bathroom, so they would not be in contact with the residents at less than three (3) feet without wearing a mask. e) An observation was conducted of the rooms of Residents #22 and #42, with the DON, on 01/08/15 at 2:50 p.m. The PPE was observed on the front of the door which was open to the inside of the room. The containers for used PPE were in the bathrooms. A used mask had been disposed of in each container. When asked if the resident could come in contact with the PPE on the door, she said :yes. The DON was asked how employees removed their PPE when they completed care of the residents. She replied, Yes, I see what you are talking about. She confirmed staff were removing their PPE, then without a mask, they were closer than three (3) feet of the resident when exiting the room. The DON also stated there should be antibacterial sanitizer and a container at the door to dispose of the PPE. f) A review of the facility's infection control protocol, on 01/08/15 at 3:00 p.m., revealed, Example of infections requiring Droplet Precautions include, but not limited to: (4) Influenza. The protocol also indicated that in addition to standard precautions, staff were to wear a mask when working within three (3) feet of the resident.",2018-01-01
6812,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2014-02-20,161,E,0,1,SDOD11,"Based on record review and staff interview, the facility failed to guarantee the security of all personal funds deposited with the facility. The facility did not have a surety bond of sufficient value to cover all of the funds. This had the potential to affect all fifty-one (51) residents with a resident trust fund account. Facility Census: 85. Findings include: a) A review of resident funds on deposit with the facility, at 2:00 p.m. on 02/18/14, found the facility's current surety bond (# 9358) was for a sum of $30,000.00. An account summary for January 2014 had an average ledger balance of $33,310.60 and an average available balance of $32,775.69. Further review, on 01/06/14, noted the account balance was $50,309.40. In a discussion with the Administrator and Employee #112, Bookkeeper, on 02/18/14 at 4:00 p.m., they both acknowledged the amount of money in the resident trust account was higher than the surety bond's coverage and stated they would apply for an increase in surety bond.",2017-11-01
6813,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2014-02-20,225,F,0,1,SDOD11,"Based on personnel record review, review of the requirements for criminal background checks in West Virginia, review of the Bureau for Medical Services manual and memorandum, and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law. The facility did not make reasonable efforts to uncover information about any past criminal prosecutions by use of fingerprinting, which is a required procedure to ensure a statewide criminal background check in West Virginia. This was true for six (6) of ten (10) employees whose files were reviewed. This had the potential to affect all residents. Facility census: 85. Findings include: a) Thorough Criminal Background Checks On 02/18/14 at 9:00 a.m., a personnel file review was completed. Ten (10) personnel files were reviewed. Six (6) of six (6) employees hired after 01/01/13 had no fingerprints, or criminal background checks based on fingerprinting, in their files. The files all contained criminal background checks completed by Company #1. When asked, at 9:30 a.m. on 02/18/14, Employee #99, the individual responsible for human resources and payroll, stated they did not use fingerprinting with the Company #1. The employees with no evidence of the requisite fingerprinting, as required for a statewide criminal background check in West Virginia were: -- Employee#1, a licensed practical nurse (LPN), hired 01/07/14; -- Employee #121, LPN, hired 01/21/14 ; -- Employee #4, LPN, hired 01/07/14; -- Employee #122, a nursing assistant, (NA)m hired 02/04/14; -- Employee #20, LPN, hired 09/03/13; and -- Employee #27, NA, hired 05/28/13. In a discussion with the Administrator and Employee #99, at 4:00 p.m. on 02/18/14, both denied knowledge of any regulations requiring criminal background checks based on fingerprinting. They agreed the facility had not been performing such checks on their new hires. To ensure the facility has not employed an individual who has been found guilty of abusing, neglecting, or mistreating residents by a court of law, West Virginia requires submission of fingerprints to the agency contracted by the West Virginia State Police. The Bureau for Medical Services manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on February 15, 2013. The memo included . at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility until March 1, 2014, to have all current employees up to date with criminal investigation background checks. For any new hires in the nursing facility, the policy is effective for those individuals as of January 1, 2013.",2017-11-01