{"rowid": 3705, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2018-07-19", "deficiency_tag": 580, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "W6NO11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify an incapacitated resident's medical power of attorney when a change in condition occurred. This affected one (1) of twenty-two (22) sampled residents. Resident identifier: #65. Facility census: 96. Findings included: a) Resident #65 The medical record was reviewed on 07/17/18. On Thursday, 07/13/18, a physician progress notes [REDACTED]. At that time, the physician assessed her with [MEDICAL CONDITION]. On Friday, 07/14/18, the physician ordered blood work and a chest x-ray to be completed on 07/16/18,. He also wrote a new order to begin [MEDICATION NAME] (an antibiotic) 100 milligrams twice daily for seven (7) days. On 07/16/18 the chest x-ray confirmed the [DIAGNOSES REDACTED]. Further review of the medical record found no evidence that this incapacitated resident's medical power of attorney (MPOA) was notified of this change in condition. An interview was conducted with the assistant director of nursing (ADON) on 07/18/18 at 1:45 p.m. She reviewed the medical record, then looked in several offices for evidence of MPOA notification. At 2:00 p.m. on 07/18/18, the ADON agreed there was no evidence that the MPOA was notified of the resident's change of condition. The ADON said the MPOA should have been notified of the change in condition at the time of occurrence. She said she instructed the resident's nurse to contact the MPOA right away to notify her of the [DIAGNOSES REDACTED].", "filedate": "2020-09-01"}
{"rowid": 3706, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2018-07-19", "deficiency_tag": 583, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "W6NO11", "inspection_text": "Based on observation and staff interview, the facility failed to protect the personal privacy of residents including medical and health information. Various resident treatments were left unattended in a bath/shower room. Personal identifiers including resident names, medications, and other health information were viewable by anyone. This was a random observation. Resident identifiers: #27, #31, and #48. Facility census: 79. Findings included: a) Observation A random observation, on 07/16/18 at 11:15 am, on the East B Hall, revealed Resident #27, #31, and #48's treatments were left unsecured and unattended in the bath/shower room. Each treatment container had a pharmacy label that contained the following information: -Resident's name -Medication prescribed -Physician's name b) Interview An interview with Certified Nursing Assistant (CNA) #101, on 07/16/18 at 11:20 AM, revealed the resident's treatments should be locked up in the treatment carts. The CNA stated she would immediately remove them.", "filedate": "2020-09-01"}
{"rowid": 3707, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2018-07-19", "deficiency_tag": 584, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "W6NO11", "inspection_text": "Based on observation and staff interview, the facility failed to provide maintenance services for six (6) of forty-three (43) rooms observed during the Long Term Care Survey Process (LTCSP). The issues identified included dining and lounge rooms with scratched doors with missing paint. Room identifiers: A-Dining Room, B-Dining Room, C-Dining Room, D-Dining Room, A/C Lounge, and B/D Lounge. Facility census: 79. Findings included: a) Observations The following observations were made on 07/16/18 and 07/17/18 during the LTCSP: -A Dining Room-The doors were scratched and missing paint. -B Dining Room-The doors were scratched and missing paint. -C Dining Room-The doors were scratched and missing paint. -D Dining Room-The doors were scratched and missing paint. -A/C Lounge-The doors were scratched and missing paint. -B/D Lounge-The doors were scratched and missing paint. b) Interview An interview with the Building Grounds Manager (BGM), on 07/18/18 at 10:00 AM, revealed maintenance rounds are done monthly. The BGM stated since the building is old and big it is hard to keep up with all the needs. The BGM stated he was aware of the dining room doors being scratched and would paint them as soon as possible.", "filedate": "2020-09-01"}
{"rowid": 3708, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2018-07-19", "deficiency_tag": 623, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "W6NO11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record information it was determined the facility had not notified the ombudsman of the transfer of resident #54 to the hospital. This was evident for 1 of 2 residents reviewed for hospitalization s. Census 79. Findings included: a) Resident #54 A review of the medical record on 07/17/18 indicted the resident was hospitalized from [DATE] to 05/16/18. Documentation in the record did not show that the Ombudsman had been notified the resident had been sent to the hospital. This is required per the regulation. 07/19/18 08:28 AM surveyor met with ADON to see if the Ombudsman had been notified of the transfer. She was unable to locate any info in the chart regarding the Ombudsman. She stated they fill out a document in the record and then it is faxed to the ombudsman's office. She attempted to locate the fax form. after this discussion. At 9:05 a.m. she returned to the surveyor and stated they were not able to locate any documentation that showed info was sent to the ombudsman.", "filedate": "2020-09-01"}
{"rowid": 3709, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2018-07-19", "deficiency_tag": 641, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "W6NO11", "inspection_text": "**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 three (3) of twenty-two (22) assessments reviewed during the investigation process of the survey. The MDS for Resident #30, #34, and #61 did not accurately reflect the use of restraints and for Resident #37 there was a wrong [DIAGNOSES REDACTED]. Resident identifier: #30, #34, #37 and #61. Facility census: 79. Findings include a) Resident #30 A review of the medical record for Resident #30 on 07/18/18 revealed the quarterly mimimum data set (MDS) with an assessment reference date (ARD) of 05/02/18 was inaccurately coded for the use of limb restraints in Section P. A review of the current physician's orders for (MONTH) (YEAR) and care plan had no indication this resident required limb restraints. In an interview with the assistant director of nursing (ADON) on 07/18/18 at 1:41PM, reported Resident #30 had a bed alarm discontinued in (MONTH) 2012 and that this facility does not use limb restraints, she also verified this section of the MDS had been coded incorrectly. b) Resident #34 A review of the medical record for Resident #34 on 07/18/18 revealed the quarterly MDS with an assessment reference date (ARD) of 05/17/18 was inaccurately coded for use of a trunk restraint in Section P. A review of the current physician's orders for (MONTH) (YEAR) and care plan had no indication this resident required a trunk restraint. In an interview with the ADON on 07/18/18 at 3:03 PM, reported Resident #34 did not require a trunk restraint and this section of the MDS had been coded incorrectly. c) Resident #37 A review of the medial record for Resident #37 on 07/19/18 revalued the quarterly MDS with an ARD of 05/181/8 was inaccurately coded for the [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. In an interview with Employee #48, registered nurse (RN) on 07/19/18 at 10:39 AM, verified the [DIAGNOSES REDACTED].#37. d) Resident #61 07/17/18 09:44 AM the surveyor noted the use of a limb restraint used less than daily on the Minimum Data Set (MDS). Current physician orders did not have any restraints listed in the current course of treatment. Additionally the care plan did not have a problem with restrain use incorportated or interventions in place. Discussion with MDS staff 07/18/18 10:22 a.m.revealed the MDS had been marked in error to show a limb restraint. The resident does not use any restraints at this time. She corrected it and showed surveyor the error correction after surveyor intervention.", "filedate": "2020-09-01"}
{"rowid": 3710, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2018-07-19", "deficiency_tag": 657, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "W6NO11", "inspection_text": "Based on medical record review and staff interview the facility failed to revise and evaluate the effectiveness of the interventions for fall prevention for Resident # 45 and Resident #57 needed accident interventions revised. This was true for two (2) of three (3) residents reviewed for the care area of accidents reviewed during the survey process. Resident identifiers: #45 and #57. Facility census: 79. Findings include a) Resident #45 A review of the medical record review on 07/18/18 revealed the care plan had not been revised to include falls Further review of the Incident and Accident reports revealed this resident had sustained three (3) falls without injury on 02/25/18, 05/03/18 and 06/21/18. A review of the minimum data set (MDS) with an assessment reference date (ARD) of 05/22/18 was coded to reflect this resident had two (2) or more falls without injury since prior assessment. In an interview with the assistant director of nursing (ADON) on 07/18/18 at 3:45 PM, verified the care plan had not been revised to include the three (3) falls nor did the revision indicate an evaluation of the effectiveness of interventions for the preventions of falls for Resident #45. b) Resident #57 A review of he medical record review on 07/18/18 revealed the care plan had not been revised to include interventions of unsteadiness for Resident #57 while walking. This unsteadiness has contributed to her bumping into furniture, which causes bruising to her lower extremities. A review of the Incident and Accident reports included an incident on 05/16/18 where Resident #57 had a bruise on her left hip from bumping into furniture due to her unsteadiness while walking. In an interview with Employee #48, registered nurse (RN) on 07/18/18 11:11 AM verified she had not revised the care plan for Resident # 57 to include her occasionally bumping into furniture due to unsteadiness while walking.", "filedate": "2020-09-01"}
{"rowid": 3711, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2018-07-19", "deficiency_tag": 684, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "W6NO11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to follow physician orders [REDACTED]. Resident identifiers: #1, #40, and #48. Facility census: 79. Findings include: a) Resident #1 A random observation of Resident #1, on 07/18/18 at 8:15 AM, revealed the Resident's fall mat was off the floor beside the bed and leaned against the wall. The Resident was in bed at the time of the observation. An interview with Licensed Practical Nurse (LPN) #151, on 07/18/18 at 8:20 AM, revealed the fall mat was supposed to be on the floor beside Resident #1's bed due to a high fall risk. A review of Resident #1's physician orders, on 07/18/18 at 8:30 AM, revealed an order for [REDACTED].>A review of the Care Plan was conducted on 07/18/18 at 8:55 AM. The Care Plan, with a creation date of 01/12/18, contained the problem the Resident is at risk for falls related to impaired mobility due to lower extremity impairment, history of fracture, antidepressant medications, and noncompliance with asking for assistance with the intervention mat at bedside. b.) A review of the medical record, for Resident #40, on 07/17/18, revealed a physician's orders [REDACTED]. Observations made on 07/17/18, at 11:02, Resident #40 was having difficulty maneuvering the wheelchair. During an interview, on 07/17/18, at 11:35 AM, Resident #40 stated he wanted his walker back. An interview with LPN#153, on 07/18/18, at 11:05 AM revealed Resident #40 uses a wheelchair to Propel on and off the unit and not the forward wheeled walker as ordered by the physician. c) Resident #48 The medical record was reviewed on 07/18/18. Pertinent [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The physician's orders [REDACTED]. Nursing staff documented they administered the [MEDICATION NAME] daily at 8:00 p.m. in July, (YEAR). Review of the vital signs record found that the blood pressure and pulse rate were assessed most days in July, (YEAR), at 8:00 a.m. and at 4:00 p.m. daily. However, on (MONTH) 02, 07, 12 the blood pressure and pulse rate were assessed only once daily at 4:00 p.m. On (MONTH) 13 and 14 the blood pressure and pulse rate were assessed only once daily at 8:00 a.m. The medical record was silent every day in (MONTH) (YEAR) for any blood pressure or pulse assessments just prior to the administration of the nightly [MEDICATION NAME]. This failure to check the the blood pressure and pulse would therefore make it impossible for the nurse to know whether to hold or to administer this medication. Review of the pulse rate assessments found that the pulse rate was less than 60 beats per minute on the following dates and times: -07/01/18 at 8:00 a.m., pulse rate 55 beats per minute. -07/05/18 at 8:00 a.m., pulse rate 58 beats per minute. -07/11/18 at 8:00 a.m., pulse rate 58 beats per minute. -07/11/18 at 4:00 p.m., pulse rate 56 beats per minute. -07/16/18 at 2:41 p.m., pulse rate 56 beats per minute. An interview was conducted with the assistant director of nursing (ADON) on 07/18/18 at 1:05 p.m. She said staff obtained the vital signs twice daily at 8:00 a.m. and 4:00 p.m. in July. She admitted that a few days they were taken only once per day. She said their computer system does not remind the nurse to assess the blood pressure and pulse prior to administering the 8:00 p.m. [MEDICATION NAME], and to hold the medication if the systolic was less that 60 mm/hg or the pulse rate less than 60 beats per minute. She acknowledged that the nurse would not know whether to hold or administer the [MEDICATION NAME] at 8:00 p.m. if the nurse did not assess the vital signs at that time.", "filedate": "2020-09-01"}
{"rowid": 3712, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2018-07-19", "deficiency_tag": 689, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "W6NO11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. A medication cart was unlocked, used needles were not properly disposed of, and a shower room contained hygiene products, chemicals, and razors, accessible to anyone. This practice had the potential to affect more than a limited number of residents. Facility census: 79. Findings include: a) Medication Cart An observation during medication administration of the West C Hall, on 07/18/18 at 7:55 AM, revealed the medication cart was unlocked while in the hallway. The cart was unlocked, unattended, and out of sight of any staff from 7:55 AM until 8:00 AM. The cart contained the medications for the C Hall residents. An interview with Licensed Practical Nurse (LPN) #151, on 07/18/18 at 8:05 AM, revealed the medication cart should always be locked when not in sight of the nurse. The LPN stated she usually locks the cart but was nervous being watched by the surveyor. b) Needles An observation of the West C Hall, on 07/18/18 at 8:15 AM, revealed the medication cart's sharps disposal box had two (2) used insulin syringe needles and three (3) used insulin lancets lying on top. An interview with Licensed Practical Nurse (LPN) #151, on 07/18/18 at 8:17 AM, revealed the used needles and lancets should have been placed inside the sharps disposal box and not on top. c) Shower Room A random observation of the East B Hall Shower Room, on 07/16/18 at 11:15 AM, revealed the room did not have a lock and contained the following unsecured items: -One (1) container of TNT Foaming Disinfectant Cleaner-Staphylocidal-Salmonellacidal, Pseudomonicidal, Virucidal with the warning Caution-Keep out of reach of children-Hazard to Humans and Domestic Animals-Causes moderate eye damage. -Two (2) containers of McKesson Anti-Perspirant with the warning Keep out of reach of children. -Two (2) containers of McKesson Shaving Cream with the warning Keep out of reach of children. -One (1) container of [MEDICATION NAME] 100,000 Units. -One (1) container of [MEDICATION NAME] Blue Medicated Shampoo with the warning Keep out of reach of children. -One (1) container of [MEDICATION NAME] 2% Shampoo. -One (1) container of [MEDICATION NAME] Topical Suspension 2.5%. -Two (2) capped shaving razors. An interview with Certified Nursing Assistant (CNA) #101, on 07/16/18 at 11:15 AM, revealed the shower room should always be locked. The CNA stated the bathing products, razors, and chemicals should not be accessible to any residents.", "filedate": "2020-09-01"}
{"rowid": 3713, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2018-07-19", "deficiency_tag": 880, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "W6NO11", "inspection_text": "Based on observation and staff interview, the facility failed to prevent the development and transmission of disease and infection. A nurse conducting a dressing change did not change their gloves after removing a soiled dressing, apply gloves before opening wound care supplies, or supply a barrier on the table being used for wound care supplies. This practice affected one (1) of two (2) residents observed for dressing changes. Resident identifier: #54. Facility census: 79. Findings included: a) Observation An observation of Licensed Practical Nurse (LPN) #151, on 07/18/18 at 2:30 PM, revealed the nurse was conducting a dressing change of Resident #54's pressure ulcer to his hip and coccyx area. The LPN first put on a pair of gloves, handled her work keys, removed a soiled dressing, then continued to clean the resident's wound without donning a new pair of gloves. The LPN then removed the gloves and opened a foam dressing with her bare hands. The dressing was handled in several places before the LPN placed the dressing on the table. The table did not have a barrier. The LPN then donned a new pair of gloves and attempted to place the foam dressing from the table onto the Resident. b) Interview An interview with LPN #151, on 07/18 at 2:45 PM, revealed the LPN usually changes gloves during every step of the dressing change but was nervous and forgot to do so. The LPN stated she never lays a barrier on the table while conducting dressing changes. The LPN stated she should have put gloves on before touching the dressing used on the Resident.", "filedate": "2020-09-01"}
{"rowid": 3714, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2019-09-12", "deficiency_tag": 583, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "K00K11", "inspection_text": "Based on observation, staff interview and policy review, the facility failed to honor Resident #70's privacy while administering an insulin injection. This was a random opportunity for discovery. Resident identifier: #70. Facility census: 75. Findings included: On 09/10/19 at 11:16 a.m. observation was made of an insulin injection being administered to Resident # 70 in an in the hallway of the C-Wing unit. Licensed Practical Nurse (LPN) #34 administered an insulin injection to Resident #70 while he was setting in a geriatric chair in the hallway with other residents, staff, and visitors present. LPN #34 raised Resident #70's shirt and administered the insulin in his left abdomen without providing any privacy or moving the Resident to his room. During an interview on 09/10/19 at 3:10 p.m., Charge Nurse #34 confirmed the insulin injection should not have been administered in the hallway and the resident should have been taken into his room for privacy. Review of the facility's Medication Administration policy on 09/11/19 at 2:12 p.m. revealed a guideline for injections that stated: All Injections should be administered in the resident's room.", "filedate": "2020-09-01"}
{"rowid": 3715, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2019-09-12", "deficiency_tag": 600, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "K00K11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and resident interview, the facility failed to ensure Resident's #21, #22, #11 and #66 were free from psychological and verbal abuse. The facility failed to prevent Resident #51 from wandering into other resident's rooms/space; cursing at others; taking, touching, and rummaging through other resident's personal property thus evoking resident to resident altercations, evoking fear and unrest among other residents. This was true for five (5) of six (6) residents reviewed for resident to resident altercations. Resident identifiers: #51, #22, #66, #21, and #11. Facility census: 75. Findings included: a) Resident #51 Review of the resident's most recent Minimum Data Set (MDS) with an assessment reference date of 08/02/19, coded the resident as having physical behavior (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) as having occurred 4 to 6 times in the last 7 days but less than daily. Verbal behavior directed towards other, threatening screaming, and cursing as having occurred daily in the last 7 days. b) Observation of Resident #51 behaviors During the initial tour as well as meal observation on 09/09/19 at 12:53 PM, Resident #51 was wandering around the A wing dining room. The following are observations on the day of entrance to the facility. --09/09/19 12:53 PM, R 51 wandering around A wing. --09/09/19 12:56 PM, R 51 trying to touch items on other resident's trays. Resident #51 stands over Resident #11 as R #11 is trying to eat her lunch. --09/09/19 12:58 PM, Employee #22, LPN, redirected R #51 from R #11's food --09/09/19 1:07, R #51 going in and out of rooms on A North wing. R #51 removed water pitcher from Room A-5. R #51 placed the water pitcher on a blue recliner that was covered in plastic protective cover that was located in the hallway. R #51 rummaged in all drawers in room A-2. R #51 then lies in bed in A-2. R #51 goes in and out of that room. There was no staff supervision during these observations. --09/09/19 1:08 PM, R #51 goes into room A-1. Employee #115, housekeeper, was cleaning in Room A-1. Employee #115 told Resident #51 that the room was not her room and that the resident could not be in that room. Employee #115 remained cleaning Room A-1 while Resident #51 was still in Room A-1. --09/09/19 01:09 PM, R #51 went into Room A-3. There were no staff on hall that were visible. R #51 was rummaging in Room A-3. --09/09/19 01:10 PM, R #51 went back into Room A-1. Employee #22, LPN, was present A North Hall. Employee #22 walked by R #51 while she was in Room A-1. Employee #22 did not stop R #51 from going into room that was not hers nor did Employee #22 try to redirect R #51 from rummaging and touching items in Room A-1. --09/09/19 1:11 PM, R #51 entered Room A-2. R #51 and was rummaging on all 3 beds in that are in Room A-3. Employee #22 was still present on A North wing. Employee #22 did not attempt to stop nor redirect Resident #51. --09/09/19 1:12 PM, Resident #51 entered Room A-3. R #51 was rummaging on bed. This is not R #51's room. Employee #22, LP, walked off of the hall of A North wing and exited through the doors at the nurses' station. Employee #22 did not intervene nor redirect R #51 from being in Room A-3. During this time, R #51, was rummaging on another bed. R #51 was touching and adjusting 2 of the 3 beds in this room. --09/09/19 01:13 PM, Resident #51 went back into Room A-3. R #51 walked around the room and touched nightstands, bed, and chairs. --09/09/19 01:14 PM, Resident #51 went back into Room A-3. Employee #22 walked in and out of this room while R #51 was wandering in this room. This is not Resident #51's room. Employee #22 did not redirect or try to have resident exit room. R #51 exited the room at 1:15 pm. --09/09/19 01:19 PM, R #51 entered Room A-1. R #51 was rummaging through this room. --09/09/19 01:20 PM, Resident #51 entered Room A-2 and walked around the room touching various items in this room, including items that are not hers. --09/09/19 01:21 PM, Resident entered Room A-2. This is R #51's room; however, R #51 was going through other resident items that on the other beds in this room. --09/09/19 01:24 PM, Resident #51 was going in and out of rooms on A east. Employee #22, LPN did see Resident #51, but did not redirect the resident. --09/09/19 04:06 PM, Resident #51 was cursing another resident (Resident #1). This occurred in the hallway at the entrance door to A East. Resident #51 was telling Resident #1 that he is going to hell. --09/09/19 04:09 PM, Resident #51 entered Room A-11. --09/09/19 04:15 PM, Resident #51 was touching Resident #18's drink. Resident #18 stated you go on. leave that alone. c) Nursing notes found in Resident #51's medical record. A record review of Resident #51 noted the following nurses notes (copied as written in resident's chart) --6/2/19 at 15:46: Resident cont. (continued) to be restless and agitated this shift. PRN ( as needed) [MEDICATION NAME] given per order with minimal effect. Resident has been going into resident #9180 room causing that resident to become agitated. Multiple attempts at redirection, but behavior cont. throughout this shift. Placed on cb for physician review charge nurse notified of prn [MEDICATION NAME] and resident change in behavior, notified POA/family [NAME] of residents change in behavior. Family noted to increase in agitation, as they attempted an outing with resident when she became extremely agitated and attempted to bite daughter. Pre restraint form completed. --6/3/19 at 20:00: Resident receives prn [MEDICATION NAME] having agitation, yelling very loud in dayroom as staff attempts to redirect her from going in other resident's rooms, she refuses snacks and drinks as staff attempts to change her mood with snack or drink, resident spills pop on her bed leaving the near full can on her blankets. --6/5/19 at 00:02: Resident receives her prn [MEDICATION NAME] for agitation as she has been offered snacks and drinks to shift her mood, while she was in the bathroom, she removed her depends, torn up depends but into the three bathroom sinks and turned the water on, staff has returned her to her bed several times since 10:30 pm and hopefully she will be able to get some rest having received her prn. --6/5/19 at 01:32: Resident up out of bed, ambulates to bathroom on A North, spends a little time in the bathroom, water could be heard running, staff goes to the bathroom to find all three sinks with paper towels and toilet paper in the sink with the water running strong and water overflowing into the floor, one toilet plugged up also, night shift staff clean up bathroom, resident currently in room lying on bed as if asleep. --6/5/19 at 21:41: Resident agitated, shouting at staff. PRN [MEDICATION NAME] given at 730 pm. Is currently asleep in her bed. --6/6/19 at 12:25: Night shift charge nurse reported concerns about (name of resident) and her recent worsening of behaviors, her increase incidents of behaviors, such as wandering, taking items from others, screaming at staff, making false accusations, plugging up the toilet and sink, tearing dressing off her arm. (Psychiatric Physician name) ask us to consult with (Attending Physician name), and to do medical work up such as labs and ua. Notified (attending physician) of the above concerns and he plans to see (resident) on his visit tomorrow. --6/8/19 at 20:00: Resident receives prn [MEDICATION NAME] for aggression, as we were unable to change her mood by offering snacks, drinks or restroom needs, she had returned to the bathroom and was found with wet towels in the sink and the water running, she has been pacing and can be heard repeating herself, she speaks hateful when staff attempts to move her away from the bathroom sink or away from another resident as she stands in their personal space. --6/9/19 at 20:20: Resident receives pen [MEDICATION NAME] for aggression, she can be heard talking hateful as staff attempts to redirect her away from other residents, she is not concerned with a snack or drink this writer offers a drink and she will say 'I don't want it', she had been following staff into other resident's room as staff is assisting other resident's to bed, she stands in the doorway talking to herself, when staff asks her to leave or the resident of the room asks her to leave she becomes hateful in her response by the time staff walks her out of the room she is fitful and returns to the same place as if she intends to do what she wants. --6/11/19 at 06:31: Resident given PRN [MEDICATION NAME] at HS for agitation. Rsdt (Resident) walking very quickly down the halls, clenching fists and yelling, 'I'm leaving, I'm leaving.' Slept through night and woke up at appx 5 am and picked off scabbed areas on lower R (right) arm. Areas cleaned and dry dressings applied and also covered with long sleeve. --6/11/19 at 23:00: Resident received prn [MEDICATION NAME] for aggression, being unable to calm self, uncooperative to accept sandwich or drink, she has been yelling very loud paces hallways is returned to unit per staff and continues to be loud. --6/15/19 at 11:40: Resident given PRN [MEDICATION NAME] 1mg d/t increased agitation; and [MEDICATION NAME] 50 mg, Tylenol 650 mg po d/t increased pain. Resident increased pacing and crying at this time. Resident having moments of yelling. --6/17/19 at 20:00: Resident receives prn [MEDICATION NAME] for anxiety as drinks and snacks does not seem to help improve her mood, she continues to pace, repeat herself and speaks of leaving. --6/20/19 at 20:15: Resident received prn [MEDICATION NAME] for agitation, staff unable to improve her mood with drinks or snacks, she is loud at intervals repeats herself, paces and argumentative. --6/21/19 at 06:17: Resident agitated this evening, yelling at staff, stating that she wants to leave, walking very quickly up and down the halls. Unable to redirect with snack. PRN [MEDICATION NAME] given at 8pm. --6/22/19 at 06:04: Resident very agitated, picking at scabs on her arm and saying she wants to 'get out of here and never coming back.' Attempts to redirect her with a snack and juice are unsuccessful. PRN [MEDICATION NAME] given per MD order. --7/4/19 at 09:08: Resident ambulating in hallway, agitated. yelling at staff. Uncooperative with care. Multiple attempts at Redirection unsuccessful. Prn med given with success. --7/5/19 at 20:46: HSW (health services worker) stated that resident has been turning on all the sinks, yelling at residents in the hallway, saying, 'it hurts, I've got to get out of here!' Unable to redirect her. Gave her a PRN [MEDICATION NAME] for her agitation . --7/9/19 at 10:00: Resident was getting into trash and other resident's belongings. Pacing back and forth. Redirection unsuccessful. [MEDICATION NAME] 1mg po given per order. --7/11/19 at 20:00: Received prn [MEDICATION NAME] for anxiety, after receiving a drink, snack, and encouraged to sit down, but continued pacing and yelling. --7/12/19 at 10:44: Resident pacing and yelling. Drinks and food offered with no success. PRN [MEDICATION NAME] given as ordered. --7/15/19 at 20:15: Resident had got into the big trash can on the unit and got a diaper out of it and rubbed her face with it getting BM on her nose and cheek. Hsw cleaned it off and redirected resident to stay out of the trash can. --7/15/19 at 20:30: Resident receives prn [MEDICATION NAME] for agitation after receiving snacks and a drink and being unable to improve her mood, she has been unable to verbally redirect as she paces the unit, goes in and out of other resident's rooms, she picked up a blanket belonging to another resident becomes more loud and argumentative when verbally redirected to return items, other residents become upset which has caused loud outburst on unit, she removes several pairs of depends off the cart, takes gloves out of the boxes on the wall, tears on the occupied sign that is on the staff's restroom door. --7/16/19 at 10:22: Resident was becoming more agitated, getting into other resident's belongings. Got resident # 9120 remote. Very uncooperative. [MEDICATION NAME] 1mg po given. --7/17/19 at 01:45: Resident had been asleep earlier but is now awake, assisted to bathroom, assisted back to bed but up gotten up self up out of bed and walking unit, going into other resident's rooms, becomes argumentative when verbally redirected by staff, encouraged to sit in chair on hall and would only sit for a brief period of time, received drink and snack but did not improve her mood, received [MEDICATION NAME] PRN PO (by mouth) for agitation. --7/17/19 at 20:15: Receives PRN PO [MEDICATION NAME] for agitation after resident's mood is unchanged by being offered snacks, drink, urged to sit down, or lay down, she has been pacing hallway and going into other resident's rooms. Some residents fuss at her to leave the room she then becomes loud, has a frown and stomps as she walks and talks as if angry, 'I'm leaving here, I'm not coming back' she repeats this phrase and as she continues this behavior. --7/19/19 06:27: Resident was given PRN [MEDICATION NAME] at HS d/t her behaviors. She was agitated, pacing the floor, yelling at others. Unable to distract resident by offering a snack or a drink. Took medications without incident. --7/21/19 at 20:00: Med prn for anxiety et pain. Pacing et worried expression. (et means and) --7/23/19 at 06:40: PRN [MEDICATION NAME] administered at 730pm, d/t resident being agitated, yelling at other residents, shouting, 'I have to leave!' Resident went to sleep appx 830 pm and slept well without further incident. --7/24/19 at 06:42: Resident was repeating, 'it hurts, it hurts. She was walking very quickly into other resident rooms, getting into the trash can in the hallway, turning on the sinks in the bathroom. Unable to distract rsdt with juice or snacks and wouldn't sit in the recliner. Administered PRN [MEDICATION NAME] for her agitation . --7/25/19 at 21:19: Resident was screaming at HSWs that were trying to calm her down, asking her to sit in the chair. HSW ( health service worker) reported that for the past few hours, rsdt has been going into the bathroom and turning on the sinks; digging in the trash, going into others rooms and messing with others belongings and picking at her arms. At 8pm, this nurse administered a PRN [MEDICATION NAME] to her, per MD order. --7/26/19 at 00:53: Resident awoke at approx 2400. She is very irritable, screaming at the HSW and running down the hall. She continuously entered bedrooms that weren't' her own, sitting on top of resident who were sleeping. Tried to redirect with a drink and a snack, but resident became louder and angrier. Administered a PRN [MEDICATION NAME] per MD order at this time --7/29/19 at 00:02: Resident pulling dirty briefs out of the trash. She is very upset, yelling at HSW, 'I've got to go, get out, get out!' Unable to redirect to recliner. Offered snack, but declined. Administered PRN [MEDICATION NAME] per MD order at this time. --7/30/19 at 16:30: This resident was getting anxious, pacing back and forth and going into other residents rooms. Redirection unsuccessful, would just get more agitated. [MEDICATION NAME] 1mg po given per order. 7/31/19 at 08:09: Resident ambulating up and down hallway. In and out of other resident rooms. screaming 'it hurts' Redirection unsuccessful. Prn [MEDICATION NAME] and anxiety med given with success. --8/3/19 at 06:51: Resident ambulating on the unit, yelling out, 'It hurts, it hurts.' --8/4/19 at 18:05: Resident was screaming in the hall 'he hit me he hit me' when I walked on the hall she was walking back to her unit holding her chest saying he hit me. Co resident was in the hallway in a wheelchair at the time. Resident has a reddened area on her mid sternal area with no bruising at this time. Vital signs within the resident's normal limits. Resident was removed from he area where she sat in the chair and calmed herself down. message left with POA, charge nurse notified. --8/5/19 at 00:16: rec'd resident anxious et pacing et loud. Routine meds given. stated pain in back but [MEDICATION NAME] is effective an hour later. Resting in bed by 9pm. No additional effects of incident earlier. --8/6/19 at 17:35: Resident has experienced a multitude of outbursts this shift, yelling at everyone in her line of site, cussing, and screaming at the top of her lungs without reason. Resident is also displaying increased agitation. Placed on concern board for MD. Will continue to monitor. --8/6/19 at 22:06: Resident has displayed increased agitation / anxiety during this HS med pass. She is going into the bathroom, turning on the faucets, then will start screaming profanities very loudly when attempting to redirect her. She shouts, 'I'm leaving. I'm going home, I'm not coming back, F--- you. Attempted to redirect resident with different snacks, juices, but with no success. Took HS medication without incident. --8/7/19 at 02:26: Resident ist still awake and has not been to sleep yet tonight. She has woken several other residents on the hall by screaming. Unable to get her into a recliner or into her bed. --8/7/19 at 15:15: This resident was standing out in the hall and resident #9152 rolled up to her and hit her in the stomach. Resident yelled out and resident #9152 rolled on down the hall in his w/c (wheelchair). --8/21/19 at 06:20: Resident seems agitated with staff and with other residents. Attempted to redirect her. Offered snack/drinks. Walked briskly through the halls and was saying, 'I'm leaving, I'm leaving. It hurts, hurts, hurts, blood, blood.' PRN [MEDICATION NAME] per MD order. --8/23/19 at 23:20: Resident was getting into the towels and wash clothes and had them in the floor in the bathroom. Going into other residents rooms while they are sleeping. [MEDICATION NAME] 1mg po given. --8/28/19 at 02:06: Resident with increased agitation, attempting to get into bed with other residents, yelling at Staff, attempts were made to help Resident get comfortable, PRN [MEDICATION NAME] administered, will continue to monitor. --8/30/19 at 04:34: Resident showing increased agitation during HS (at bedtime) med pass. She was going into other residents rooms, climbing into their beds, screaming out. Unable to redirect to a recliner or with a snack. PRN [MEDICATION NAME] administered per MD order. --08/31/19 at 06:35: Resident was very agitated, pacing the halls, yelling out at other residents. Offered a snack/drink; Unable to redirect at this time. PRN [MEDICATION NAME] given at this time, per MD order for agitation. --09/05/19 at 07:15: Resident already agitated this morning, yelling and pacing. PRN [MEDICATION NAME] and PRN [MEDICATION NAME] administered. Will continue to monitor. --09/05/19 at 11:55: Administered second dose of PRN [MEDICATION NAME] and PRN [MEDICATION NAME] due to the resident expressing being in pain as well as starting to pace and become agitated when being redirected. Will continue to monitor. --09/05/19 at 14:32: Reported by ADON (assistant director of nursing) to this nurse that resident was found lying in another resident's bed on C wing. No incident occurred. Resident redirected out of room / bed. Will continue to monitor. --09/06/19 at 14:12: Resident has not experiences any falls this shift. Anxiety and pain continues with PRN [MEDICATION NAME] and PRN [MEDICATION NAME] administered per order. Will continue to monitor. --09/09/19 at 14:33: Resident making false remarks saying another resident hit her. The resident she was accusing is sitting quietly in the hallway with her arms crossed. d) Incident/accident report On 08/04/19 the resident was screaming another resident hit her. Resident #51 was huddled against the wall. Residents were separated. On 08/07/19 the resident was again struck by another resident in the abdomen. e) Resident #22 On 09/09/19 at 1:16 PM, the resident expressed she had problems with Resident #51. She called Resident #51 by her first name and said, I have hit her but only once after she hit me first. I had to stand up for myself. She takes all my stuff. Resident #22 said Resident #51 wants to eat all her food. She goes into my room and takes my stuff. The resident said, Usually staff get my stuff from her and bring it back to my room. She said she didn't have to tell staff because they are all aware of Resident #22's behaviors and they don't do anything about her. Review of the Resident's most recent MDS with an ARD of 06/14/19 found the resident has a score of 15 on the Brief Interview for Mental Status (BIMS). A score of 15 is the highest score obtainable and indicates the Resident is cognitively intact. This resident was also coded as having no behavior problems. Review of the resident's medical record found no evidence of physical altercations between Resident #22 and Resident #51. On 09/10/19 at 1:15 PM, the Social Work Supervisor (SWS) #56 said she was unaware of a physical altercation between the 2 residents. SWS said, Resident #51, just wanders around the facility. The SWS was unaware Resident #51's behaviors were affecting other resident. f) Resident #66 On 09/09/19 at 1:01 PM, Resident #66 voiced a complaint regarding Resident #51. Resident #66 called Resident #51 by her first and last name and said she goes into my room all the time and takes my stuff. She takes the remote control for the television also. sometimes she scares me because of the way she curses and carries on all the time, I never know what she is going to do. Resident #66 said staff know what she is doing but they can't keep up with her. Review of the Resident's most recent MDS with an ARD of 08/13/19 found the resident has a score of 15 on the Brief Interview for Mental Status (BIMS). A score of 15 is the highest score obtainable and indicates the Resident is cognitively intact. This resident was also coded as having no behavior problems. On 09/10/19 at 1:15 PM, the Social Work Supervisor (SWS) #56 said, Resident #51, just wanders around the facility. The SWS was unaware Resident #51's behaviors were affecting other resident. An interview with the administrator on 09/11/19 at 10:56 AM revealed the administrator was unaware of any problems with Resident #51. On 09/10/19 at 11:52 AM, the surveyor spoke with DON regarding Resident #51. The DON stated that Resident #51 has a behavior tracking tool for her behaviors. The DON did note that Resident #51 was not care planned to go in and out of other resident rooms. The DON further noted that she was aware that several residents on A wing had voiced complaints regarding Resident #51's behaviors at meal times and when Resident #51 ambulates on the halls. During an interview with Employee #131, MDS nurse on 09/10/19 at 2:20 PM, Employee #131 stated that Resident #51 is not care planned for behavior of wandering and going in and out of other resident rooms. Moreover, Employee #131 reviewed the care plan the facility provided and stated that she did not see where wandering in resident rooms had been care planned. MDS #131 said she did not know about the residents behaviors, yet she was the same nurse that coded the resident as having the having physical and verbal behaviors. Resident #131 confirmed she was responsible for this resident, her care planning and her MDS. Under the guidance to surveyors, F 600 notes the following: In addition, the risk for abuse may increase when a resident exhibits a behavior(s) that may provoke a reaction by staff, residents, or others, such as: Verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group, intimidating; Physically aggressive behavior, such as hitting, kicking, grabbing, scratching, pushing/shoving, biting, spitting, threatening gestures, throwing objects; Sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing; Taking, touching, or rummaging through other's property; Wandering into other's rooms/space; and Resistive to care and services. g) Resident #21 According to the quarterly Minimum Data Set (MDS) assessment for Resident #21, with an Assessment Reference Date (ARD) of 07/03/19, Resident #51 has a Brief Interview for Mental Status (BIMS) score of 10. During an interview with Resident #21 on 09/09/19 at 12:15 PM, Resident #21 stated that one resident (Resident #51) bothered her. Resident #21 stated that Resident #51 was getting in other resident rooms when the residents didn't want her in the rooms. Resident #21 stated that she was a resident on the same wing / hall as Resident #51. Resident #21 stated that Resident #51 bothers us when we are trying to eat. She goes through our rooms and messes with our things. She also pours water on the floors in the hallway. You have to keep your door shut to keep her out. On 09/10/19 at 11:52 AM, this surveyor spoke with Director of Nursing (DON) regarding Resident #51. This surveyor interviewed the DON regarding Resident #51's behaviors. The DON stated that Resident #51 has a behavior tracking tool for her behaviors. The DON did note that Resident #51 was not care planned to go in and out of other resident rooms. The DON further noted that she was aware that several residents on A wing had voiced complaints regarding Resident #51's behaviors at meal times and when Resident #51 ambulates on the halls. The DON noted that one of the reasons Resident #51 eats lunch in Special Needs is for her weight loss as well as trying to keep her occupied as to not disturb the residents on A wing. During an interview with Employee #131, MDS nurse on 09/10/19 at 02:20 PM, Employee #131 stated that Resident #51 is not care planned for behavior of wandering and going in and out of other resident rooms. Moreover, Employee #131 reviewed the care plan the facility provided and stated that she did not see where wandering in resident rooms had been careplanned. During an interview on 09/11/19 at 10:15 AM, with Employee #103, Therapeutic Program Director, has Resident #51 on caseload. Resident #51 comes to the Special Needs department for meal training, Monday thru Friday for lunch. On the weekends, Resident #51 eats her meals back on unit. Employee #103 noted that Resident #51 was referred to Special Needs for weight loss, meal intake, and to provide more supervision for resident's behavior. The surveyor spoke with the DON on 09/11/19 at 01:07 PM concerning findings. No further information was provided. h) Resident #11 According to the quarterly Minimum Data Set (MDS) assessment for Resident #11, with an Assessment Reference Date (ARD) of 06/11/19, Resident #51 has a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. During an interview with Resident #11 on 09/09/19 at 12:22 PM, Resident #11 stated that she only had one issue. Resident #11 stated that Resident #51 gets into people's food when they are eating. (NAME of Resident #51) puts her fingers in our food. During the weekdays, they (staff) take her to special needs. But on the weekends, there is not enough staff, so she eats her meals in this (A Wing) dining room. They (staff) need to sit with her so she won't get into people's food. Resident #11 stated that Resident #51 touches other resident's food, paces in the dining room, and yells and rants at the other residents mostly on the weekends. Resident #11 states that she has told staff about her concerns and issues with Resident #51. Resident #11 states that Resident #51 eats in the A wing dining room weekdays for breakfast and dinner and all three meals on the weekends. On 09/10/19 at 11:52 AM, this surveyor spoke with Director of Nursing (DON) regarding Resident #51. This surveyor interviewed the DON regarding Resident #51's behaviors. The DON stated that Resident #51 has a behavior tracking tool for her behaviors. The DON did note that Resident #51 was not care planned to go in and out of other resident rooms. The DON further noted that she was aware that several residents on A wing had voiced complaints regarding Resident #51's behaviors at meal times and when Resident #51 ambulates on the halls. The DON noted that one of the reasons Resident #51 eats lunch in Special Needs is for her weight loss as well as trying to keep her occupied as to not disturb the residents on A wing. During an interview with Employee #131, MDS nurse on 09/10/19 at 02:20 PM, Employee #131 stated that Resident #51 is not care planned for behavior of wandering and going in and out of other resident rooms. Moreover, Employee #131 reviewed the care plan the facility provided and stated that she did not see where wandering in resident rooms had been careplanned. During an interview on 09/11/19 at 10:15 AM, with Employee #103, Therapeutic Program Director, has Resident #51 on caseload. Resident #51 comes to the Special Needs department for meal training, Monday thru Friday for lunch. On the weekends, Resident #51 eats her meals back on unit. Employee #103 noted that Resident #51 was referred to Special Needs for weight loss, meal intake, and to provide more supervision for resident's behavior. The surveyor spoke with the DON on 09/11/19 at 01:07 PM concerning findings. No further information was provided.", "filedate": "2020-09-01"}
{"rowid": 3716, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2019-09-12", "deficiency_tag": 607, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "K00K11", "inspection_text": "Based on review of the facility suggestion/complaint forms, policy and procedure, and staff interview, the facility failed to implement written policies and procedures to investigate allegations of neglect for Residents #54, #4, and #64. This was a random opportunity for discovery with the potential to affect a limited number of residents. Resident identifiers: #54, #4, and #64. Facility census: 75. Findings included: a) Review of facility suggestion/complaint forms Review of a facility document entitled, Suggestion/Complaint Form (To be used by all concerned persons) at 1:00 PM on 09/10/19, found a Health Service Assistant (HSA) #171 filed a hand written complaint on behalf of C- North Hall Residents #54, #4 and #64 on 08/23/19. The name of resident's was listed as C North Residents, evening shift. Description of the incident: Residents not being given showers. Attached to the complaint form was a hand written statement from HSA #171: (Typed as written), This is a formal complaint on behalf of several residents that I myself have observed when on the units. I was on C-North today with (Name of Resident # 54) he smelled so bad it was a sour smell. This was not the first time I have smelled that with (Name of Resident #54). He states he has not been in the shower this week they wipe him off and shower him in bed. He also states that when the day shift leaves he gets offered Nothing to drink. Then I observed (Name of Resident #4 ) had crud I'm thinking poop thick under his finger nails and smeared between some of his toes. I know it had to been there a while because it was hard. Also I was told by one/two of day shift CNA's (certified nursing assistants) that (name of resident #64) has not been cleaned properly due to when they change him the cleaning rag would be black. I'm sure there's more but this is what I witnessed myself . I feel I need to speak up for these residents. I will state the ones I mentioned are evening showers that aren't being done. Attached to the complaint form was also a hand written statement from Health Services Worker (HSW) #145, dated 8/23/19. There has been multiple occasions that I have worked with (name of Resident #54) and he has made the statement that he did not get a shower, yet his face had been shaved. When I ask him where did they shave you at he has stated in my bed. (Name of Resident #54) has also had an odor coming from him. When wiping and doing care on (Name of Resident #64 a brown residue is left on the wash rag Also attached to the complaint form was a handwritten statement, dated 08/23/19, from HSW #134. There have been multiple times that myself and other HSW have went in to do care on (Resident name) and have noticed a very strong odor coming from him. Resident also stated to HSW that they only shave him and wipe him off while laying in bed. Also, while doing care on (Name of Resident) I noticed as you wipe him a brown residue will come off of him. The suggestion/complaint form required the following to be completed: Steps taken to investigate: Check the shower schedule, et (typed as written) monitor the bathing of the patients. Summary of findings/conclusion: Rsdt's (Residents) were bathed as scheduled. Witnessed rsdt's shower via shower gurney. Statement Complaint valid/not valid: Not valid. Corrective action? (if any) Monitor rsdt's et their bathing schedule et ensure completion. The form was signed only by the Assistant Director Of Nursing (ADON). The form also required the signature of the administrator. The form was not signed. On 09/10/19 at 03:58 PM, a facility social work supervisor (SWS) #56 said she was aware of the allegations but she did not investigate them. She said the allegations were not reported to the proper state agencies because she didn't think the allegations were true. An interview with the ADON on 09/10/19 at 4:09 PM, revealed the allegations were not reported to State authorities. The ADON said she had placed a sticky note on the complaint form noting each resident was showered. The ADON pointed to the note which indicated each resident was showered on 08/23/19; #54 received a shower at 3:30 PM, #4 received at shower at 3:50 PM, and #64 received a shower at 4:10 PM. When asked if she had any other information to provide regarding the situation, she said, no. The ADON retrieved the shower schedule for the 3 residents in question. All 3 residents are to receive showers on the afternoon shift. Review of the schedule with the ADON revealed the following information from 08/01/19 through 08/23/19: Resident #54 receives showers on Monday, Wednesday, and Friday. Resident #54 was not showered on the following Mondays in August, 2019 8/5/19, 8/19/19. Resident #54 was not showered on the following Fridays in August, 2019: 08/02/19, 08/09/19, 08/16/19. Resident #4 receives showers on Saturday, Tuesday and Thursday. Resident #4 missed the following showers on Saturdays: 08/10/19, 08/17/19. Resident #64 is showered on Monday, Wednesday, and Friday. Resident #64 did not receive a shower on 08/02/19, 08/05/19, 08/09/19, and 08/16/19. The ADON agreed the residents were not bathed as scheduled prior to the allegation. The ADON said she did not obtain any statements from other staff. She obtained no statements from the afternoon staff responsible for bathing the 3 residents. She did not have any information to determine why these 3 residents were not provided showers as scheduled. There was also no investigation into the allegation regarding Resident #54, Doesn't get anything to drink. An interview with HSA #171 on 09/11/19 at 10:13 AM, found she works on the special needs unit. HSA verified she made a complaint because, These Residents need to be taken care of. She said she witnessed what she believed to be human feces on Resident #4. She also witnessed a odor coming from Resident #54. She said another worker told her about Resident #64. An interview with the administrator on 09/11/19 at 10:56 AM revealed the administrator was unaware of the suggestion/complaint form completed on 08/23/19. Review of the facility's policy, entitled Abuse and Neglect Reporting/investigation, defines neglect as, The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Under the heading investigation: The hospital will investigate different types of incidents and identify the staff member responsible for initial reporting, investigation of alleged violations and reporting of results to the proper authorities. 4. The investigation will focus on determining if abuse, neglect, exploitation, involuntary seclusion, misappropriation of resident property and/or mistreatment has occurred, the extent, and cause.", "filedate": "2020-09-01"}
{"rowid": 3717, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2019-09-12", "deficiency_tag": 609, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "K00K11", "inspection_text": "Based on review of the facility suggestion/complaint forms, facility policy and procedure, and staff interview, the facility failed to ensure allegations of neglect were reported in accordance with State law to the State Survey Agency, Ombudsman, and adult protective services. In addition, the administrator was unaware of the allegations. This was a random opportunity for discovery with the potential to affect a limited number of residents. Resident identifiers: #54, #4, and #64. Facility census: 75. Findings included: a) Review of facility suggestion/complaint forms Review of a facility document entitled, Suggestion/Complaint Form (To be used by all concerned persons) at 1:00 PM on 09/10/19, found a Health Service Assistant (HSA) #171 filed a hand written complaint on behalf of C- North Hall Residents #54, #4 and #64 on 08/23/19. The name of resident's was listed as C North Residents, evening shift. Description of the incident: Residents not being given showers. Attached to the complaint form was a hand written statement from HSA #171: (Typed as written), This is a formal complaint on behalf of several residents that I myself have observed when on the units. I was on C-North today with (Name of Resident # 54) he smelled so bad it was a sour smell. This was not the first time I have smelled that with (Name of Resident #54). He states he has not been in the shower this week they wipe him off and shower him in bed. He also states that when the day shift leaves he gets offered Nothing to drink. Then I observed (Name of Resident #4 ) had crud I'm thinking poop thick under his finger nails and smeared between some of his toes. I know it had to been there a while because it was hard. Also I was told by one/two of day shift CNA's (certified nursing assistants) that (name of resident #64) has not been cleaned properly due to when they change him the cleaning rag would be black. I'm sure there's more but this is what I witnessed myself . I feel I need to speak up for these residents. I will state the ones I mentioned are evening showers that aren't being done. Attached to the complaint form was also a hand written statement from Health Services Worker (HSW) #145, dated 8/23/19. There has been multiple occasions that I have worked with (name of Resident #54) and he has made the statement that he did not get a shower, yet his face had been shaved. When I ask him where did they shave you at he has stated in my bed. (Name of Resident #54) has also had an odor coming from him. When wiping and doing care on (Name of Resident #64 a brown residue is left on the wash rag Also attached to the complaint form was a handwritten statement, dated 08/23/19, from HSW #134. There have been multiple times that myself and other HSW have went in to do care on (Resident name) and have noticed a very strong odor coming from him. Resident also stated to HSW that they only shave him and wipe him off while laying in bed. Also, while doing care on (Name of Resident) I noticed as you wipe him a brown residue will come off of him. The suggestion/complaint form required the following to be completed: Steps taken to investigate: Check the shower schedule, et (typed as written) monitor the bathing of the patients. Summary of findings/conclusion: Rsdt's (Residents) were bathed as scheduled. Witnessed rsdt's shower via shower gurney. Statement Complaint valid/not valid: Not valid. Corrective action? (if any) Monitor rsdt's et their bathing schedule et ensure completion. The form was signed only by the Assistant Director Of Nursing (ADON). The form also required the signature of the administrator. The form was not signed. On 09/10/19 at 03:58 PM, a facility social work supervisor (SWS) #56 said she was aware of the allegations but she did not investigate them. She said the allegations were not reported to the proper state agencies because she didn't think the allegations were true. An interview with the ADON on 09/10/19 at 4:09 PM, revealed the allegations were not reported to State authorities. The ADON said she had placed a sticky note on the complaint form noting each resident was showered. The ADON pointed to the note which indicated each resident was showered on 08/23/19; #54 received a shower at 3:30 PM, #4 received at shower at 3:50 PM, and #64 received a shower at 4:10 PM. When asked if she had any other information to provide regarding the situation, she said, no. The ADON retrieved the shower schedule for the 3 residents in question. All 3 residents are to receive showers on the afternoon shift. Review of the schedule with the ADON revealed the following information from 08/01/19 through 08/23/19: Resident #54 receives showers on Monday, Wednesday, and Friday. Resident #54 was not showered on the following Mondays in August, 2019 8/5/19, 8/19/19. Resident #54 was not showered on the following Fridays in August, 2019: 08/02/19, 08/09/19, 08/16/19. Resident #4 receives showers on Saturday, Tuesday and Thursday. Resident #4 missed the following showers on Saturdays: 08/10/19, 08/17/19. Resident #64 is showered on Monday, Wednesday, and Friday. Resident #64 did not receive a shower on 08/02/19, 08/05/19, 08/09/19, and 08/16/19. b) Interviews with staff The ADON agreed the residents were not bathed as scheduled prior to the allegation. The ADON said she did not obtain any statements from other staff. She obtained no statements from the afternoon staff responsible for bathing the 3 residents. She did not have any information to determine why these 3 residents were not provided showers as scheduled. There was also no investigation into the allegation regarding Resident #54, Doesn't get anything to drink. An interview with HSA #171 on 09/11/19 at 10:13 AM, found she works on the special needs unit. HSA verified she made a complaint because, These Residents need to be taken care of. She said she witnessed what she believed to be human feces on Resident #4. She also witnessed a odor coming from Resident #54. She said another worker told her about Resident #64. An interview with the administrator on 09/11/19 at 10:56 AM revealed the administrator was unaware of the suggestion/complaint form completed on 08/23/19. The administrator was unaware of any investigations that may or may not have occurred. The administrator verified she should have been made aware of the concern form. c) Facility Policy and procedure for Abuse and Neglect Reporting/Investigation Review of the facility's policy, entitled Abuse and Neglect Reporting/reporting/response: A covered individual (mandatory reported) will immediately report to Adult Protective Services, State Agency, (OHFLAC), the administrator and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's. The mandatory reported may contact the Resident Advocate/Grievance Official for assistance if needed. The Charge Nurse will assist with reporting of allegations on nights, weekends and holidays Allegations that DO NOT involve abuse or result in serious bodily injury must be reported to appropriate State agencies no later than 24 hours after allegation is made. Additionally, as a result of the investigation the facility will take all necessary actions which may include, but are not limited to, the following: Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; Defining how care provision will be changed and /or improved to protect residents receiving services; Training of staff on changes made and demonstration of staff competency after training is implemented; Identification of staff responsible for implementation of corrective actions; The expected date for implementation; and Identification of staff responsible for monitoring the implementation of the plan.", "filedate": "2020-09-01"}
{"rowid": 3718, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2019-09-12", "deficiency_tag": 656, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "K00K11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and resident interview, the facility failed to ensure each resident will have a person-centered comprehensive care plan developed and implemented to meet his / her other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs for Residents #51, #60, #58, and #63. For Resident #51, the facility failed to develop a care plan to address the resident's wandering as it relates to potential accidents, implement the care plan for activities, and develop a care plan for behaviors. For Resident #60, the facility failed to implement a care plan for a resident with dementia. For Resident #58, the facility failed to implement a care plan for a resident with fall precautions. For Resident #63, the facility failed to develop a care plan to address a resident's dental issues. This was true for four (4) of eighteen (18) residents reviewed. Resident identifiers: #51, #58, #58, and #63. Facility census 75. Findings included: a -1 ) Resident #51 (Accidents) During the initial tour as well as meal observation on 09/09/19 at 12:53 PM, Resident #51 was wandering around the A wing dining room. Below are the observations the day of entrance of Resident #51's behaviors: --09/09/19 12:53 PM R 51 wandering. --09/09/19 12:56 PM R 51 trying to touch items on other resident's trays. Resident #51 stands over Resident #11 as R #11 is trying to eat her lunch. --09/09/19 12:58 PM Employee #22, LPN, redirected R #51 from R #11's food --09/09/19 01:07 R #51 going in and out of rooms on A North wing. R #51 removed water pitcher from Room A-5. R #51 placed the water pitcher on a blue recliner that was covered in plastic protective cover that was located in the hallway. R #51 rummaged in all drawers in room A-2. R #51 then lies in bed in A-2. R #51 goes in and out of that room. There are no staff that can be seen on this A North unit at this time. --09/09/19 01:08 PM R #51 goes into room A-1. Employee #115, housekeeper, was cleaning in Room A-1. Employee #115 told Resident #51 that the room was not her room and that the resident could not be in that room. Employee #115 remained cleaning Room A-1 while Resident #51 was still in Room A-1. --09/09/19 01:09 PM R #51 went into Room A-3. There were no staff on hall that were visible. R #51 was rummaging in Room A-3. --09/09/19 01:10 PM R #51 went back into Room A-1. Employee #22, LPN, was present A North hall. Employee #22 walked by R #51 while she was in Room A-1. Employee #22 did not stop R #51 from going into room that was not hers nor did Employee #22 try to redirect R #51 from rummaging and touching items in Room A-1. --09/09/19 01:11 PM R #51 went back into Room A-2. R #51 was rummaging on all 3 beds in that are in Room A-3. Employee #22 was still present on A North wing. Employee #22 did not attempt to stop nor redirect Resident #51. --09/09/19 01:12 PM Resident #51 entered Room A-3. R #51 was rummaging on bed. This is not R #51's room. Employee #22, LPN, walked off of the hall of A North wing and exited through the doors at the nurses' station. Employee #22 did not intervene nor redirect R #51 from being in Room A-3. During this time, R #51, was rummaging on another bed. R #51 was touching and adjusting 2 of the 3 beds in this room. --09/09/19 01:13 PM Resident #51 went back into Room A-3. R #51 walked around the room and touched nightstands, bed, and chairs. --09/09/19 01:14 PM Resident #51 went back into Room A-3. Employee #22 walked in and out of this room while R #51 was wandering in this room. This is not Resident #51's room. Employee #22 did not redirect or try to have resident exit room. R #51 exited the room at 1:15 PM. --09/09/19 01:19 PM R #51 entered Room A-1. R #51 was rummaging through this room. --09/09/19 01:20 PM Resident #51 entered Room A-2 and walked around the room touching various items in this room, including items that are not hers. --09/09/19 01:21 PM Resident entered Room A-2. This is R #51's room; however, R #51 was going through other resident items that on the other beds in this room. --09/09/19 01:24 PM Resident #51 was going in and out of rooms on A east. Employee #22, LPN did see Resident #51, but did not redirect the resident. --09/09/19 04:06 PM Resident #51 was cursing another resident (Resident #1). This occurred in the hallway before the entrance door to A East. Resident #51 was telling Resident #1 that he is going to hell. --09/09/19 04:09 PM Resident #51 entered Room A-11. --09/09/19 04:15 PM Resident #51 was touching Resident #18's drink. Resident #18 stated you go on. leave that alone. Review of Residents #51's care plan found a focus/problem: --Needs assistance with ADL's, is at risk for decline due to cognitive loss, alteration in thought process r/t [DIAGNOSES REDACTED], history of incontinence. The goal associated with this problem: --Will be able to continue self care a much as possible and accept staff assistance PRN with ADL's over the next review. Interventions included: --May observe 1 : 1 of line of sight if resident appears agitated / and or unsteady prn. --History of using razors to shave her face causing her face and neck to have open areas bleeding. Refer to MD. Shave [NAME] PRN. Maintain razor safety. A record review of Resident #51 noted that this resident had two (2) incident / accident reports since 07/31/19. On 07/31/19 at 01:45 PM, Resident #51 was discovered in the employee bathroom. The incident / accident report description stated, Resident went into employee bathroom and attempted to urinate in tub. Resident pulled her pants down and fell backward into tub. Resident was not hurt. On 09/05/19 at 09:05 am, Resident #51 was lying in her bed, at some point woke up and urinated / defecated on her bed and floor. At that time, resident attempted to stand and slipped ion her urine on the floor causing her to fall at bedside. A record review of Resident #51's chart revealed an Elopement Risk Evaluation Tool dated 08/02/19. Resident #51 had a total score of 10. On the Elopement Risk Evaluation Tool, there is a scale to define each score. A score of 9+ is defined as high risk to wander requires secure care device care plan and monitor as directed. Resident #51 had behavior / intervention monthly flow record in her chart. The behaviors listed on these tracking forms for staff to monitor for were agitated / pacing and panic / anxiety. A record review of the facility's behavior / intervention monthly flow record for the months from (MONTH) 2019 to (MONTH) 2019 listed a behavior of agitated / pacing. However, on each month's sheet, the staff documented only zero's (O) on the tracking tools. On 09/11/19 at 12:39 PM, during an interview with Assistant Director of Nursing (ADON), this surveyor asked the ADON what a zero (0) on the behavior tracking form meant. The ADON responded that a zero (0) meant that the staff stated that the behavior did not occur. A record review of Resident #51 noted the following nurses notes (copied as written in resident's chart): --6/2/19 at 15:46: Resident cont. (continues) to be restless and agitated this shift. PRN (as needed) [MEDICATION NAME] given per order with minimal effect. Resident has been going into resident #9180 room causing that resident to become agitated. Multiple attempts at redirection, but behavior cont. throughout this shift. Placed on cb for physician review charge nurse notified of prn [MEDICATION NAME] and resident change in behavior, notified POA (Power of Attorney)/family [NAME] of residents change in behavior. Family noted to increase in agitation, as they attempted an outing with resident when she became extremely agitated and attempted to bite daughter. Pre restraint form completed. --6/3/19 at 20:00: Resident receives prn [MEDICATION NAME] having agitation, yelling very loud in dayroom as staff attempts to redirect her from going in other resident's rooms, she refuses snacks and drinks as staff attempts to change her mood with snack or drink, resident spills pop on her bed leaving the near full can on her blankets. --6/5/19 at 00:02: Resident receives her prn [MEDICATION NAME] for agitation as she has been offered snacks and drinks to shift her mood, while she was in the bathroom, she removed her depends, torn up depends but into the three bathroom sinks and turned the water on, staff has returned her to her bed several times since 10:30pm and hopefully she will be able to get some rest having received her prn. --6/5/19 at 01:32 Reside up out of bed, ambulates to bathroom on A North, spends a little time in the bathroom, water could be heard running, staff goes to the bathroom to find all three sinks with paper towels and toilet paper in the sink with the water running strong and water overflowing into the floor, one toilet plugged up also, night shift staff clean up bathroom, resident currently in room lying on bed as if asleep. --6/6/19 at 12:25 Night shift charge nurse reported concerns about [NAME] and her recent worsening of behaviors, her increase incidents of behaviors, such as wandering, taking items from others, screaming at staff, making false accusations, plugging up the toilet and sink, tearing dressing off her arm. (Psychiatric Physician name) ask us to consult with (Attending Physician name), and to do medical work up such as labs and ua. Notified (attending physician) of the above concerns and he plans to see (resident) on his visit tomorrow. --6/8/19 at 20:00 Resident receives prn [MEDICATION NAME] for aggression, as we were unable to change her mood by offering snacks, drinks or restroom needs, she had returned to the bathroom and was found with wet towels in the sink and the water running, she has been pacing and can be heard repeating herself, she speaks hateful when staff attempts to move her away from the bathroom sink or away from another resident as she stands in their personal space. --6/9/19 at 20:20 Resident receives prn [MEDICATION NAME] for aggression, she can be heard talking hateful as staff attempts to redirect her away from other residents, she is not concerned with a snack or drink this writer offers a drink and she will say 'I don't want it', she had been following staff into other resident's room as staff is assisting other resident's to bed, she stands in the doorway talking to herself, when staff asks her to leave or the resident of the room asks her to leave she becomes hateful in her response by the time staff walks her out of the room she is fitful and returns to the same place as if she intends to do what she wants. --6/11/19 at 06:31 Resident given PRN [MEDICATION NAME] at HS for agitation. Rsdt walking very quickly down the halls, clenching fists and yelling, 'I'm leaving, I'm leaving.' Slept through night and woke up at appx 5 am and picked off scabbed areas on lower R arm. Areas cleaned and dry dressings applied and also covered with long sleeve. --6/11/19 at 23:00 Resident received prn [MEDICATION NAME] for aggression, being unable to calm self, uncooperative to accept sandwich or drink, she has been yelling very loud paces hallways is returned to unit per staff and continues to be loud. --6/17/19 at 20:00 Resident receives prn [MEDICATION NAME] for anxiety as drinks and snacks does not seem to help improve her mood, she continues to pace, repeat herself and speaks of leaving. --6/21/19 at 06:17 Resident agitated this evening, yelling at staff, stating that she wants to leave, walking very quickly up and down the halls. Unable to redirect with snack. PRN [MEDICATION NAME] given at 8pm. --6/22/19 at 06:04 Resident very agitated, picking at scabs on her arm and saying she wants to 'get out of here and never coming back.' Attempts to redirect her with a snack and juice are unsuccessful. PRN [MEDICATION NAME] given per MD order. --7/4/19 at 09:08 Resident ambulating in hallway, agitated. yelling at staff. Uncooperative with care. Multiple attempts at Redirection unsuccessful. Prn med given with success. --7/5/19 at 20:46 HSW (health service worker) stated that resident has been turning on all the sinks, yelling at residents in the hallway, saying, 'it hurts, I've got to get out of here!' Unable to redirect her. Gave her a PRN [MEDICATION NAME] for her agitation . --7/9/19 at 10:00 Resident was getting into trash and other resident's belongings. Pacing back and forth. Redirection unsuccessful. [MEDICATION NAME] 1mg po given per order. --7/11/19 at 20:00 Received prn [MEDICATION NAME] for anxiety, after receiving a drink, snack, and encouraged to sit down, but continued pacing and yelling. --7/12/19 at 10:44 Resident pacing and yelling. Drinks and food offered with no success. PRN [MEDICATION NAME] given as ordered. --7/15/19 at 20:15 Resident had got into the big trash can on the unit and got a diaper out of it and rubbed her face with it getting BM on her nose and cheek. Hsw cleaned it off and redirected resident to stay out of the trash can. --7/15/19 at 20:30 Resident receives prn [MEDICATION NAME] for agitation after receiving snacks and a drink and being unable to improve her mood, she has been unable to verbally redirect as she paces the unit, goes in and out of other resident's rooms, she picked up a blanket belonging to another resident becomes more loud and argumentative when verbally redirected to return items, other residents become upset which has caused loud outburst on unit, she removes several pairs of depends off the cart, takes gloves out of the boxes on the wall, tears on the occupied sign that is on the staff's restroom door. --7/16/19 at 10:22 Resident was becoming more agitated, getting into other resident's belongings. Got resident # 9120 remote. Very uncooperative. [MEDICATION NAME] 1mg po given. --7/17/19 at 01:45 Resident had been asleep earlier but is now awake, assisted to bathroom, assisted back to bed but up gotten up self up out of bed and walking unit, going into other resident's rooms, becomes argumentative when verbally redirected by staff, encouraged to sit in chair on hall and would only sit for a brief period of time, received drink and snack but did not improve her mood, received [MEDICATION NAME] PRN PO for agitation. --7/17/19 at 20:15 Receives PRN PO (by mouth) [MEDICATION NAME] for agitation after resident's mood is unchanged by being offered snacks, drink, urged to sit down, or lay down, she has been pacing hallway and going into other resident's rooms. Some residents fuss at her to leave the room she then becomes loud, has a frown and stomps as she walks and talks as if angry, 'I'm leaving here, I'm not coming back' she repeats this phrase and as she continues this behavior. --7/19/19 06:27 Resident was given PRN [MEDICATION NAME] at HS (at bedtime) d/t (due to) her behaviors. She was agitated, pacing the floor, yelling at others. Unable to distract resident by offering a snack or a drink. Took medications without incident. --7/21/19 at 20:00 Med prn for anxiety et pain. Pacing et (and) worried expression. --7/24/19 at 06:42 Resident was repeating, 'it hurts, it hurts. She was walking very quickly into other resident rooms, getting into the trash can in the hallway, turning on the sinks in the bathroom. Unable to distract rsdt with juice or snacks and wouldn't sit in the recliner. Administered PRN [MEDICATION NAME] for her agitation . --7/25/19 at 21:19 Resident was screaming at HSWs that were trying to calm her down, asking her to sit in the chair. HSW reported that for the past few hours, rsdt has been going into the bathroom and turning on the sinks; digging in the trash, going into others rooms and messing with others belongings and picking at her arms. At 8pm, this nurse administered a PRN [MEDICATION NAME] to her, per MD order. --7/26/19 at 00:53 Resident awoke at approx 2400. She is very irritable, screaming at the HSW and running down the hall. She continuously entered bedrooms that weren't' her own, sitting on top of resident who were sleeping. Tried to redirect with a drink and a snack, but resident became louder and angrier. Administered a PRN [MEDICATION NAME] per MD order at this time --7/29/19 at 00:02 Resident pulling dirty briefs out of the trash. She is very upset, yelling at HSW, 'I've got to go, get out, get out!' Unable to redirect to recliner. Offered snack, but declined. Administered PRN [MEDICATION NAME] per MD order at this time. --7/30/19 at 16:30 This resident was getting anxious, pacing back and forth and going into other residents rooms. Redirection unsuccessful, would just get more agitated. [MEDICATION NAME] 1mg po given per order. --7/31/19 at 08:09 Resident ambulating up and down hallway. In and out of other resident rooms. screaming 'it hurts' Redirection unsuccessful. Prn [MEDICATION NAME] and anxiety med given with success. --8/3/19 at 06:51 Resident ambulating on the unit, yelling out, 'It hurts, it hurts.' --8/6/19 at 22:06 Resident has displayed increased agitation / anxiety during this HS med pass. She is going into the bathroom, turning on the faucets, then will start screaming profanities very loudly when attempting to redirect her. She shouts, 'I'm leaving. I'm going home, I'm not coming back, F--k you. Attempted to redirect resident with different snacks, juices, but with no success. Took HS medication without incident. --8/7/19 at 15:15 This resident was standing out in the hall and resident #9152 rolled up to her and hit her in the stomach. Resident yelled out and resident #9152 rolled on down the hall in his w/c (wheelchair). --8/21/19 at 06:20 Resident seems agitated with staff and with other residents. Attempted to redirect her. Offered snack/drinks. Walked briskly through the halls and was saying, 'I'm leaving, I'm leaving. It hurts, hurts, hurts, blood, blood.' PRN [MEDICATION NAME] per MD order. --8/23/19 at 23:20 Resident was getting into the towels and wash clothes and had them in the floor in the bathroom. Going into other residents rooms while they are sleeping. [MEDICATION NAME] 1mg po given. --8/28/19 at 02:06 Resident with increased agitation, attempting to get into bed with other residents, yelling at Staff, attempts were made to help Resident get comfortable, PRN [MEDICATION NAME] administered, will continue to monitor. --8/30/19 at 04:34 Resident showing increased agitation during HS med pass. She was going into other residents rooms, climbing into their beds, screaming out. Unable to redirect to a recliner or with a snack. PRN [MEDICATION NAME] administered per MD order. --08/31/19 at 06:35 Resident was very agitated, pacing the halls, yelling out at other residents. Offered a snack/drink; Unable to redirect at this time. PRN [MEDICATION NAME] given at this time, per MD order for agitation. --09/05/19 at 07:15 Resident already agitated this morning, yelling and pacing. PRN [MEDICATION NAME] and PRN [MEDICATION NAME] administered. Will continue to monitor. --09/05/19 at 11:55 Administered second dose of PRN [MEDICATION NAME] and PRN [MEDICATION NAME] due to the resident expressing being in pain as well as starting to pace and become agitated when being redirected. Will continue to monitor. --09/05/19 at 14:32 Reported by ADON to this nurse that resident was found lying in another resident's bed on C wing. No incident occurred. Resident redirected out of room / bed. Will continue to monitor. During an interview with Employee #131, Minimum Data Set (MDS) nurse on 09/10/19 at 02:20 PM regarding Resident #51's care plan, Employee #131 and this surveyor reviewed Resident #51's care plan provided by the facility. This surveyor asked Employee #131 where the care plan would state that Resident #51 went into other resident rooms as well as other areas of the facility. Employee #131 stated that she was not aware that Resident #51 entered other resident rooms and went through items of other residents. This surveyor noted that there were nurses notes regarding the resident's behavior. Surveyor asked Employee #131 why the access to razors still remained on Resident #51's care plan. Employee # responded that Resident #51 was still able to have access to razors. There are residents on the unit that can shave themselves and there are razors on the unit for those residents to use. (NAME OF RESIDENT #51) is care planned for a history of razors since she is able to get razors and shave face. Once Resident #51 was no longer able to shave herself, the staff had to confiscate razors. The nurse aids shave her now. We do have residents on that wing who use razors. Employee #131 was not able to find where Resident #51 was care planned for wandering into other resident rooms as well as other rooms on the unit and any interventions to address that behavior. Employee #131 did state that with Resident #51 going into areas on the unit as well as other resident rooms, that would pose an potential for an accident. On 09/11/19 at 01:07 PM, this surveyor spoke with Director of Nursing (DON) concerning findings. No additional information was provided. a-2) Resident #2 (Activities) During the initial tour as well as meal observation on 09/09/19 at 12:53 PM, Resident #51 was wandering around the A wing dining room. Resident #51 tried to touch the food items on Resident #11's lunch tray. Resident #51 would pace and wander the A wing dining room., then return to a seat near Resident #11. When Resident #51 would sit near Resident #11, Resident #51 would attempt to touch Resident #11's food items and grab at the items on Resident #11's tray. Below are the observations the day of entrance of Resident #51's behaviors: --09/09/19 12:53 PM R 51 wandering. --09/09/19 12:56 PM R 51 trying to touch items on other resident's trays. Resident #51 stands over Resident #11 as R #11 is trying to eat her lunch. --09/09/19 12:58 PM Employee #22, LPN, redirected R #51 from R #11's food --09/09/19 01:07 R #51 going in and out of rooms on A North wing. R #51 removed water pitcher from Room A-5. R #51 placed the water pitcher on a blue recliner that was covered in plastic protective cover that was located in the hallway. R #51 rummaged in all drawers in room A-2. R #51 then lies in bed in A-2. R #51 goes in and out of that room. There are no staff that can be seen on this A North unit at this time. --09/09/19 01:08 PM R #51 goes into room A-1. Employee #115, housekeeper, was cleaning in Room A-1. Employee #115 told Resident #51 that the room was not her room and that the resident could not be in that room. Employee #115 remained cleaning Room A-1 while Resident #51 was still in Room A-1. --09/09/19 01:09 PM R #51 went into Room A-3. There were no staff on hall that were visible. R #51 was rummaging in Room A-3. --09/09/19 01:10 PM R #51 went back into Room A-1. Employee #22, LPN, was present A North hall. Employee #22 walked by R #51 while she was in Room A-1. Employee #22 did not stop R #51 from going into room that was not hers nor did Employee #22 try to redirect R #51 from rummaging and touching items in Room A-1. --09/09/19 01:11 PM R #51 went back into Room A-2. R #51 was rummaging on all 3 beds in that are in Room A-3. Employee #22 was still present on A North wing. Employee #22 did not attempt to stop nor redirect Resident #51. --09/09/19 01:12 PM Resident #51 entered Room A-3. R #51 was rummaging on bed. This is not R #51's room. Employee #22, LPN, walked off of the hall of A North wing and exited through the doors at the nurses' station. Employee #22 did not intervene nor redirect R #51 from being in Room A-3. During this time, R #51, was rummaging on another bed. R #51 was touching and adjusting 2 of the 3 beds in this room. --09/09/19 01:13 PM Resident #51 went back into Room A-3. R #51 walked around the room and touched nightstands, bed, and chairs. --09/09/19 01:14 PM Resident #51 went back into Room A-3. Employee #22 walked in and out of this room while R #51 was wandering in this room. This is not Resident #51's room. Employee #22 did not redirect or try to have resident exit room. R #51 exited the room at 1:15 PM. --09/09/19 01:19 PM R #51 entered Room A-1. R #51 was rummaging through this room. --09/09/19 01:20 PM Resident #51 entered Room A-2 and walked around the room touching various items in this room, including items that are not hers. --09/09/19 01:21 PM Resident entered Room A-2. This is R #51's room; however, R #51 was going through other resident items that on the other beds in this room. --09/09/19 01:24 PM Resident #51 was going in and out of rooms on A east. Employee #22, LPN did see Resident #51, but did not redirect the resident. --09/09/19 04:06 PM Resident #51 was cursing another resident (Resident #1). This occurred in the hallway before the entrance door to A East. Resident #51 was telling Resident #1 that he is going to hell. --09/09/19 04:09 PM Resident #51 entered Room A-11. --09/09/19 04:15 PM Resident #51 was touching Resident #18's drink. Resident #18 stated you go on. leave that alone. Review of Residents #51's care plan found a focus/problem: 001 - At risk for [MEDICAL CONDITIONS], GERD, weight loss from pacing throughout the facility, history of zinc/[MEDICATION NAME] and vitamin B 12 deficiency. The goal associated with this problem: Will not have complications r/t [MEDICAL CONDITION], stomach discomfort, mineral deficiencies, and weight loss, over the next review period. Interventions included: -- History of taking food from other residents, monitor to prevent occurrences. -- Activities to provide activities at lunch time for [NAME] when is finished lunch. During an interview with Employee #131, Minimum Data Set (MDS) nurse, on 09/10/19 at 02:20 PM regarding Resident #51's care plan, Employee #131 and this surveyor reviewed Resident #51's care plan provided by the facility. This surveyor asked Employee #131 why Resident #51 was referred to Special Needs. Employee #131 stated that there was an order for [REDACTED].#51's trying to take their food while they were eating. On 09/11/19 at 01:07 PM, this surveyor spoke with Director of Nursing (DON) concerning findings. No additional information was provided. a- c) Resident #51 (behavioral / mood) A record review of Resident #51's most recent Minimum Data Set (MDS), with an assessment reference date (ARD) of 08/02/19, coded the resident as having physical behavior (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) as having occurred 4 to 6 times in the last 7 days but less than daily. Verbal behavior directed towards other, threatening screaming, and cursing as having occurred daily in the last 7 days. During the initial tour as well as meal observation on 09/09/19 at 12:53 PM, Resident #51 was wandering around the A wing dining room. Resident #51 tried to touch the food items on Resident #11's lunch tray. Resident #51 would pace and wander the A wing dining room., then return to a seat near Resident #11. When Resident #51 would sit near Resident #, Resident #51 would attempt to touch Resident #11's food items and grab at the items on Resident #11's tray. Below are the observations the day of entrance of Resident #51's behaviors: --09/09/19 12:53 PM R 51 wandering on A wing. --09/09/19 12:56 PM R 51 trying to touch items on other resident's trays. Resident #51 stands over Resident #11 as R #11 is trying to eat her lunch. --09/09/19 12:58 PM Employee #22, LPN, redirected R #51 from R #11's food --09/09/19 01:07 R #51 going in and out of rooms on A North wing. R #51 removed water pitcher from Room A-5. R #51 placed the water pitcher on a blue recliner that was covered in plastic protective cover that was located in the hallway. R #51 rummaged in all drawers in room A-2. R #51 then lies in bed in A-2. R #51 goes in and out of that room. There are no staff that can be seen on this A North unit at this time. --09/09/19 01:08 PM R #51 goes into room A-1. Employee #115, housekeeper, was cleaning in Room A-1. Employee #115 told Resident #51 that the room was not her room and that the resident could not be in that room. Employee #115 remained cleaning Room A-1 while Resident #51 was still in Room A-1. --09/09/19 01:09 PM R #51 went into Room A-3. There were no staff on hall that were visible. R #51 was rummaging in Room A-3. --09/09/19 01:10 PM R #51 went back into Room A-1. Employee #22, LPN, was present A North hall. Employee #22 walked by R #51 while she was in Room A-1. Employee #22 did not stop R #51 from going into room that was not hers nor did Employee #22 try to redirect R #51 from rummaging and touching items in Room A-1. --09/09/19 01:11 PM R #51 went back into Room A-2. R #51 was rummaging on all 3 beds in that are in Room A-3. Employee #22 was still present on A North wing. Employee #22 did not attempt to stop nor redirect Resident #51. --09/09/19 01:12 PM Resident #51 entered Room A-3. R #51 was rummaging on bed. This is not R #51's room. Employee #22, LPN, walked off of the hall of A North wing and exited through the doors at the nurses' station. Employee #22 did not intervene nor redirect R #51 from being in Room A-3. During this time, R #51, was rummaging on another bed. R #51 was touching and adjusting 2 of the 3 beds in this room. --09/09/19 01:13 PM Resident #51 went back into Room A-3. R #51 walked around the room and touched nightstands, bed, and chairs. --09/09/19 01:14 PM Resident #51 went back into Room A-3. Employee #22 walked in and out of this room while R #51 was wandering in this room. This is not Resident #51's room. Employee #22 did not redirect or try to have resident exit room. R #51 exited the room at 1:15 PM. --09/09/19 01:19 PM R #51 entered Room A-1. R #51 was rummaging through this room. --09/09/19 01:20 PM Resident #51 entered Room A-2 and walked around the room touching various items in this room, including items that are not hers. --09/09/19 01:21 PM Resident entered Room A-2. This is R #51's room; however, R #51 was going through other resident items that on the other beds in this room. --09/09/19 01:24 PM Resident #51 was going in and out of rooms on A east. Employee #22, LPN did see Resident #51, but did not redirect the resident. --09/09/19 04:06 PM Resident #51 was cursing another resident (Resident #1). This occurred in the hallway before the entrance door to A East. Resident #51 was telling Resident #1 that he is going to hell. --09/09/19 04:09 PM Resident #51 entered Room A-11. --09/09/19 04:15 PM Resident #51 was touching Resident #18's drink. Resident #18 stated you go on. leave that alone. Review of Residents #51's care plan found a focus/problem: At risk for [MEDICAL CONDITIONS], GERD, weight loss from pacing throughout the facility, history of zinc/[MEDICATION NAME] and vitamin B 12 deficiency. The goal associated with this problem: Will not have complications r/t [MEDICAL CONDITION], stomach discomfort, mineral deficiencies, and weight loss, over the next review period. Interventions included: -- [NAME] paces and wanders throughout the facility throughout the day, [MEDICAL CONDITION] with her ambulation. History of thinking she is fat. -- History of taking food from other residents, monitor to prevent occurrences. Needs assistance with ADL's, is at risk for decline due to cognitive loss, alteration in thought process r/t [DIAGNOSES REDACTED], history of incontinence. The goal associated with this problem: Will be able to continue self care a much as possi (TRUNCATED)", "filedate": "2020-09-01"}
{"rowid": 3719, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2019-09-12", "deficiency_tag": 697, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "K00K11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview the facility failed to evaluate the effectiveness of an as needed (PRN) pain medication that was administered to Resident #1. This was true for one (1) of (2) Residents reviewed in the care area of pain. Resident identifier: #1. Facility census: 75. Findings included: a) Resident #1 During an interview on 09/09/19 at 11:20 am, Resident #1 complained of pain and hurting in his lower back and stomach area. Review of Active Orders revealed the Resident had an order for [REDACTED]. Review of the facility's Medication Administration policy stated for PRN medications the nurse must assess the Resident prior to the first dose of any PRN or STAT medication and then reassess the Resident within 60 minutes and complete the PRN effectiveness report. Record review of the Medication Therapy Report indicated from 08/01/19 - 09/11/19 Resident #1 was administered [MEDICATION NAME] 50mg as needed (PRN) pain medication for a total of fourteen (14) occurrences. Reassessment of pain medication effectiveness to monitor the Resident's response to the intervention was only completed for two (2) of the fourteen (14) administered doses of [MEDICATION NAME]. On 09/11/19 at 11:22 a.m. the Director of Nursing (DON) confirmed the Resident was not reassessed to evaluate the effectiveness of the administered [MEDICATION NAME]. The DON stated, I am calling in every nurse that administered those doses (of pain medication) and educating them. What else can I say, they didn't do it.", "filedate": "2020-09-01"}
{"rowid": 3720, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2019-09-12", "deficiency_tag": 741, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "K00K11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record, review, and staff interview the facility failed to provide non-pharmacological interventions before administering an antipsychotic medication to Resident #51 who was diagnosed with [REDACTED]. Resident identifier: # 51. Facility census 75. Findings included: a) Resident #51 Review of the resident's most recent Minimum Data Set (MDS) with an assessment reference date of 08/02/19, coded the resident as having physical behavior (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) as having occurred 4 to 6 times in the last 7 days but less than daily. Verbal behavior directed towards other, threatening screaming, and cursing as having occurred daily in the last 7 days Resident #51 has a [DIAGNOSES REDACTED]. A record review of Resident #51 medications revealed the resident had a current physician's orders [REDACTED]. The physician's orders [REDACTED]. PRN was renewed within 14 days as required by the regulations. The resident had orders for PRN [MEDICATION NAME] since at least 01/20/19. During an interview with the Director of Nursing (DON) on 09/10/19 at 11:52 AM, the DON stated the nursing staff were to conduct a pre-restraint assessment prior to giving [MEDICATION NAME]. The DON further noted on the pre-restraint assessment, the nursing staff have to indicate any non-pharmalogical interventions they attempted and / or provided the resident prior to administering the medication. A record review of Resident #51's [MEDICATION NAME] record for 08/11/19 to 09/10/19 revealed Resident #51 received 42 doses of [MEDICATION NAME] during the past 30 days. On 09/11/19 at 12:39 PM, an interview was conducted with the Assistant Director of Nursing (ADON). This surveyor and the ADON reviewed the [MEDICATION NAME] administration record from 08/11/19 to 09/10/19. The ADON examined the nurses notes as well as the pre-restraint assessment to reveal if any non-pharmalogical interventions were attempted prior to administering [MEDICATION NAME]. Per the ADON, the pre-restraint assessment is supposed to be completed before given this medication. The ADON also stated that the nursing staff may have documented in a nursing note whether non-pharmalogical interventions had been attempted prior to administering the medication to the resident. The ADON reviewed each date that was printed on the [MEDICATION NAME] administration report. Resident #51 received [MEDICATION NAME] 42 times during the timeframe of 08/11/19 to 09/10/19. The ADON could find 10 times that the facility could prove either by nurses notes or the pre-restraint assessment that Resident #51 was offered a non-pharmalogical interventions before giving the PRN [MEDICATION NAME]. The surveyor spoke with the DON on 09/11/19 at 01:07 PM concerning findings. No further information was provided.", "filedate": "2020-09-01"}
{"rowid": 3721, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2019-09-12", "deficiency_tag": 755, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "K00K11", "inspection_text": "Based on record review, staff interview, and observation the facility failed to maintain a secure storage method for controlled medications awaiting final disposition. This was a random opportunity for discovery with potential to affect more than a limited number of residents. Facility census: 75 Findings included: a) Controlled substance disposal storage On 09/10/10 at 1:52 p.m. Director of Nursing (DON) was asked to present the storage area for controlled medications awaiting final disposition. The DON then pointed out to a portable black plastic folding storage crate on wheels measuring approximately 18 x 18 x 20 inches. The storage crate was setting in the floor in the corner of her office and was verified by the DON as the designated storage area for the facility's controlled substances awaiting disposal. When the DON was asked if the storage crate was secure, affixed to the floor/wall and locked the DON replied, No, but my office door locks and the other door out there is locked after hours too. Access to a restroom from within the DON's office was noted, with entry to an adjoining office within the restroom. The DON confirmed the adjoining restroom to her office provided an open pathway for entry from the adjoining office and that the door was not locked at all times (and was not locked at the time of observation) and her office could be accessed through the restroom from the adjoining office. During the survey, the DON's office door was observed to be open at various times without her presence in the office, allowing access to the unsecure controlled medications. At 2:00 p.m. on 09/10/11 review of the contents of the black plastic portable storage crate revealed 74 medication cards (bubble packs) containing various controlled mediations awaiting destruction. Review of the Controlled Medication Destruction Log revealed the controlled medications had been removed from the facility's active medication supply as far back as 01/24/19 and were still awaiting destruction with no periodic reconciliation completed. The DON verified the last time any controlled medications were disposed of was 01/16/19, in which at that time all the controlled medications awaiting destruction for last year (2018) were disposed of. The facility's policy and procedure for Storage of Medication (revision date 05/09/18) stated: Compartments (including but not limited to, drawers, cabinets, room, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. The facility's policy for Storing of Controlled Medications (revision date 07/11/18) stated: The facility must store narcotics in separately locked, permanently affixed compartments. The facility's pharmacy services policy and procedure for Controlled Substance Storage declared the Schedule II-V (controlled) medications and other medications subject to abuse or diversion are to be stored in a permanently affixed double locked compartment. During an interview on 09/10/19 at 4:20 p.m. the DON stated, The pharmacist comes once a month, so we have the opportunity to destroy the medications, but I just have not done it yet. I haven't taken the time. The DON then further stated, I have moved the meds (medications) to the charge nurse's office where they are now locked in a metal file cabinet where they are secure.", "filedate": "2020-09-01"}
{"rowid": 3722, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2019-09-12", "deficiency_tag": 758, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "K00K11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to implement a Gradual Dose Reduction (GDR) for a [MEDICAL CONDITION] medication and a [DIAGNOSES REDACTED]. Resident identifier: #33. Facility census: 75. Findings included: a) Resident #33 On 09/10/19 at 12:05 PM, record review of the Resident's Plan of Care (P[NAME]) from 08/01/17 showed the Resident's 'Problems/Strengths' were Antipsychotic medication use, and antianxiety medication use, takes [MEDICATION NAME] for [MEDICAL CONDITION], [MEDICATION NAME] for anxiety. Mirtazepine for depression and Donepezil for Alzheimer's. On 07/07/16 the Resident was admitted to the facility with physician's orders [REDACTED]. To date the Resident has not been diagnosed with [REDACTED]. Record review of the Medication Record Review (MRR) dated 03/05/19 showed the Pharmacist recommended a GDR for [MEDICATION NAME]. Directions for the [MEDICATION NAME] 0.5 milligrams (mg) was Take 1 tablet twice daily for [MEDICAL CONDITION]. The physician disagreed with the Pharmacist's recommendation by checking a box on the MRR form which read Discontinuation likely will be harmful to resident and for others or it will disrupt their provision of care. On 09/11/19 at 3:47 PM, staff interview with the Director of Nursing (DoN) confirmed the physician had not attempted a GDR for [MEDICATION NAME].The DoN confirmed the resident has not had a GDR since she was admitted on [DATE] with the medication.", "filedate": "2020-09-01"}
{"rowid": 4438, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2016-03-10", "deficiency_tag": 276, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "EQIS11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument User's Manual - Version 3.0 (RAI Manual), and staff interview, the facility failed to complete quarterly minimum data sets (MDS) as specified by the State and approved by the Centers for Medicare and Medicaid Services (CMS). Quarterly assessments were not completed within fourteen (14) days of the assessment reference date (ARD) for four (4) of twenty-one (21) residents whose MDSs were reviewed during Stage 2 of the Quality Indicator Survey (QIS). This was true for Residents #95, #96, #72, and #92. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #95, #96, #72, and #92. Facility census: 96. Findings include: a) Resident #95 On 03/07/16 at 11:25 a.m., reconciliation of the current residents residing in the facility found Resident #95 was not on the list of residents who had resided or continued to reside in the facility. This resident had resided in the facility since admission date of [DATE]. Review of Resident #95's MDSs found an MDS with an ARD of 02/16/16, was incomplete in sections A, B, C, G, H, I, J, L, M, N, S, and Z. On 03/08/16 at 1:00 p.m., review of the MDS with the ARD of 02/16/16, found item Z0400, signed and dated on 02/26/16 by MDS Coordinator #78 to indicate sections A, B, C, G, H, I, J, L, M, N, and S were completed on 02/26/16. In addition, Item Z0500 - Signature of RN Assessment Coordinator Verifying Assessment Completion, was signed MDS Coordinator #78 on 02/26/16 to certify the assessment was complete. Review of the MDS assessment report for the MDS with the ARD of 02/16/16, found MDS Coordinator #78 had not completed sections A, B, C, G, H, I, J, L, M, N, S, and Z until 03/08/16 at 11:39 a.m. The MDS Coordinator had certified the assessment as complete and ready for submission on 03/08/16 at 12:24 p.m. According to the RAI Manual, Chapter 2, page 16, the assessment must be complete by fourteen (14) calendar days of the ARD date. Interview on 03/08/16 at 2:30 p.m., with MDS Coordinator #78 revealed she thought she had 28 days to complete, certify, and submit the MDS. On 03/08/16 at 3:15 p.m., during a review of the MDS with the ARD of 02/16/16 with the director of nursing (DON), she agreed the MDS should have been completed by 03/01/16. She also verified the MDS was completed on 03/08/16, not 02/26/16 as indicated in Section Z by MDS Coordinator #78. b) Resident #96 On 03/07/16 at 11:45 a.m., reconciliation of the current residents residing in the facility also found Resident #96 was not on the list of current residents. This resident had resided in the facility since admission on 02/02/01. Review of Resident #96's MDSs found an MDS with an ARD of 02/19/16. Sections A, B, C, G, H, I, J, L, M, N, S, and Z of this assessment were incomplete. On 03/08/16 at 3:30 p.m., the MDS with an ARD of 02/19/16 was reviewed with the director of nursing (DON). She agreed the MDS should have been completed by 03/04/16. She also verified the MDS remained incomplete at the time of the interview. c) Resident #72 Review of Resident #72's medical records on 03/08/16 at 12:30 p.m., found an MDS with an ARD of 02/19/16. This MDS was found to be incomplete in sections A, B, C, G, H, I, J, L, M, N, S, and Z. On 03/08/16 at 3:30 p.m., after review of the MDS with an ARD of 02/19/16 with the director of nursing (DON), she agreed the MDS should have been completed by 03/04/16. She also verified the MDS remained incomplete at the time of the interview. d) Resident #92 Record review at 10:00 a.m. on 03/09/16, found a quarterly minimum data set (MDS) with an assessment reference date (ARD) of 02/19/16. Sections J - Health conditions, L - oral/dental status, M - skin conditions, and N - medications had not been completed. The MDS should have been completed on 03/04/16.", "filedate": "2019-11-01"}
{"rowid": 4439, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2016-03-10", "deficiency_tag": 278, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "EQIS11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete assessments prior to signing and certify the minimum data sets (MDS) were complete. This was found for one (1) of twenty-one (21) residents whose MDSs were reviewed during Stage 2 of the Quality Indicator Survey (QIS). This was true for Residents #95. Additionally, for two (2) of five (5) resident's reviewed for the care area of unnecessary medication, Residents #76 and #90, the facility failed to completed accurate MDSs in regards to active [DIAGNOSES REDACTED]. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #95, #76, and #90. Facility census: 96. Findings include: a) Resident #95 On 03/07/16 at 11:25 a.m., reconciliation of the current residents residing in the facility found Resident #95 was not on the list of residents who had resided or continued to reside in the facility. This resident had resided in the facility since admission date of [DATE]. Review of Resident #95's MDSs on 03/08/15 at 1:00 p.m., found an MDS with an ARD of 02/16/16, was incomplete in sections A, B, C, G, H, I, J, L, M, N, S, and Z. Item Z0400, was signed and dated on 02/26/16 by MDS Coordinator #78 to indicate sections A, B, C, G, H, I, J, L, M, N, and S were completed on 02/26/16. In addition, Item Z0500 - Signature of RN Assessment Coordinator Verifying Assessment Completion, was signed MDS Coordinator #78 on 02/26/16 to certify the assessment was complete. Review of the MDS assessment report for the MDS with the ARD of 02/16/16, found MDS Coordinator #78 had not completed sections A, B, C, G, H, I, J, L, M, N, S, and Z until 03/08/16 at 11:39 a.m The MDS Coordinator had certified the assessment as complete and ready for submission on 03/08/16 at 12:24 p.m. According to the MDS 3.0 Resident Assessment Instrument (RAI) Manuel, Chapter 2, page 16, the assessment must be complete by fourteen (14) calendar days of the ARD date. Interview on 03/08/16 at 2:30 p.m., with MDS Coordinator #78 revealed she thought she had 28 days to complete, certify, and submit the MDS. On 03/08/16 at 3:15 p.m., during a review of the MDS with the ARD of 02/16/16 with the director of nursing (DON), she agreed the MDS should have been completed by 03/01/16. She also verified the MDS was completed on 03/08/16, not 02/26/16 as indicated in Section Z by MDS Coordinator #78. b) Resident #76 A review of the medical record for Resident #76 on 03/08/16 at 2:21 p.m., revealed the quarterly MDS assessment with the assessment reference date (ARD) of 12/11/15 did not accurately reflect the [DIAGNOSES REDACTED]. During further review, it was noted in the physician's orders [REDACTED].#76 had orders for [MEDICATION NAME] 0.5 milligrams (mg) daily for anxiety and [MEDICATION NAME] 20 mg daily for GERD. A review of the Medication Administration Record [REDACTED]. In an interview on 03/09/16 at 3:32 p.m., the MDS Coordinator verified Section I - Active [DIAGNOSES REDACTED].#76. c) Resident #90 A review of the medical record for Resident #90 on 03/09/16 at 10:44 a.m., revealed the quarterly MDS assessment with the ARD of 12/28/15 did not accurately reflect the [DIAGNOSES REDACTED]. During further review, it was noted in the physician's orders [REDACTED].#90 had an order for [REDACTED]. An interview on 03/09/16 at 12:10 p.m., with the MDS Coordinator verified Section I - Active [DIAGNOSES REDACTED].#90.", "filedate": "2019-11-01"}
{"rowid": 4440, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2016-03-10", "deficiency_tag": 280, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "EQIS11", "inspection_text": "**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 to reflect changes in condition for one (1) of four (4) residents reviewed for the care area of nutrition during the survey process. The care plan of Resident #68 was not revised after a significant weight loss. Resident identifier: #68. Facility census: 96. Findings include: a) Resident #68 This resident's record was reviewed for the care area of nutrition during Stage 2 of the QIS due to weight loss. Record review on 03/08/16 at 2:24 p.m., found this [AGE] year-old male resident was admitted to the facility with a gastrostomy tube feeding on 09/23/15. The following weights were obtained from the electronic medical record: -- 01/13/16 - 142.4# (pounds) -- 01/20/16 - 140.4# -- 01/27/16 - 138.6# -- 02/03/16 (the resident's medical record reflected two (2) weights-136.2# and 129.0# -- 02/10/16 - 130.5# -- 03/02/16 - 126.6# The resident had a 15.8# weight loss between 01/13/16 and 03/02/16. Further review of the medical record found the resident was noted to be combative with his bolus gastric tube feedings and had a history of [REDACTED]. The physician discontinued the bolus feedings and added continuous tube feedings. An abdominal binder was applied. On 02/15/16, the dietitian evaluated the resident and a supplement was added. A psychological consult was also ordered to address the resident's weight loss. Review of the resident's current care plan, dated 01/08/16, revised on 02/25/16, found a problem of, (Name of resident) receives a tube feeding. The goal associated with this problem was, Will remain at current weight plus or minus 3# in next three month period AEB (as evidenced by) recorded weights. Interventions included: -- Diet as ordered. -- Notify MD (doctor) as needed for weight changes or decreased intake. -- Flushes as ordered. -- Raise head of bed 30 during feeding. -- Monitor weight as ordered. -- Provide formula and rate as: [MEDICATION NAME] (high-protein, fiber fortified formula that provides balanced nutrition for long or short term tube feeding) 1.5 full strength, 22 hours on and 2 hours off. -- Assess tube-feeding orders for adequate daily intake of protein, calories, and fluids. At 3:12 p.m. on 03/08/16, Registered Dietitian (RD) #16 confirmed he had forgotten to update the care plan to reflect the resident's weight loss.", "filedate": "2019-11-01"}
{"rowid": 4441, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2016-03-10", "deficiency_tag": 309, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "EQIS11", "inspection_text": "**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 four (4) residents reviewed for the care area of nutrition received the necessary care and services to maintain and/or attain the highest practicable level of well-being. Resident #93 and Resident #34 both had physician orders [REDACTED]. The facility failed to ensure they consumed fluids less than or equal too the ordered restriction on a daily basis. Resident identifiers: #93 and #34. Facility census: 96. Findings include: a) Resident #93 A review of Resident #93's medical record at 2:46 p.m. on 03/08/16, found a physician's progress note dated 12/17/15. This note indicated Resident #93's attending physician saw her on 12/17/15 and indicated the resident needed a work up for [MEDICAL CONDITION] ([MEDICAL CONDITION] is a condition that occurs when the level of sodium in the blood is abnormally low. Sodium is an electrolyte, and it helps regulate the amount of water that's in and around the cells) and that this condition was probably chronic and due to SIADH (syndrome of inappropriate antidiuretic hormone secretion). The attending physician indicated that he would start a fluid restriction and if the resident had any changes in her mental status, they would infuse urgently. Further review of Resident #93's medical record found a physician's orders [REDACTED]. (Please note one (1) ml equals one (1) cubic centimeter (cc).) Review of Resident #93's total fluid intake for 02/24/16 through 03/08/16 found the following dates when Resident #93 consumed more than 1000 ml per day: -- 02/26/16 she had a fluid intake of 1,340 cc which was 340 cc over her fluid restriction.-- 02/26/16 she had a fluid intake of 1,340 cc which was 340 cc over her fluid restriction. -- 02/27/16 she had a fluid intake of 1,220 cc which was 220 cc over her fluid restriction. -- 02/28/16 she had a fluid intake of 1,380 cc which was 380 cc over her fluid restriction. -- 03/01/16 she had a fluid intake of 1,240 cc which was 240 cc over her fluid restriction. -- 03/02/16 she had a fluid intake of 1,280 cc which was 280 cc over her fluid restriction. -- 03/03/16 she had a fluid intake of 1,200 cc which was 200 cc over her fluid restriction. -- 03/04/16 she had a fluid intake of 1,400 cc which was 400 cc over her fluid restriction. -- 03/08/16 she had a fluid intake of 1,560 cc which was 560 cc over her fluid restriction. An interview with the License Dietitian at 8:43 a.m. on 03/09/16, confirmed Resident #93 was on a fluid restriction of 1,000 ml per day. He indicated they had a breakdown of what fluids to send to the resident on her meal trays. Upon request, the Licensed Dietitian provided a sheet of paper with Resident #93's name on it which indicated she she would receive daily from the dietary department, Breakfast -- Whole Milk 240 cc -- Coffee 240 cc, Lunch -- Whole Milk 240 cc, and Dinner -- While Milk 240 cc. Fluid Total = 960 cc. The Licensed Dietitian said nursing would provide the remaining 40 cc of fluid daily. An interview with Licensed Practical Nurse (LPN) #22 at 9:49 a.m. on 03/09/16, confirmed she was the nurse assigned to care for Resident #93 on that date. She indicated the resident was on a 1000 cc fluid restriction. When asked how much of that fluid nursing was to provide to the resident, and how much Resident #93 was to receive with each one of her medication passes, LPN #22 went to speak with Health Service Worker (HSW) #51 and HSW #45 about how much fluid Resident #93 received on her breakfast and lunch trays. HSW #51 and #45 agreed that Resident #93 received milk and coffee on her breakfast and lunch trays. They indicated she would usually drink both the milk and coffee for a total of 480 cc for each meal. HSWs #51 and #45 did not know what fluids Resident #93 drank with her dinner meal. When asked if Resident #93 ever asked for any additional fluids to drink, LPN #22, HSW #51, and HSW #45 all agreed the resident only drank what was provided to her with her meals and what was given with her medication administrations. LPN #22 was again asked how much fluid she provided Resident #93 with her medications every morning, to which she replied, She hardly even takes any water to take her medications it is not even enough to count. During an interview with the Director of Nursing (DON) at 2:10 p.m. on 03/09/16. she was asked to review Resident #93's fluid intakes for 02/24/16, 02/27/16, 02/28/16, 03/01/16, 03/02/16, 03/03/16, 03/04/16, and 03/08/16. Upon completion of her review, she confirmed Resident #93 exceeded her fluid restriction on those dates. She stated, It is a problem we need to fix. . b) Resident #34 Record review on 03/09/16 at 8:15 a.m. found this fifty-five (55) year old male resident received outpatient [MEDICAL TREATMENT] services. His admitting [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. Review of the medical record found a physician's orders [REDACTED]. (Nepro supplement is a drink that helps support nutritional needs while on [MEDICAL TREATMENT].) The resident was receiving the supplement at 10:00 a.m., 2:00 p.m., and at bedtime. The orders did not specify the amount of fluid to be provided by the dietary and nursing departments. At 9:19 a.m. on 03/09/16, the facility's form entitled, 24 hour I & O (intake and output) worksheet, for 03/07/16, was reviewed with the facility's nutritionist, Registered Dietitian (RD) #16. Review of the worksheet for 03/07/16 found the health services workers (HSWs) recorded 720 cubic centimeters (cc) of fluid on the day shift, 720 cc of fluid on the afternoon shift and 360 cc of fluid on the night shift - for a total of 1800 cc in a twenty-four (24) hour period. RD #16 said the resident was only allowed 1500 cc of fluid in a twenty-four (24) hour period and he confirmed the resident had exceed his daily allowable amount of fluid for 03/07/16. At 9:27 a.m., on 03/09/16, an interview with HSW #111, found she was unaware of how much fluid Resident #34 could have in a twenty-four (24) hour period. (RD #16 was present during the interview.) HSW #111 said she recorded the fluid on the I & O forms, but she would have to look to see how much fluid the resident could have. After review of the instructions provided to the HSWs, HSW #111 provided a copy of a, confidential ad hoc summary, which included, Additional diet order: 1.5 L/day fluid restriction (not to include Nepro supplement). The instructions were dated 08/07/14. When asked how many cc of fluids were in a liter, HSW #111 said she did not know. RD #16 said a conversion sheet should have been available for the health services workers and confirmed a conversion sheet was not available for Resident #34. RD #16 said he did not know how many cc of fluid was allowed for the resident's medication pass. At 10:01 a.m. on 03/09/16, Licensed Practical Nurse (LPN) #63, the resident's nurse, was asked how much fluid she provided with her medication pass. She stated she really did not know, but probably a few sips, but sometimes the resident drank more. She said if it were a significant amount, she would tell the HSW so the fluid could be recorded. She defined a significant amount as 120 cc or more. At 10:09 a.m. on 03/09/16, Assistant Director of Nursing (ADON) #44 said she was unaware the health service workers did not have a, sheet available that tells them how many cc of fluid the resident can have on each shift. ADON #44 reviewed the resident's fluid intake for 03/04/16, 03/05/16 and 03/06/16. She verified the following information: -- On 03/04/16, the resident consumed 1830 cc of fluid in 24 hours, -- On 03/06/16, day and night shift failed to record the cc of fluid consumed. -- On 03/05/16, day shift did not record the resident's fluid consumption. At 10:25 a.m. on 03/09/16, ADON #44 confirmed the facility was not following the physician's orders [REDACTED]. On 03/09/16, at 9:35 a.m., the director of nursing (DON) confirmed the facility had reviewed the fluid restriction orders with the resident's physician and the physician had discontinued the fluid restrictions for Resident #34.", "filedate": "2019-11-01"}
{"rowid": 5687, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2015-01-14", "deficiency_tag": 248, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "RMOB11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observation, and record review, the facility failed to provide a meaningful activity program for one (1) of three (3) residents reviewed for activities. The Stage 2 sample was 28. Resident identifier: #40. Facility census: 89. Findings include: a) Resident #40 Resident #40 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. His most recent Minimum Data Set (MDS) assessment, dated 11/12/14, documented Resident #40 had short term and long term memory loss and was moderately cognitively impaired for daily decision making. The MDS also documented the resident was at times resistant to care and would wander on the unit. Review of the annual MDS, dated [DATE], found Resident #40 was assessed to enjoy being around animals, liked books, reading, keeping up with the news, and religious activities. The current care plan, dated 11/26/14, documented Resident #40 enjoyed church and coloring books. The care plan also documented the resident was not able to voice his choice regarding activities; therefore, staff were to anticipate his activity needs, inform him of scheduled activities, encourage him to participate, inform him when church services were being conducted, and escort him if needed. Review of the activity calendar for (MONTH) (YEAR), found on 01/12/15 at 3:00 p.m. and on 01/13/15 at 10:30 a.m., individual and small group activities were to take place on the individual resident units. Observations on these dates and times identified there were no activities conducted on C Unit due to the fact the activity staff for the C unit had called in ill. Further review of the (MONTH) activity calendar revealed Church services were offered on 01/04/15, 01/08/15, and 01/11/15. There was no evidence Resident #40 attended Church services on any of those dates. The activity calendar also indicated one-on-one activities were to be conducted on the individual units on 01/05/15, 01/07/15, and 01/12/15. There was no evidence Resident #40 was invited or attended these activities. Observations on 01/12/15 at 9:30 a.m., 1:10 p.m., and 3:30 p.m., revealed Resident #40 was in his wheelchair on the unit, but was not participating in any activities. Observation on 01/13/15 at 2:05 p.m. revealed he was in bed. Observation on 01/14/15 at 9:30 a.m. revealed he was in his wheelchair on the unit. Interview with Health Service Trainee #141, on 01/13/14 at 2:40 p.m., revealed she was not aware of any activities that occurred on the unit that Resident #40 attended. She stated she had never seen Resident #40 leave the unit during her shift from 7:00 a.m. until 3:00 p.m. to attend activities. She also stated she had never seen the activity staff come to the unit and do one-on-one activities with Resident #40. She stated he usually spent the day in his wheelchair or in his bed. She said he was mobile in his chair, but stated she was not aware of any activities he was involved in throughout the day. Interview with Activity Staff #129, on 01/13/15 at 2:05 p.m., revealed she was not the staff member responsible for providing one-on-one activities for the residents on the C unit. She indicated Activity Staff #29 was responsible for that unit, but he was off work ill on this date. She stated he called in ill yesterday and 01/13/15 was his day off. She stated she was aware Resident #40 liked to be read to, drink his coffee, and reminisce. Upon request to see the activity logs for Resident #40, she stated they did not keep good records of what they did for the residents in regards to one-on-one activities. She stated if the resident attended large group activities she would have documentation of that participation. She was not able to provide any documentation of one-on-one or any activities that were provided to Resident #40 on the unit, or off the unit, for (MONTH) 2014 or (MONTH) (YEAR). She stated she used to document on a standard form for individual resident participation when she conducted one-on-one activities with residents, but she did not document on that form anymore. Therefore there was no evidence of one-on-one activities participation for residents. Further interview with Activity Staff #129 on 01/14/15 at 3:22 p.m. revealed if an activity staff member was ill and could not provide the scheduled activities for their designated unit, the other activity staff did not cover that unit. She stated Activity Staff #29 had been off for three (3) days so the residents on the C units who were to receive one-on-one activities would not have received activities for those days. Activity Staff #129 said the only time activity staff would cover each other's units would be if an activity staff member was going to be off for an extended amount of time. This information was shared with the Director of Nursing Staff #6 on 01/14/15 at 9:08 a.m. She verified activity staff should be recording any activities provided to the residents. She also verified if an activity staff member was ill, another activity staff member should be covering that unit to ensure the residents were provided meaningful activities according to their care plans.", "filedate": "2018-09-01"}
{"rowid": 5688, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2015-01-14", "deficiency_tag": 280, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "RMOB11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to review and revise a nutrition care plan for one (1) of fifteen (15) residents whose care plans were reviewed. The Stage 2 sample was 28. Resident identifier: #66. Facility census: 89. Findings include: a) Resident #66 Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/02/14, found Resident #55 required assistance from staff for set up of his meals and he was to be supervised during meals. This MDS also documented the resident's Brief Interview for Mental Status score was 0, indicating cognitive impairment. He was also noted to reject care from the staff daily. Review of the nutrition care plan, dated 10/16/14, revealed Resident #66 required a textured diet, staff were to honor his food preferences, were to monitor food and meal intake, and were to offer alternatives for foods he refused to eat. Review of the nurse aide documentation for meal intake revealed Resident #66 had often been refusing to eat. Review of the food intake log for Resident #66 revealed on 12/04/14, 12/05/14, 12/06/14, 12/07/14, 12/31/14, and 01/12/15 he refused his breakfast and his lunch. In addition, the food intake log also revealed on 12/03/14, 12/04/14 and 12/09/14 he also refused to eat his supper. On these dates of refusal, there was no evidence staff offered him a supplement of any kind. Further review of the dietary food intake log revealed during the months of (MONTH) 2014 and (MONTH) 2014, there were greater than 50 meals where staff documented the resident consumed less than 50% of his meal. Interview with Health Service Worker (HSW) #147, on 01/13/15 at 10:20 a.m., revealed Resident #66 had been refusing to eat meals lately and when he did eat, it was often less than 50%. She stated he would not allow the staff to assist him to eat, but they did cue him to eat when he refused. She stated she was not aware of any ordered supplements that the resident was currently receiving. Review of the weight log for Resident #66 revealed the following: -- On 01/06/2015 weight was recorded as 133 pounds -- On 10/03/2014 weight was recorded as 152 pounds -- On 08/05/2014 weight was recorded as 143 pounds These documented weights indicated Resident #66 had experienced a 19 pound weight loss (or 14.3%) from 10/03/14 to 01/06/15. There was no evidence the nutrition care plan had been reviewed or revised to include new interventions to address Resident #66's weight loss of 19 pounds over the past 4 months. This was verified during an interview with the Dietary Manager Staff #47 on 01/13/14 at 10:55 a.m. He verified he had documented the weight difference for Resident #66 from the 10/03/14 weight of 152 pounds to the 01/06/15 weight of 133 pounds, but stated somehow it was not picked up and acted upon with new interventions to prevent further weight loss for Resident #66.", "filedate": "2018-09-01"}
{"rowid": 5689, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2015-01-14", "deficiency_tag": 282, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "RMOB11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and observations, the facility failed to implement the care plans for two (2) of fifteen (15) residents whose care plans were reviewed. Activities interventions were not implemented for Resident #41 and fall interventions were not implemented for Resident #15. The Stage 2 Sample was 28. Resident identifiers: #40 and #15. Facility census was 89. Findings include: a) Resident #40 Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his most recent Minimum Data Set (MDS) assessment, dated 11/12/14, found it documented Resident #40 had short term and long term memory loss and was moderately cognitively impaired for daily decision making. The MDS also documented the resident was at times resistant to care and at times and would wander on the unit. Review of the annual MDS, dated [DATE], found Resident #40 enjoyed being around animals, liked books, reading, and keeping up with the news and religious activities. Review of the current care plan, dated 11/26/14, found it documented Resident #40 enjoyed church and coloring books. The care plan also documented the resident was not able to voice his choice regarding activities, therefore staff were to anticipate his activity needs, inform him of scheduled activities, encourage him to participate, and to inform him when Church services were conducted and escort him if needed. Review of the activity calendar for (MONTH) (YEAR) revealed on 01/12/15 at 3:00 p.m. and on 01/13/15 at 10:30 a.m., the activity calendar identified individual and small group activities were to take place on the units. According to observations on these dates and times, there were no activities conducted on C unit due to the fact the activity staff for the C unit had called in ill. On 01/13/15 at 10:30 a.m., the activity calendar indicated individual and small group activities were to take place on the units. There were no activities observed being provided at that time. Review of the (MONTH) (YEAR) activity calendar revealed Church services were offered on 01/04/15, 01/08/14, and 01/11/15. There was no evidence Resident #40 attended Church service on any of those dates. The activity calendar also indicated one-on-one activities were to be provided on the unit on 01/05/15, 01/07/15, and 01/12/15. There was no evidence Resident #40 was invited or attended these activities. Observations on 01/12/15 at 9:30 a.m., 1:10 p.m., and 3:30 p.m. revealed Resident #40 was in his wheelchair on the unit, but was not participating in any activities. Observation on 01/13/15 at 2:05 p.m. revealed he was in bed. Observation on 01/14/15 at 9:30 a.m. revealed he was in his wheelchair on the unit An interview with Health Service Trainee #141 on 01/13/14 at 2:40 p.m. revealed she was not aware of any activities that occurred on the unit that Resident #40 attended. She stated she had never seen Resident #40 leave the unit during her shift from 7:00 a.m. until 3:00 p.m. to attend activities. She also stated she had never seen activity staff come to the unit and do one-on-one activities with the resident. She stated he usually spent the day in his wheelchair or in his bed. She said he was mobile in his chair, but stated she was not aware of him being involved in any type of activities. Interview with Activity Staff #129, on 01/13/15 at 2:05 p.m., revealed she was not the staff member responsible for providing one-on-one activities for the residents on the C unit. She indicated Activity Staff #29 was responsible for Unit C activities, but he had been off for the past three (3) days. She stated she was aware Resident #40 liked to be read to, drink coffee, and reminisce, but she was unable to provide activity logs that documented these actives were provided to Resident #40 in accordance with his current activity care plan. She stated she used to document on a standard form for individual resident participation when she conducted one-on-one activities with resident, but she did not document on that form anymore. Therefore, there was no evidence of Resident #40 attending any activities in (MONTH) 2014 or (MONTH) (YEAR) in accordance with his current care plan. This information was shared with the Director of Nursing Staff #6 on 01/14/15 at 9:08 a.m She verified activity staff should be recording any activities provided to the residents. She also verified activities should ensure the residents were provided meaningful activities in accordance with their care plans. . b) Resident #15 Resident #15 was admitted with [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set, dated dated [DATE], indicated the resident had severely impaired cognition. The resident required limited assistance with transferring and walking in his room. He was independent with locomotion on and off the unit. A review of the nursing notes indicated Resident #15 had a fall on 01/03/15. The resident was ambulating without assistance and fell to the floor. A review of Resident #15's physician's orders [REDACTED]. A review of the resident's care plan, dated 06/04/14, and last reviewed by the facility on 12/09/14, found Resident #15 was identified as At risk for fall and injury related to impaired cognition, impaired mobility and [MEDICAL CONDITION] drug use, and [MEDICAL CONDITION]. The interventions included, Hipsters at all times due to high fall risk, unsteadiness on his feet, not asking for assistance and non-compliant with alarms. During an interview and observation on 01/14/15 at 9:30 a.m., Health Service Trainee (HST) #137 was questioned about the resident's fall interventions. She stated the resident was supposed to wear hipsters at all times. She looked in the resident's dresser for the hipsters. The hipster was a tan colored undergarment with padding at the hip area. She indicated the hipsters were worn under his clothing, on top of his incontinence brief. HST #137 checked Resident #15 and found he was not wearing the hipster. She stated the night shift usually got him dressed. She indicated she had not noticed he was not wearing the hipster that morning. During an interview on 01/14/15 at 9:45 a.m., HST #68 was questioned about the resident's fall interventions. She indicated the resident was supposed to wear hipsters every day because he was at risk for falls. She stated he had three (3) or four (4) pairs. She said on the weekends, they ran out of the hipsters because they were sent to the laundry for cleaning. She added the laundry staff did not work on the weekends, and they had to wait until Monday to get the hipsters cleaned. She stated on Sundays, when she dressed the resident, he usually did not have any hipsters. HST #68 stated she had asked laundry for extra pairs, but did not always get the hipsters. HST #68 indicated if she was working on Fridays, then she asked the laundry staff to clean the hipsters to ensure he had enough for the weekend. During an interview on 01/14/15 at 10:05 a.m., Laundry Worker #23 stated sometimes the staff called on Friday and asked for more hipsters. She indicated on Fridays, laundry staff delivered all the residents' clothing on all the units. She stated Resident #15 had two (2) to three (3) pairs of hipsters sent to laundry every day to be washed. She stated they kept an inventory log of the resident's hipsters. She said she was returning all of Resident #15's hipsters from the laundry at that time. A review of Resident #15's Clothing/Inventory List, indicated on 12/31/12, the resident had two (2) pairs of hipsters. On 04/28/14, the resident had three (3) pairs of hipsters. During an observation and interview on 01/14/15 at 10:26 a.m., HST #68 checked the resident's room, and indicated he had four (40 pairs of hipsters. He had three (3) pairs in his dresser, and he was currently wearing a pair of hipsters. During an interview with the Director of Nursing on 01/14/15 at 10:55 a.m., she stated she had not been informed and was not aware that the resident was running out of hipsters over the weekend. The staff had not reported the concern of the lack of availability of hipsters for Resident #15 on the weekends.", "filedate": "2018-09-01"}
{"rowid": 5690, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2015-01-14", "deficiency_tag": 325, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "RMOB11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure one (1) of (4) residents reviewed for nutrition was provided care and services to maintain acceptable parameters of nutritional status. Resident #66 experienced a severe weight loss of 14.3% in three (3) months. Documentation revealed the resident frequently refused meals in the two (2) months prior to the time the resident's recorded weight indicated a severe weight loss. The weight loss was determined actual harm as there was no evidence the weight loss was assessed for causal factors, and no evidence substitutes were offered when the resident refused meals. In addition, there was no evidence the facility attempted to provide any interventions to prevent further weight loss. The Stage 2 Sample was 28. Resident identifier: #66. Facility census: 89 residents. Findings include: a) Resident #66 Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/02/14, found the resident required assistance from staff to set up his meals and he was to be supervised during meals. This MDS also documented the resident's Brief Interview for Mental Status score was 0 indicating cognitive impairment. He was also noted to reject care from the staff daily. Review of the nutrition care plan, dated 10/16/14, revealed Resident #66 required a textured diet, staff were to honor his food preferences, monitor food and meal intake, and were to offer alternatives when he refused to eat. Review of the dietary progress notes revealed there were only two (2) progress notes for the year 2014. The last note, documented on 11/17/14, indicated Resident #66 had gained weight, but the weight gain was not significant and was more desirable than undesirable. There were no dietary progress notes found after Resident #66 was identified, on 01/06/15, as experiencing a 19 pound weight loss from (MONTH) 2014 until (MONTH) (YEAR). Review of the nurse aide documentation for meal intake revealed Resident #66 often refused to eat. Review of the food intake log for Resident #66 revealed on 12/04/14, 12/05/14, 12/06/14, 12/07/14, 12/31/14, and 01/12/15 Resident #66 refused his breakfast and his lunch. On 12/03/14, 12/04/14, and 12/09/14, he also refused to eat his supper. On these dates of refusal, there was no evidence the staff offered him a supplement of any kind. Further review of the dietary food intake log revealed, during the month of (MONTH) 2014 and (MONTH) 2014, there were greater than 50 meals where staff documented the resident consumed less than 50% of his meal. There was no evidence the staff had offered him any substitutes or supplements. Review of the current physician orders [REDACTED]. Review of the weight log for Resident #66 revealed the following: -- On 08/05/14 weight was 143 pounds -- On 10/03/14 weight was 152 pounds -- On 01/06/15 weight was 133 pounds These documented weights indicated Resident #66 had experienced a 19 pound, or 14.3%, weight loss from 10/03/14 to 01/06/15. According to nursing documentation, in (MONTH) 2014 and (MONTH) 2014 there were greater than 50 meals when the resident consumed less than 50%, observation of lunch, on 01/13/15 at 12:05 p.m., revealed Resident #66 fed himself 100% of his meal with no staff cueing. He was served chopped meat and two (2) types of vegetables, milk, juice, and water. Interview with Health Service Worker (HSW) #147, on 01/13/15 at 10:20 a.m., revealed Resident #66 had been refusing to eat meals lately, and when he did eat, it was often less than 50%. She stated he would not allow the staff to assist him to eat, but they did cue him to eat when he refused. She stated she was not aware of any ordered supplements the resident was currently receiving. Interview with Dietary Manager #47, on 01/13/14 at 10:55 a.m., revealed he had documented the weight difference for Resident #66 from the 10/03/14 weight of 152 pounds to the 01/06/15 weight of 133 pounds. He stated somehow this weight loss was not acted upon when he conducted his weekly review of residents with weight loss. He was not able to explain why this identified weight loss for Resident #66 was not addressed and interventions put into place to ensure no further weight loss occurred. He stated it could be that the weight obtained on 01/06/15 was inaccurate and he would have the staff re-weigh the resident. This surveyor observed the resident being re-weighed on 01/13/14 at 11:15 a.m. The weight was 133 pounds. Dietary Manager #47 stated this was the same weight that he had documented on 01/06/15. The dietary manager stated he should have acted on the identified weight loss at that time. He stated he spoke with health service worker staff after the resident was re-weighed. They advised him that the resident had not been eating well lately and had been refusing meals more often. Further interview with Dietary Manager #47 revealed he would be putting new interventions into place, on this date, to include notifying the physician to attempt to get an appetite stimulant and he was also going to obtain an order for [REDACTED]. On 01/13/15 at 1:22 p.m., the director of nursing (DON) described the procedure for how weights were obtained and reported to the dietary staff. The DON said the Health Service Workers obtained the weights and documented them in the computer. The assistant director of nursing (ADON) then compared the weight to the previous weight. If a loss was noted, the ADON would send a consultation request to the dietary manager. She stated the ADON had been off since (MONTH) 2014 on maternity leave. The DON said she had been trying to cover this process, but somehow the identification of weight loss for Resident #66 was missed.", "filedate": "2018-09-01"}
{"rowid": 7236, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2014-07-23", "deficiency_tag": 164, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "R9GB11", "inspection_text": "Based on observation and staff interview, the facility failed to ensure one (1) resident identified through random observation was treated in a manner that maintained the resident's privacy during toileting. Resident #34 was being assisted in the bathroom by a health service worker (HSW). The HSW failed to ensure the bathroom door was closed, leaving the resident exposed below the waist. Resident identifier: #34. Facility census: 94. Findings include: a) Resident #34 During random observations in the C North Area Day Room at 4:08 p.m. on 07/22/14, a resident pointed to the bathroom door. Resident #34 was standing in the bathroom facing the bathroom door which opened into the C North Day Room. The resident was unclothed from the waist down. A licensed practical nurse (LPN) #107 was nearby and was asked to look into the bathroom at 4:09 p.m. on 07/22/14. She immediately went into the bathroom and closed the door. When she returned from the bathroom she was asked whether Resident #34 had gone into the bathroom alone. She stated, No, a health service worker (HSW) was in there with him. She indicated Resident #34 needed assistance toileting. When asked if the HSW should have assisted the resident with his toileting needs with the door open she replied, No, absolutely not.", "filedate": "2017-07-01"}
{"rowid": 7237, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2014-07-23", "deficiency_tag": 282, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "R9GB11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident observation, the facility failed to implement the care plan for one (1) of five (5) residents. Resident #43 had a care plan intervention and physician's orders [REDACTED]. Upon observation, Resident #43 did not have a personal alarm in use. Resident identifier: #43. Facility census: 94. Findings include: a) Resident #43 A review of Resident #43's care plan at 12:15 p.m. on 07/21/14, found an intervention of, Use personal alarm in wheelchair to alert staff of need of assistance. This intervention was added to Resident #43's care plan on 07/10/14. An observation of Resident #43, at 10:06 a.m. on 07/22/14, found the resident sitting in the D West Day Lounge in her wheelchair. Resident #43's personal alarm was not observed in use at that time. At 10:10 a.m. on 07/22/14, Licensed Practical Nurse (LPN) #25, was asked whether Resident #43 should have a personal alarm in use. She replied, Yes, she should. She then observed Resident #43 and stated, I will have to go and get an alarm to put on her because she currently does not have one in place. During an interview at 10:15 a.m. on 07/22/14, the director of nursing confirmed the physician's orders [REDACTED].#43 indicated the resident was to have a personal alarm on at all times when in her wheelchair. After this confirmation, the DON excused herself and stated, I really need to go get an alarm and put it on her.", "filedate": "2017-07-01"}
{"rowid": 7238, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2014-07-23", "deficiency_tag": 323, "scope_severity": "G", "complaint": 1, "standard": 0, "eventid": "R9GB11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the resident environment was as free from accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents. This was true for one (1) of five (5) sampled residents reviewed for accidents Resident #43 was identified at a high risk for falls on admission. The facility failed to implement interventions to reduce the resident's risk of falling and/or reduce risk of injury should a fall occur, until after the resident experienced a fall resulting in a nasal fracture, a closed head injury, and a cervical strain. This failure resulted in actual harm to Resident #43. Resident Identifier: #43. Facility Census: 94. Findings Include: a) Resident #43 Review of the facility's incident and accident reports, at 12:00 p.m. on 07/21/14, revealed on 07/05/14 at 12:55 p.m., while sitting near the nurses' desk, Resident #43 fell forward out of her wheelchair and landed on the floor. The report indicated the resident possibly had become tired and sleepy. The report also noted the resident had a very long torso and had a thick cushion on the seat of her wheelchair. A review of Resident #43's medical record, at 12:15 p.m. on 07/21/14, revealed a Fall Risk Evaluation was completed on 06/25/14, the date of the resident's admission to the facility. According to the assessment's scoring criteria, any score above a 10 represented high risk. The resident's score was 14. Nurse's progress notes, dated 06/25/14, revealed nursing staff were made aware the resident was at high risk for falls. The note was (typed as written): Rsdt has fall score of 14. Review of the minimum data set assessment (MDS), with an assessment reference date (ARD) of 07/03/14, indicated the resident's Brief Interview for Mental Status (BIMS) score was 6, indicating severe cognitive impairment. The assessment indicated the resident did not walk and was only able to stabilize with human assistance in moving from a seated to standing position. She had impairment in functional range of motion of one upper extremity and both lower extremities. The assessment indicated the resident had experienced a fall in the month prior to admission. In addition, the MDS indicated the resident took 1-2 medications which could increase her risk of falls, and had 1- 2 predisposing diseases which also could increase her risk for falls. On 07/05/14 at 1:12 p.m., a nurse's note indicated (typed as written): Resident was sitting in her wheelchair on the unit when she fell forward onto the floor at approximately 1:00 p.m. Hematoma noted on mid forehead and laceration across the bridge of her nose. Resident alert. Eyes open. Moaning quietly. (Name of Registered Nurse) present and assessed resident. Directed to send to ER (emergency room ). ER notified of resident's condition and need for transfer for evaluation. EMS notified. Arrived at 1:20 p.m. Left with resident at 1:28 p.m. en route to (name of local hospital) ER. Review of the resident's ER records revealed Resident #43 was treated for [REDACTED]. She was not admitted to the hospital and returned to the facility later in the day on 07/05/14. According to the nursing home medical record, the resident's cushion was removed from her chair immediately after the fall because it was identified as a contributing factor. Additionally, the facility ordered a personal alarm for the resident to use while in her wheelchair. These interventions were put into place only after the resident sustained [REDACTED]. In an interview with the Director of Nursing (DON) at 10:15 a.m. on 07/22/14, she confirmed the fall assessment completed on the date of admission indicated Resident #43 was at high risk for falls. When asked what interventions or further assessments the facility did when the resident was identified as a high risk for falls, the DON stated, She was a two person assist for transfers and that is all I see. The DON stated they felt Resident #43's cushion in her wheelchair was the cause of her fall. She stated the resident brought the cushion from home and was admitted with it. The DON was asked who evaluated the residents for proper positioning in their wheelchairs. She said occupational therapy (OT) usually did that. She said a consult request was made to OT upon the resident's admission on 06/25/14, and again on 07/01/14. The DON acknowledged the OT evaluation did not occur until 07/11/14, six (6) days after the resident's fall with injury. When asked why it took OT so long to evaluate the resident, she replied, They don't actually work here and only come in about once every two (2) weeks. When the OT screened the resident, on 07/11/14, she noted the resident leaned forward in her wheelchair with two (2) degrees of kyphosis (curving of the spine). This would have been information the facility should have known, prior to the fall, particularly with the resident's long torso and use of a cushion in the wheelchair. The OT also noted the use of a personal alarm would be beneficial due to the fact the resident leaned forward in her wheelchair. This intervention for a personal alarm was put into place only after the resident sustained [REDACTED]. Prior to 07/05/14, the facility had already identified the resident at high risk for falls; however, no interventions were developed in an effort to prevent falls. During the interview at 10:15 a.m. on 07/22/14, the DON was asked why no interventions were put into place for Resident #43 when she was assessed upon admission at high risk for falls. The DON replied, Not everyone who is at high risk for falls needs interventions. The DON agreed the facility should have put fall interventions into place prior to the 07/05/14 incident. She agreed the facility's knowledge of a fall assessment at the time of admission and the resident's prior history of falls made it necessary for the facility to put interventions in place to try to prevent future falls and injuries associated with falls. She confirmed the facility had not put those interventions in place prior to the fall on 07/05/14.", "filedate": "2017-07-01"}
{"rowid": 7328, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2013-10-22", "deficiency_tag": 157, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TQVD11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, and policy review, the facility failed to notify the physician when one (1) of two (2) residents reviewed for accidents during Stage 2 of the Quality Indicator Survey had an accident which resulted in injury and required medical intervention. The physician was not notified when the resident burned herself with a cigarette. Resident identifier: #38. Facility census: 87. Findings include: a) Resident #38 Medical record review, on 10/17/13 at 8:00 a.m., found a nursing note dated 09/23/13 at 1:20 p.m. which indicated when Resident #38 returned to the facility after a smoke break she had an orangish/black burn mark on her right middle finger. Further review of the medical record found no evidence the physician was notified of the injury. The resident confirmed, during an interview on 10/21/13 at 12:39 p.m., she had burned her finger while she was outside smoking. She said, The nurse treated it with burn cream. Employee #179, a licensed practical nurse (LPN) was interviewed on 10/21/13 at 12:50 p.m. She said she was not aware of a burn, but had noted brown nicotine stains on the resident's fingers. Another LPN, Employee #27, was interviewed on 10/22/13 at 12:50 p.m. She said she was aware of the burn / injury. Employee #27 stated the resident's burn was treated with triple antibiotic ointment. She related the protocol was to complete an incident report and to notify the physician. The LPN reviewed the medical record, including physician's orders [REDACTED]. She confirmed there was no evidence to indicate the physician was notified. The policy book, dated 2005, was reviewed with the director of nursing (DON) at 3:00 p.m. on 10/17/13. The DON confirmed a report was to be generated for each and every event/accident, and routed to the medical director for review/signature/date and /or investigation. The DON was unable to find the report which should have been generated after the resident's burn. The DON further reviewed physician's orders [REDACTED]. She acknowledged she was unable to find any evidence the physician was notified the resident burned herself with a cigarette and facility staff had treated the burn with triple antibiotic ointment. .", "filedate": "2017-06-01"}
{"rowid": 7329, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2013-10-22", "deficiency_tag": 241, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "TQVD11", "inspection_text": "Based on observation and staff interview, the facility failed to maintain a dignified dining experience for residents. Meal service in several dining rooms was observed during the survey with the following concerns noted: one dining area smelled of cigarette smoke; there was no opportunity for hand cleansing prior to the meal; Resident #84 was seated at a table with three (3) other residents, but did not receive her meal until 30 minutes after her table mates; residents were seated in the dining room for an extended period of time before arrival of their meals with no pre-meal activities offered; Resident #91 stood up and said she needed to go to the bathroom, but did not receive prompt assistance to go to the bathroom; Resident #56 attempted to leave the dining room, but a staff member pulled the resident backwards, returned the resident to the table, all without speaking to the resident. This practice had the potential to affect all residents who received meals in the dining rooms. Resident identifiers: #84, #56, #91, and #78. Facility census: 87. Findings include: a) Dining room C-West Observation of the C-West dining room began at 4:35 p.m. on 10/15/13. The following were noted: -- The dining room smelled of cigarette smoke. Not all residents who ate in the dining room smoked, nor could they express whether they objected to the smoke smell. -- Residents waited for approximately 45 minutes before the first tray was served at 5:26 p.m. During this wait, there were no pre-meal activities. During the evening meal on 10/15/13, Employee #180, a health services worker was asked if there were any pre-meal activities. Employee #180 replied, It would be nice, but only fine dining gets that. -- There was no opportunity provided for residents to cleanse their hands. Some residents were brought in by staff, some walked in, and others wheeled themselves in to the rooms. Many of the residents had been in the halls for an extended period of time prior to going to the dining room and did not have access to a sink to wash their hands prior to going to meals. Some of the residents who wheeled themselves into the dining room, had used their hands to propel their wheelchairs and needed to be afforded the opportunity to clean their hands before eating. It was observed that staff cleaned their own hands with hand sanitizer, but did not provide residents with an opportunity to clean their hands before the dinner meal was served. A second meal observation was made during the noon meal on 10/17/13. Residents were seated in the dining room and waited approximately 40 minutes before the arrival of the trays at 12:02 p.m Again there were no pre-meal activities, no hand sanitation for residents, no beverages were offered (pre-meal) and the odor of cigarette smoke was strong. b) Dining room B-D Observation of the evening meal on 10/15/13 at 5:14 p.m. in the, B-D dining room found residents were not offered hand wipes or any means by which to wash their hands prior to the meal. This procedure did not enhance the residents' dignity during meals by allowing them to eat with unclean hands. This observation was discussed with the director of nursing, Employee #6, on the morning of 10/22/13 at which time she was in agreement that residents should be afforded the opportunity to wash their hands prior to meals. c) Dining room AC An observation was conducted in the AC dining room on 10/15/13 at 5:30 p.m. Resident's #1, #19, #84, and #88 were all seated at the same table. All four (4) of these residents required total assistance with eating. Resident's #1, #19, and #88 were served their trays at 5:30 p.m. and were being fed by Employees #40, #77, and #81 (all Health Service Workers). Resident #84 did not receive her tray until 6:00 p.m., after the other residents at her table had finished their meal. An interview with Employee #70, a licensed practical nurse, on 10/15/13 at 6:00 p.m., revealed all residents seated at the same table in the dining room should be served and fed at the same time. This employee stated she did not realize Resident #84 had not been served or she would have served and fed her. An interview was conducted with Employee #81, a health services worker, on 10/15/13 at 6:15 p.m. This employee stated All residents are normally served and fed at the same time however today was a little chaotic. d) Resident #91 During an observation on 10/15/13 at 5:50 p.m. in the A dining room, Resident #91 stood up from the table and an alarm started to sound as she started to walk away. The health service worker (Employee #81) was observed to be sitting close by, feeding another resident. She got up and approached this resident and instructed her to sit back down. The resident stated I have to go to the bathroom. Employee #91 replied to the resident that she needed to sit down until someone could help her. The resident then stated I think I am going to have a bowel movement. The health service worker again told the resident that she needed to sit back down until someone could help her. She assisted the resident back to her chair and when she sat her down the alarm stopped sounding. Employee #81 then went back to feeding the other resident and did not ask anyone to assist this resident to the bathroom. Resident #91 was observed in the dining area another ten (10) minutes, until 6:00 p.m., sitting in her chair staring straight ahead. The licensed nurse (Employee # 70) was assisting residents in the dining room and was made aware of this observation. She immediately approached the resident and ask her if she needed to go to the restroom. The resident stated No I do not need to go now. The nurse told the resident she would assist her and the resident again said no. The nurse agreed that the health service worker should not have told this resident to sit back down and not had someone take her to the restroom when she requested. The Director of Nursing (Employee #6) was made aware of this observation on 10/17/13 at 3:00 p.m. She agreed that the health service worker did not respond to this resident's request appropriately. e) Resident #56 During an observation of the middle A wing dining room on 10/15/13 at 6:00 p.m., Resident #56 was observed sitting in a geri-chair. She had completed her meal and was attempting to leave the dining room. She was observed moving her geri-chair with her feet and was partially out the door. At that time, the health service worker (Employee #81) was observed to stop feeding the resident she was assisting in the dining room. She grabbed Resident #56's chair from the back without saying a word to the resident to inform her she was going to move her. She then pulled the resident's chair backwards without speaking to the resident and put her back at the table where she had been sitting. The health service worker did not speak to the resident or tell her what she was doing. The health service worker then resumed feeding the other resident without ever speaking to Resident #56. It was determined that pulling the resident's chair backwards without speaking to her, or telling her what she was doing, and placing her back in the dining room at the table, was not treating the resident with respect and dignity. The Director of Nursing (Employee #6) was made aware of the dining room observations on 10/17/13 at 3:00 p.m. She agreed that not speaking to the resident and telling her what you are going to do prior to pulling her backwards was not treating the resident in a dignified manner. f) Resident #78 During a lunch meal, on 10/16/13, at 11:30 a.m., a health service worker (HSW) was assisting Resident #78 with his meal. Observation from 11:30 a.m. until 11:55 a.m. revealed no evidence of communication between the resident and the staff member. After Resident #78 completed his meal, the HSW assisted another resident, and did not converse with him either.", "filedate": "2017-06-01"}
{"rowid": 7330, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2013-10-22", "deficiency_tag": 253, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "TQVD11", "inspection_text": "Based on observation and staff interview, it was determined the facility failed to ensure effective maintenance services. The AC dining room was not in good repair. The ceiling tiles and blinds were covered with a yellow stain and the entrance door was scratched and rusted. This was found for one (1) of six (6) dining rooms observed; however, the practice had the potential to affect more than an isolated number of residents. Facility census: 87. Findings Include: a) Observation of the AC dining room on 10/15/13 at 4:40 p.m. found the ceiling tiles and window blinds were covered with a yellow stain. The entrance door to the AC dining room was rusted and the paint was missing in several areas. An interview with Employee #6, the director of nursing (DON) on 10/22/13 at 11:45 a.m. revealed the AC dining room was used for residents who smoke. The DON stated the appearance of AC dining room was unacceptable and would be redone as soon as money was available. An interview with Employee #82 (Building and Grounds Manager) was conducted on 10/22/13 at 12:00 p.m. Employee #82 stated, he had let the AC dining room slip through the cracks due to money issues.", "filedate": "2017-06-01"}
{"rowid": 7331, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2013-10-22", "deficiency_tag": 272, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TQVD11", "inspection_text": "Based on resident interview, family interview, staff interview, medical record review, and observation, the facility failed to ensure Resident #38's comprehensive assessment accurately reflected the resident's current dental status. The care area assessment (CAA) for Resident #24 did not address the issue of the resident's loose dentures. Two (2) of twenty-two (22) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS) were affected. Resident identifiers: #38 and #24. Facility census: 87. Findings include: a) Resident #38 During an interview with Resident #38 in Stage 1 of the QIS, at 5:07 p.m. on 10/15/13, the resident said her lower front denture was broken. She said it had been broken since she was admitted . Observation of the resident's mouth revealed a missing tooth from the lower front denture. Review of the minimum data set (MDS), with an assessment reference date (ARD) of 08/21/13, noted a dash in the area of the resident's oral/dental status of broken or loosely fitting full or partial dentures (chipped, cracked,. ) During an interview with Employee #110 (nurse assessment coordinator), on 10/01/13 at 1:40 p.m., she related the dash indicated the resident had no broken dentures. She related she was unaware the resident's dentures were still broken, and acknowledged the MDS was incorrect. b) Resident #24 Review of the resident's significant change MDS, with an ARD of 09/04/13, found Section (L) was coded to indicate the resident had broken or loosely fitting full or partial dentures and no natural teeth or tooth fragments. The 09/23/13 CAA, triggered by the information in Section (L) of the MDS for Dental Care, found the following documentation: This residents dental condition triggered due to not having any teeth mouth care is bid (twice a day) and prn (as needed) by staff. Report painful areas in mouth, decreased appetite, refusal of meals. Risk factors include cognitive impairment for oral hygiene, not being able to do her own mouth care, staff anticipate all her wants and needs. Proceed with plan of care. During a family interview, conducted on 10/16/13 at 3:00 p.m., it was identified this resident received new dentures a while back, but the family member was not sure when this occurred. The family member stated when she visited Resident #24, the resident's dentures were never in her mouth. The family member said she was not sure why the resident did not wear them. On 10/21/13 at 3:00 p.m., staff placed the resident's dentures in her mouth at the request of the surveyor. The dentures were too big and did not stay in the resident's mouth. The resident was unable to talk with the dentures in her mouth. The CAA note did not indicate the need for further assessment of the ill filling dentures. Although the MDS identified the dentures were broken and loosely fitting, there was no further assessment to identify if other interventions were needed.", "filedate": "2017-06-01"}
{"rowid": 7332, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2013-10-22", "deficiency_tag": 278, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TQVD11", "inspection_text": "Based on resident interview, family interview, staff interview, medical record review, and observation, the individual completing Section L (Oral/Dental Status) of the Minimum Data Set (MDS) assessment for Resident #38 failed to ensure the assessment accurately reflected the resident's dental status. This was found for one (1) of twenty-two (22) residents reviewed during Stage 2 of the Quality Indicator Survey. Resident identifiers: Facility census: 87. Findings include: a) Resident #38 During an interview with Resident #38 in Stage I of the Quality Indicator Survey, at 5:07 p.m. on 10/15/13, the resident said her lower front denture was broken. She said it had been broken since the time of admission. Observation of the resident's mouth revealed the lower front denture was a missing tooth. Review of the minimum data set (MDS), with an assessment reference date (ARD) of 08/21/13, noted a dash in the area of the area of the resident's oral/dental status of broken or loosely fitting full or partial dentures (chipped, cracked, .) During an interview with Employee #110 (nurse assessment coordinator), on 10/1/13 at 1:40 p.m., she related the dash indicated the resident had no broken dentures. She said she was unaware the resident's dentures were still broken, and acknowledged the MDS was incorrect, however, the MDS had been signed as being accurate.", "filedate": "2017-06-01"}
{"rowid": 7333, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2013-10-22", "deficiency_tag": 279, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TQVD11", "inspection_text": "Based on medical record review, staff interview, resident interview, family interview, and observation, the facility failed to develop a care plan for two (2) of twenty-two (22) residents reviewed during Stage 2 of the Quality Indicator Survey. A care plan was not developed to ensure the safety of a resident (Resident #38) who smoked and had a prior history of unsafe smoking practices. Resident #24 was identified with dental needs, but this issue was not addressed in the resident's care plan. Resident identifiers: #38 and #24. Facility census: 87. Findings include: a) Resident #38 Medical record review on 10/17/13 at 8:00 a.m. found a nursing note, dated 09/23/13 at 1:20 p.m. The note indicated Resident #38 returned to the facility, after a smoke break, with an orangish/black burn mark on her right middle finger. According to the note, the resident informed the nurse she had burned herself with a cigarette. The resident confirmed during an interview, on 10/21/13 at 1:20 p.m., she had burned her finger while smoking. Further review of the medical record revealed a hospital transfer summary, dated 05/13/13. The transfer summary noted the resident was a danger to herself and others because she had burned herself several times and had minor accidents at home with the lighted end of the cigarette. On 10/22/13 at 10:45 a.m., the director of nursing (DON) confirmed she was unable to provide evidence a care plan was developed to address how the facility would ensure safe smoking practices for the resident. b) Resident #24 The current care plan, dated 09/04/13, was reviewed for this resident. This care plan identified that Resident #24 received an altered texture diet related to edentulous. The goal was, She will eat the amount of food she is able to eat at each meal daily over the next three (3) months. An intervention for this goal said, Edentulous/ dental PRN (as needed ) for c/o (complaints) of pain or symptoms. During a family interview, conducted on 10/16/13 at 3:00 p.m., it was identified this resident received new dentures a while back, but the family member was not sure when this occurred. The family member stated when she visited Resident #24, her dentures were never in her mouth. The family member stated she was not sure why the resident did not wear them. During an interview with the unit licensed practical nurse, Employee #2, on 10/21/13 at 3:00 p.m., she verified the resident had not worn her dentures in a long time. Employee #2 was asked if she could place the dentures in the resident's mouth providing the resident did not refuse. Employee #2 was observed to place the dentures in the resident's mouth and the dentures were noticeably loose. The resident was unable to talk due to the dentures slipping out of her mouth. The resident then allowed the nurse to apply adhesive to the dentures. After applying the adhesive, the dentures continued to slip out of the resident's mouth. Employee #2 stated she would make an appointment for a dental consult for the resident. There was no care plan identifying the resident's dentures did not fit and she needed a dental consult.", "filedate": "2017-06-01"}
{"rowid": 7334, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2013-10-22", "deficiency_tag": 318, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TQVD11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure a resident, identified as having contractures, received the services specified in his care plan to prevent further decrease in range of motion. This was true for one (1) of two (2) residents who triggered the care area of range of motion in Stage 2 of the Quality Indicator Survey. Resident identifier: #4. Facility census: 87. Findings include: a) Resident #4 The resident was identified during Stage 1 of the Quality Indicator Survey (QIS), at 2:34 p.m. on 10/16/13, as having a contracture of the left hand with no splinting devices. Further review of the care plan, on 10/21/13 at 12:52 p.m., noted a [DIAGNOSES REDACTED]. The goal was to maintain the resident's current range of motion (ROM) with no further contractures. Active/passive ROM was to be provided by nursing staff while providing activities of daily living (ADL) care. Occupational therapy (OT) and physical therapy (PT) referrals were to be made as changes occurred. Resident #4 was to attend special needs classes for grasp and release exercises as recommended. Review of the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 09/05/13, found the resident was coded as having contractures of the left hand, wrist and elbow. No special treatments were noted for therapy or restorative care. An interview with Employee #60, the program manager (PM), on 10/21/13 at 2:11 p.m., revealed the resident was to attend restorative therapy five (5) days a week. Employee #60 stated staff try to bring him to the special needs unit, but if not, staff will work with him on the unit. She added the resident will swat them away if he does not want to attend. According to this employee, Employee #64, a health service assistant, usually worked with this resident. Employee #60 provided a log indicating the special needs unit worked on grasp and release. The log indicated he used only his right hand. Notes for October 2013 were reviewed. The notes indicated the resident participated on 10/01/13, 10/03/13, 10/04/13, 10/07/13, 10/08/13, 10/09/13, 10/10/13, 10/15/13, 10/16/13, 10/17/13, and 10/21/13. He was noted as sleeping on 10/11/13 and 10/18/13. The staff member was not working on 10/14/13. Activities included: placing blocks in an open can, tossing a ball, stacking cones, put rings on a stacking base, using a round jumbo peg board, and placing blocks in an open canister. It was noted he completed tasks with his right hand. A dash was noted for his left hand. An interview with a health service worker (HSW), Employee #155, on 10/21/13 at 2:33 p.m., revealed nursing staff did not provide interventions related to Resident #4's left hand contracture. She said that restorative worked with him. The HSW said she only worked with the resident occasionally, but was not aware of any intervention by nursing staff. Another interview, with a health service worker (Employee #129), on 10/21/13 at 2:37 p.m., revealed she was unaware of any interventions related to the left hand contracture. She too, said restorative worked with the resident. Employee #27, a licensed practical nurse (LPN) was interviewed on 10/22/13 at 8:35 a.m. She said Resident #4 did not use his left hand. She said restorative therapy was responsible for range of motion services. The health service assistant, Employee #64, was interviewed on 10/21/13. When asked about range of motion services, she said range of motion was only completed with the right had. She said the resident had ticks, and some days he would grab the thumb of his left hand and just shake it. The care plan was reviewed with the director of nurses on 10/22/13. She acknowledged the care plan was not being implemented as indicated for range of motion services for the left hand. She agreed the interventions were being used to provide range of motion to the right hand only. She indicated the resident was noncompliant with care, but she was unable to provide evidence range of motion had been attempted with the resident's left hand.", "filedate": "2017-06-01"}
{"rowid": 7335, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2013-10-22", "deficiency_tag": 323, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TQVD11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, policy review, and medical record review, the facility failed to identify and evaluate risks for one (1) of (2) residents reviewed for the care area of accidents. The facility was aware the resident had a prior history of unsafe smoking habits and failed to follow their policy to complete a smoking assessment to identify and prevent future incidents / accidents. Resident identifier: #38. Facility census: 87. Findings include: a) Resident #38 Medical record review, on 10/17/13 at 8:00 a.m., found a nursing note dated 09/23/13 at 1:20 p.m. which indicated when Resident #38 returned to the facility, she had an orangish/black burn mark on her right middle finger. According to the note, the resident informed the nurse she had burned herself with a cigarette. Further review of the medical record revealed a hospital transfer note, dated 05/13/13, which noted the resident was a danger to herself and others because she had burned herself several times and had minor accidents at home with the lighted end of a cigarette. The resident confirmed, during an interview on 10/21/13 at 12:39 p.m., she had burned her finger while outside the facility, and was treated for [REDACTED]. She said, The nurse treated it with burn cream. Employee #179, a licensed practical nurse (LPN) was interviewed on 10/21/13 at 12:50 p.m. She related registered nurses (RN) completed smoking evaluations. She said she was not aware of a burn, but had noted brown nicotine stains on the resident's fingers. Further review of the medical record found no evidence a smoking assessment had been completed. Review of the facility's safe smoking policy assessment policy revealed an assessment was to completed within seven (7) days of admission and annually. The assessment was to be reviewed on the next conference date. During an interview with the director of nursing (DON), on 10/17/13 at 3:00 p.m., she said she would look for a smoking safety assessment. On 10/22/13 at 10:45 a.m., the DON confirmed she was unable to provide evidence a smoking evaluation had been completed between admission and 10/17/13. She said one should have been completed on admission, but had not been completed until 10/18/13, after the inquiry was made.", "filedate": "2017-06-01"}
{"rowid": 7336, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2013-10-22", "deficiency_tag": 333, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TQVD11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and observation, the facility failed to ensure residents were free from significant medication errors. A resident who had been recently readmitted was given twice the ordered dose of [MEDICATION NAME]. One (1) of four (4) residents observed during the observation of medication administration was affected. There were twenty-five (25) opportunities for error. Resident identifier: #43. Facility census: 87. Findings include: a) Resident #43 During medication administration pass observation with Employee #27, a Licensed Practiced Nurse (LPN), she was observed giving medications to Resident #43. During the process, she stated she was giving the resident [MEDICATION NAME] 200 mg (milligrams) po (by mouth). She then removed [MEDICATION NAME] 200 mg from the medication cart. Upon reconciliation of the observed medication pass with the physicians' orders following the medication administration pass, it was found the order was actually for [MEDICATION NAME] 100 mg po. The Medication Administration Record [REDACTED]. On 10/23/13 at 10:30 a.m., this was discussed with the Director of Nursing who agreed it was a significant medication error. She immediately had a [MEDICATION NAME] level ordered for the resident. The medication cart was checked at 10:45 a.m. on 10/23/13. It contained both 100 mg and 200 mg packages of [MEDICATION NAME] for this resident. The nurse removed the 200 mg dose at that time to prevent future error.", "filedate": "2017-06-01"}
{"rowid": 7337, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2013-10-22", "deficiency_tag": 371, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "TQVD11", "inspection_text": "Based on staff interview and observations, it was determined the dietary staff did not maintain foods under sanitary conditions. The equipment needed to dispose of used paper towels was not available and there was no internal thermometer in the ice cream freezer to ensure the items were being kept at the proper temperature. This had the potential to affect all residents who consumed foods by oral meals as all foods were prepared and served from this central location. Census: 87. Findings include: a) During the initial tour of the dietary department on 10/15/13 at 1:30 p.m., with Employee #55, nutritionist, the following issues were observed: 1. The hand sink in the kitchen area near the food preparation area did not have a trash can with a step-on device to raise the lid. This was needed prevent the potential for contamination of the employees' hands should they use their clean hands to lift the lid off of a regular type trash receptacle. 2. A chest type freezer, in which ice cream cartons were kept, had no internal thermometer which would enable staff to determine if items were being maintained at the appropriate temperature. This was confirmed with Employee #55 who was present during the tour.", "filedate": "2017-06-01"}
{"rowid": 7338, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2013-10-22", "deficiency_tag": 412, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TQVD11", "inspection_text": "Based on observation, staff interview, and record review, the facility failed to obtain dental services for a resident when her dentures did not fit properly. Resident #24's dentures were too large and this had not been addressed by the facility to ensure the resident's dental needs were met. This was true for one (1) of three (3) residents who were reviewed in Stage 2 for the dental care area. Resident identifier: #24 . Facility Census: 87. Findings include: a) Resident #24 During an observation on 10/21/21 at 3:00 p.m., Resident #24 was observed without her dentures. When Employee #2, a nurse, was questioned, the nurse obtained the dentures and placed them in the resident's mouth. The dentures were too big and were moving up and down in the resident's mouth. The resident was unable to make herself understood when speaking due to the loose dentures. The nurse removed the dentures and applied dental adhesive to the dentures, which did not help. The dentures continued to move up and down and eventually fell out of the resident's mouth. Employee #2 stated the resident had a past consult and the dentures had been repaired. This employee reviewed the medical record and verified the dentures were repaired on 09/28/10 (more than three (3) years prior to this date). The nurse verified there was no evidence the resident had any dental consults after 09/28/10. After identification of this issue during the survey, a dental consult was made on 10/21/13 for the resident's loose fitting dentures.", "filedate": "2017-06-01"}
{"rowid": 7339, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2013-10-22", "deficiency_tag": 441, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "TQVD11", "inspection_text": "Based on observation and staff interview, the facility failed to reduce the potential for the spread of infection and cross contamination. Residents were not provided an opportunity to wash their hands prior to eating their meals. This was identified for all dining areas and had the potential to affect all residents requiring assistance with hand washing. Facility Census: #87. Findings include: a) Hand washing During an observation of the facility dining rooms on 10/15/13, beginning at 4:15 p.m., the residents were observed to arrive in the dining areas for dinner. Some residents were brought in by staff, some walked in, and others wheeled themselves in to the rooms. Many of the residents had been in the halls for an extended period of time prior to going to the dining room and did not have access to a sink to wash their hands prior to going to meals. Some of the residents who wheeled themselves into the dining room, had used their hands to propel their wheelchairs and needed to be afforded the opportunity to clean their hands before eating. It was observed that staff cleaned their own hands with hand sanitizer, but did not provide residents with an opportunity to clean their hands before the dinner meal was served. A second meal observation was of the noon meal on 10/17/13. Again it was noted residents were not provided an opportunity to clean their hands prior to the meal service. During an interview with a licensed nurse (Employee #1), on 10/22/13 at 11:35 a.m., she confirmed staff should have used hand sanitizer to clean the resident's hands prior to meals. She stated since this had been brought to the facility's attention, they will make sure this is done.", "filedate": "2017-06-01"}
{"rowid": 8737, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2012-08-17", "deficiency_tag": 166, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4EJV11", "inspection_text": "Based on resident interview, staff interview, review of facility policy and procedure investigations of complaints/allegations, and medical record review, the facility failed to safeguard the resident's personal property by failing to investigate and seek a resolution when it was discovered the resident's dentures were missing. This was true for one (1) of two (2) residents reviewed for the care area of personal property in Stage II of the quality indicator survey. Resident identifier: #54. Facility census: 95. Findings include: a) Resident #54 During an interview with the resident, on 08/13/12, the resident reported her upper and lower dentures were missing. The resident was unsure how long the dentures had been missing. The resident further stated she needed her dentures and she had told, the girls, her dentures were missing. Review of the medical record found a dental consult had been scheduled for the resident on 07/20/12. An interview with the director of nursing (DON), at 12:20 p.m. on 08/15/12, revealed the resident had not been sent for the dental consult on 07/20/12 as scheduled because the resident's dentures were missing. The director of nursing stated the 07/20/12 appointment was initially scheduled because the resident's dentures were not fitting properly. On 08/16/12 at 3:30 p.m., the DON verified the facility had not initiated a search for the dentures and had not attempted to provide a resolution when it was determined the resident's dentures were missing. She verified a suggestion and complaint form should have been completed when it was discovered the dentures were missing. Review of the facility's policy entitled, Complaint/Allegation Investigation, found: .B. Complaints, Allegations of Abuse, Neglect or other Violations of Resident Rights: Allegations made under this policy may be filed in relation to any aspect of a resident's treatment, housing, services, accommodations, etc. F. Investigation: 1. The Resident Advocate will immediately begin to gather facts, conduct interviews, and review medical records as necessary to determine the circumstances surrounding the allegation (s)", "filedate": "2016-04-01"}
{"rowid": 8738, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2012-08-17", "deficiency_tag": 225, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4EJV11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's Suggestion and Complaint Forms, Abuse / Neglect Reporting Requirements for West Virginia Nursing Homes and Nursing Facilities (Revised October 2011), and staff interview, the facility failed to report an allegation of physical abuse to the proper state agencies as required. This was true for one (1) of thirty (30) suggestion and complaint forms reviewed. Resident identifier: #67. Facility census: 95. Findings include: a) Resident #67 Review of the facility's, Suggestion & Complaint Form, found a complaint, dated 01/03/12, in regards to Resident #67. The form included Attempting to give (name of resident) a [MEDICATION NAME] injection. Held him down to give [MEDICATION NAME] shot. He got a skin tear on elbow and knuckle-right arm. Upper left arm was squeezed. Watchband broken. The allegation was signed by the resident. Further review of the complaint form found the facility's response to the corrective action taken was documented as: None, resident said not their fault it was my fault. I resisted them. Will order you a new watch band. The director of nursing was interviewed, at 5:00 p.m. on 08/14/12, and was unable to provide any evidence the allegation of abuse was reported to the appropriate State agencies as required by law. According to the Reporting Guidelines for West Virginia Nursing Homes and Nursing Facilities, abuse is defined as, The infliction or threat to inflict physical pain or injury on or the imprisonment of any incapacitated adult or facility resident. The guidelines further require reporting of allegations of abuse to Adult Protective Services, the Ombudsman, and Office of Health Facility Licensure and Certification (OHFLAC).", "filedate": "2016-04-01"}
{"rowid": 8739, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2012-08-17", "deficiency_tag": 241, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "4EJV11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interviews/comments, medical record review, and staff interview/comments, the facility failed to maintain dignity for residents during the service of the evening meal on 08/13/12. This affected ten (10) of ninety-five (95) residents whose meal service was observed. Resident identifiers: #85, #96, #21, #90, #54, #59, #101, #5, #64, and #48. The facility also failed to ensure residents were treated with dignity and respect when interacting/conversing with residents. This was true for two (2) randomly observed residents. Resident identifiers: #88 and #23. Facility census: 95. Findings include: a) Observations of B/D dining room The B/D dining room evening meal service was observed from 5:10 p.m. through 6:10 p.m. on 08/13/12. The facility staff failed to serve all residents who were seated together at a table at the same time. 1) Resident #21 was seated at the first table with Resident #90. Resident #21 received a tray, then staff proceeded to serve Resident #75 seated at a second table with Resident #96. Residents #35, #59, and #101 were seated at a third table. Only Resident #35 received a tray. Staff then served Resident #85 who was seated at a fourth table. 2) Resident #54 This resident received a tray at 5:15 p.m. on 08/13/12. The resident looked at the food items on her tray and stated, I don't want this, I want pizza, I ordered pizza. (Pizza was the substitute for the evening meal). Employee #140 responded, It's not on your diet, and failed to offer choices of any other food items. The resident continued to state over and over, I don't want this, get this out of here, I want pizza. At 5:30 p.m., another staff member told the resident she would have someone from the kitchen come and talk with her. At 5:35 p.m., the dietary manager told the resident she could have a grilled cheese sandwich and soup, which the resident agreed to eat. Several minutes after the dietary manager left the dining room, the Resident began yelling, Where is my food? At 6:05 p.m. on 08/13/12, a licensed practical nurse, Employee #27, entered the dining room and stated, I don't know where her soup and sandwich are,but I'm going to the kitchen to get it myself. At 6:10 p.m., the resident received her soup and a sandwich. By this time, all the other residents in the dining room had finished eating their meal and were exiting the dining room. 3) Resident #21 This resident received a tray, at 5:10 p.m. on 08/13/12, from Employee #53, a health services worker. The resident was seated in a reclining geri-chair horizontally placed at the table. Employee #53 did not speak to the resident or set up his tray. The lids remained on the beverages and the dome cover remained on his plate. The resident was unable to reach any of the food items on his tray. At 5:30 p.m. the surveyor asked Employee #53 if she was going to set up the Resident's tray. She replied, He's a feed. At 6:00 p.m., Employee #53 asked the resident if he wanted to eat and he replied, No. She then removed the tray without attempting to encourage the resident to eat or even telling the resident what food items were on his tray. 4) Resident #85 Resident #85 was observed trying to leave the dining room at 5:45 p.m. Employee #53 told the Resident, You can't leave here, we are all in here, there's nobody out there. Employee #53 then pushed the resident's wheelchair back to his table. b) These issues that were observed in the dining room were discussed with Employee #27 at 6:10 p.m. on 08/13/12. The director of nursing was also advised of the observations made in the B/D dining room at 6:20 p.m. on 08/13/12. c) A/C Inner Dining Observation During an observation of the dinner meal, on 08/13/12 at 5:30 p.m., it was determined this meal was not a pleasant and dignified dining experience. 1) Residents #5, #64, and #48 were observed to be sitting at the same table in the A/C inner dining area. There was a white substance spilled on the table (milky appearance) and was running all over their table. The liquid was soaked into the place mats on the table. The residents ate the entire meal without intervention from staff to clean up the spilled milky substance. 2) There were three (3) flies observed at Residents #5, #64, and #48's table the entire meal from 5:30 p.m. to 6:30 p.m. These flies kept landing on each resident's food and never left the table the entire meal. 3) Resident #48 This resident was observed to be eating with a large handled spoon and did not have a fork. She had a piece of pizza, a bowel of pears, and a garden salad. She was observed to try to eat her pizza and was having difficulty. On two (2) different occasions she was heard yelling out help and the staff members working in the dining area would say what do you need, but they never went to her table to see whether she needed help and she did not answer them. She ask the surveyor will you help me cut this up. The staff members did not treat this resident with dignity when she requested assistance and ignored her repeated requests for help. Resident #48 was observed for the entire meal and she did finally eat a piece of pizza with much difficulty. She tried to eat her pears, but they kept falling off of the spoon. It was determined this resident's dinner experience was unpleasant as the table at which she sat had spills soaking through her place mat, flies were landing on her food continuously throughout the entire meal, staff ignored her requests for help, and she was trying to eat her food with only a spoon. The Dietary Supervisor (Employee #55) was questioned at 5:45 p.m. on 08/13/12 about Resident #48's eating utensils. When asked if there was a reason she did not have a fork, he stated the large handled spoon was all that was on her tray card and was all they sent. He also observed the flies and the spilled milk on the table. 4) The A/C Inner Dining Area was observed and there were five (5) staff members assisting residents in that area for dinner on 08/13/12. The staff members did not talk to the residents while they were feeding them. There were no conversation between staff and residents to make this a pleasant dining experience. d) Resident #88 Review of the medical record revealed a nursing entry, dated 08/12/12 at 21:33, that included stated that the resident was making too much noise behind her and that she shouldn't have to listen to that. It was then recorded the HSW (health service worker) redirected her by saying that the dining room was for all the residents and everyone had as much right to be in there as she did. The resident finished her lunch with no more complaints about her fell ow residents. The assistant director of nursing (ADON), Employee #4, was made aware of this entry and agreed that this was not treating the resident with dignity and it would have been better to just move the resident. During an interview with this resident, on 08/16/12 at 2:00 p.m., the resident stated she wore earplugs all of the time because noise bothered her. She said she had a [MEDICAL CONDITION] and it caused the noises to bother her. e) Resident #23 During an observation, on 08/16/12 at 4:30 p.m., this surveyor was sitting at the nurses' station by the D wing. Employee #82 was observed to be halfway down the D hall administering medications. Resident #23 said she had to go to the bathroom again. Employee #82 was heard saying you have went to the bathroom a lot maybe you have a UTI (urinary tract infection) how many times have you peed today? This statement was overheard by the surveyor sitting at the nurses' station and there were five (5) residents sitting in the hall that could hear the statement made by the nurse. Employee #4 was made aware of the nurse's comment to the resident, at 4:45 p.m. on 08/16/12. She confirmed this was not treating the resident in a dignified manner.", "filedate": "2016-04-01"}
{"rowid": 8740, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2012-08-17", "deficiency_tag": 242, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4EJV11", "inspection_text": "Based on record review and staff interview, the facility failed to honor the request of a resident to have a male provide assistance with bathing. This affected one (1) of four (4) residents who triggered for choices during Stage I of the survey process. Resident identifier: Resident #69. Facility Census: 95. Findings include: a) Resident #69 On 08/14/12 at 1:00 p.m., a review of the social history summary sheet, dated 03/07/12, found a statement, He (Resident #69) prefers a shower and he is a VERY private person and needs to have a male staff help him with his shower. This was noted by the social worker (Employee #152). A review of the care plan, on 08/14/12 at 2:00 p.m., revealed the care plan had been reviewed on 05/29/12. Interventions included, Cue resident regarding personal hygiene as needed and assist only to the extent needed. Encourage independence. Baths per facility schedule - . prefers a shower. He requires oversight assistance with bathing. Respect his request for privacy. No interventions were found regarding Resident #69's request for a male to assist with a shower. In an interview, with the director of nursing, on 08/15/12 at 3:15 p.m., she agreed the care plan did not contain interventions regarding Resident 69's request for a male to assist with bathing. She further stated, the facility only had two male nursing assistants. On 08/17/12 at 8:30 a.m., an interview with a licensed practical nurse (Employee #9) revealed Resident #69 takes most of his bath by himself. She stated when he needs help whoever, male or female, will help him.", "filedate": "2016-04-01"}
{"rowid": 8741, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2012-08-17", "deficiency_tag": 272, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4EJV11", "inspection_text": "Based on record review and staff interview, the facility failed to identify the presence of a pressure ulcer on the Minimum Data Set (MDS) assessment. The skin condition for Resident #91 was not accurately coded to reflect his condition at the time of the assessment. This was found for one (1) of twenty-five (25) residents whose MDS assessments were reviewed for the Stage II sample. Resident identifier: #91. Facility census: 95. Findings Include: a) Resident #91 A nursing progress note, dated 06/01/12, revealed this resident had impaired skin integrity r/t (related to) incontinence and frequent friction when sitting in chair as resident slides and repositions himself frequently. Stage 3 (three) pressure ulcer to lt inner buttock and stage 2 (two) pressure ulcer to the right inner buttock superficial layer of tissue is peeling. Current measurements: lt (left) buttock wound 1.5 cml (cm long) x 1.4 cmw (cm wide) x 0.1 cmd (cm deep) rt (right) buttock wound 0.5 cml x 0.5 cmw x 0 cmd. The treatment records, for June 2012 and July 2012, contained an entry that instructed cleanse the open area to coccyx with wound cleaner and apply allevyn dressing. The instructions stated to change this dressing every three (3) days. The treatment record indicated that this had been checked and confirmed that this area was present at the time of the MDS completed on 07/01/12. A significant change in status MDS, with an assessment reference date (ARD) of 07/01/12, revealed no problem with this resident's skin condition. Section M0210 asked does the resident have one or more unhealed pressure ulcers at Stage 1 (one) or higher. This section was coded 0. This coding meant that no pressure areas were present. During an interview with the MDS nurse (Employee #14) the morning of 08/16/12, she stated It should be in section M, but it isn't there .", "filedate": "2016-04-01"}
{"rowid": 8742, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2012-08-17", "deficiency_tag": 280, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4EJV11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure care plans were revised to reflect the current treatment needs of residents. The care plan for Resident #59 was not updated when there were changes to her [MEDICAL TREATMENT] treatment plan; Resident #88's care plan did not reflect the resident's skin condition; and the care plans for Residents #21 and #62 were not revised to reflect the changes in their nutritional needs. The care plans were not revised and updated for four (4) of twenty-five (25) sampled Stage II residents. Resident identifiers: #59, #88, #21, and #62. Facility Census: 95. Findings Include: a) Resident #59 A review of the medical record revealed this resident had a care plan that was last reviewed 07/03/12. The plan reflected she was receiving [MEDICAL TREATMENT] three (3) times a week. The interventions stated the facility was to send the resident's blood pressure medications with resident to the [MEDICAL TREATMENT] center on [MEDICAL TREATMENT] days. On those days, the medications were not to be given at the facility. During an interview with the nurse (Employee #78), on 08/16/12 at 10:25 a.m., she verified the facility did not do this anymore because the [MEDICAL TREATMENT] center said they do not need them to send her medication because her blood pressure was never up and they did not have to give the medication. Employee #4 (assistant director of nursing) was made aware that according to the nurse, they did not send the medications to [MEDICAL TREATMENT] anymore as instructed in the care plan. She verified the care plan interventions had not been updated to reflect this. b) Resident #88 The care plan for this resident was last updated 06/22/12. The problem High risk for skin breakdown and the goal residents skin will remain intact and she will have no breakdown by next review was reviewed and continued at that time. Review of the medical record revealed that she had skin irritation to her buttocks and inner thighs and she was not to wear briefs at HS (hours of sleep). The medical record also confirmed, that on 06/15/12, the resident had a blister present on her inner thigh. It was verified this was present when her care plan was updated on 06/22/12, but her care plan was not revised to reflect that she had and actual skin condition problems at that time. Employee # 4 confirmed that this skin condition was present at the time of the care conference on 06/22/12. She also confirmed that the resident developed further skin breakdown on 06/29/12. This area was treated and measures were implemented, but the plan of care was not updated to reflect the true skin condition. c) Resident #21 Review of the medical record found the resident had experienced a decline in activities of daily living, increased confusion, lethargy and falls related to a [MEDICAL CONDITION]. The resident began receiving hospice services on 07/17/12. Review of the hospice care plan found the problem, Nutrition. The goal associated with this problem was: Patient/caregiver will verbalize understanding of changes in appetite related to advancing disease process, and / or impending death. The interventions were: Educate / review on nutrition as related to the normal process of dying and eating for pleasure as desired. Further review of the facility's care plan, dated 07/12/12, found a problem: weight: low weight (113#) and BMI (17.7). The goal associated with this problem was: Resident will lose or gain weight until within IBW (ideal body weight) range 133-163. Review of the resident's weights found the last recorded weight was 115.2 pounds on 07/25/12. Review of the daily percentage of meal consumption for August 1, 2012 through August 15, 2012 found the resident refused 30 of 42 meals recorded on the meal consumption sheet. On 08/16/12 at 10:45 a.m., an interview was conducted with Employee #55, the nutritionist, and Employee #14, a registered nurse, regarding the care plan. Employee #55 stated the care plan was not updated after the resident began receiving hospice services and stated the resident was not refusing meals when the care plan was written on 07/12/12. d) Resident #62 Review of the medical record found a consult from the registered dietitian, completed on 05/28/12. The consult included, Weight history indicates a sign.(significant) weight loss x 30 days. Unsure of reason for such a weight loss x 1 month, however please note res. (resident) is now back at weight x 6 months ago. It should be noted Res. weights fluctuate greatly from 172 - 203 # (pounds). res. (resident) should continue to be monitored for fluid gains/losses. Believe current plan remains appropriate. If weight loss continues at sign rate may need to consider nutritional supplement. Review of the resident's current dietary care plan, dated 06/26/12, revealed a problem: Receiving a therapeutic diet. The goal associated with this problem was: (name of resident) blood glucose level will be maintained WNL (within normal limits) daily. Will maintain adequate nutritional status as evidenced by lab values of DM-2 (diabetes mellitus, type 2) [MEDICAL CONDITION](hypertension) status for next three month period. The care plan failed to address the resident's current weight loss, fluctuating weights and how the facility planned to evaluate/determine the underlying reasons for the resident's weight loss. During an interview with the DON (director of nursing) and the dietary manager, at 5:30 p.m. on 08/15/12, the DON stated the physician had evaluated the resident's weight loss and had taken steps to determine the reasons for the weight loss. She agreed the interventions the facility had taken to address and evaluate the resident's fluctuating weight loss, such as scheduling an appointment with a [MEDICATION NAME], had not been added to the care plan.", "filedate": "2016-04-01"}
{"rowid": 8743, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2012-08-17", "deficiency_tag": 282, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4EJV11", "inspection_text": "Based on record review and staff interview, the facility failed to ensure that a nutritional consult was completed in a timely manner. This nutritional consult was request on 07/17/12 due to the resident's weight loss. During the medical record review, no evidence could be found to show the nutritional consult had been completed as of 08/14/12. This practice affected one (1) of four (4) residents reviewed for nutrition during Stage II of the survey. Resident identifier: #74. Facility census: 95. Findings Include: a) Resident #74 Review of the resident's medical record noted Resident #74's weight on 03/01/12 was 113 pounds. On 07/17/12, the resident's weight was recorded as 101 pounds. A nutritional consult request sheet had been completed on 07/17/12. The reason for this request stated please evaluate for wt (weight) loss. On 08/14/12, there was no evidence found in the medical record to verify this consult had been completed. On 08/15/12 at 9:30 a.m., the Assistant Director of Nursing, Employee #4, was made aware there was no evidence of the nutritional consult having been completed. She returned with a consultation note with an entry date of 08/15/12 at 10:45 a.m. This entry date was after the surveyor's finding.", "filedate": "2016-04-01"}
{"rowid": 8744, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2012-08-17", "deficiency_tag": 329, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4EJV11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and a review of the nursing drug handbook, the facility failed to ensure Resident #81 did not receive unnecessary medications. The resident was receiving the medication Levothyroxin ([MEDICATION NAME]) and the resident did not have a [DIAGNOSES REDACTED]. This was true for one (1) of seven 7 sampled residents. Resident identifier: #81. Facility Census: 95. Findings include: a) Resident #81 During a review of the medical record, completed on 08/15/2012 at 4:47 p.m., it was found Resident # 81 was receiving the medication [MEDICATION NAME] ([MEDICATION NAME]) 75 mcg (micrograms) every morning. Further review of the medical record found no [DIAGNOSES REDACTED]. It was further identified there was no laboratory data in the medical record to monitor the use of this medication after 12/31/10. In an interview with Employee #9 (Licensed Practical Nurse), on 08/16/12 at 9:25 a.m., she reported giving this medication to the resident for over a year and was unsure why the resident was taking this medication. A review, on 08/16/12 at 9:47 a.m., of the nursing drug handbook, PharMerica 2012 found a list of the specific conditions for which this medication was prescribed. There was no evidence in the medical record indicating this resident had any of those conditions.", "filedate": "2016-04-01"}
{"rowid": 8745, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2012-08-17", "deficiency_tag": 364, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4EJV11", "inspection_text": "Based on observation and staff interview, the facility failed to serve pureed food in an attractive and appealing manner. When the food items were plated, they flowed together on the plate. This had the potential to affect 45 residents who were ordered pureed foods. Facility census: 95. Findings include: a) On 08/15/12 at 12:00 p.m., observation of the lunch meal, in the C-1 Day Room, revealed the pureed meat, vegetables, and rice had the appearance of flattened patties which were all blending together. The nutritionist was present during this observation. He agreed the food did not look appealing and were not of the appropriate consistency to prevent the blending of foods.", "filedate": "2016-04-01"}
{"rowid": 8746, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2012-08-17", "deficiency_tag": 366, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4EJV11", "inspection_text": "Based on observation, resident interview, and staff interview, the facility failed to ensure residents were offered substitutes when they refused to eat the items on the menu that were served to them. Two (2) residents were served a dinner tray and did not eat any of the served items. The staff did not offer them a substitute of any kind for that meal. This was observed for two (2) of ninety-five (95) residents observed at the dinner meal. Resident identifiers: #64 and #21. Facility Census: 95. Findings include: a) Resident #64 During an observation, on 8/13/12 at 5:10 p.m., Resident #64 was observed in the dining area and was served a pureed meal. She sat and stared at the food, but did not take a bite of food the entire time she was observed. This table was observed from 5:10 p.m. to 5:55 p.m. This resident was asked on two (2) different occasions why she was not eating. She replied I did not want this. The resident did not eat any of her food during that time and there were no staff members observed to come to assist her or to try to encourage her to eat. She was not offered an alternate meal when she did not eat any of the food served to her. The resident was observed to leave the table at 5:55 p.m. and she still had not eaten any of the food she was served. She still had not been offered assistance or an alternative meal. The Director of Nursing was made aware of this observation on 8/14/12 at 2:00 p.m. She was also made aware that it had been recorded in the medical record that this resident ate 100% of her meal when she had been observed to eat nothing that was on her tray on 08/13/12 for dinner. b) Resident #21 Employee #53, a health service worker, was observed to serve this resident his tray at 5:10 p.m. on 08/13/12. At 6:00 p.m., Employee #53 asked the resident if he wanted to eat. The resident replied, No. The employee picked up the resident's tray without any further conversation. The resident was never informed of what the food items were on his tray and was never offered or given the opportunity to receive any substitutes.", "filedate": "2016-04-01"}
{"rowid": 8747, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2012-08-17", "deficiency_tag": 428, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4EJV11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, a review of the nursing drug handbook, and the pharmacist ' s monthly drug regimen reports, the pharmacist failed to identify irregularities in a resident ' s drug regimen. Resident #81 was receiving the medication Levothyroxine (Synthroid) with no [DIAGNOSES REDACTED]. Additionally, there was no evidence laboratory data had been collected in order to monitor the use of this medication. This was true for one (1) seven (7) sampled residents. Resident identifier: #81. Facility Census: 95. Findings include: a) Resident #81 A review of the medical record, on 08/14/12 at 4:47 p.m., found Resident #81 had the following Diagnosis: [REDACTED]. Further review of the medical record identified that Resident # 81 was receiving the medication Levothyroxine (Synthroid) 75 micrograms every morning. There was no [DIAGNOSES REDACTED]. It was further identified there was no laboratory data in the medical record to monitor the use of this medication since 12/31/10. On 08/16/12 at 9:50 a.m., Employee #132 (Registered Nurse), after reviewing the pharmacy monthly drug regimen reports and the laboratory reports, verified there was no [DIAGNOSES REDACTED]. A review of the nursing drug handbook, PharMerica 2012 found the conditions for which this medication was used. This medication reference book also indicated the medication should be monitored every six (6) to eight (8) weeks until normalized; eight (8) to twelve (12) weeks after a dosage change; and every six (6) to twelve (12) months throughout therapy. A review of the monthly drug regimen reviews revealed the pharmacist had not identified a need for a [DIAGNOSES REDACTED].", "filedate": "2016-04-01"}
{"rowid": 8748, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2012-08-17", "deficiency_tag": 441, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "4EJV11", "inspection_text": "Based on observation and staff interview, the facility failed to ensure staff employed appropriate infection control practices to help prevent the development and transmission of diseases and infection. A staff member was observed to use the same hair brush on three (3) different residents, employees were observed to not wash their hands when indicated and/or to perform handwashing incorrectly. These practices had the potential to affect more than an isolated number of residents. Resident identifiers: #5, #48, #76, and residents who were assisted after staff did not wash their hands. Facility Census: 95. Findings include: a) Residents #5, #48, and #76 During an observation, on 08/16/12 at 3:30 p.m., Employee #144, a health service trainee, was observed on the A-East unit with a hair brush. She was observed to brush Resident #5's hair, then Resident #48's hair, then she went to Resident #76 and brushed her hair. This was done using the same hair brush for each of these residents. Employee #144 was immediately questioned about this practice 08/15/12 at 3:40 p.m She stated that everyone has their own hairbrush and she was not supposed to use the same brush for the residents. b) Handwashing Observation during the dinner meal. on 08/13/12 at 4:55 p.m., found a licensed practical nurse (Employee #27) washed her hands and dried her hands with paper towels. After turning off the water faucet with the paper towels, she finished drying her hands with the same contaminated paper towels. She then proceeded to serve residents drinks, silverware, and the lunch meal. c) Clothing Protectors During an observation of the A/C inner Dining room, on 08/13/12 at 5:35 p.m., a health service worker (HSW), Employee #79, was observed cleaning a large amount of liquid from the floor with a soiled resident clothing protector. She continued assisting residents in the dining room and did not wash her hands. It was observed that this HSW did not completely clean the liquid off of the floor. The Licensed Practical Nurse (LPN), Employee #94 was observed at 5:38 p.m. (three minutes following the first observation), cleaning the remainder of the liquid from the floor with another soiled resident clothing protector. This employee was then observed to continue assisting the residents in the dining room without washing her hands. On 08/16/12 at 3:00 p.m., the director of nursing (Employee #5) was asked whether it was an acceptable practice to clean spills off of the floor using clothing protectors the residents used at meal times. She stated No.", "filedate": "2016-04-01"}
{"rowid": 8749, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2012-08-17", "deficiency_tag": 469, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "4EJV11", "inspection_text": "Based on observation, review of the facility's pest control program, and staff interview, the facility failed to maintain an effective pest control program as evidenced by flies being observed in the kitchen, resident rooms and resident dining areas during the entire survey and by all members of the survey team. Facility census: 95. Findings include: a) Kitchen observation - During the initial kitchen tour, on 08/13/12 at 1:30 p.m., flies were observed in all areas of the kitchen. Additional observations made on 08/14/12, and 08/15/12 at 12:00 p.m., found flies were again in the kitchen. The nutritionist was present during these tours and agreed there were flies in the kitchen. b) Environmental tour - During the initial tour of the facility, on 08/13/12 at 1:30 p.m., flies were reported in resident rooms, hallways, and day rooms by all survey team members. At each daily survey team meeting, the flies remained an issue. Observations made by other survey team members included a nurse giving medications and waving her hands to get flies away from the medication cart; flies flying around residents' heads while they were in bed; two (2) flies flying around a resident's head during a meal in the C-1 dining room; and flies in the day rooms during meals. The nutritionist was present when the observation was made in the C-1 dining room and agreed with the observation. - On 08/17/12 at 9:15 a.m., an interview was conducted with the director of maintenance. He stated no problems had been reported to him regarding the flies. He further stated, the facility is in the middle of a farm area and the flies have been bad. - A review of the pest control program found the facility had been sprayed for ants on 07/25/12, with no mention of flies. c) Dining Room Observation During an observation of the dinner meal, on 08/13/12 at 5:30 p.m., in the A/C inner dining area, Residents #5, #64, and #48 were observed to be sitting at the same table. There were three (3) flies observed at this table throughout the entire meal. These flies kept landing on each residents' food and never left the table the entire meal. There was no intervention by the staff in an attempt to alleviate these pests from the residents' dining table the entire meal.", "filedate": "2016-04-01"}
{"rowid": 8750, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2012-08-17", "deficiency_tag": 492, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4EJV11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the personnel records, staff interview, The West Virginia Criteria Manual (State Standard), and Federal Regulation 42 CFR 75(7), the facility failed to ensure a nursing assistant was registered with the long-term care nursing assistant program as required. This was true for one (1) of two (2) nursing assistant personnel records reviewed. Employee identifier: #113. Findings include: a) Employee #113 Personnel record review, on [DATE] at 1:00 p.m., revealed a Nursing Assistant Registry search result, dated [DATE] for Employee #113 (Health Service Worker). The expiration date for this individual's registration was [DATE]. Information from state registry provided different information. The document was verified by Employee #139 (Administrative Service Manager1, Human Resources) on [DATE] at 1:15 p.m. Reapplication for registration was made by Employee #113 on [DATE]. Employee #113 had worked from [DATE] until [DATE] on expired credentials. The facility had just sent Employee #113 home the day before ([DATE]) due to expired registration. The nursing assistant registry search results, dated [DATE], showed Employee #113 had an original date of registration on [DATE]. The individual's registration had expired on [DATE]. Employee #4 (Nurse IV, Assistant Director Of Nursing) verified this document when presented on [DATE] at 1:30 p.m. She stated they check registrations monthly. In an interview with Employee #5 (Nurse Director I), on [DATE] at 8:50 a.m. Employee #5, it was verified Employee #113 (HSW) had worked from [DATE] until [DATE] with a lapsed registration. When asked if Employee #113 acknowledged expired registration, Employee #5 stated that Employee #113 assumed with re-registration in Ohio that West Virginia registration would also be renewed. The office secretary normally checked monthly for upcoming renewals, somehow he had slipped through.", "filedate": "2016-04-01"}
{"rowid": 8751, "facility_name": "LAKIN HOSPITAL", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2012-08-17", "deficiency_tag": 514, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4EJV11", "inspection_text": "Based on observations, record review, and staff interview, the facility failed to ensure medical records were completed with accurate information to reflect the status of the residents. Resident #64 had her meal intake recorded inaccurately. Resident #62 had a dental assessment by nursing that was not accurate and did not reflect the true status of the resident. This was true for two (2) of twenty-five (25) sampled Stage II residents. Resident identifiers: #64 and #62. Facility Census: 95. Findings Include: a) Resident #64 During an observation, on 8/13/12 at 5:10 p.m., Resident #64 was observed in the dining area and was served a pureed meal for dinner. She sat and stared at the food, but did not take a bite of anything the entire time she was observed. This table was observed from 5:10 p.m. until 5:55 p.m. This resident was questioned on two different occasions why she was not eating and she replied that I did not want this. The resident did not eat any of her food during that time and there were no staff members observed to come to assist her or to try to encourage her to eat. She was not offered an alternate meal when she did not eat any of the food served to her. The resident was observed to leave her table at 5:55 p.m. She still had not eaten any of the food she was served. She still not been offered assistance or an alternative meal. On 08/14/12 at 3:00 p.m., the meal intake records were reviewed for this resident. According to these records, it was recorded that on 08/13/12 she ate 100% of her dinner. The Director of Nursing was made aware it had been recorded in the medical record this resident had eaten 100% of her meal when she had been observed to eat nothing that was on her tray on 08/13/12 for dinner and was observed leaving her table with her food untouched. b) Resident #62 Medical record review found a nursing assessment had been completed on 06/13/12. According to the nursing assessment, the resident had both upper and lower dentures. Review of the significant change minimum data set (MDS) assessment, with an assessment reference date (ARD) of 06/18/12, found the resident had been coded as having no dentures. On 08/15/12 at 2:00 p.m., the DON (director of nursing) was interviewed regarding the conflicting information. The DON stated the nursing assessment was incorrect, the resident had been admitted without upper or lower dentures.", "filedate": "2016-04-01"}
{"rowid": 10494, "facility_name": "LAKIN HOSPITAL - STATE", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2011-01-12", "deficiency_tag": 431, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "630F11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and a review of Pharmacy Consultation expectations, the facility failed to identify and dispose of outdated medications. This occurred for two (2) of four (4) medications rooms observed and had the potential to affect more than an isolated number of residents. Facility census: 90. Findings include: a) Observation of the medication room on D Wing, with a licensed practical nurse (LPN - Employee #156) on [DATE] at 2:00 p.m., found the following medications with outdated expiration dates: - Tea Tree Oil expired on ,[DATE]; - Mag Delay capsules expired in ,[DATE]; - Lorazepam 2mg/ml, 30ml expired ,[DATE]; - Vaseline expired ,[DATE]; and - Two packages containing Cavicide (located in the treatment cart) expired in ,[DATE]. - b) Observation of the medication room on C Wing, with Employee #27 (an LPN) on [DATE] at 2:30 p.m., found two (2) Acetaminophen 325 mg suppositories expired in ,[DATE]. In addition, a bottle of Peroxide was found on the stock shelf with a broken lid. - c) On [DATE] during the mid-afternoon, an interview with the director of nursing found the facility did not have a policy regarding medication storage expiration dates. She did present for review \"Standards for Consultant Pharmacists\", which she said included the Consultant Pharmacist's expectations. Section 1. Services, Item A.1.c., stated, \"Assure that drug storage rooms, medication carts, IV carts and medical supply areas are maintained in a clean and safe manner and are free of expired and/or discontinued drugs and biologicals.\"", "filedate": "2015-03-01"}
{"rowid": 11317, "facility_name": "LAKIN HOSPITAL - STATE", "facility_id": 5.1e+125, "address": "1 BATEMAN CIRCLE", "city": "WEST COLUMBIA", "state": "WV", "zip": 25287, "inspection_date": "2011-01-12", "deficiency_tag": 323, "scope_severity": "G", "complaint": 1, "standard": 0, "eventid": "630F11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide adequate supervision to prevent an avoidable accident to one (1) of four (4) residents reviewed for swallowing problems. During the evening meal on 12/02/10, dietary staff provided for Resident #83 a mechanically altered meal contrary to his physician order [REDACTED]. Prior to the on-site investigation into this choking incident by the State survey and certification agency, the facility took prompt actions to identify and correct system failures that permitted dietary staff to send the wrong tray to a resident and that allowed the nursing staff to serve the wrong diet, to ensure this type of avoidable accident did not recur. Resident identifier: #83. Facility census: 90. Findings include: a) Resident #83 Review of facility records revealed Resident #83 suffered a choking episode during the evening meal on 12/02/10, which resulted in the need for nursing staff to administer the Heimlich maneuver to expel a bolus of food that obstructed the resident's airway. This choking episode was an avoidable accident, which resulted from the resident receiving and consuming foods that were not pureed in accordance with his physician-ordered therapeutic diet. Interview with the administrator and director of nursing (DON), on 01/10/11 at 3:20 p.m., revealed Resident #83 had resided on the B wing until 12/02/10, when a decline in his condition promoted the facility to transfer him to C wing where his health status could be more closely monitored. When, during the evening meal on 12/02/10, Resident #83's meal tray did not arrive on the new unit (C wing), nursing staff contacted the dietary department to request another tray. Two (2) residents on C wing (Residents #83 and #100) had the same last name. Dietary staff was not aware of Resident #83's room transfer and prepared a tray for Resident #100 (the other resident on C wing with the same last name). Resident #100 had a physician's orders [REDACTED].#83 had a physician's orders [REDACTED]. Nursing staff then proceeded to serve Resident #83 the mechanical soft diet, which resulted in the choking episode. Nursing staff immediately reacted to the choking by performing the Heimlich maneuver, which successfully dislodged the bolus of food that was obstructing Resident #83's airway. Nursing staff immediately notified the physician of the choking episode and received instructions to monitor the resident. On the following day, the resident sustained [REDACTED]. The administrative staff immediately began an investigation into the root cause of this adverse event. A comprehensive investigation by the facility's administrative staff identified that both dietary and nursing staff was responsible for this avoidable accident. The incident was reported to all State agencies as required. The staff members involved received suspensions, all dietary staff was re-educated on the need to carefully prepare meal trays in accordance with each resident's physician-ordered diet, and all nursing staff was re-educated on the need to verify that mechanically altered diets were correct prior to service to each resident, by reviewing each resident's tray card. The system failures that contributed to this adverse event were identified and corrected by the facility prior to this on-site complaint investigation by the State survey and certification agency.", "filedate": "2014-07-01"}
{"rowid": 3767, "facility_name": "WAR MEMORIAL HOSPITAL", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2020-02-05", "deficiency_tag": 583, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0VLH11", "inspection_text": "Based on observation and staff interview the facility failed to safeguard the content of Resident personal information displayed on a computer. This is a random opportunity for discovery. Resident identifier: #10. Facility census: 16. Findings included: a) Resident #10 During medication pass on 02/05/20 at 1:20 PM licensed nurse (LPN) #15 used a computer to determine medications to give to Resident #10 and then walked away from the computer to administer the medication. Licensed nurse #15 did close the screen on the computer leaving the residents' medical information available for any person passing by to observe. Interview with licensed nurse #15 on 02/05/20 at 1:30 PM agreed she forgot to clear the computer screen.", "filedate": "2020-09-01"}
{"rowid": 3768, "facility_name": "WAR MEMORIAL HOSPITAL", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2020-02-05", "deficiency_tag": 695, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0VLH11", "inspection_text": "Based on observation and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. An oxygen humidifier bottle was not labeled with a date as to when it was last changed. This practice has the potential to affect a limited number of residents receiving respiratory care services. Resident identifiers: #15. Resident census: 16. Findings included: a) Resident #15 An observation on 02/04/20 at 08:40 AM, revealed the Resident #15 had an oxygen humidifier bottle attached to the wall oxygen flowmeter. There was no date on the oxygen humidifier bottle. An interview with Licensed Practical Nurse (LPN) #15, on 02/04/20 at 8:45 AM, revealed the oxygen humidifier bottle should be changed and dated every seven (7) days. She stated, the night shift nurse is responsible for changing and dating the humidifier bottle. LPN #15 verified the tubing was not dated and immediately changed and dated the humidifier bottle.", "filedate": "2020-09-01"}
{"rowid": 3769, "facility_name": "WAR MEMORIAL HOSPITAL", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2019-04-17", "deficiency_tag": 759, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "R53F11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of manufacturer's guidelines, and review of Nursing 2019 drug handbook, the facility failed to maintain a medication administration error rate of less than five percent (5%). The error rate was 7.69% (percent). This was evident for two (2) medication errors out of twenty-six (26) opportunities. Resident identifier: #10. Facility census: 16. Findings included: a) During an observation on 04/16/19 at 7:36 AM licensed practical nurse #30 (LPN #30) handed a [MEDICATION NAME] 160/4.5 microgram inhaler to resident #10. Resident #10 immediately inhaled two (2) puffs of the medication in rapid succession, then rinsed her mouth with water. On 04/16/19 at 7:37 AM LPN #30 handed her a ProAir 90 microgram inhaler. The resident again immediately inhaled two (2) puffs of the medication in rapid succession, then rinsed her mouth with water. Review of manufacturer's instructions for [MEDICATION NAME] administration found directives to wait at least one (1) minute between successive inhalations for maximum effectiveness. Review of manufacturer's instructions for ProAir administration found directives to wait at least one (1) minute between successive inhalations for maximum effectiveness. Review of the Nursing 2019 handbook which was kept at the nurses' station for reference, found directives that if using other inhalers at the same time, wait at least two (2) minutes between the use of each medication. An interview was conducted with the director of nursing (DON) on 04/16/19 at 8:55 AM. She said this resident will not allow nurses to administer inhalers. Rather, the resident uses her inhalers in the presence of the nurses. Upon inquiry, the DON said she did not know if anyone had educated the resident on the correct spacing of the inhaled medications. She said the facility has no policy or procedure about the spacing of inhaled medications. On 04/17/19 at 12 PM the DON stated that nursing completed education with the resident today as to the correct use of inhaled medications. The DON stated that the resident told her she used the inhalers at the facility the same way she used them at home prior to coming to the facility, and did not realize there was a more effective way to use them.", "filedate": "2020-09-01"}
{"rowid": 3770, "facility_name": "WAR MEMORIAL HOSPITAL", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2019-04-17", "deficiency_tag": 812, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "R53F11", "inspection_text": "Based on observation, staff interview, and policy review, the facility failed to store food in accordance with professional standards of food safety. There were multiple items in the walk-in cooler which were stored beyond the use by date, not dated when opened, and/or stored beyond the manufacturer's sell by date. This had the potential to affect all of the resident's in the facility. Facility census: 16. Findings included: a) Initial Tour of the Kitchen An initial tour of the kitchen on 04/15/19 beginning at 11:00 AM and concluding at 11:31 AM with dietary employee #23, found the following concerns in the walk-in refrigerator: 1. An opened, partially used plastic bag of cubed Swiss cheese, which weighed approximately two (2) pounds, was dated as having first been opened for use on 03/31/19. Its label directed to use by 04/09/19. 2. A clear, plastic, four (4) quart bowl was filled to the two (2) quart line with kidney beans. This bowl of beans was dated 04/07/19, with directions to use by 04/13/19. 3. An opened, partially used plastic bag of shredded mozzarella cheese, which weighed approximately one (1) pound, was dated as having first been opened for use on 04/05/19. Its label directed to use by 04/12/19. 4. An opened, partially used plastic bag of cubed cheddar cheese, which weighed about half a pound, was dated as having first been opened for use on 04/04/19. Its label directed to use by 04/13/19. 5. An opened, partially used plastic bag of Romano cheese, which weighed about one (1) pound, was dated as having first been opened for use on 03/29/19. Its label directed to use by 04/07/19. 6. An opened, nearly full gallon jug of Dairy Pure 2% reduced fat milk was labeled to sell by 04/08/19. There was no date to indicate when it was first opened for use. 7. An opened, nearly empty gallon jug of whole milk was labeled to sell by 04/15/19. There was no date to indicate when it had first been opened for use. There was approximately three (3) inches of milk which remained in the bottom of the milk jug. The above listed food items were shown to dietary employee #23 on 04/15/19 at 11:31 AM. She agreed the first five (5) items named above should have been discarded by the use by dates inscribed. She agreed that the milk items listed in number six (6) and in number seven (7) should have been dated when initially opened. She immediately began to dispose of those seven (7) items. An interview was conducted with the dietary manager on 04/16/19 at 3:00 PM. She was aware that dietary employee #23 discarded those seven (7) named food items yesterday. On 04/17/19 the facility provided a copy of the Food Storage and Refrigerator Safety policy and procedure which was most recently reviewed in 02/2019. Under section [NAME], Practices to maintain safe refrigerated storage, item number seven (7) included Labeling, dating and monitoring of refrigerated food, so it is used by the expiration date or discarded.", "filedate": "2020-09-01"}
{"rowid": 3771, "facility_name": "WAR MEMORIAL HOSPITAL", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2018-05-09", "deficiency_tag": 812, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "ONYB11", "inspection_text": "Based on observation and staff interview, the facility failed to prepare and serve food in a sanitary manner. This had the potential to affect any resident who receives nourishment from the dietary kitchen. Facility census: 16. Findings included: a) Lunch tray serve line observation in the kitchen On 05/08/18 at 11:50 a.m., water was observed on the floor beside the tray serve line in the dietary kitchen. Cook Employee #10's (E#10) work station on the food serve line ensured that she stood between the tray line and the water spill on the floor. At this time of observation, E#10 was in the process of assisting to serve food to the residents and to the patients in the hospital. She wore purple-colored latex gloves during the food tray serve to ensure her bare hands did not come into direct contact with resident's or hospital patient's food or items on the tray. At 11:50 a.m. on 05/08/18, E#10 used a white-colored cleaning cloth to mop the water spill on the floor, while wearing her purple-colored latex gloves. After she wiped the spill thoroughly, E#10 carried the wet cloth into the area which housed the dishwashing machine and disposed of the now wet, dirty, cleaning cloth. E#10 immediately returned to her station on the tray line serve, to resume serving the lunch meal to residents. As she reached for a clean plate, she wore the same purple-colored latex gloves which she wore while wiping the water spill on the floor. Upon inquiry as to whether she should change gloves and wash hands now, she replied in the affirmative and thanked the questioner for the reminder. On 05/08/18 at 12:22 p.m., an interview was conducted with the dietary manager, Employee #59. She said Employee #10 should have washed hands and changed gloves after wiping up the water on the floor. E#59 said the water on the floor came from condensation from the steamer, which is located across from the tray line. She said that all dietary staff have received on-going in-service education on cleanliness and infection control, which included hand hygiene principles.", "filedate": "2020-09-01"}
{"rowid": 4887, "facility_name": "WAR MEMORIAL HOSPITAL", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2016-03-11", "deficiency_tag": 225, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "LRMX11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel file review, facility policy/procedure review, review of Chapter 514.4 of the Medicaid manual and a clarification memorandum from the Bureau for Medical Services (BMS) regarding the requirements of the Affordable Care Act, and staff interview, the facility failed to ensure criminal background investigations were completed for all employees prior to hire and every 3 years there after throughout the remainder of employment to determine whether the individuals had been found guilty of abuse, neglect, or mistreatment of [REDACTED]. This was not completed for one (1) of ten (10) employees whose personnel files were reviewed. Employee identifier: #48. Facility census: 16. Findings include: a) Employee #48, Rehabilitation Physical Therapy Aide (Rehab PTA) Review of the personnel files on 03/08/16 at 3:50 p.m. with Senior Human Resources Director (SRD #159), revealed Rehab PTA #48's file lacked a criminal background check. SRD# 159 stated, I will not be here tomorrow but will research and provide the criminal background check. On 03/09/16 at 8:55 a.m., the Administrator provided copies of communication from the West Virginia State Police to Rehab PTA #48. A copy of an email sent to an employee in the Human Resources Department on 02/18/14 from WV Easypath-Morpho Trust with a letterhead from the West Virginia State Police. The FBI (Federal Bureau Investigations) has rejected the fingerprint submission and the employee must be re-fingerprinted. A review of the facility Resident Abuse/Neglect policy and procedure on 03/09/16 at 9:00 a.m. stated; .D. Miscellaneous Screening Efforts 1. as part of the pre-employment process, all applicants for employment on the long term care facility will have a criminal conviction investigation completed and a complete set of fingerprints. On 03/09/16 at 9:10 a.m. the Director of Nursing (DON) stated, We do not have anything on her (Rehab PTA #48) for any background checks. She has been working with out a background check on file since her hire date (hire date 06/26/1984). 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment ). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on (MONTH) 15, 2013. The memo included . at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility until (MONTH) 1, 2014, to have all current employees up to date with criminal investigation background checks. For any new hires in the nursing facility, the policy is effective for those individuals as of (MONTH) 1, 2013", "filedate": "2019-07-01"}
{"rowid": 4888, "facility_name": "WAR MEMORIAL HOSPITAL", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2016-03-11", "deficiency_tag": 371, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "LRMX11", "inspection_text": "Based on observation and staff interview the facility failed to ensure food was served under sanitary conditions. An employee did not practice proper hygienic practices by not keeping their hands away from their hair and face when serving meals. This practice had the potential to affect all residents who received food from the kitchen. Facility census: 16. Findings include: a) During observation of the noon meal service, on 03/08/16 at 12:00 p.m., Activities Director (AD) #146 was observed serving lunch trays to the residents in the dining room and the residents' rooms. AD #146 pushed her long unsecured hair behind her ear each time she retrieved a lunch tray from the meal cart. In addition, her long unsecured hair touched the meal trays as she delivered each tray to the residents. At 12:02 p.m. on 03/08/16, Licensed Practical Nurse (LPN) #16 confirmed AD# 146 was touching her hair every time she retrieved a lunch tray from the meal cart. On 03/08/16 at 12:05 p.m. AD# 146 acknowledged she was pushing her hair back while pulling meal trays from the food cart. She immediately obtained a hair clip and pulled her hair back before delivering the remainder of the lunch trays. During an interview on 03/09/16 at 8:00 a.m. Infection control nurse #97 stated, Our policy is their hair is to be pulled back when serving meals.", "filedate": "2019-07-01"}
{"rowid": 6225, "facility_name": "WAR MEMORIAL HOSPITAL", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2015-02-04", "deficiency_tag": 272, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "Y4QQ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete a Significant Correction to a Prior Quarterly Assessment (SCQA) after the Interdisciplinary Team (IDT) determined the resident's recent assessment contained a significant error identifying a change in her condition. Resident #19's minimum data set (MDS) assessment was incorrect related to independent functioning. Resident identifier: #19. Facility census: 16 Findings include: a) Resident #19 Review of the resident's medical record, on 02/03/15 at 2:00 p.m., found her quarterly minimum data set (MDS), with an assessment reference date (ARD) of 01/01/15, indicated her ability to function independently with bed mobility, transfers and toileting had declined since the prior assessment with an ARD of 10/02/14. The prior assessment indicated she required limited to extensive assistance to complete these functions. A progress note, dated 01/15/15, stated the Quarterly MDS with an ARD of 01/01/15 was incorrectly coded to indicate the resident needed extensive assistance with bed mobility, toileting, and dressing. The resident was re-evaluated and found to require only supervision to limited assistance with all of her activities of daily living (ADLs). The Centers for Medicare and Medicaid Services (CMS) resident assessment instrument (RAI) version 3.0 manual dated October 2014 states on page 2-32, The Significant Correction to Prior Quarterly Assessment (SCQA) is an Omnibus Budget Reconciliation Act (OBRA) non-compliance assessment that must be completed when the IDT determines that a resident's prior assessment contains a significant error A significant error is an error in an assessment where: 1. The resident's overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment; and 2. The error has not been corrected via a submission of a more recent assessment. No documentation was found indicating the facility filed a correction. Nurse aide #18, reported Resident #19 was pretty much independent with all of her ADL care, during an interview on 02/03/15 at 2:13 p.m. In an interview with the MDS nurse, Employee #7, on 02/03/15 at 2:30 p.m., she confirmed the assessment dated [DATE] was coded incorrectly, as nursing assistant documentation showed the resident was more independent in ADLs than the MDS indicated. She acknowledged she had not submitted a correction after the therapy department reevaluated the resident and verified she did not decline in her ADL functions.", "filedate": "2018-05-01"}
{"rowid": 6601, "facility_name": "WAR MEMORIAL HOSPITAL", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2013-10-17", "deficiency_tag": 279, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "9QWX11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop measurable goals for the care plan for one (1) of five (5) residents reviewed for unnecessary medications. The care plan identified Resident #2 had problematic behaviors and received antipsychotic medication daily. The care plan contained no measurable goals for which treatment and interventions were being provided related to the behaviors. Resident identifier: #2. Facility census: 15. Findings include: a) Resident #2 The medical record was reviewed for Resident #2. This resident was diagnosed with [REDACTED]. This was defined by specific behaviors as quantitatively (number of episodes) and objectively (such as biting biting, kicking, and scratching) documented by the facility which cause the resident to actually interfere with staff's ability to provide care. This resulted in the initiation of [MEDICATION NAME] (an antipsychotic medication) 25 milligrams (mg) daily. The [MEDICATION NAME] was begun on 09/28/13. Review of the care plan revealed this resident had repetitive obsessive behaviors. Numerous behaviors and interventions to treat the behaviors were identified on the care plan. However, the care plan contained no goals related to potential outcomes as the result of using the antipsychotic medication and the non-pharmacological interventions. On 10/16/13 at 2:10 p.m., an interview was completed with a licensed nurse, Employee #16. She said this resident had been sleeping during the day, especially when up to activities. She said she had noticed an improvement in the resident's activity participation and wakefulness over the past few weeks. An interview was conducted with the consultant administrator (Employee #48) on 10/16/13 at 2:15 p.m. She said this resident had been awake a good bit during the nights while displaying repetitive, obsessive behaviors. Numerous non-pharmacological interventions were tried by staff, to no avail. As a result of these obsessive, repetitive behaviors during the nights, she would then be too tired by day to take part in activities she once enjoyed. She said since beginning the [MEDICATION NAME] a few weeks ago, this resident had been getting more rest at night. Subsequently, the resident was more wakeful, active and able to socialize more by day. Employee #48 said she believed the resident's quality of life had improved since beginning the [MEDICATION NAME]. On 10/16/13 at 4:20 p.m., an interview was completed with the Director of Nursing (DON) and Employee #48. They acknowledged there were no measurable goals on the care plan related to the obsessive behaviors. They agreed there were no non-pharmacological interventions noted on the psychoactive medication monthly flow record, as there was not a place for that information. They said non-pharmacological interventions would be documented in the nurses' progress notes. However, since beginning the [MEDICATION NAME] on 09/28/13, there was no evidence staff were consistently trying non-pharmacological methods to address the behaviors. There were nineteen (19) shifts in October on the monthly flow record with documented obsessive behaviors. Review of nurses' progress notes for those shifts found no evidence of which, if any, non-pharmacological interventions may have been tried. Employee #48 said it was such a small facility, staff would just know what worked for the resident. She said staff should have documented the interventions, to receive credit for what they did. She added this issue would be addressed.", "filedate": "2018-01-01"}
{"rowid": 6602, "facility_name": "WAR MEMORIAL HOSPITAL", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2013-10-17", "deficiency_tag": 428, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "9QWX11", "inspection_text": "Based on medical record review and staff interviews, the facility failed to ensure the pharmacist identified and reported irregularities to the physician and the director of nursing for two (2) of five (5) Stage 2 sample residents reviewed for unnecessary medications. Each of these residents used antidepressant medications for an excessive period of time without an attempt at a gradual dose reduction. There was no evidence the pharmacist identified this and recommended the consideration of a gradual dose reductions. Resident identifiers: #5 and #13. Facility Census: 15. Findings Include: a) Resident #5 Review of Resident #5's medical record revealed the resident was prescribed the antidepressant Zoloft since 01/14/11. The pharmacist's monthly drug regimen reviews, from December 2012 through October 2013 revealed no indication the pharmacist had made a recommendation for a gradual dose reduction for this medication. The records did not identify a history of failed dose reductions of the Zoloft. b) Resident #13 Review of Resident #13's medication administration records revealed the resident was prescribed the antidepressant Lexapro since 07/08/11. The resident's drug regimen reviews revealed no indication the pharmacist had made any recommendations for a gradual dose reduction for this medication. The resident's records did not identify a history of any failed dose reductions of the Lexapro. c) During an interview on 10/17/13 at 9:40 a.m., the administrator, Employee #48, stated the facility had focused on anti-psychotics and did not complete gradual dose reduction reviews on anti-depressants. An interview on 10/16/13 at 4:40 p.m., with the facility pharmacist, Employee #50, revealed she had not completed gradual dose reduction recommendations on antidepressants due to being focused on antipsychotics.", "filedate": "2018-01-01"}
{"rowid": 8618, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2012-12-07", "deficiency_tag": 221, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "L97I11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure a restraint was used only as required to treat medical symptoms for one (1) of fourteen (14) sample residents. The resident was restrained in a tilt geri-chair. There was no assessment prior to initiating the physical restraint, and no physician's order reflecting the presence of a medical condition to warrant the restraint use. The faciilty also was unable to provide evidence the responsible party was made aware of the potential risks and benefits of restraint use. Additionally, there was no care plan to re-evaluate the need for the restraint and no systematic plan to reduce the use of the restraint. Resident identifier: Resident #1. Facility census 16. Findings include: a) Resident #1 Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. The resident had been deemed to lack capacity to make her own health care decisions for the past several years. She was alert at times but, was not oriented to person, place and time. A Brief Interview for Mental Status (BIMS) had not been attempted because of rambling incoherent speech. The resident exhibited both short and long term memory loss. She also exhibited repetitive body and limb movements daily. The resident's care plan included the use of a bed alarm, a low bed with floor mats, and the daily use of a chair to prevent rising. This chair was identified as a physical restraint in both the care plan and the minimum data set (MDS) assessments dated 04/22/12, 07/22/12, and 10/22/12. There was no physician's order reflecting the presence of a medical symptom that would necessitate the use of a physical restraint. There was no evidence in the record that the responsible party for Resident #1 was informed of the risks and/or benefits associated with the use of a restraint, and no evidence the resident was assessed for the suitability of this particular restraint. There was no evidence the use of the restraint had been periodically evaluated for elimination or, that alternative measures had been considered in an attempt to reduce the restraint. During a staff interview with Employee #9 (nursing assistant) at 3:50 p.m. on 12/04/12, she agreed the resident could not rise and exit the geri-chair when it was tilted back. She stated the resident was in the geri-chair in a tilted position whenever she was out of bed. The Director of Nurses (DON) and the Social Worker (SW) were interviewed at 8:45 a.m. on 12/06/12. They agreed, after reviewing the record, they failed to secure a physician's statement of a medical symptom necessitating the restraint, and confirmed they could not locate documentation of an assessment for the use of the restraint. They could provide no evidence information had been provided to the responsible party (daughter) prior to use of the tilt chair but, stated she visited almost daily and was aware of the use of the tilt chair. The resident's daughter was not seen at the facility during the survey.", "filedate": "2016-05-01"}
{"rowid": 8619, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2012-12-07", "deficiency_tag": 248, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "L97I11", "inspection_text": "Based on observation, medical record review, and staff interview the facility failed to provide an ongoing program of activities to meet the interests and psychosocial well-being as outlined in the resident's care plan for one (1) of three (3) residents reviewed for the care area of activities during stage two (2) of the survey. The resident's care plan noted several activity preferences, including baseball games, sports and Catholic mass on TV, music, and one-to-one interactions with staff. There was no evidence the resident was provided these activities. Resident identifier: Resident #7. Facility census: 16. Findings include: a) Resident #7 Random observations during the afternoon of 12/03/12 and throughout the day on 12/04/12 found the resident always in bed in his room. There was a television and a radio in the room, but neither were playing. Review of the medical record revealed the resident was bedridden and dependent on staff for all activities of daily living (ADLs) including social interactions and turning on audiovisual stimulation. The Care Area Assessment (CAA), dated 06/18/12, identified the resident's activity choices as one-on-one visits with family, staff, and his dog, baseball games and Catholic mass on television (TV), and music. The current care plan, dated 09/14/12 addressed the resident's activity preferences of baseball games, sports and Catholic mass on TV, music, and one-to-one interactions with staff. Review of the resident's daily participation records, on 12/05/12, for August, September, and October 2012 revealed the only activity noted was observed for Movies/TV/Radio for nearly every day. In November 2012, the same observed for Movies/TV/Radio was noted nearly every day. In addition, the activity participation record noted the resident was active for Coffee/Goodie Cart. When asked how the resident participated in the Coffee/Goodie Cart, on 12/05/12 at 8:20 a.m., the social worker/activity director (Employee #23) stated this cart was taken around to the residents, and drinks were offered. Due to the resident's mental status, this resident could not have selected a beverage when offered. A follow up observation on 12/05/12 at 10:00 a.m., after discussing the concern regarding the provision of activities for this resident with Employee #23, found someone had turned on the resident's television.", "filedate": "2016-05-01"}
{"rowid": 8620, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2012-12-07", "deficiency_tag": 272, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "L97I11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and family interview, the facility failed to ensure the accuracy of the minimum data set (MDS) for one (1) of three (3) residents reviewed in the area of vision during stage 2 of the survey. Resident identifier: Resident #7. Facility census: 16. Findings include: a) Resident #7 Review of the medical record, on 12/05/12, identified the resident had a history of [REDACTED]. The Care Area Assessment (CAA) tool dated 06/18/08 noted the inability of the assessor to assess vision because the resident was unable to follow one-step commands. The current CAA dated 06/19/12 identified the resident wore glasses at one time. Review of the annual MDS, dated [DATE] and the quarterly MDS, dated [DATE], under section B1000, vision, found an entry code of 2, which indicated: impaired - sees large print, but not regular print in newspapers/books. An interview with the resident's daughter, on 12/04/12 at 4:00 p.m., confirmed the resident had a history of [REDACTED]. During an interview, on 12/05/12 at 8:46 a.m., with the MDS Registered Nurse (RN) Employee #2, she acknowledged she was unaware how to code the vision assessment on the MDS for a resident that was unable to communicate. The MDS guidelines indicate if the resident is unable to communicate, section B1000 should be coded #3, not #2. .", "filedate": "2016-05-01"}
{"rowid": 8621, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2012-12-07", "deficiency_tag": 278, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "L97I11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the minimum data set (MDS) registered nurse (RN), Employee #2 failed to ensure the accuracy of the MDS for one (1) of three (3) residents reviewed in the area of vision during stage 2 of the survey. Resident identifier: #7. Facility census: 16. Findings include: a) Resident #7 Review of the medical record, on 12/05/12, identified the resident had a history of [REDACTED]. The Care Area Assessment (CAA) tool, dated 06/18/08, noted the inability of the assessor to assess vision because the resident was unable to follow one-step commands. The current CAA, dated 06/19/12, identified the resident wore glasses at one time. Review of the annual MDS, dated [DATE] and the quarterly MDS, dated [DATE], under section B1000, vision, found an entry code of 2, which indicated: impaired - sees large print, but not regular print in newspapers/books. During an interview, on 12/05/12 at 8:46 a.m., with the MDS Registered Nurse (RN) Employee #2, she stated she was unaware how to code the vision assessment on the MDS for a resident who was unable to communicate. The MDS guidelines indicate if the resident is unable to communicate, section B1000 should be coded #3, not #2. .", "filedate": "2016-05-01"}
{"rowid": 8622, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2012-12-07", "deficiency_tag": 279, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "L97I11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a complete care plan addressing all identified problems by not including measurable goals and/or acceptable interventions for four (4) of fourteen (14) stage 2 sampled residents. Resident identifiers: Residents #9, #1, #2, and #7. Facility census 16. Findings include: a) Resident #9 Review of the medical record for Resident #9 revealed the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. The resident had been receiving the medication [MEDICATION NAME] 1.25mg PO (by mouth) every evening for agitation since 10/25/2011. The medication was discontinued on 10/24/12, for a trial period at the request of the pharmacist who stated the following in a Psychoactive Pharmacy Drug Review: Olanazepin 1.25mg q hs (every night) with behavior noted by nursing notes as pleasant and cooperative. The medication was restarted on 11/14/12, when the resident was again exhibiting behaviors. Review of the current care plan revealed the facility had not adequately addressed the use of psychoactive medications. Although the medication was mentioned as an intervention associated with particular problems, the care plan did not describe problems that could arise from the use of the psychoactive medication, such as common side effects of the medication to which staff should be alerted. During an interview with the director of nurses (DON), at 4:00 p.m. on 12/06/12, she acknowledged, after reviewing the care plan, that it did not directly address psychoactive medications and problems that could arise from their use. b) Resident #1 Review of the medical record revealed Resident #1 was admitted to the facility, on 04/21/04, with a [DIAGNOSES REDACTED]. To treat those behaviors she was receiving [MEDICATION NAME] three (3) times daily. A review of her care plan revealed the following entry, dated 11/04/09, under Problems: Cognition, Behavior, Mood, & Psychoactive Drug Use: however, there was no measurable goal established for the use of psychoactive medications. The interventions included: Monitor for medication induced side effects and document behavior on Psychoactive Medication Record and Behavior Monitoring Record, and AIMS assessment every six (6) months, does exhibit extra pyramidal symptoms. The pharmacist reviewed the psychoactive medication use on 10/11/12, and suggested a change in the medication and/or dosage due to repetative tongue movements reported by the dietitian. The physician lowered the dosage of the [MEDICATION NAME] on 10/25/12, but no changes were made to the care plan. A measureable goal related to this was not established. During an interview with the DONat 4:00 p.m. on 12/06/12, she acknowledged, after reviewing the care plan, that although there was an entry for psychoactive medications in the problems, there had NOT been a measurable goal set. She stated she would talk to the pharmacist about doing so. c) Resident #6 On 12/06/12 at 2:30 p.m., a review, of the care plan for Resident #6, revealed there was no problem statement, goal, and/or interventions for [MEDICATION NAME] (a heart medication). d) Resident #2 During an interview, on 12/03/12 at 2:48 p.m., this resident stated she had a hard time chewing food because of her old teeth. A review of the medical record, on 12/06/12, revealed the resident had dental problems which might affect her nutrition intake. The care plan, dated 10/25/12, identified the resident's oral care, including dental visits, but lacked measurable goals to meet the resident's needs regarding her dental problems. During an interview, on 12/06/12 at 12:50 a.m. with licensed practical nurse (LPN) #19 she stated, staff assists resident with meal selection every week and the resident has never reported any difficulty with eating certain foods. Normal routine is to offer the resident another selection if she does not eat her meal. e) Resident #7 Review of the medical record revealed the resident is bedridden and dependent on staff for all activities of daily living (ADL) including social interactions and audiovisual stimulation. The Care Area Assessment (CAA) dated 06/18/12 identifies the resident's disease process and lists his choices as one on one visits with family, staff, and his dog; baseball games and catholic mass on television (TV); and music. Current care plan dated 12/14/12 lacks measurable goals and a time table related to activities for the resident. The care plan states staff will turn the television (TV) on for baseball games, sports and catholic mass, music is at the bedside and provided by the family, and the resident will receive one to one interactions with his family and/or the staff. The resident's daily participation records for August, September, October and November 2012, were reviewed by the social worker/activities director employee #23 during an interview on 12/05/12 at 9:20 a.m. She stated The nursing assistants haven't been filling them out.", "filedate": "2016-05-01"}
{"rowid": 8623, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2012-12-07", "deficiency_tag": 280, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "L97I11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to review, assess the effectiveness of, and revise the care plan when two (2) of fourteen (14) sampled residents had changes in their healthcare needs. Resident identifiers: #1 and #12. Facility census 16. Findings include: a) Resident #1 A review of the record revealed that Resident #1 had been admitted on [DATE]. The resident was observed at 4:00 p.m. on 12/03/12, sitting in a tilted back geri chair in her room. She moves her body and limbs with jerky movements and calls out occasionally. She was being fed a pureed diet by a nursing assistant. During an interview with Employee #9 (nurse aide) at 3:50 p.m. on 12/04/12, she stated the resident stayed up a large part of the day and was in the tilted geri-chair because she would try to reach her feet to take off her socks and staff were afraid she would fall out of the chair. The aide stated that this had been the daily practice for the four (4) months she had worked at the facility. During an interview with Employee #1 (Registered Nurse) at 6:45 a.m. on 12/05/12, the nurse stated they had found when the chair was tilted back, the resident could not fall out as she had in the past. The nurse did not remember how long they had been doing this, but at least for several months. She stated the resident exhibited these repetitive movements daily. A review of the current care plan dated 05/07/09 - 01/03/13 revealed the following interventions regarding the geri-chair: During periods of agitated behavior, tray table to be up when up in geri chair ., While resident is up in geri-chair staff will check resident at least every hour and will assist and provide ADLs, fluids, toileting, and meals. When sitting up in chair, resident's feet will be supported by foot rest if chair is not reclined., and Chair alarm when up in chair (when tray table not in use) to notify staff that resident needs assistance. There is nothing in the care plan about using the tilt position when the resident is in the geri-chair, although it was observed in use daily. The annual MDS (minimum data set) section P0100G is marked for a restraint, described Chair Prevents Rising and the CAA (care area assessment)indicated that it would be addressed in the care plan. During an interview with the Director of Nursing (DON) at 8:45 a.m. on 12/06/12, these findings were discussed. At 9:30 a.m. during a follow-up interview with the DON and Social Worker they agreed, after reviewing the record, the use of the tilt-chair had not been addressed in the resident's care plan. b) Resident #12 A review of the medical record revealed Resident #12 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her annual screening by Rehabilitation Services on 08/29/12, indicated that her left hand was contracted and suggested continuing the use of a splint on this hand, although the resident removed it at times. The active physician's orders [REDACTED]. This order was added on 09/30/11. The care plan was not revised to include the presence of a contraction with a measurable goal. The care plan continues to include Arm sling to left arm while up and Adjustable resting splint to (L) hand/wrist 20 - 24 hours per day to manage (L) digits and wrist in neutral position. Employee #1 (Registered Nurse) stated at 6:30 a.m. on 12/05/12, that the sling or the splint were no longer used because the resident would not leave them on. The resident was observed daily during the survey and a sling or splint was at not time in place. At 9:50 a.m. on 12/06/12, Employee #19 (nurse) was asked to locate the sling and splint in the resident's room. After searching, she did locate a clean sling and sheepskin hand wrap in a storage cabinet in the room, but she and the DON, who was also present, agreed the staff were not attempting to use them on a regular basis. During an interview, shortly after, the DON acknowledged that the care plan had not been revised to accurately describe the care of the resident.", "filedate": "2016-05-01"}
{"rowid": 8624, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2012-12-07", "deficiency_tag": 282, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "L97I11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to ensure the interventions in the Care Plan were carried out for one of fourteen sampled residents, making an accurate evaluation of the interventions difficult. Resident identification: #12. Facility census 16. Findings include: a) Resident #12 A review of the medical record revealed that Resident #12 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her annual screening by Rehabillation Services on 08/29/12, indicated that her left hand was contracted and suggested continuing the use of a splint on this hand, although the resident removed it at times. The active physician's orders [REDACTED]. This order was added on 09/30/11. The care plan continues to include Arm sling to left arm while up and Adjustable resting splint to (L) hand/wrist 20 - 24 hours per day to manage (L) digits and wrist in neutralposition. Employee #1 (Registered Nurse) stated at 6:30 a.m. on 12/05/12, that the sling or the splint were no longer used because the resident would not leave them on. During an interview with Employee #17 (nurse aide) at 6:30 a.m. on 12/05/12, she stated that they no longer applied the sling or splint because the resident would just remove them. During an observation of the resident at 8:20 a.m. on 12/5/12, the resident was being positioned and served her meal. The resident exhibits limitations on her left and did not have a splint on. The resident was observed daily during the survey and never had either a sling or splint applied. At 9:50 a.m. on 12/06/12, Employee #19 (nurse) was asked to locate the sling and splint in the resident's room. After searching, she did locate a clean sling and sheepskin hand wrap in a storage cabinet in the room, but she and the DON, who was also present, agreed that the staff were NOT attempting to use them on a regular basis. During an interview, shortly after, the DON acknowledged that the care plan was not being followed by the aides, but stated that she needed to speak to the physician and change the order and the care plan.", "filedate": "2016-05-01"}
{"rowid": 8625, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2012-12-07", "deficiency_tag": 286, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "L97I11", "inspection_text": "Based on record review and staff interview the facility failed to assure that all portions of the medical record of all residents was readily and easily accessible by all professional staff members by limiting the access to the Minimal Data Set (MDS) which includes the comprehensive assessment information. This has the potential to affect all residents. Facility census 16. Findings include: a) During the initial interview with the Director of Nurses at 12:30 p.m. on 12/03/12, she informed this surveyor that all aspects of the record were available on the chart except the MDS which was in the computer and hard copies are no longer being produced for the chart. During a discussion of accessing the MDS on the morning of 12/05/12, with Employee #4 (Licensed Practical Nurse) she stated that she would have to request someone to do this as she did not have access to the computer. This was verified with the DON, who stated that only she, the unit clerk, and the MDS nurse have entry to the computer. When asked, she stated that they all worked day shift. She acknowledged that they had not considered the lack of access by the nursing staff caring for the resident when the decision was made not to print hard copies of the MDS for the chart.", "filedate": "2016-05-01"}
{"rowid": 8626, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2012-12-07", "deficiency_tag": 329, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "L97I11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy and procedure, the facility failed to ensure that medication regimens were free from unnecessary drugs. This includes duplicate therapy, excessive duration, and lack of adequate indications for administration as well as incomplete orders. In addition, the facility failed to ensure that residents receiving antipsychotic drugs receive gradual dose reduction unless clinically contraindicated. This is true for four (4) of eleven (11) stage two (2) sampled residents. Resident identifiers: Resident #5, #16, #3, and #2. Facility census sixteen (16). Findings include: a.) Resident #5 A record review performed on 12/4/12 of physician's order [REDACTED]. No indication for usage was listed. The medication administration records (MARs) for October 2012 and November 2012 verify this medication was never administered during that time period and no stop date was provided. Another order dated 11/22/2010 for Tylenol 650 mg suppository was incomplete as it did not specify a route for administration. This information was discussed with the Director of Nursing (DON) on 12/5/12 at 2:30 p.m. and she was unable to provide further information. According to the facility policy and procedure titled Stop Orders , All PRN {as needed} orders, except for [MEDICATION NAME], are discontinued in 60 days if not utilized at all during that time, unless the prescriber specifically orders them to be continued indefinitely or for a specified period of time. b.) Resident #16 Resident #16 was admitted on [DATE] with an order for [REDACTED]. A second request from pharmacy dated 10/16/12 stated Consider dose reduction or drug holiday . It was not until 10/22/12 that the dosage of [MEDICATION NAME] was reduced to 0.25 mg every morning, over two months after the initial recommendation. During the period from initial request to dose reduction, there was no evidence to suggest the reduction was contraindicated. In fact, according to Psychoactive medication monthly flow record for August 2012 through October 2012, no behaviors were documented by nursing. A staff interview was performed on 12/4/12 at 4:00 p.m. with Staff Pharmacist who verified accuracy of all information. In addition, an order was in place for [MEDICATION NAME] suppositories 25 mg 1 PR {per rectum} every 6 hours prn {as needed}. Nausea . This order was dated 8/4/12. I had not been administered during October or November, 2012. No stop date was listed. As per facility policy and procedure, all as needed medications not used in past sixty (60) days are to be discontinued. c.) Resident #3 [MEDICATION NAME] 25 mg twice a day was among the list of medications ordered for Resident #3 upon admission 2/22/12. It was not until 8/14/12 when Pharmacy first addressed [MEDICATION NAME] and stated it was still appropriate as Resident #3 was having hallucinations. On 10/11/12 pharmacy made a recommendation for the physician to try and taper the [MEDICATION NAME]. On 10/24/12 the physician completely discontinued the [MEDICATION NAME]. On 10/25 there was a physician's order [REDACTED]. This was discussed and verified with the Pharmacist on 12/4/12 at 4 p.m. In addition, Resident #3 had physician orders [REDACTED]. There is no order to specify under what situation the nurse should apply Preparation H and when to apply the [MEDICATION NAME]. The Preparation H order is incomplete and does not include a site where to apply, nor does it have a stop date. The original order was written 9/9/2005. The [MEDICATION NAME] order also does not have a stop date and is dated 4/1/2009. An order dated 3/1/11 stated [MEDICATION NAME] Cream to vaginal area and labia PRN {as needed} . This order has no stop date and gives no indication as to what symptoms constitute as needed . These orders were discussed with the DON on 12/5/12 at 2:30 p.m. and she had no further information. The policy clearly states that all as needed medications not used in sixty (60) days will be discontinued. According to the Medication Administration Record [REDACTED]. d) Resident #2 Review of the medical record on 12/06/12 revealed the following prn medications: [REDACTED]. [MEDICATION NAME] 4 mg was administered once between 08/01/12 and 11/30/12 on 09/29/12 and currently remains on the residents MAR indicated [REDACTED] The pharmacy reconciliation notes dated 01/12/12 through 12/04/12 verifies the pharmacist failed to recognize and notify the physician to discontinue prn medications which were not used for 60 days as the policy states. During a staff interview on 12/06/12 at 9:30 a.m. with the Director of Nursing (DON) employee #11 she acknowledged they were not following the facility's policy which is to automatically stop prn medications after thirty (30) days. The pharmacy policy received on 12/06/12 at 10:27 a.m. from the DON employee #11, states All new medication orders are subject to automatic stop orders unless the medication orders specify the number of doses or duration of medication. A time limit is included in recapped orders. All prn medication orders, except for [MEDICATION NAME], are discontinued in 60 days if not utilized at all during that time, unless the prescriber specifically orders them to be continued indefinitely or for a special period of time.", "filedate": "2016-05-01"}
{"rowid": 8627, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2012-12-07", "deficiency_tag": 332, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "L97I11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record and facility policy review, the facility failed to administer medications at an error rate of less than 5% for two (2) residents. Three (3) errors were observed for ten (10) residents with 58 opportunities for a medication error rate of 5.17%. Resident identifiers: #6, and #16. Facility census: 16. Findings include: Error #1 and #2 On 12/05/12 at 8:30 a.m., medications were observed being given to Resident #6 by a licensed practical nurse (LPN), (Employee #4). The resident's medications included Potassium Chloride (KCl) 10 milliequivalent (meq) orally. Resident #6 was also given [MEDICATION NAME] 0.125 mg (milligrams) orally. Employee #4 completed a radial pulse check and stated the residents pulse was 64. When Employee #4 was asked what the facility policy was regarding the amount of fluids to be given with KCl and checking the heart rate prior to giving the [MEDICATION NAME] she stated it was not specified. This employee also stated there was no specified policy regarding the amount of fluids to be given when administering KCl. Errors #3 On 12/05/12 at 8:50 a.m., medications were observed being given to Resident #16 by a licensed practical nurse (LPN), (Employee #4). The resident's medications included KCl 10 meq orally. When Employee #4 was asked what the facility policy was regarding the amount of fluids to be given with KCl she stated there was no specified policy regarding the amount of fluids to be given when administering KCl. In an interview with the director of nursing (DON), on 12/05/12 at 10:00 a.m., the DON stated all staff knew an apical pulse was to the taken prior to giving [MEDICATION NAME]. The DON further stated she was unaware of any fluid requirements when administering KCl other than laboratory requirements. The DON stated she would provide a copy of the facility policy and procedure for the administering of [MEDICATION NAME] and KCl. On 10/05/12 at 10:30 a.m., a review of the facility policy and procedure titled, Medication Monitoring, under STATEMENT OF PROCEDURE 1. [MEDICATION NAME] Check apical pulse immediately before administering, with the resident at rest. If the pulse . 10. POTASSIUM SUPPLEMENTS Obtain serum electrolytes every six months unless the physician orders differently. Contact the physician . A concurrent review of the facility policy titled Oral Medication Administration Procedure, revealed under section 6. Follow all medication with 4-8 ounces of water. Preparation containing iron are .", "filedate": "2016-05-01"}
{"rowid": 8628, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2012-12-07", "deficiency_tag": 364, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "L97I11", "inspection_text": "The facility failed to provide pureed foods attractive in appearance. This was true for four (4) of nine (9) residents. Resident identifiers: Resident #1, #9, #6, #15. Facility census sixteen (16). Findings include: a.) During lunch on 12/3/12, two (2) residents were observed with pureed meals with food white in color and lacking any accent color with the meal. Resident identifiers #6 and #15. b.) When Breakfast was served to Resident #1 on 12/4/12 it was all white and shades of beige. c.) The lunch meal received by Residents #1 and #9 on 12/4/12 was also white and shades of beige. d.) On 12/5/12 Resident #9 was served a lunch that was all white and lacked any accent color. e.) The appearance of the meals was discussed with the DON at 3:00 p.m. on 12/5/12. The Dietary Manager and the Dietician at 8:00 a.m. on 12/7/12.", "filedate": "2016-05-01"}
{"rowid": 8629, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2012-12-07", "deficiency_tag": 428, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "L97I11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and staff interview, the pharmacist failed to recognize and report drug irregularities for five (5) of eleven (11) sampled residents. Resident #2 had eight (8) as needed (prn) medications: [REDACTED]. In addition she had a prn order for Zofran four (4) milligrams (mg) which had not been administered for over sixty (60) days. There were no stop dates documented for these medications. Resident #6 was receiving the medication Digoxin 0.125 milligrams (mg) everyday for congestive heart failure. The facility policy states serum Digoxin levels are to be drawn every six (6) months. There were no orders or laboratory results in the medical records for a Digoxin level. Resident #5 had an order written [REDACTED]. According to the medication administration records (MAR) dated October 2012 and November 2012 this medication was never given and a stop date was not provided. In addition an order for [REDACTED]. Resident #16 had an order for [REDACTED]. Resident #3 was prescribed Seroquel twenty-five (25) milligrams (mg) twice a day on admission 02/22/12. Pharmacy first addressed this medication on 08/14/12 stating that it was appropriate for this resident and on 10/11/12 pharmacy recommended an attempt to taper the Seroquel dose. In addition the resident had incomplete as needed orders for Preperation H and Anusol creams. There was no specification as to when and where to apply which cream nor a stop date identified. Nystatin cream was ordered on [DATE] for an as needed basis but lacked a stop date and an indication for use. Resident identifiers: #2, #6, #5, #16, #3. Facility census: 16. Findings include: a) Resident #2 Review of the medical record on 12/06/12 revealed the following prn medications: [REDACTED]. Zofran 4 mg was administered once between 08/01/12 and 11/30/12 on 09/29/12 and currently remains on the residents MAR indicated [REDACTED] The pharmacy reconciliation notes dated 01/12/12 through 12/04/12 verifies the pharmacist failed to recognize and notify the physician to discontinue prn medications which were not used for 60 days as the facility policy states. A staff interview on 12/06/12 at 9:30 a.m. with the Director of Nursing (DON) employee #11 revealed the facility's routine is to automatically stop prn medications after thirty (30) days. She admitted they had not been following this policy and discontinuing the prn medications that were not being administered. The pharmacy Stop Orders policy received on 12/06/12 at 10:27 a.m. from the DON employee #11, states All new medication orders are subject to automatic stop orders unless the medication orders specify the number of doses or duration of medication. A time limit is included in recapped orders. All prn medication orders, except for nitroglycerin, are discontinued in 60 days if not utilized at all during that time, unless the prescriber specifically orders them to be continued indefinitely or for a special period of time. b) Resident #6 Medical record review on 12/05/12 at 10:30 a.m., revealed Resident #6 was ordered Digoxin 0.25 mg (milligrams) daily for congestive heart failure (CHF). A review of the monthly drug regime reviews conducted, by the consulting pharmacist, revealed no information regarding monitoring of the digoxin level for Resident #6. A previously provided copy of the facility policy titled Medication Monitoring was reviewed. Under the following section the policy states: 1. DIGOXIN ? A six months serum digoxin level is obtained, unless the physician orders [REDACTED]. On 12/06/12 at 3:00 p.m., a review of the physician orders [REDACTED]. The DON was asked if any evidence of a digoxin level being obtained could be produced. On 12/06/12 at 3:45 p.m., in an interview with the DON, revealed a digoxin level had last been completed on 04/04/11. She agreed the monitoring of a digoxin level had not been obtained for this resident in over a year. c.) Resident #5 A record review performed on 12/4/12 of physician's order [REDACTED]. No indication for usage was listed. The medication administration records (MARs) for October 2012 and November 2012 verify this medication was never administered during that time period and no stop date was provided. Another order dated 11/22/2010 for Tylenol 650 mg suppository was incomplete as it did not specify a route for administration. This information was discussed with the Director of Nursing (DON) on 12/5/12 at 2:30 p.m. and she was unable to provide further information. According to the facility policy titled Stop Orders , All PRN {as needed} orders, except for nitroglycerin, are discontinued in 60 days if not utilized at all during that time, unless the prescriber specifically orders them to be continued indefinitely or for a specified period of time. d.) Resident #16 A physician's orders [REDACTED].{per rectum} every 6 hours prn {as needed}. Nausea . This order was dated 8/4/12. I had not been administered during October or November, 2012. No stop date was listed. As per facility policy and procedure, all as needed medications not used in past 60 (sixty) days are to be discontinued. e.) Resident #3 Seroquel 25 mg twice a day was among the list of medications ordered for Resident #3 upon admission 2/22/12. It was not until 8/14/12 when Pharmacy first addressed Seroquel and stated it was still appropriate as Resident #3 was having hallucinations. On 10/11/12 pharmacy made a recommendation for the physician to try and taper the Seroquel. On 10/24/12 the physician completely discontinued the Seroquel. On 10/25 there was a physician's order [REDACTED]. This was discussed and verified with the Pharmacist on 12/4/12 at 4 p.m. In addition, Resident #3 had physician orders [REDACTED]. There is no order to specify under what situation the nurse should apply Preparation H and when to apply the Anusol. The Preparation H order is incomplete and does not include a site where to apply, nor does it have a stop date. The original order was written 9/9/2005. The Anusol order also does not have a stop date and is dated 4/1/2009. An order dated 3/1/11 stated Nystatin Cream to vaginal area and labia PRN {as needed} . This order has no stop date and gives no indication as to what symptoms constitute as needed . These orders were discussed with the DON on 12/5/12 at 2:30 p.m. and she had no further information. The policy clearly states that all as needed medications not used in sixty (60) days will be discontinued. According to the Medication Administration Record [REDACTED].", "filedate": "2016-05-01"}
{"rowid": 8630, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2012-12-07", "deficiency_tag": 431, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "L97I11", "inspection_text": "Based on observation and staff interview, the facility failed to label over-the-counter (OTC) medications with the opened date. Medications were found in a medication cart and the medication storage room were not dated as to when the medication had been opened. This has the potential to affect all residents receiving OTC's. Facility census: 16. Findings include: a) On 12/04/12 at 12:00 p.m., an observation was made, with the director of nursing (DON), of the medication room. A open bottle of ferrous sulfate was found with no date as to when the medication had been opened. The DON agreed the medication was not dated. She further agreed the facility policy was to date and initial any medication when it is initially opened. Inspection of the medication cart, conducted on 12/04/12 at 2:45 p.m., with a licensed practical nurse (LPN - Employee #4), revealed MiAcid (Mylanta), milk of magnesia (MOM), OsCal, and Allergra not dated as to when the medication had been opened. Employee #4 agreed the policy was to date and initial the medication when it was opened. On 12/05/12 at 8:30 a.m., Employee #4 was observed opening a new bottle of medication and proceeding to date and initial the new bottle.", "filedate": "2016-05-01"}
{"rowid": 8631, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2012-12-07", "deficiency_tag": 441, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "L97I11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review and staff interview, the facility failed to follow sanitary infection control practices to prevent the contamination of medications. During the observation of a medication pass, a medication, dropped on the medication cart, administered to a resident. Furthermore, a nurse used fingers to remove medications from multiple bottles of over-the-counter medications. This affected two (2) of ten (10) residents observed during a medication pass. Resident identifiers: Resident #15 and #16. Facility census: 16. Findings included: a) Resident #15 On 12/05/12 at 8:50 a.m., observation of a licensed practical nurse (LPN - Employee #4), revealed an [MEDICATION NAME] tablet was dropped on the medication cart, picked up and placed in the medication cup. Furthermore, Employee #4 used her fingers to remove [MEDICATION NAME] sulfate and aspirin from the bottles of medication. This employee then proceeded to give the medications to Resident #15. b) Resident #16 On 12/05/12 at 8:27 a.m., observation of a licensed practical nurse (LPN - Employee #4), revealed this employee used her fingers to remove aspirin from the bottle. This employee then proceeded to give the medication to Resident #16. In an interview with Employee #4, on 12/05/12 at 9:15 a.m., revealed this employee agreed medications were not removed from medication bottles with fingers. This employee agreed the medication dropped on the medication cart were to be discarded. On 12/05/12 at 2:00 p.m., a review of the facility policy titled, Oral Medication Administration Procedure, revealed under section Key Points the following: 6. Pour the correct number of tablets or capsules into the medication cup. * Never touch any of the medications with fingers.", "filedate": "2016-05-01"}
{"rowid": 8632, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2012-12-07", "deficiency_tag": 514, "scope_severity": "C", "complaint": 0, "standard": 1, "eventid": "L97I11", "inspection_text": "Based on record review, observation, and staff interview the facility failed to assure that a part of the medical record for all residents was readily accessable for resident care in accordance with accepted professional standards. This had the potential to effect all residents. Facility census 16. Findings include: a) During the initial interview with the Director of Nurses at 12:30 p.m. on 12/03/12, she informed this surveyor that all aspects of the record were available on the chart except the MDS which was in the computer and hard copies are no longer being produced for the chart. During a discussion of accessing the MDS on the morning of 12/05/12, with Employee #4 (Licensed Practical Nurse) she stated that she would have to request someone to do this as she did not have access to the computer. This was verified with the DON, who stated that only she, the unit clerk, and the MDS nurse have entry to the computer. When asked, she stated that they all worked day shift. She acknowledged that they had not considered the lack of access by the nursing staff caring for the resident when the decision was made not to print hard copies of the MDS for the chart.", "filedate": "2016-05-01"}
{"rowid": 9161, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2013-02-13", "deficiency_tag": 280, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "1G6H11", "inspection_text": "br>Based on medical record record review and staff interview, the facility failed to revise a care plan for one (1) of five (5) sampled residents, to include additional activities and/or services to ensure optimal quality of life. Resident identifier: #1. Facility census: 14. Findings include: a) Resident #1 Review of a social service's progress note, dated 09/14/12, revealed the Medical Power of Attorney (MPOA) had asked about hospice services. The MPOA's goals for hospice services were to ensure more people visited the resident because the MPOA was not able to visit often. A social services progress note, dated 10/12/12, revealed the MPOA had met with the facility care plan team. An agreement was reached to have increased visits from pastoral care and volunteers in lieu of Hospice, related to the MPOA only wanting Hospice for increased visits. The current care plan included interventions to increase 1:1 visits with staff and activities, as the resident enjoyed 1:1 visits and conversation. According to the current care plan, he enjoyed 1:1 making over him, smiles, laughs and loves extra attention. The current care plan made no mention of increased visits from pastors and volunteers, as previously decided in the October 2012 care plan meeting. During an interview with the licensed social service manager, on 02/13/13 at 9:45 a.m., she said that Resident #1 receives pastoral visits from two (2) to four (4) times each month. She said that he does not have an assigned volunteer, but when volunteers visit during the week, they will visit with him 1:1. During an interview with the MDS (Minimum Data Set) coordinator/registered nurse, Employee #18, and the consultant administrator, on 02/13/13 at 4:00 p.m., they agreed there was not a care plan to have extra pastoral visits and volunteer visits.", "filedate": "2016-02-01"}
{"rowid": 9162, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2013-02-13", "deficiency_tag": 367, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "1G6H11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and physician interview, the facility failed to follow physician's orders for a prescribed diet, or alternatively, to consult the physician regarding a need for a change in the resident's diet order for one (1) of five (5) sampled residents. Resident identifier: #1. Facility census: 14. Findings include: a) Resident #1 Observation of the morning meal, on 02/13/13 at 8:30 a.m., found Resident #1 being assisted with his meal which included french toast. He showed no visible signs at that time of choking, or difficulty swallowing. Observation of the noon meal, on 02/13/13 at 12:15 p.m., found a nursing assistant sitting by his side in the dining/activity room, assisting him with his meal. He was served a chicken salad sandwich that had been cut in half, as well as soup and some pureed food and Ensure. During an interview with a licensed nurse, Employee #14, on 02/13/13 at 12:30 p.m., she said Resident #1 was on a regular diet when he first arrived from an assisted living facility, but he would not eat well. He would pocket food in his cheek. He had no dentures and no natural teeth, and he could not chew all foods on a regular diet. He received a regular diet at breakfast with soft foods such as scrambled eggs and french toast or pancakes with syrup. She said he was served a soft sandwich at lunch and dinner daily. Sometimes he refused the sandwich, and at other times he ate nothing but the sandwich. He also received soft textured foods such as ice cream, pie without the hardened crust, cake, soft vegetables, soup, soft fruit such as bananas. She said the texture of the food served was in relation to his being edentulous. She said his food intake declined while on a regular diet, but increased when the texture was changed to pureed. She said he did not choke on foods to her knowledge. Review of a social service care plan note, dated 10/12/12, revealed the Medical Power of Attorney (MPOA) had concerns with pureed food, and the MPOA asked that he have a sandwich at lunch and dinner time. The registered dietitian agreed to try this, and send it along with his pureed food. The Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 12/31/12, was reviewed. It revealed his Brief Mental Assessment (BIM) score was only three (3) which signified severe cognitive loss. He was coded as having a swallowing/nutritional status problem with loss of liquids/solids from his mouth, coughing or choking. He was 74 inches tall, and weighed 119 pounds. A dietary progress note, dated 01/03/13, revealed the resident had a regular diet for breakfast and NDD1 (National Dysphagia Diet - a pureed diet) for lunch and dinner. In this note, the dietitian said the resident continued to have loss of liquid from the mouth, coughing and choking at meal times, and he was on a mechanically altered diet. Review of an Informed Refusal form, dated 01/25/13, revealed physical therapy, occupational therapy, and speech/language pathology had made a recommendation for a pureed diet for all meals. This was also recommended by the Interdisciplinary Team (IDT), but was refused by the MPOA. The purpose and benefit of those care or treatment recommendations was noted, as well as the risks of refusing them, and of possible alternatives. The current care plan was reviewed. It revealed the resident received a regular diet for breakfast and a NDD2 (National Dysphagia Diet - a mechanically altered diet) for lunch and dinner, and he coughed and choked at meals at times. Review of the current physician's orders revealed an order for [REDACTED]. During an interview with the MDS coordinator/registered nurse, Employee #18, and consultant administrator, Employee #22, on 02/13/13 at 4:00 p.m., they agreed there was not a physician's order for the sandwiches for lunch and dinner which the resident was receiving daily. During a telephone interview with the physician, on 02/13/12 at 4:30 p.m., he said he recalled the MPOA asking him if it would hurt the resident to have a sandwich once in awhile, to which he told her that it would not hurt him. He said he did not recall if nursing staff had requested sandwiches for the lunch and dinner meals, but said they probably did, and he would write an order to that effect. He said he did not recall anyone asking for regular diets for all meals.", "filedate": "2016-02-01"}
{"rowid": 10495, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2011-01-06", "deficiency_tag": 225, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "CROM11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of a fall investigation, policy review, and staff interview, the facility failed to immediately report an injury involving possible neglect, and failed to report the findings of a thorough investigation into the event within five (5) working days of the incident. On 11/18/10, one (1) of seven (7) sampled residents fell from a Hoyer lift when the sling became detached, sustaining a fracture that required surgical repair. The facility's immediately ruled out mechanical failure of the lift as the cause of the sling becoming detached from the device, but the facility failed to immediately report the incident as having resulted from possible neglect by the nurse aide involved; instead, the facility reported the event as an \"unusual occurrence\". The facility also failed to report the findings of an investigation into the incident to State officials as required within five (5) working days, although the facility implemented measures, such as requiring the assistance of two (2) staff members with all transfers via mechanical lift, following the occurrence of this incident. Resident identifier: #8. Facility census: 16. Findings include: a) Resident #8 A review of Resident #8's medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Review of an incident report for 11/18/10 revealed the resident had fallen while being transferred from a chair to her bed by a nurse aide using a Hoyer lift; the lift sling became unattached, and the resident fell and sustained a [MEDICAL CONDITION] femur requiring hospitalization and surgical repair. The facility recognized immediately there was no obvious malfunction of the lift, and they reported the incident to the State survey and certification agency as an \"unusual occurrence\". Having ruled out mechanical failure as the cause, the facility failed to identify and report the fall as having been the result of possible neglect by the nurse aide involved. In an interview with the facility's risk manager (who was in charge of the reporting process) at 10:40 a.m. on 01/04/11, she stated that an in-depth investigation had been done and was still part of a quality assurance root cause analysis that was not yet complete. She produced the documentation of the investigation and acknowledged that the facility immediately made procedural changes by posting the requirement that two (2) staff members be present for all mechanically assisted transfers (posted on 12/22/10). She stated that she would report the incident as soon as possible. During an interview with the nursing director of the unit at 9:30 a.m. on 01/05/11, she verified that the lift had been checked thoroughly for malfunction immediately after the incident, and nothing was mechanically wrong with the lift. It was pointed out to her that the facility's policy / procedure for using the lift stated: \"5. Check and verify proper sling attachment before starting the process.\" \"10. The resident should be lifted slightly off a surface, and the lift paused, to check balance of the resident and the strap connections.\" She agreed that, if these things had not been done, it would have been considered neglect and would have been reported as such, but she did not comment on actual findings of the investigation. .", "filedate": "2015-03-01"}
{"rowid": 10496, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2011-01-06", "deficiency_tag": 241, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "CROM11", "inspection_text": ". Based on observations, staff interview, and record review, the facility did not ensure two (2) of seven (7) sampled residents received care in a manner that maintained or enhanced each resident's dignity and respect in full recognition of the resident's individuality. Resident identifiers: #3 and #61. Facility census: 16. Findings include: a) Residents #3 and #61 An observation, at 5:00 p.m. on 01/03/11, revealed food trays were placed in the room shared by Residents #3 and #61. The residents were observed sitting in bed with an overbed table and food tray in front of each resident. Residents #3 and #61 were observed sleeping at 5:30 p.m., and neither resident had not started to eat their food. At 5:45 p.m., both residents were again observed, and the director of nursing (DON - Employee #14) was in the room and was encouraging the residents to eat. The DON stated to the residents, \"The food is cold, and I will get you something else to eat.\" The residents did not consume any of their food. An interview with the DON, on 01/03/11 at 5:45 p.m., revealed that someone should have gone into the residents' room and encouraged both of the residents to eat. Record review revealed Residents #3 and #61 did not have capacity and required supervision and staff assistance with meals. .", "filedate": "2015-03-01"}
{"rowid": 10497, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2011-01-06", "deficiency_tag": 258, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "CROM11", "inspection_text": ". Based on observation and staff interview, the facility did not provide for the maintenance of comfortable sound levels in the facility's only dining room during meal service. Six (6) randomly observed residents were present during an observation of the evening meal at 5:30 p.m. on 01/03/11, which found residents yelling out and banging on surfaces. This had the potential to affect more than a minimal number of residents. Resident census: 16. Findings include: a) An observation of the facility's dining room, on 01/03/11 at 5:30 p.m., revealed six (6) residents eating dinner. Two (2) of the residents were yelling loudly, and one (1) of the two (2) was banging on the lap table. A resident was observed sitting between these two (2) residents making the loud sounds. A nurse aide asked the resident if she wanted to move to the other side of the dining room, and the resident continued to eat and shook her head to indicate \"no\". Three (3) residents were observed sitting on the other side of the dining room, and the loud sounds were also heard in this area. An interview on 01/04/11 at 2:00 p.m., the director of nursing (DON - Employee #14) acknowledged the dining room was small and reported that the residents who required total care with eating were brought in at the same time as other residents who may only require supervision or assistance. The dining room's noise level was usually high because of residents who were unable to control their behavior of yelling. .", "filedate": "2015-03-01"}
{"rowid": 10498, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2011-01-06", "deficiency_tag": 279, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "CROM11", "inspection_text": ". Based on record review, family interview, observation, and staff interview, the facility failed to develop a comprehensive care plan that included measurable objectives and timetables to meet a resident's medical needs as identified in the comprehensive assessment for one (1) resident of seven (7) sampled residents. The resident had functional limitations in range of motion that were not address in the care plan. Resident identifier: #12. Facility census: 16. Findings include: a) Resident #12 A review of an assessment of Resident #12 for functional limitation in range of motion, dated 12/19/10, indicated, \"Impairment of both sides for upper extremity: shoulder, elbow, wrist and hand and impairment on both sides lower extremity: hip knee, ankle and foot.\" A review of the resident's care plan did not address the resident's limited range of motion. An interview with the resident's daughter, on 01/04/11 at 10:00 a.m., revealed the family did not want a splint applied to the resident right's hand. Observation revealed the fingers of the resident's right hand were able to extend without difficulty, but the wrist was contracted and did not move. An interview with the director of nursing (DON - Employee #14), on 01/04/11 at 3:00 p.m., confirmed the resident's care plan did not address limitations in range of motion, but she felt they should take credit for doing passive range of motion for the resident. She further stated a care plan will be developed immediately to address the resident's limited range of motion. .", "filedate": "2015-03-01"}
{"rowid": 10499, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2011-01-06", "deficiency_tag": 280, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "CROM11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed, for one (1) of seven (7) residents reviewed, to review and revise the resident's care plan to assure conditions were accurately addressed, when the resident had experienced a significant weight loss and when the resident consistently refused to participate in a program of restorative nursing services that had been established by the therapy department. Resident identifier: #15. Facility census: 16. Findings include: a) Resident #15 1. When reviewed during the course of the annual re-survey event from 01/03/11 through 01/05/11, Resident #15's medical record was found to contain a note entered by the facility's consultant registered dietician (RD) dated 01/04/11, stating the resident had a \"33 pound weight loss since admission\". The resident was admitted to the facility on [DATE]. Review of the resident's vital signs and weight record revealed the following weights: - 147# on 09/27/10 - 141# on 10/01/10 - 124# on 11/04/10 - 119# on 12/02/10 - 115# on 01/04/11 This represented a loss of 32# in approximately three (3) months. Further review disclosed that, on 10/11/10, the facility received a physician's orders [REDACTED]. On 11/03/10, the facility had changed the resident's diet from regular consistency foods at all meals to pureed consistency foods for lunch and dinner and regular consistency foods at breakfast. The resident's comprehensive care plan, established on 10/11/10, identified as a problem: \"Leaves 25% of meals uneaten. Self feeding difficulty. Constant drooling-loss of liquids and food during mealtime.\" It was also noted that the resident had \"Potential for dehydration\". The resident's care plan had not been revised to reflect the resident's current nutritional status or to reflect the steps taken (e.g., nutritional supplement and diet change) in an effort to reverse the weight loss. When the resident continued to lose weight after 11/03/10, the interdisciplinary team failed to develop or implement any additional measures in an effort to retard or reverse this unplanned weight loss. - 2. The resident's record, when further reviewed, disclosed a physical therapy daily note, dated 10/01/10, with directives to \"D/C to restorative program.\" The restorative nursing program plans, as stated on the restorative nursing and progress summary form, stated: \"Ambulate on level surface with CAN (sic) and no loss of balance x 50 feet with rolling walker. Appropriate use of rolling walker during stand, pivot, transfer (sic). Exercise to improve function.\" The care plan problem was noted to be: \"Decreased posture, decreased balance, decreased functional mobility. Recent decreased function / cognition. Dx (diagnosis): [MEDICAL CONDITION].\" Approaches included: \"Ambulate with rolling walker 250 feet with supervision. Promote good seated / standing posture, transfer with supervision.\" Review of the restorative nursing and progress summary reports revealed that, after 11/07/10, the resident did not participate in the restorative program. As of 01/04/11, there had been no reassessment to determine why the resident was refusing to participate. The resident's care plan had noted the development of a restorative services plan on 10/01/10, but it had not been updated at any time since the resident began to refuse the services on 11/08/10. .", "filedate": "2015-03-01"}
{"rowid": 10500, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2011-01-06", "deficiency_tag": 282, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "CROM11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed, for one (1) of seven (7) residents reviewed, to provide services as established in his written plan of care. The resident was noted to be seated in a multi-positional wheelchair where he sat, during one (1) observation period, without re-positioning for long periods of time and, at another time, his feet were dangling unsupported several inches above the floor. His care plan indicated he was supposed to be positioned for comfort, and the unit's director of nursing (DON) acknowledged that his feet should have been supported by foot rests. Resident identifier: #15. Facility census: 16. Findings include: a) Resident #15 At the time of entrance to the facility on [DATE] at 1:30 p.m., observation found Resident #15 sitting in a wheelchair in the hall near the nurse's station. Although it appeared the back of the wheelchair was able to be reclined, the resident was observed in the upright position with his feet on the foot rests secured with some sort of band-like device. The resident was observed at numerous times during this afternoon by two (2) surveyors, and never was he observed to be in a different position. At approximately 5:30 p.m. on 01/03/11, the resident was moved to the common area where some residents took their meals. The resident remained in the same position. The resident, at this time, became agitated, reaching out for objects that were not there, etc. The resident's position was not changed throughout the meal, which ended at approximately 6:00 p.m. On 01/04/11 at 2:17 p.m., the resident was observed to be up in the same wheelchair in a slightly back-tilted position with his feet not secured on the foot rests and dangling approximately four (4) inches from the floor. - On 01/05/11 at 9:50 a.m., the DON (Employee #14), designated as being in charge of the unit, was interviewed. When asked about the resident's ability to move himself in the chair, Employee #14 stated he could not reposition himself. When told of the observations on 01/03/11 of the resident not being repositioned between 1:30 p.m. and 6:00 p.m., this employee stated that all residents were toileted at shift change, around 3:00 p.m., in preparation for dinner. She did not see this observe this having occurred for Resident #15 on 01/03/11; nor did the surveyors observe this to have occurred. Employee #14 also stated the resident's feet should not have been dangling unsupported but should have been positioned on the foot rests. When asked how this resident was supposed to be positioned, Employee #14 stated that Resident #15 was in a wheelchair that could be reclined and this would alternate areas of pressure; she also confirmed his feet should be positioned on the foot rests. - The resident's admission minimum data set assessment (MDS), dated [DATE], was reviewed and, although chair positioning was not directly addressed, the assessor encoded, in Section G0110 (Activities of Daily Living related to Bed Mobility) the resident as requiring the extensive assistance of two (2) or more persons for repositioning. The resident's care plan (dated 09/28/10) identified a problem of \"altered comfort\". Although the resident's inability to reposition himself was not directly addressed, the interdisciplinary team (IDT) determined the resident required the following interventions: \"positioned for comfort, encourage rest periods throughout the day depending on resident's activity level or [MEDICAL CONDITION], monitor lower extremities for [MEDICAL CONDITION] and elevate lower extremities if [MEDICAL CONDITION] is present.\" In the area of resident's medical [DIAGNOSES REDACTED]. - At the time of exit from the facility on 01/05/11 at 1:45 p.m., facility staff could provide no evidence that staff was implementing the resident's care plan as determined necessary when it was established on 09/28/10. .", "filedate": "2015-03-01"}
{"rowid": 10501, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2011-01-06", "deficiency_tag": 309, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "CROM11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide care and services to one (1) of seven (7) sampled residents as determined necessary by his comprehensive assessment and plan of care to attain the highest practicable physical status. Resident #15 was admitted to the facility on [DATE], at which time he weighed 147 pounds (#). On 10/01/10, he weighed 141#, the physician ordered a nutritional supplement three (3) times daily for additional calories. On 11/03/10, the physician ordered changes to the consistency of his meals, serving pureed foods at lunch and dinner, and on 11/04/10, he weighed 124#. The resident continued to lose weight after 11/04/10, with no evidence of further assessments for the cause(s) of the unplanned weight loss and no further additional interventions implemented in an effort to slow or reverse the weight loss. By 01/04/11, he weighed 115#, which represented a 32# unplanned weight loss over a period of approximately three (3) months with no evidence to reflect this weight loss was clinically unavoidable. Additionally, on 10/01/10, the physician ordered restorative nursing services to improve his physical functioning. The resident refused to participate in the restorative nursing programs for two (2) months. A significant change in status assessment, with an assessment reference date of 01/04/11, revealed he had experienced a significant decline in self-performance of activities of daily living in at least five (5) areas since admission. There was no evidence of efforts by the facility's interdisciplinary team, prior to this survey event, to reassess or revise the resident's care plan to address the resident's refusal of participate in the restorative services intended to improve his physical functioning. Resident identifier: #15. Facility census: 16. Findings include: a) Resident #15 When reviewed on 01/04/11, Resident #15's medical record revealed this [AGE] year old male had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. Record review revealed a note entered by the facility's consultant registered dietitian (RD), dated 01/04/11, stating the resident had a \"33 pound weight loss since admission\". Review of the resident's vital signs and weight record revealed the following weights: - 147# on 09/27/10 - 141# on 10/01/10 - 124# on 11/04/10 - 119# on 12/02/10 - 115# on 01/04/11 This represented a loss of 32# in approximately three (3) months. Further review disclosed that, on 10/11/10 (the date of the care plan review), the facility received a physician's orders [REDACTED]. Documentation on a \"Resident Nutritional Assessment\" revealed notations of the resident's weights and a note, dated 11/03/10, stating the resident's diet was changed from regular consistency foods at all meals to regular consistency foods for breakfast only and pureed consistency foods for lunch and dinner; the author also noted that the resident did not want nursing staff to feed him. There were no further entries in the record by dietary personnel until 01/04/11, when the RD noted the resident's weight loss, described meal intakes, medications, etc., and ended by saying \"resident is currently not meeting care plan goal of consuming 70% of meals or maintaining his weight.\" The medical record revealed no evidence of further interventions related to this significant unplanned weight loss. - 2. A physical therapy daily note, dated 10/01/10, discontinued the resident from physical therapy to a restorative nursing program. The restorative nursing program plans stated: \"Ambulate on level surface with CAN (sic) and no loss of balance x 50 feet with rolling walker. Appropriate use of rolling walker during stand, pivot, transfer (sic). Exercise to improve function.\" The care plan problem was noted to be: \"Decreased posture, decreased balance, decreased functional mobility. Recent decreased function / cognition. Dx (diagnosis): [MEDICAL CONDITION].\" Approaches included: \"Ambulate with rolling walker 250 feet with supervision. Promote good seated / standing posture, transfer with supervision.\" Review of the restorative nursing and progress summary reports revealed that, after 11/07/10, the resident did not participate in the restorative program. As of 01/04/11, there had been no reassessment to determine why the resident was refusing to participate, nor was any revision made to the care plan in light of the resident's refusal of treatment. - 3. Review of the resident's admission assessment, with an assessment reference date (ARD) of 10/07/10, revealed in Section G the resident required supervision and set-up assistance with eating; the limited assistance of one (1) person for walking in the corridor, locomotion off the unit, and toilet use; the limited assistance of two or more persons with transfers; and the extensive physical assistance of two (2) or more persons with walking in the room. Review of a significant change in status assessment, with an ARD of 01/03/11, revealed in Section G the resident required the limited assistance of one (1) person with eating; the extensive physical assistance of two (2) or more persons for transfers and toilet use; the activity of walking in the room occurred only once or twice during the reference period and required the assistance of one (1) person; the activity of walking in the corridor did not occur at all during the reference period; the resident was totally dependent on one (1) person for locomotion off the unit. A comparison of these two (2) assessments revealed the resident had significant declines in self-performance in transfers, walking in room, walking in the corridor, locomotion off the unit; and toilet use in a three (3) month period. - 4. The director of nursing (DON - Employee #14), when interviewed on 01/04/11 at 4:14 p.m., confirmed that staff was aware of the resident's weight loss and that, other than the addition of the Mighty Shakes and a change of consistency of the resident's diet early in his stay, nothing else had been done. Employee #14 further stated the resident's medical power of attorney representative did not want aggressive treatment. This employee confirmed the resident had refused to participate in the physician-ordered restorative nursing services and that no reassessment or revision to the resident's care plan had occurred. - 5. At the time of survey team's exit from the facility at 1:15 p.m. on 01/05/11, facility staff had not provided evidence that the resident's significant unplanned weight loss had been discussed with him and/or his responsible party in an effort to assess for cause(s) of the loss and to develop and implement a plan to reverse the weight loss. .", "filedate": "2015-03-01"}
{"rowid": 10502, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2011-01-06", "deficiency_tag": 314, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "CROM11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of seven (7) residents reviewed who entered the facility without a pressure ulcer, to provide care and services to prevent the development of a pressure ulcer. When admitted to the facility on [DATE], Resident #15 had no pressure ulcers present and no history of having had resolved pressure sores. Facility staff failed to implement measures to assure the resident maintained good nutritional status, and the resident experienced a clinically avoidable 32 pound (#) weight loss in three (3) months at the facility. Physical therapy had developed a plan for restorative nursing care, in which the resident refused to participate for two (2) months with no re-assessment by staff. Staff interview confirmed Resident #15 had sustained a significant unplanned weight loss and that the resident's refusal to participate in restorative services could have contributed to the pressure ulcer development. The resident developed two (2) Stage II pressure ulcers with no evidence to indicate this skin breakdown was clinically unavoidable. Resident identifier: #15. Facility census: 16. Findings include: a) Resident #15 When reviewed on 01/04/11, Resident #15's medical record revealed this [AGE] year old male had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Documentation on the resident's comprehensive assessment, completed at the time of admission on 09/27/10 at 10:45 a.m., stated (in the area of skin assessment) the resident had a lesion on left upper eyelid, a bruise on his left forearm, a brown birthmark on his posterior right leg, and a skin tear on the anterior right lower leg. This document stated the resident, at that time, had no pressure ulcers and no history of resolved pressure ulcers. An initial care plan developed on 09/28/10 identified: \"Alteration in skin integrity (sic) episodes of incontinence and Hx (history) of acne / rash (sic) Currently on neck base of hair line.\" The goal associated with this problem stated: \"Resident will have no skin breakdown through next review.\" The interventions to assist the resident achieving this goal were: \"1) Assess skin every shift and observe for signs of reddness (sic). Charge nurse will notify physician for treatment orders. 2) Bactrim DS i (1) PO (by mouth) everyday - MPOA (medical power of attorney representative) states resident has history of pustules on face - resolved with maintenance dose of bactrim (sic). Currently has rash on neck - hair / collar line. Will observe for signs of healing or if treatment is needed. 3) Resident's functional ability to transfer and ambulate has declined over last several wks (weeks) - assist resident, but encourage functional activity, ROM (range of motion), exercise. Therapy to evaluate for restorative nursing program.\" - According to the resident's comprehensive care plan dated 10/11/10, the interdisciplinary team (IDT) identified the following problem: \"History of acne / rash currently on neck base of hair line. At risk for skin breakdown due to decreased mobility, medication use, disease process. Fragile skin, bruises easily, Skin (sic) tear RFA (right forearm). Pressure ulcers (sic).\" (Note: According to documentation in the resident's record, the resident had no pressure ulcers at this time.) The goal related to this problem statement was: \"Resident will have no skin breakdown through next review.\" The interventions to assist the resident in achieving this goal remained essentially the same as stated in the initial care plan, with the following additions: \"Braden skin assessment quarterly. Wound / pressure ucler (sic) record if indicated. RFA skin tear treatment: [MEDICATION NAME] (sic) dressing covered with opsite (sic). Change prn (as needed) discontinue when healed. Notify physician if there are signs of infection or poor healing. When sitting up, ensure that resident is sitting on foam cushion.\" - Documentation recorded on forms titled \"Pressure Ulcer Record\" described the development of a Stage II pressure ulcer to his left heel on 11/17/10 and a Stage II pressure ulcer on his right buttock on 12/12/10. - Further record review disclosed that, on 10/11/10 (the date the resident's comprehensive care plan was established), the facility received a physician's orders [REDACTED]. On 11/03/10, the facility changed the resident's diet from regular consistency foods at all meals to pureed consistency foods for lunch and dinner and regular consistency foods at breakfast. Review of the resident's nutritional assessment disclosed that, by the time the first pressure ulcer developed on the resident's left heel, the resident had already experienced an unplanned weight loss of 13# from his admitting body weight of 147#. At that time, no new nutritional interventions were implemented to promote wound healing / skin integrity. Review of the resident's vital signs and weight record revealed the following weights: - 147# on 09/27/10 - 141# on 10/01/10 - 124# on 11/04/10 - 119# on 12/02/10 - 115# on 01/04/11 This represented a loss of 32# in approximately three (3) months. After 11/02/10, there were no further entries in the record by dietary personnel until 01/04/11, when the registered dietitian noted the resident's weight loss, described meal intakes, medications, etc., and ended by saying \"resident is currently not meeting care plan goal of consuming 70% of meals or maintaining his weight.\" The medical record revealed no evidence of interventions (after 11/03/10) related to this significant unplanned weight loss or evidence of efforts to improve the resident's nutritional status as a means of promoting wound healing. - A physical therapy daily note, dated 10/01/10, discontinued the resident from physical therapy to a restorative nursing program. The restorative nursing program plans stated: \"Ambulate on level surface with CAN (sic) and no loss of balance x 50 feet with rolling walker. Appropriate use of rolling walker during stand, pivot, transfer (sic). Exercise to improve function.\" The care plan problem was noted to be: \"Decreased posture, decreased balance, decreased functional mobility. Recent decreased function / cognition. Dx (diagnosis): [MEDICAL CONDITION].\" Approaches included: \"Ambulate with rolling walker 250 feet with supervision. Promote good seated / standing posture, transfer with supervision.\" Review of the restorative nursing and progress summary reports revealed that, after 11/07/10, the resident did not participate in the restorative program. As of 01/04/11, there had been no reassessment to determine why the resident was refusing to participate, nor was any revision made to the care plan in light of the resident's refusal of treatment. - According to a Braden assessment of the resident's risk for developing pressure sores, completed on 10/03/10, the resident scored \"17\", indicating he was at \"mild risk\" for developing a pressure sore. According to a subsequent Braden assessment, completed on 01/03/11, the resident scored \"12\", indicating he was now at \"high risk\" for developing a pressure sore. - When interviewed on 01/04/11, the unit's director of nursing (DON - Employee #14) was not aware the resident had a pressure ulcer. Employee #14 confirmed Resident #15 had sustained a significant unplanned weight loss and that the resident's refusal to participate in restorative services could have contributed to the pressure ulcer development. .", "filedate": "2015-03-01"}
{"rowid": 10503, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2011-01-06", "deficiency_tag": 323, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "CROM11", "inspection_text": ". Based on observation, staff interview, and record review, the facility failed, for one (1) of seven (7) residents reviewed, to assure each resident's environment was as free from accident hazards as possible, by restraining a cognitively impaired resident in an unsafe device and placing her in a room without staff supervision. Resident #4, whose assessment revealed she had severely impaired cognitive skills for daily decision making and an impaired ability to communicate, was seated in a geriatric chair with the tray table in place that prevented rising. There was sufficient space between the chair and the tray to allow the resident to scoot out of the chair, and the resident was placed in an area with other confused residents without staff present to monitor for safety. Resident identifier: #4. Facility census: 16. Findings include: a) Resident #4 Observation, during the initial tour of the facility on 01/02/11 at approximately 1:15 p.m., found Resident #4 sitting in a geriatric chair with a tray attached; the resident was located in the unit's activity / dining area with two (2) other residents. The tray, when in place, did not allow the resident to rise from the chair. The resident was not being fed, and no staff was present in the room. Further observation revealed that, due to the resident's small body size, there were several inches between her body and the tray. The resident was observed to remain in this chair, in almost constant motion, until approximately 2:30 p.m., when a nursing assistant assisted the resident from the chair to the bathroom. The resident was able to walk with staff assistance. The nursing assistant (Employee #1), when asked why the resident was in the chair, reported that it was to prevent her from ambulating independently. When asked, this nursing assistant agreed that it could be possible for the resident to slid from the chair under the tray. The unit's director of nursing (DON - Employee #14) was made aware of the resident's unsafe restraint and, at that time, the tray from the chair was removed and the chair was reclined. The resident's medical record, when reviewed on 01/04/11, disclosed the most recent minimum data set was dated as completed on 10/27/10. In Section B, the assessor noted the resident was sometimes understood by staff and sometimes able to understand staff. In Section C, the assessor noted the resident's cognitive skills for daily decision making was severely impaired - never / rarely makes decisions. This assessment would indicate the resident did not have the ability to remain safe in the unsafe device. .", "filedate": "2015-03-01"}
{"rowid": 10504, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2011-01-06", "deficiency_tag": 325, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "CROM11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide care and services, to one (1) of seven (7) sampled residents, to maintain acceptable parameters of nutritional status. Resident #15 was admitted to the facility on [DATE], at which time he weighed 147 pounds (#). On 10/01/10, he weighed 141#, and the physician ordered a nutritional supplement three (3) times daily for additional calories. On 11/03/10, the physician ordered changes to the consistency of his meals, serving pureed foods at lunch and dinner, and on 11/04/10, he weighed 124#. The resident continued to lose weight after 11/04/10, with no evidence of discussions with the resident or responsible party about the weight loss, no evidence of further assessments to identify possible reversible causes of the unplanned weight loss, and no evidence of further interventions implemented in an effort to slow or reverse the weight loss. By 01/04/11, he weighed 115#, which represented a 32# unplanned weight loss over a period of approximately three (3) months with no evidence to reflect this weight loss was clinically unavoidable. Resident identifier: #15. Facility census: 16. Findings include: a) Resident #15 When reviewed on 01/04/11, Resident #15's medical record revealed this [AGE] year old male had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a combined medical power of attorney and living will document dated 10/05/09, which identified his chosen representative and the following directives: \"no tube feeding, breathing machines, [MEDICAL TREATMENT], cardiopulmonary resuscitation.\" Review of the resident's vital signs and weight record revealed that, on the date of admission (09/27/10), he weighed 147# with a height of 62 inches. According to his admission assessment with an assessment reference date (ARD) of 10/07/10, the assessor encoded in Section G that the resident required only supervision and set-up assistance with eating. According to the resident's initial comprehensive care plan (dated 10/11/10), the interdisciplinary team identified the following problem: \"Leaves 25% of meals uneaten. Self feeding difficulty. constant (sic) drooling - loss of liquids and food during mealtime. Nutrition (sic).\" At the bottom of this problem statement was: \"Potential for dehydration.\" (This handwritten entry was not dated.) The goal related to this problem was: \"Resident will consume 70% of meals and maintain current weight plus or minus 5 pounds of baseline through next review.\" Interventions to assist the resident in achieving this goal were: \"Will provide menu for resident and friend to complete and return to dietary weekly with resident' (sic) personal food preferences. Will check labs, weights and intakes as available. Will provide nutritional supplement 3x/day (three times daily) with meals. Nursing or friend will assist with feeding as needed. Resident will be provided with opportunity to drinks fluids throughout the day. Coffee / snack cart will provide between meals coffee and snacks twice daily.\" As of 01/04/11, no additions or modifications had been made to this care plan since it was established on 10/11/10. - Review of the resident's record revealed a note entered by the facility's consultant registered dietitian (RD), dated 01/04/11, stating the resident had a \"33 pound weight loss since admission\". Review of the resident's vital signs and weight record revealed the following weights: - 147# on 09/27/10 - 141# on 10/01/10 - 124# on 11/04/10 - 119# on 12/02/10 - 115# on 01/04/11 This represented a loss of 32# in approximately three (3) months. Further review disclosed that, on 10/11/10 (the date the resident's comprehensive care plan was first established), the facility received a physician's orders [REDACTED]. Documentation on a \"Resident Nutritional Assessment\" revealed notation of the weights and a note, dated 11/03/10, stating the resident's diet was changed from regular consistency foods at all meals to regular consistency foods for breakfast only and pureed consistency foods for lunch and dinner; the author also noted that the resident did not want nursing staff to feed him. There were no further entries in the record by dietary personnel until 01/04/11, when the RD noted the resident's weight loss, described meal intakes, medications, etc., and ended by saying \"resident is currently not meeting care plan goal of consuming 70% of meals or maintaining his weight.\" The medical record revealed no evidence of further interventions related to this significant unplanned weight loss. - When interviewed on 01/04/11 at 4:14 p.m., the unit's director of nursing (DON - Employee #14) confirmed that staff was aware of the weight loss; she also confirmed that, other than the interventions of the Mighty Shakes and a change in the consistency of foods served to the resident early in his stay, nothing else had been done to address the resident's weight loss. This employee further stated the resident's medical power of attorney representative did not want aggressive treatment. At the time of survey exit at 1:15 p.m. on 01/05/11, facility staff had not provided evidence that the resident's significant unplanned weight loss had been discussed with him and/or his responsible party, in an effort to identify possible reversible causes of the weight loss and/or additional interventions to retard or reverse the weight loss. .", "filedate": "2015-03-01"}
{"rowid": 10505, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2011-01-06", "deficiency_tag": 329, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "CROM11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed to ensure the drug regimen, for one (1) resident of seven (7) sampled residents, was free of unnecessary drugs. Resident #7 had been receiving a nightly dose of [MEDICATION NAME] for [MEDICAL CONDITION] for months without any improvement in her difficulty sleeping, and there was no evidence to reflect the facility had identified the resident continued to receive this medication in the absence of therapeutic benefit. Resident identifier: #7. Facility census: 16. Findings include: a) Resident #7 Review of the resident's medical record found a physician order, dated 04/09/10, for [MEDICATION NAME] 1 mg at night, which had been reduced from a previous order to administer 2 mg. A review of nursing notes found the resident stayed awake at night during the months of August through December 2010; the resident was not sleeping at night even after receiving the dose of [MEDICATION NAME]. An interview with a nurse (Employee #21), on 01/05/11 at 10:00 a.m., revealed the resident was getting worse, wanting to sleep during the day time and not at night. Observation, on 01/03/10 at 3:00 p.m., found the resident sitting in a geri-chair in front of the nursing station sleeping. On 01/04/10 at 11:00 a.m., 2:00 p.m. and 4:00 p.m., observations found the resident sleeping. An interview with the director of nursing (DON - Employee #14), on 01/05/11 at 11:00 a.m., revealed the order for [MEDICATION NAME] would be discontinued. She further stated, \"The [MEDICATION NAME] has not been working for the resident for months and needs to be discontinued.\" .", "filedate": "2015-03-01"}
{"rowid": 10506, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2011-01-06", "deficiency_tag": 371, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "CROM11", "inspection_text": ". Based on observation and staff interview, the facility did not ensure food was stored, prepared, and/or served under sanitary conditions. This had the potential to affect all sixteen (16) residents of the facility, as all received foods prepared from this central location. Facility census: 16. Findings include: a) An observation made in the nutritional pantry on the nursing unit, on 01/03/11 at 3:00 p.m., revealed an open bottle of liquid in the pantry refrigerator that did not have a label specifying the contents of the bottle or a date to indicate when the bottle was placed in the refrigerator. In an interview on 01/03/11 at 3:00 p.m., the director of nursing (DON - Employee #14) stated the bottle of liquid should be discarded, and she was observed pouring the liquid from the bottle down the drain in sink. - b) Observation, on 01/03/11 at 4:30 p.m., found the holding temperature for cole slaw that had been plated for service to residents was 50 degrees Fahrenheit (F). The cole slaw, a potentially hazardous food that needed to be held at or below 41 degrees F, was intended to be delivered to ten (10) residents. The cook (Employee #25) placed the cole slaw in the refrigerator for thirty (30) minutes and took the temperature again. The temperature remained at 50 degrees F. The registered dietitian (RD - Employee #24) then directed dietary personnel to substitute the cole slaw with green beans. An interview with the RD, on 01/03/11 at 5:00 p.m., revealed the cole slaw could not be served to the residents at a 50 degree F. - c) An observation, on 01/03/11 at 4:30 p.m., revealed a large container in the refrigerator with a label indicating the date \"12/16/10\". Employee #25 indicated they never keep the sour cream on the shelf that long. - d) An observation, on 01/03/11 at 4:30 p.m., found two (2) dietary staff (Employees #26 and #25) with their hair not completely covered. The hair coverings were setting on the backs of their heads, exposing all of their hair in the front. .", "filedate": "2015-03-01"}
{"rowid": 10507, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2011-01-06", "deficiency_tag": 428, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "CROM11", "inspection_text": ". Based on observation, record review, and staff interview, the facility failed to ensure an irregularity in the drug regimen of one (1) of seven (7) sampled residents was identified or addressed by the consultant pharmacist. Resident #7 had been receiving a nightly dose of Lunesta for insomnia for months without any improvement in her difficulty sleeping, and there was no evidence to reflect the consultant pharmacist had identified the resident continued to receive this medication in the absence of therapeutic benefit. Resident identifier: #7. Facility census: 16. Findings include: a) Resident #7 Review of the resident's medical record found a physician order, dated 04/09/10, for Lunesta 1 mg at night, which had been reduced from a previous order to administer 2 mg. A review of nursing notes found the resident stayed awake at night during the months of August through December 2010; the resident was not sleeping at night even after receiving the dose of Lunesta. An interview with a nurse (Employee #21), on 01/05/11 at 10:00 a.m., revealed the resident was getting worse, wanting to sleep during the day time and not at night. She further stated the resident started to stay up all night beginning in August 2010. Observation, on 01/03/10 at 3:00 p.m., found the resident sitting in a geri-chair in front of the nursing station sleeping. On 01/04/10 at 11:00 a.m., 2:00 p.m. and 4:00 p.m., observations found the resident sleeping. An interview with the director of nursing (DON - Employee #14), on 01/05/11 at 11:00 a.m., revealed the order for Lunesta would be discontinued. She further stated, \"The Lunesta has not been working for the resident for months and needs to be discontinued.\" A review of resident's drug regimen reviews, completed by the facility's consultant pharmacist for the months of May through December 2010, found no mention of any irregularities related to the use of the Lunesta. .", "filedate": "2015-03-01"}
{"rowid": 10508, "facility_name": "WAR MEMORIAL HOSP, D/P", "facility_id": 5.1e+151, "address": "1 HEALTHY WAY", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2011-01-06", "deficiency_tag": 465, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "CROM11", "inspection_text": ". Based on observation and staff interview, the facility did not ensure that geri-chairs were functional and able to be effectively sanitized between uses by different residents. The arm rests of two (2) of five (5) geri-chairs had tears in the fabric, exposing padding beneath the fabric, which rendered these surfaces unable to be sanitized between uses. Facility census: 16 Findings include: a) Observation, on 01/03/11 at 4:30 p.m., found two (2) geri chairs located in the dining room with tears in the fabric covering the arm rests which exposed the padding beneath the fabric. The torn areas affected the entire arms of each geri chair and rendered their surfaces unable to be sanitized between uses. In an interview on 01/05/11 at 1:30 p.m., the director of nursing (Employee #14) acknowledged these geri chairs needed to be repaired.", "filedate": "2015-03-01"}
{"rowid": 6948, "facility_name": "GRAFTON CITY HOSPITAL", "facility_id": 515057, "address": "1 HOSPITAL PLAZA", "city": "GRAFTON", "state": "WV", "zip": 26354, "inspection_date": "2013-06-25", "deficiency_tag": 164, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "WVZU11", "inspection_text": "Based on a random observation, review of facility policies, and staff interview, the facility failed to provide personal privacy for a medical treatment. A resident received a breathing treatment in the dining room. The treatment continued into the serving and eating of lunch. Resident identifier: #22. Facility census: 59. Findings include: a) Resident #22 During the initial tour of the facility, shortly after entrance at 11:30 a.m. on 06/17/13, Resident #22 was observed in the dining room by two (2) surveyors. He was reclined in a geri-chair and had on oxygen (O2). A staff member approached him and initiated a nebulizer treatment in front of numerous other residents who were awaiting lunch, including a resident who was sitting at Resident #22's table. This treatment was still taking place as lunch was served and as the other resident at the table was served his lunch. On 06/20/12 at 10:10 a.m., the DON was interviewed about breathing treatments. She said it should not happen during meals and it was a daily occurrence. An interview was attempted with Resident #22 on 06/20/13 at 10:30 a.m. He was cognitively unable to complete the interview. A second interview with the DON was held on 06/24/13. She discussed giving nebulizers in dining room and said it was a dignity issue. She provided the facility's medication administration policy which did not include information about giving medications in public. A policy and procedure on aerosol treatments was provided by the Director of Respiratory Therapy at 3:30 on 06/24/13. It did not include information about giving treatments in public areas. The facility practice was discussed and he said they have been doing it for a couple of years, not for the therapist's convenience, but for the resident. He felt it decreased confusion by not dragging residents back to their rooms for a treatment, and then dragging them back. He did not acknowledge a violation of privacy by giving breathing treatments in public.", "filedate": "2017-09-01"}