{"rowid": 11117, "facility_name": "NEW MARTINSVILLE CENTER", "facility_id": 515074, "address": "225 RUSSELL  AVENUE", "city": "NEW MARTINSVILLE", "state": "WV", "zip": 26155, "inspection_date": "2009-04-30", "deficiency_tag": 150, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "6TSD11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to act upon a resident's wish to change her advance directives. Resident #54, who was determined to possess the capacity to understand and make her own medical decisions, upon admission indicated she wished to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or [MEDICAL CONDITION] arrest. Shortly after admission, she decided she did not want to receive CPR, and the facility failed to act upon her request for do not resuscitate (DNR). Resident identifier: #54. Facility census: 101. Findings include: a) Resident #54 Record review, on [DATE], revealed Resident #54 was admitted to the facility on [DATE]. Review of her interdisciplinary progress notes (by nursing) revealed an entry, dated [DATE], stating the resident was a \"full code at this time\", meaning the resident was to receive CPR in the event of cardiac or [MEDICAL CONDITION] arrest. A physician's orders [REDACTED]. Review of a subsequent entry in the interdisciplinary progress notes (by social services), dated [DATE], revealed, \"POST (physician's orders [REDACTED]. Code status DNR.\" This form was completed by the resident and Employee #133, but there was no physician's signature on it. Interview with Employee #80 on [DATE], and with other staff reviewing the resident's medical record on [DATE], confirmed the facility had not followed through to ensure the resident's request for DNR was confirmed by an order signed by the attending physician. .", "filedate": "2014-08-01"}
{"rowid": 5787, "facility_name": "WEIRTON GERIATRIC CENTER", "facility_id": 515037, "address": "2525 PENNSYLVANIA AVENUE", "city": "WEIRTON", "state": "WV", "zip": 26062, "inspection_date": "2014-10-07", "deficiency_tag": 151, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "U60O11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, family interview, and staff interview, the facility failed to allow one (1) of thirty-one (31) residents reviewed to exercise his rights. The facility restricted access to his power wheelchair without evaluating the resident's physical and cognitive ability to use the power wheelchair. Resident Identifier: #111. Facility census: 132. Findings Include: a) Resident #111 On 09/24/14 at 3:30 p.m., during an interview with Resident #124, during Stage 1 of the Quality Indicator Survey (QIS) process, she voiced a concern. She said her husband, Resident #111, had left the facility in his power wheelchair at 2:00 a.m. a few weeks earlier. She reported the facility would no longer allow him to use his power wheelchair. She said staff told her that her husband could have his power wheelchair back when they could trust that he would not leave the facility. At 3:00 p.m. on 10/06/14, during a review of the facility's unusual occurrences, the elopement of Resident #111 was identified. The report stated on 08/04/14 the resident left the facility around 2:00 a.m. in his power wheelchair. When found by the police, no injuries were identified. The report further stated the power wheelchair was removed from the resident's possession for his safety. On 10/06/14 at 3:45 p.m., during an interview with Resident #111, the resident was observed self propelling in a manual wheelchair in his room. Upon inquiry as to the wheelchair in which he was seated, he said he had a power wheelchair, but the facility took it away from him. When asked why, he said because he had been a bad boy. He explained that during the summer he left the facility late one night, and had taken a road trip. He said he knew what he had done, and he knew it had been the wrong thing to do. The resident said he had just wanted to have some control over his life, and at that time, that was how he took control. He said because he had left the facility in the middle of the night, the facility had taken his chair away from him as punishment. He said he was told he might get it back if they could trust him. He also stated staff told him that by leaving the facility during the night, the place could get shut down. He further said he had no intention of leaving the facility again. The resident said he was aware he can no longer live alone or take care of himself. He said he was dependent on staff for his medications and care in regards to his tube feeding and all areas of his needs. He said he can be very ornery, and it often got him into trouble, or gives the wrong impression. He said even though he can propel himself around the facility using his feet in the a manual wheelchair, he would prefer to have his power wheelchair, and has asked staff a number of times to allow him access to his chair. He said his power wheelchair was more comfortable, as it was padded, and he could sit for longer periods of time, and move about the facility easier. He said he knew the facility took the chair from him because they thought he might leave again, and even though he and his wife have assured staff he would not attempt to leave, he had yet to have his chair returned to him. The resident further stated, if he was inclined to leave the facility again, he could do it in the manual wheelchair, but he had no intention of leaving again. Resident #111 said Employee #222 (called by name), the assistant administrator, runs the show, and she would know if he would again be able to have access to his power wheelchair. At 9:00 a.m. on 10/07/14, a review of medical records for Resident #111 revealed he was admitted to the facility on [DATE]. On 05/21/14 the physician signed the determination of capacity, stating the resident demonstrated capacity to make decisions. On 08/06/14, after the resident's road trip, the physician made a new determination of capacity which indicated the resident demonstrated incapacity to make medical decisions. The Quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 08/25/14, indicated no behaviors were identified in Section E (Behaviors). There was no evidence of therapy evaluations regarding the resident's power wheelchair, or his ability to safely use the power wheelchair. A Behavior Management program was implemented on 08/14/14. The behavior indicated was exit seeking. Less restrictive procedures included: TLC (tender loving care) and reassurance. Restrictive procedures were listed as [MEDICAL CONDITION] medications. There was no mention of his power wheelchair. On 10/07/14 at 9:45 a.m., Employee #222, licensed social worker (LSW), and assistant administrator, was interviewed. Upon inquiry as to the status of Resident #111's power wheelchair, she said she took the power wheelchair for his safety. She said she had had many conversations with the resident regarding his elopement and comments he had made since the elopement. The assistant administrator said the facility's therapy department was currently testing all residents who had or wanted power wheelchairs for safety and awareness concerns. She said Resident #111 was to be tested in a few weeks, and she anticipated his power wheelchair would be returned to him at that time. Upon inquiry as to any concerns regarding the resident's ability to safely operate his power chair prior to the elopement, she said there had been none. She said the resident had safely and without incident operated his power wheelchair throughout the facility. When made aware both the resident and the resident's wife viewed the restricted access of the power wheelchair as punishment, rather than a safety measure, Employee #222 had no comment. She said the resident had asked for the return of his power wheelchair several times, saying the manual chair was work, and he was retired and did not want to work. The assistant administrator provided a motorized chair permit form that is given to residents requesting power wheelchairs. The form stated, A motorized chair is a privilege - not a right. When asked the rationale behind the wording, privilege - not a right, she said, Every resident thinks they should have a power chair paid for by the facility. Upon inquiry as Resident #111 having had his power wheelchair prior to admission, she said the form would be used as a permit to use the power wheelchair in the facility. She said it was her intention that he would more than likely get his chair back in a few weeks, because the weather was getting colder. At 11:00 a.m. on 10/07/14, during an interview with both the administrator and the assistant administrator, the status of Resident #111's power wheelchair was discussed. Also discussed was the lack of supporting documentation for the decision to restrict the resident's access to his power wheelchair. Upon inquiry as to whether the resident had attempted to leave the facility since the occurrence in August, they said, No. The assistant administrator said the resident left his unit and went to another floor one (1) time without notifying staff. Both the administrator and the assistant administrator reported, the resident had taunted staff by saying he would leave if he wanted. Both agreed, he was physically capable of exiting the building in the manual wheelchair, but he would be moving at a slower pace. On 10/07/14 at 11:30 a.m., upon inquiry, Employee #74, a licensed practical nurse (LPN) on the resident's unit, said the resident was able to make his needs known and effectively communicated with the staff.", "filedate": "2018-07-01"}
{"rowid": 6351, "facility_name": "BRAXTON HEALTH CARE CENTER", "facility_id": 515180, "address": "859 DAYS DRIVE", "city": "SUTTON", "state": "WV", "zip": 26601, "inspection_date": "2014-06-02", "deficiency_tag": 151, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "OMIN11", "inspection_text": "Based on resident interview, record review, review of complaints and grievances, and staff interview, the facility failed to ensure one (1) of two (2) residents, reviewed for the right to exercise rights, was afforded the opportunity to exercise her rights about how she lived in the facility. The resident was not able to exercise her right to privacy in her room. Resident Identifier: #24. Facility Census: 61. Findings Include: a) Resident #24 During an interview with Resident #24, at 10:30 a.m. on 05/28/14, she was asked, Are residents able to exercise their rights? Resident #24 responded with, That's a hard one, I would say no. The resident said she paid the facility $6,000 a month for her private room and she did not have any privacy in her room. She stated there were two (2) occasions the previous week when she came into her room and found other residents of the facility in her bathroom. She stated the interventions the facility attempted did not work. For example, she stated they were supposed to keep her door closed, but it was often left open by the staff. The resident said she also might not get it closed at times, because it was sometimes difficult to shut. The resident stated she felt she was not able to exercise her right to privacy because others went in and out of her room when she was not in there. The facility grievances and complaints were reviewed. This review revealed a Grievance/Complaint Report, dated 02/24/14, for Resident #24. The resident told Employee #61, the social service supervisor (SSS), that housekeeping said her dentures were found on the floor of her room when they went in to mop the floor. Resident #24 also told Employee #61 her bed had been getting messed up. Under the section for documentation of the facility's follow-up was, SW (social worker) suggested putting safest knob back on door, make sure door is closed. Resident #24 said they have tried those things as well as a stop sign on the door. Under the section titled, resolution of grievance/complaint was documented, Staff will continue to monitor situation, staff will redirect any resident seen entering Resident #24's room. Review of the resident's current care plan revealed there were no interventions to keep the resident's door closed, or any other interventions to maintain her privacy. An additional Grievance/Complaint form was completed on 02/26/14, after the resident council meeting on 02/26/14. It was indicated as a concern from Resident Council. This form also named Resident #24 as the complainant. The concern was, Other residents coming into rooms, mostly during the day. Under the section titled, Resolution of Grievance/Complaint the following was documented: Staff to monitor Resident who roams into others rooms and redirect. Employee #61 had signed both of the forms as the person who completed the forms. Employee #61, SSS, was interviewed at 12:43 p.m. on 05/30/14. She stated Resident #24's room was close to the nurses' station and staff redirected wandering residents when they attempted to go into her room. She stated they did not put any mechanical interventions in place to prevent other residents from entering Resident #24's room. Employee #61 stated keeping the door closed was suggested and should be done. She confirmed there were no interventions on Resident #24's care plan related to keeping her door closed or any other interventions to keep other residents out of her room. The SSS said she was not aware this was still a problem because Resident #24 had not mentioned it to her in a while. She stated she should add keeping the resident's door closed to the care plan, and fix it so the aides could see it on the Kiosk. The SSS said she would follow-up more closely with the resident in the future to ensure her concern was resolved.", "filedate": "2018-04-01"}
{"rowid": 8036, "facility_name": "BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER", "facility_id": 515055, "address": "600 MEDICAL PARK", "city": "WHEELING", "state": "WV", "zip": 26003, "inspection_date": "2012-08-22", "deficiency_tag": 151, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "8KXK11", "inspection_text": "Based on resident interview, staff interview, observations, and a review of Resident Council minutes for the months of April, May, June, and July 2012, it was determined the facility failed to notify the Resident Council of the implementation of a new non-smoking policy. This practice affected three (3) of three (3) residents who smoke in this facility. Interviews conducted with Residents #217, #68, and #150, revealed the facility had decided to implement a non-smoking policy both in the facility and on the grounds. It was also discovered during a review of Resident Council minutes this new rule had not been taken to the Resident Council prior to imposing the new policy and presenting the three (3) smoking residents with the notification. Resident identifiers: #217, #68, and #150. Facility census was 127. Findings include: a) Resident #127 During an interview with Resident #217, on 08/16/12 at 10:15 a.m., the resident stated the facility had informed the residents who smoked this facility was to become a non-smoking campus - meaning there would be no smoking allowed on the facility property. The resident further indicated the facility nursing home administrator (NHA) (Employee #116) had provided the residents who smoke a written announcement of the new policy with the effective date of 09/10/12. This notified them they would have to stop smoking on that date. Resident # 217 stated she did not want to stop smoking. The resident stated smoking was the last and only pleasure she had left in life and she could not give it up. During the interview, it was discovered there were three (3) smokers in this facility. b) Residents #68 and #150 Interviews conducted with Resident #68 and Resident #150, on 08/21/12 at 2:30 p.m., found they had also been given the non-smoking notice and informed they could receive assistance with giving up smoking. Both Residents #68 and #150 stated they did not want to quit smoking. It was observed the announcement of the new smoking policy had been distributed in the public and resident areas of the facility. c) During a review of the Resident Council Minutes for the months of April, May, June, and July 2012, it was discovered the new smoking policy had not been presented to the Resident Council. An interview with the Resident Council President (Resident #120), on 08/22/12 at 9:30 a.m., revealed the facility had not brought the new non-smoking policy to the Resident Council prior to making a new rule. During an interview with the NHA, on 08/22/12 at 2:00 p.m., it was confirmed this smoking change had not been taken to the resident council prior to making the non-smoking policy.", "filedate": "2016-10-01"}
{"rowid": 8446, "facility_name": "FAIRMONT HEALTH AND REHABILITATION CENTER", "facility_id": 515189, "address": "130 KAUFMAN DRIVE", "city": "FAIRMONT", "state": "WV", "zip": 26554, "inspection_date": "2012-06-22", "deficiency_tag": 151, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "NISF11", "inspection_text": "Based on resident/staff interview and record review, the facility failed to ensure residents were provided the opportunity to exercise their rights as a citizen. Voting rights were not maintained/promoted by the facility for 9 of 9 residents attending the group meeting (R10, R18, R27, R41, R56, R63, R64, R72, and R74) and 1 additional sampled resident (R43.) Findings include: 1. A group interview was conducted on 06/19/12 at 2:00pm with 9 residents whom the facility identified as alert, oriented, and credible historians. Interview with the group revealed 9 of the 9 residents wanted to vote; however, the facility had not assisted them with voter registration, making arrangements for transportation to the polls, or obtaining absentee ballots. 2. An individual interview was conducted with R43 on 06/19/12 at 12:35pm. The resident stated, I'm looking forward, to the coming presidential election. He indicated he was registered to vote and revealed he voted in every presidential election since he was old enough to vote. Review of the Recreation History and Assessment Long Stay form dated 06/24/11 for R43 revealed the Activities Director (AD) identified R43 as a Registered Voter. An interview with the Social Services Director (SSD) on 06/21/12 at 4:30pm revealed the facility had no system in place to get the voter information from the AD to the SSD. Interview on 06/21/12 at 3:30pm with the Social Services Director (SSD) revealed she obtained absentee ballots for any residents who asked for them, but did not have a system to assure that all residents who were capable and interested were informed of their right to vote and provided with assistance as needed. Further interview with the SSD on 06/21/12 at 4:30pm revealed she had discussed voting in resident council meetings, and information about voting should be included in the minutes of the meetings. Review of all Resident Council meeting minutes for 2012 revealed the topic of assistance with voting had not been discussed.", "filedate": "2016-06-01"}
{"rowid": 8467, "facility_name": "NELLA'S INC.", "facility_id": "51A010", "address": "399 FERGUSON ROAD", "city": "ELKINS", "state": "WV", "zip": 26241, "inspection_date": "2012-05-11", "deficiency_tag": 151, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "HIO211", "inspection_text": "Based on interview, the facility failed to ensure that residents were provided the opportunity to exercise their rights as a citizen. Voting rights were not maintained for 2 of 19 sampled residents (R54, R58) and 9 additional residents (R8, 16, 19, 36, 57, 61, 71, 81, and 84.) Findings include: During a group interview with residents identified by the facility as alert and oriented on 05/08/12 at 3:00pm, only 2 of the 13 residents stated they were registered to vote and had voted since their admission to the facility. Upon further conversation, it was determined that neither of the 2 residents who voted had been assisted to do so by the facility. R64 had a Personal Computer (PC) and independently utilized the PC to register to vote, and R26 stated his sister assisted him to register. All of the other 11 residents (R8, 16, 19, 36, 54, 57, 58, 61, 71, 81, and 84) interviewed in group said they would like to vote. All present agreed the facility Social Worker (SW) had never approached any of the attendees concerning voter's registration or educated them on their right to vote either by absentee ballot or at the nearest polling place. On 05/11/12 at 10:21am, the SW stated she personally assisted several residents to register and to vote. The only residents she could identify as having voted in the last 8 years were R64 and R26. She was unable to provide the names of other alert and oriented residents she had assisted with the voting process. She stated she was unable to provide any evidence to prove she had educated the residents on how to continue to exercise their voting rights once they were admitted to the facility.", "filedate": "2016-06-01"}
{"rowid": 8873, "facility_name": "TRINITY HEALTH CARE OF LOGAN", "facility_id": 515140, "address": "1000 WEST PARK AVENUE", "city": "LOGAN", "state": "WV", "zip": 25601, "inspection_date": "2012-05-25", "deficiency_tag": 151, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "ZX7V11", "inspection_text": "Based on interview and Resident Council Meeting Minutes review, the facility failed to ensure residents were provided the opportunity to exercise their rights as a citizen related to voting. Voting rights were not maintained nor promoted for 6 of 12 residents identified by the facility as alert and oriented. (R26, 32, 34, 45, 77, and 79.) Findings include: A group interview was conducted on 05/22/12 with 12 residents whom the facility had identified as alert, oriented, and credible historians. Interview with the group revealed that 6 of the 12 residents wanted to vote; however, the facility had not assisted them, either help with voter registration, making arrangements for transportation to the polls, or obtaining absentee ballots. Interview with R32 revealed, They used to help you, in making arrangements to vote, and R34 added, No one approached me. Interview on 05/23/12 at 2:40pm with the Social Services (SS) Director revealed that Activities staff was currently responsible for assisting with voting. She related that she used to attend the Resident Council meetings, and would provide information about voting to the residents. The SS Director related that if the need for assistance with voting was still being discussed in Resident Council, information about it should be included in the minutes of the meetings. Review of all Resident Council meeting minutes for 2012 revealed the topic of need for assistance with voting had not been discussed. On 05/22/12 at 3:10pm, interview with the Activities Director (AD) revealed that some residents in the facility were registered to vote, and several had sent in absentee ballots in the last election, two weeks prior to the survey date. She added that residents are asked upon admission if they are interested in voting. Further interview with the AD on 05/22/12 at 3:35pm revealed that she had checked the records of each of the residents present in group who had related they were interested in voting. She confirmed both R34 and R45 were registered to vote, and stated staff had not approached them to see if they preferred an absentee ballot or to be transported to their local polling place. The AD related that other residents in the group were not registered to vote at the time of their admission assessment, and there was no documented evidence of further discussion with the residents regarding assistance with their voting process.", "filedate": "2016-03-01"}
{"rowid": 9140, "facility_name": "CAREHAVEN OF PLEASANTS", "facility_id": 515191, "address": "PO BOX 625", "city": "BELMONT", "state": "WV", "zip": 26134, "inspection_date": "2012-04-26", "deficiency_tag": 151, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "JRXZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, and record review, the facility failed to allow one (1) of thirty-three (33) residents the opportunity to exercise his resident rights, and gave the resident a thirty (30) day notice for refusing care and treatment. Resident identifier: #78. Facility census: 61. Findings include: a) Resident #78. Review of the medical record found several occasions when Resident #78 had refused care and treatment. No evidence could be found the facility investigated why the resident refused care and treatment. Resident #78 was admitted to the facility on [DATE]. The admission [DIAGNOSES REDACTED]. During an interview with the resident, on 04/23/12 at 3:00 p.m., it was learned the resident did not like the type of solution used to treat his wounds. The resident stated, It's a bleach solution and [MEDICAL CONDITION] nose. The treatment was ordered twice a day. The resident stated he was not going to let the facility use Dakins solution twice a day. According to Employee #97, the treatment nurse, in an interview on 04/25/12 at 9:14 a.m., Resident #78 had voiced his opinion of the Dakins solution to her. She stated, He is non-compliant with a twice a day treatment. She further added she contacted the wound care center, but they would not change the treatment. Employee #97 was asked whether she had contacted the attending physician to get the treatment changed. She stated, He will not go against the wound care center. She stated at one time they had used a patch which only had to be changed every three (3) days, and the resident was more compliant with this treatment. No evidence could be found the physician was aware of Resident #78 having difficulty with the current treatment. No evidence could be found the facility alerted the physician to why Resident #78 was refusing treatments. The resident further stated, he had friends who worked at the facility, and he did not want them to provide his care. The resident stated, I went to school with some of them and some of them date my friends. During an interview, on the afternoon of 04/25/12, with Employee #83 (evening shift nurse), it was found Resident #78 had acquaintances who worked at the facility. She stated He does not want particular people taking care of him because he knew them. No evidence could be found the facility had made any attempts to provide care in a manner which maintained the resident's dignity. On 04/11/12, the facility issued Resident #78 a thirty (30) day notice stating they had no choice, but to give him a thirty (30) day notice related to his refusals of care and treatment. The letter further stated the facility would look for alternative placement that better suited the resident. During an interview with Employee #100 (administrator), on 04/24/12 at 5:57 p.m., he stated the facility had several meetings with Resident #78, but did not have documentation related to these meetings. He further added Resident #78 may have stated he did not want to go to another nursing home. 04/11/12 at 5:57 p.m., Employee #100 was asked for information related to education provided to Resident #78 on the risks and benefits of treatment. He stated, I'm sorry, it's not documented. On 04/24/12 at 3:37 p.m., Employee #78 (social worker/admission coordinator) was asked if he had met with Resident #78 related to his care and treatment. He stated, No, I have not had a lot of contact with him. He further added he was present when the facility gave Resident #78 a thirty (30) day notice for refusal of care. Review of the social worker notes identified only three (3) notes written from 02/14/12 through 04/23/12. On 02/29/12, Employee #78 wrote a note stating the following, Had been refusing care related to pain, but this has been corrected and he is participating more now. According to the social service note dated 02/29/12 Resident #78 was having no issues at that time.", "filedate": "2016-02-01"}
{"rowid": 10608, "facility_name": "MONTGOMERY GENERAL HOSP., D/P", "facility_id": 515081, "address": "WASHINGTON STREET AND 6TH AVENUE", "city": "MONTGOMERY", "state": "WV", "zip": 25136, "inspection_date": "2011-09-30", "deficiency_tag": 151, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "0VZD11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to allow one (1) of eight (8) sampled residents the right to exercise her rights as a resident of the facility. This resident was not permitted to choose how she wished to live her everyday life and receive care. The facility cleaned the resident's room without permission and did not allow the resident to refuse a medication when she clearly stated she did not want the medication. Resident identifier: #41. Facility census: 38. Findings include: a) Resident #41 Closed medical record review, on 09/28/11, revealed this resident was admitted to the facility on [DATE]. The resident was determined to possess the capacity to understand and make informed health care decisions in May 2011. According to the medical record, the resident was very upset on 06/06/11, because a nurse cleaned her dresser drawers, threw away some newspapers, and sent some soiled clothing to the laundry. There was no evidence that staff had obtained her permission to go through the resident's personal belongings when cleaning her room. Instead, all evidence suggested the resident was told, after the fact, why it was done. This was an infringement on the resident's rights which led to the following infringement on the resident's rights: - On 06/07/11, nurse's notes described the resident continued to be upset about her room being cleaned and her possessions being thrown away. Additionally, nurse's notes indicated the resident continued to be angry and agitated up to and including 06/10/11. - On 06/10/11, nurse's notes described the resident was agitated about the change in her medications and refused to take them. At 20:00 (8:00 p.m.), a telephone order was obtained for \"[MEDICATION NAME] 1 mg IM now\". At 20:10 (8:10 p.m.), when staff attempted to give the injection to this resident, the resident screamed, \"You're not giving me no shot.\" The resident was walked to her room, all the while screaming \"No, no, no.\" Nurse's notes described the resident as \"shaking all over\" and continued to scream as two (2) nurses assisted each other in giving the resident the injection in her left hip. According to the social worker's notes dated 06/07/11, the resident stated she did not like to take her medications because \"she does not like how it makes her feel.\" It should be noted that [MEDICATION NAME] was one (1) of the medications the resident had refused to take by mouth. The resident's rights were violated when the resident refused [MEDICATION NAME] by mouth and was forced to take the same medication by injection. On 06/13/11, the facility again attempted to violate this resident's rights. Nurse's notes, on 06/13/11 at 05:55 (5:55 a.m.) revealed another telephone order was obtained for \"[MEDICATION NAME] 1 mg IM now\". Nurse's notes continued with, \"... Unable to give resident shot. Became very agitated and belligerent and defensive. Not enough staff available @ this time to assist. She refuses to have [MEDICATION NAME].\" Interview with the acting director of nursing (DON - Employee #171), at 10:30 a.m. on 09/29/11, confirmed that a discussion should have been held with the resident regarding cleaning of her room. Additionally, Employee #171 confirmed the resident should have been afforded the right to refuse the [MEDICATION NAME], and staff violated the resident's rights when they did not allow the resident to refuse the injection of [MEDICATION NAME] on 06/10/11. .", "filedate": "2015-01-01"}
{"rowid": 107, "facility_name": "HUNTINGTON HEALTH AND REHABILITATION CENTER", "facility_id": 515007, "address": "1720 17TH STREET", "city": "HUNTINGTON", "state": "WV", "zip": 25701, "inspection_date": "2017-09-07", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "QLZ111", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility staff failed to identify the appointed Health Care Surrogate (HCS) for Resident #84, as designated by the attending physician on 06/05/17. Thus, the designated HCS was unable to exercise the resident rights to the extent provided by state law. Resident identifier: #84. Facility census: 180. Findings include: a) Resident #84 Review of Resident #84's medical records, on 08/30/17 at 11:15 a.m., found the resident was admitted to the facility on [DATE] following a hospitalization . Admission paperwork was completed by the resident's daughter. Further review found a HCS selection form completed 06/05/17, by the attending physician, designating the son as the HCS. No further HCS designation forms could be located in the medical records. Interview with Employee #122, social worker (SW), on 09/06/17 at 9:15 a.m., revealed she thought the daughter was the HCS on admission and had asked to appoint her brother the HCS due to personal issues. When asked, Is there another HCS designation form. She replied, I don't see any in the medical records. On 09/06/17 at 11:00 a.m., Employee #122, SW, provided a HCS designation form dated 05/30/17. She further confirmed this form had been faxed to her on 09/06/17 at 10:35 a.m. This HCS form indicated the Daughter was in fact appointed as the HCS while the resident was in the hospital. However, this HCS became void when the attending physician at the facility appointed Resident #84's son as the HCS on 06/05/17. The facility continued to notify Resident #84's daughter of changes in her condition and had the daughter listed as the health care decision maker on the resident face sheet even after Resident #84's son was appointed HCS on 06/05/17. On 09/07/17 at 10:25 a.m., the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was both notified. No further information was provided.", "filedate": "2020-09-01"}
{"rowid": 2959, "facility_name": "LOGAN CENTER", "facility_id": 515175, "address": "55 LOGAN MINGO MENTAL HEALTH CENTER ROAD", "city": "LOGAN", "state": "WV", "zip": 25601, "inspection_date": "2017-09-28", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "BKPR11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of death had a health care decision maker. Resident Identifier: #4. Facility census: 61. Findings include: a) Resident #4 Resident #4 was admitted to the facility on [DATE] for palliative care. The Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/02/17, Section C, Cognitive Patterns, gave a Brief Interview for Mental Status (BIMS) score of 00. Medical records review for Resident #4 revealed a Personal Care Pre-Admission Screening Form dated 07/21/17 which stated (Individual #1) and (Individual #2) were the Medical Power of Attorneys. A Designated Surrogate form dated 04/06/16 stated (Individual #2) was designated as surrogate. The Designated Surrogate form was not signed by a physician. According to facility records, (Individual #1) was designated by the facility as first emergency contact and Medical Power of Attorney. (Individual #2) was designated as second emergency contact and alternate Medical Power of Attorney. During an interview on 09/27/17 at 3:55 p.m., the Center Executive Director was shown the Personal Care Pre-Admission Screening Form dated 07/21/17 and the Designated Surrogate form dated 04/06/16. The Center Executive Director was unable to produce a document appointing a health care decision maker. She stated the Pre-Admission Screening Form dated 07/21/17 might have been the document the facility believed appointed the Medical Power of Attorney.", "filedate": "2020-09-01"}
{"rowid": 4550, "facility_name": "ST. BARBARA'S MEMORIAL NURSING HOME", "facility_id": 515012, "address": "PO BOX 9066", "city": "FAIRMONT", "state": "WV", "zip": 26555, "inspection_date": "2016-11-22", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "EZR311", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, resident interview, staff interview, and review of West Virginia State Nursing Home Licensure Rule 64-13, the facility failed to ensure the legal surrogate designated in accordance with State law only exercised the resident's rights to the extent provided by State law. This was found for one (1) random resident reviewed for capacity to make informed medical decisions. Resident identifier: #10. Facility census: 55. Findings include: a) Review of the medical record for Resident #10, began on 11/15/16 at 2:45 p.m., revealed she was [AGE] years of age, and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was determined by a physician to possess the capacity to make informed medical decisions. b) Record review found Resident #10 was determined by the attending physician to lack the capacity to make informed medical decisions upon her admission. The determination was reversed on 08/02/16 at which time the attending physician determined she possessed the capacity to make informed medical decisions. c) Pertinent social services notes were found as follows (typed as written): --05/11/16 at 1:02 p.m. a Social Service Note stated: Quarterly MDS (minimum data set assessment) Review: The resident is alert with confusion at times secondary to Dementia. She has been deemed to lack capacity. Her daughter is acting as her MPOA (Medical Power of Attorney). BIMS (Brief Interview for Mental Status) score of 14 this review. A dx. (diagnosis) of Depression is present with orders in place for [MEDICATION NAME], anti-depressant medication. The resident denies any s/s (signs and symptoms) of an altered mood this review. A care plan remains in place to address her impaired decision making and risk for increased s/s of an altered mood. No behavioral issues noted. Code status reviewed as DNR (do not resusitate.) --08/08/16 at 10:36 a.m. a Social Service Note stated: Annual residents rights review mailed out in June, but the signed acknowledgement form has not yet been returned. Overview of residents rights re-mailed to the responsible party at this time. --08/12/16 at 11:53 a.m. a Social Service Note stated: Annual Review: The resident is alert with confusion at times secondary to Dementia. She has been deemed to lack capacity. Her daughter is acting as her MPOA. BIMS score of 13 this review. A dx. of Depression is present with orders in place for [MEDICATION NAME], anti-depressant medication. The resident currently reports little energy at times following [MEDICAL TREATMENT] treatments. She also does continue to request the use of ear muffs r/t (related to) a fear that bugs will get in her ears. A care plan remains in place to address her impaired decision making and risk for increased s/s of an altered mood. No behavioral issues noted. Code status reviewed as DNR. --09/19/16 at 12:40 p.m. a Social Service Note stated: Residents rights review again mailed for signature. --11/10/16 at 2:21 p.m. a Social Service Note stated: Quarterly Review: The resident is alert with confusion at times secondary to Dementia. She has been deemed to lack capacity. Her daughter, (name) is acting as her MPOA. BIMS score of 13 this review. A dx of Depression is present with orders in place for [MEDICATION NAME], anti-depressant medication. The resident currently reports only minimal s/s of an altered mood. She does continue to request the use of ear muffs r/t a fear that bugs will get in her ears. A care plan remains in place to address her impaired decision making and risk for increased s/s of an altered mood. No behavioral issues noted. Code status reviewed as DNR. Long term placement needed. d) Multiple interviews with Resident #10 throughout the survey from 11/14/16 through 11/17/16 found she was able to describe and discuss pertinent details regarding her care being provided both in the facility and also by an outside contractor for [MEDICAL TREATMENT] services including dates, times, and procedures. e) Review of West Virginia State Code of regulations 64-13-4.3.f stated, After a resident has been determined to lack capacity to make health care decisions a nursing home shall reevaluate the resident's capacity to make health care decisions at least annually. Regulation 64-13-4.3.g states: If the resident regains his or her capacity to make health care decisions, the powers of the legal representative shall cease immediately. f) During an interview with social worker #70, on 11/21/16 at 10:12 a.m., she confirmed the determination had been changed, but she was unaware this had taken place. The facility continued to consider the legal representative as the decision maker and the person to be notified.", "filedate": "2019-09-01"}
{"rowid": 5099, "facility_name": "RALEIGH CENTER", "facility_id": 515088, "address": "1631 RITTER DRIVE", "city": "DANIELS", "state": "WV", "zip": 25832, "inspection_date": "2015-04-10", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "CRGX11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, the West Virginia Health Care Decisions Act, and staff interview, the facility failed to ensure residents' health care surrogate appointments were completed and implemented in accordance with State law. For Resident #66, the physician's determination of capacity failed to include the reason for the incapacity, the expected duration of incapacity, and evidence the resident was informed of who would be making her decisions. For Resident #21, the facility allowed a person who was not appointed as the health care surrogate to complete advance directives for the resident. This was found for two (2) of two (2) residents while reviewing for participation in planning care. Resident identifiers: #66 and #21. Facility census: 66. Findings include: a) Resident #66 At 11:10 a.m. on 04/06/15, during stage 1 of the Quality Indicator Survey (QIS), Resident #66 stated she did not have any input into her care at the facility. She did not understand why the facility was allowing her daughter to make medical decisions for her. The resident stated she did not want her daughter involved, because she could speak for herself. She gave the following example: I had a feeding tube. I had been eating for months by mouth, eating food that looks like baby food. I wanted my feeding tube removed and they didn't listen so I took it out myself a few weeks ago. Review of the medical record, on 04/07/14, found the resident's daughter was appointed the resident's health care surrogate decision maker on 12/09/12 during a hospitalization . This form indicated the appointment was temporary and was the result of a [MEDICATION NAME] hemorrhage. Record review, on 04/07/15, found the facility's physician completed a determination of capacity on 02/05/13, after the resident was admitted to the nursing home. The capacity statement noted the resident lacked capacity to make medical decisions. The nature of the incapacity and the [DIAGNOSES REDACTED]. The form indicated the resident was to be informed of the person who would be making health care decisions for her during her incapacity. This information was not documented on the incapacity form. The resident's last full minimum date set (MDS), with an assessment reference date (ARD) of 02/05/15, found the resident's score on the brief interview for mental status (BIMS) was a fifteen (15), the highest possible score, indicating she was cognitively intact. The resident's initial admission MDS, with an ARD of 02/02/13, found the resident's score on the BIMS was a six (6), indicating severe impairment. The medical record contained no further evaluations of the resident's capacity, since the 02/05/13 evaluation. A progress note entered in the medical record by the activity director on 02/25/15 found, . She is becoming more independent in communicating her needs and decisions daily. At 2:30 p.m. on 04/07/15, the social worker, Employee #59, verified the 02/05/13 physician's determination of capacity was the only one completed since the resident was admitted . When asked if the facility had completed the determination of capacity as directed on the form, Employee #59 replied, No. The West Virginia Health Care Decisions Act, 16-30-7, of the West Virginia Legislative Code requires: . (b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. (c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decision-maker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED].> b) Resident #21 On 04/06/15 at 11:04 a.m., during an interview with the resident's husband, who was appointed as her medical power of attorney (MPOA), the MPOA said staff did not inform him of his wife's condition. The MPOA became visibly upset when discussing the matter. The MPOA stated, The facility staff thinks I have no sense, they always call our daughter instead of telling me Review of Resident #21's medical record, on 04/07/15 at 2:30 p.m., revealed Resident #21 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On 06/13/13, the attending physician determined Resident #21 lacked the capacity to make informed medical decisions. Further record review found a State of West Virginia Medical Power of Attorney (MPOA) completed on 05/09/11. According to that document, Resident #21 appointed her husband as her representative to act on her behalf to give, withhold, or withdraw informed consent regarding health care decisions. On admission to the facility, the facility allowed the resident's daughter to sign all admission documents, including the Physician order [REDACTED]. An interview with Employee #42, Director of Admissions (DOA) and Employee #59, Social Services (SS), on 04/08/15 at 1:15 p.m., confirmed Resident #52's husband was her MPOA and should have completed her admission papers. They further confirmed the husband should be informed of the resident's condition.", "filedate": "2019-03-01"}
{"rowid": 6377, "facility_name": "GREENBRIER HEALTH CARE CENTER", "facility_id": 515185, "address": "1115 MAPLEWOOD AVENUE", "city": "LEWISBURG", "state": "WV", "zip": 24901, "inspection_date": "2014-06-27", "deficiency_tag": 152, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "35BV11", "inspection_text": "Based on staff interview, observation, review of facility policy, family interview, and resident interview, the facility failed to ensure four (4) of four (4) residents reviewed for rights were afforded the opportunity to exercise their rights. Residents were not free to exercise their rights regarding the use of side rails. Resident identifiers: # 98, #71, #29, and #2. Facility census: 77. Findings include: a) During the survey, residents and family members expressed serious concerns regarding the facility's decision to discontinue the use of side rails. The residents who expressed concern were those who used the side rails for turning and repositioning. An interview with Employee #1 (director of nursing), on 06/24/14 at 9:30 a.m., revealed the side rails were discontinued on 06/11/14 at the request of the medical director. Review of a new policy regarding side rails, which the facility implemented on 06/11/14, revealed the statement, No Resident will have side rails, unless the resident has capacity. Capacity to make health care decisions and the right to use side rails are not one and the same. The decision to discontinue the side rails was not discussed with the resident to judge how well the resident understood the facility's concerns with the use of side rails and/or how the resident used the side rails. Each of the residents for whom concerns were raised were deemed to not have capacity to make health care decisions. The facility also did not allow the person appointed under State law to act on the resident's behalf regarding the use of the side rails. 1) Resident #98 On 06/23/14 at 1:47 p.m., during an interview with Resident #98 and his wife, who acts as the resident's medical power of attorney (MPOA), the MPOA said a couple of weeks ago a facility staff member informed them the resident could no longer use his side rails. The MPOA became visibly upset when discussing the matter. The MPOA stated the facility staff member said, State says we can't use side rails because someone may get their head caught in them. The two (2) 1/4 side rails on the resident's bed were secured in the lowered position with two (2) zip ties on each side rail. The MPOA said Resident #98 could turn and reposition himself independently when the side rails were in the up position. Without the side rails, the resident had to call staff to assist him to turn and reposition. The MPOA said recently the resident had an itch on his back, and they had to use the call light to get staff to help him turn so he could scratch his back. She said the resident was upset by this and told her he did not want to have to push his button every time he had an itch. During the interview, the resident asked if he would again be able to use his side rails. The resident and his wife/MPOA said they were not consulted in the decision regarding discontinuation of the use of the side rails. 2) Resident #71 On 06/25/14 at 3:30 p.m., Resident #71 was observed in her bed. Her side rails were in the down position secured with two (2) zip ties on each side rail. The resident said she wished she still had her side rails because she used them to position herself in the bed. She asked if she would ever get them back. During a telephone conversation, on 06/25/14 at 5:00 p.m., with the MPOA for Resident #71, the Resident's MPOA said she received a letter stating the side rails would no longer be allowed to be used by the residents. She thought the letter came from the State. She said her mother was very upset about losing her side rails, as she was able to turn and reposition independently while in bed. She said her mother no longer feels safe in bed, and now requires assistance to turn and reposition. The MPOA said it was her opinion, as well as her Mother's opinion that she (the resident )could do more and felt safer with the side rails. She said she wanted her mother to once again be able to utilize her side rails. 3) Resident #29 During an interview on 06/17/14 at 4:20 p.m., Resident #29 said her side rails were removed about a week ago. She said she was informed by staff that she could no longer use them. On 06/25/14 at 11:20 a.m., Resident #29 said she almost fell getting out of bed that morning because she did not have her side rail to assist her. Several times during the conversation, she expressed a fear of falling. The resident said she used to be able to get out of bed herself using the side rail and the arm of her recliner. She said she no longer attempts to get out of bed, without staff, due to a fear of falling. The resident said when she had her side rails, she was not fearful of falling. She said her anxiety was higher now because she cannot have her side rails. During a telephone interview with the resident's MPOA, on 06/25/14 at 11:31 a.m., the MPOA said she really believed Resident #29 needed her side rails. She voiced fear for the risk of injury to the resident was greater without the side rails than with the side rails. The MPOA said when she talked with the administrator and expressed her desire for the resident to have side rails, the administrator told her, State says side rails cannot be used, and I just can't go against State rules. The MPOA said the facility made a decision to discontnue the use of side rails regardless of the resident's or the MPOA's wishes. She said she thought the decision made the resident require staff assistance in areas in which she did not previously need assistance. The MPOA also said the entire situation had made the resident's anxiety worse. 4) Resident #2 On 06/11/14 the facility implemented a policy which stated No Resident will have side rails, unless the resident has capacity. An interview with Resident #2, on 06/20/14 at 9:10 a.m., she demonstrated she could raise the bed, but was not able to reposition in bed or raise the head of the bed due to the controls being on the lowered secured side rail. Observation of the resident's side rails revealed the side rails were secured in the lowered position. An interview on 06/24/14 at 9:30 a.m. with the director of nursing revealed there was no assessment completed for Resident #2 prior to implementing the policy and discontinuing the resident's side rails. She stated she had ordered two (2) devices to assist with bed mobility, but they had not yet arrived. She verified the side rails were discontinued prior to the alternative devices being in place. An interview with the medical director on 06/25/14 at 8:00 a.m. revealed residents were to be assessed by physical therapy and alternate bed control and positioning devices were to be in place prior to the discontinuation of the bed rails. She confirmed the facility had not completed the physical therapy evaluations. She also said the facility had not received the positioning devices they ordered.", "filedate": "2018-04-01"}
{"rowid": 6526, "facility_name": "EASTBROOK CENTER", "facility_id": 515089, "address": "3819 CHESTERFIELD AVENUE", "city": "CHARLESTON", "state": "WV", "zip": 25304, "inspection_date": "2015-02-17", "deficiency_tag": 152, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "O5Z211", "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 person appointed by the court to act on the resident's behalf exercised the rights of a resident, who was adjudicated incompetent by a court of law. The facility allowed Resident #126 to leave the facility for several hours with family members on three (3) separate occasions. There was no evidence to support the court appointed guardian gave consent for the visits with family members. This was true for one (1) of seven (7) residents whose closed records were reviewed for the care area of admission, transfer, and discharge. Resident identifier: #126. Facility census: 125. Findings include: a) Resident #126 Medical record review, on 02/16/15 at 1:00 p.m., found this fifty-eight (58) year old resident was admitted to the facility on [DATE]. The circuit court appointed the Department of Health and Human Services (DHHR), Adult Protective Services (APS) to act as guardian for the resident on 10/17/13. A representative of the DHHR completed the admission paper work at the time of the resident's admission. Review of the admission social services assessment contained no information of any family members. The only contacts listed for the resident on the admission record was the DHHR. On the afternoon of 02/16/15 at 3:30 p.m., Assistant Director of Nursing #106, provided a copy of the occasions the resident had been out with family members. She explained each resident did not have their own individual sheet and she had to review all daily sheets for every resident to compile a list of occasions when this resident went out with family members. Review of the information, provided by Employee #106 found the resident had been out of the facility on 11/27/14, 12/24/14, and 01/14/15 with family members. Review of the medical record, on 02/16/15 at 4:00 p.m., found no documentation the resident was signed out by family on 11/27/14. There was no evidence the resident was assessed upon return and no evidence the DHHR was contacted or aware of the resident's out of the facility visit with family. Further review of the medical record found a nurse's note, written at 10:00 a.m. on 12/24/15, Resident out of facility with family member (name of member), will return later this evening. This was the only note written on 12/24/15. There was no indication of the time the resident returned, no indication the resident was assessed upon his return from the visit, and no indication the DHHR was contacted regarding the visit. A social service entry, written on 01/02/15 noted, I spoke with DHHR (name of worker). I explained the behaviors that resident has been exhibiting. (Name of worker) stated that (name of resident) had been out of the facility and visited with his brother from (name of another state). She felt that the behaviors may be from something inappropriate he was exposed to when he was out of the facility with his brother. She stated that she does not want him going out of the facility with his family until further notice On 01/14/15 a nursing entry, written at 1:18 p.m., noted, Resident was compliant with AM (morning) PO (by mouth) meds. (medications) with encouragement from his brother that was present at the time, resident was signed out by brother at 9:10 a.m. to attend funeral service for a family member. At 11:00 p.m. on 01/14/15, a nurse wrote, Resident lying quietly in bed with eyes closed. Took medications without difficulty. No complaints of pain or s/s (signs and symptoms) of behavior issues. Record review found no evidence the DHHR was contacted prior to any of the resident's family outings. Written correspondence from the DHHR, dated 01/21/15, confirmed they had not granted permission for the resident to attend a funeral on 01/14/15. At 4:15 p.m. on 02/16/15, the facility's administrator was asked if she had any evidence the resident's guardian, the DHHR, gave permission for the resident to visit with family members out of the facility. The administrator stated it was all verbal permission. She said the DHHR worker later denied she granted permission for the resident to attend the funeral on 01/14/15. She said she had learned a valuable lesson and the next time everything would be in writing. The administrator also said the DHHR worker was always aware the resident had visits with family members and had encouraged the visits. The administrator stated she had nothing in writing to verify the DHHR granted permission for the resident's visits with family. On 02/17/15 at 12:18 p.m. the administrator provided copies of a documented telephone conversation the DHHR, written on 01/14/15 at 4:08 p.m. The documentation included, .Discussed with (name of DHHR worker) telephone conversation several days we had regarding (name of resident) going to brothers funeral. Worker gave permission on the basis that (name of resident) would take morning medication. Relayed information to staff. However, worker now saying she did not give permission The administrator was unable to provide evidence the resident's guardian, the DHHR, gave permission for the resident to attend the funeral of his brother prior to his departure at 9:10 a.m. on 01/14/15. This note was written after the resident went to the funeral.", "filedate": "2018-02-01"}
{"rowid": 7013, "facility_name": "SHENANDOAH CENTER", "facility_id": 515167, "address": "50 MULBERRY TREE STREET", "city": "CHARLES TOWN", "state": "WV", "zip": 25414, "inspection_date": "2013-08-29", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "30TC11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident was evaluated for capacity to make medical decisions, according to the law. The medical record contained two (2) conflicting statements regarding the resident's capacity to make health care decisions. Both statements were completed by the same physician. This was true for one (1) of twenty (20) residents reviewed during Stage 2 of the quality indicator survey. Resident identifier: #177. Facility census: 73. Findings include: a) Resident #177 Medical record review found the resident was admitted to the facility on [DATE]. Further review of the medical record, on 08/26/13, found two (2) conflicting statements of determination of capacity for health care decision-making in the resident's medical record. The first determination of capacity was completed by the facility physician on 07/07/13. It indicated the resident did not have capacity to make medical decisions based on cognitive loss and an inability to understand or make medical decisions. The expected duration of incapacity (long term or short term) was not completed by the physician. A second determination of capacity, dated only July 2013, indicated the resident had capacity to make medical decisions. This was completed by the same physician. The physician did not document the exact day this capacity determination was completed. The director of nursing (DON), Employee #23, was interviewed on 08/26/13 at 2:00 p.m. After she reviewed the conflicting statements for determination of capacity she verified she did not know if the resident had capacity or did not have capacity to make medical decisions. The DON reviewed the physician's progress notes in an attempt to determine when the undated determination of capacity form was completed. She presented a copy of the physician's progress note, dated 07/04/13, which contained the following information: His daughter was in today . She would also like to have him declared as demonstrated incapacity to allow her to make all medical decisions. The physician then documented, The patient was examined by me and was oriented to person, place and time. I explained that his daughter would like to make all medical decisions for him and he agreed to this arrangement. The DON did not know why the resident was then determined to have incapacity by the same physician on 07/07/13, just three (3) days after the physician stated the resident was oriented to person, place and time. She could not find a physician's progress note or any notes to explain the decision made by the physician on 07/07/13. The facility's social services director, Employee #27, was interviewed on 08/26/13 at 2:35 p.m. She stated she believed the resident had capacity upon admission. She did not know when the capacity statement was signed by the physician. She thought the determination of capacity was made before the determination of incapacity, but she was not sure. Employee #27 completed a social history and initial assessment of of the resident on 07/05/13. The resident's Brief Interview for Mental Status (BIMS) score was 11, which indicated the resident's cognition was moderately impaired. Further review of the medical record found the admission coordinator, Employee #89, wrote a progress note on 06/28/13, the day of admission, . resident was without capacity. Employee #89 stated, on 08/29/13 at 10:47, she never found any written evidence the resident had been evaluated for determination of capacity prior to or on 06/28/13, I just took the daughter's word that he lacked capacity. On 08/26/13 at 2:45 p.m., the DON agreed the conflicting statement of capacity resulted in the facility's inability to determine if the resident did or did not have capacity to make medical decisions on 08/26/13 at 2:45 p.m.", "filedate": "2017-09-01"}
{"rowid": 7171, "facility_name": "PINEY VALLEY", "facility_id": 515122, "address": "135 SOUTHERN DRIVE", "city": "KEYSER", "state": "WV", "zip": 26726, "inspection_date": "2014-07-16", "deficiency_tag": 152, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "1X1U11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to establish a resident who had been determined to lack the capacity to make health care decisions had a legally appointed individual, appointed under State law, to act on her behalf to help exercise her rights on admission to the long term care facility. This decision applied to one (1) of nine (9) residents reviewed during the investigation of a complaint. Resident identifier: #61. Facility census: 104. Findings include: a) Resident #61 A review of the medical record revealed Resident #61 was a [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital. Her [DIAGNOSES REDACTED]. She also had deep tissue injuries to both feet, right hip, coccyx, both ears, and left hip. The 5 foot 4 inch tall resident weighed 90.2 pounds on admission. Both the physician who discharged the resident from acute care, and the attending physician at the nursing home, who was the resident's prior family physician, determined the resident lacked the capacity to process the information needed to form her health care decisions. A review of the hospital records forwarded to the facility revealed the resident had been referred to Adult Protective Services (APS) on admission to the hospital (07/01/14) because of suspected elder abuse neglect. A Forensic Nurse Examiner Consult completed on 07/02/14, revealed, . patient is confused, does know her name and that she lives in (name of town/city). The Nurse affirmed an APS referral had been made. She also indicated the hospital Social Worker had informed them the resident's Son #1, who was indicated to be the responsible party, had agreed to nursing home placement. Resident #61 was admitted to the facility on [DATE]. The nurses' notes indicated she arrived by ambulance and indicated Son #2 and his wife were notified. There was no evidence of an attempt to contact Son #1, the resident's medical power of attorney (MPOA). The nurses' notes revealed Son #1 was in to visit the resident on the evening of her admission (07/06/14). The nurses' notes revealed the APS worker visited the resident on 07/08/14. During a review of the clinical record for Resident #61, at 9:00 a.m. on 07/10/14, a full-sized red paper was found on the opening of the chart. This document indicate the resident's code status, should her heart or breathing stop, was Do Not Resuscitate (DNR). Further review failed to find documented evidence of a Physician's Orders for Scope of Treatment (POST) form or any document indicating who the legally responsible person was for Resident #61. The resident had been deemed to lack the capacity to form her own health care decisions by the attending physician, who had also written an order for [REDACTED]. During an interview with Employees #119 and #131 (both Licensed Social Workers) at 10:00 a.m. on 07/10/14, they were asked to provide evidence that Resident #61 had a legally appointed health care surrogate. Employee #131 stated the daughter-in-law was making decisions, but she acknowledged the absence of a HCS document. She stated Son #2 and his wife had gone on vacation and said they would take care of that on their return. When asked about the status of Son #1, they stated they had been unable to reach him and he had not contacted them. They were asked about the status of the APS investigation and both acknowledged they had not contacted APS since the resident's admission. They stated the contact had been made at the hospital and they had not heard anything. They were not aware the APS worker had been to the facility to interview the resident. A review of the entire record revealed only one entry of an attempt to reach Son #1 since admission, and it was by the director of nurses (DON) on 07/10/14. At 11:35 a.m. on 07/14/14, Resident #61 was observed meeting her son (Son #1) in the hall next to the South Nurses' Station. Both were happy to see the other and greeted each other warmly. Both were being pushed in wheelchairs. They continued to the dining room and were observed sitting next to each other during the meal, where he stayed to visit her while she ate. During an interview with Employee #131 at 2:00 p.m. on 07/14/14, she stated she had contacted APS and confirmed an investigation was pending. She had also contacted the attending physician who informed her he was the family doctor for both the resident and Son #1, who was also sick. When asked why there was still no evidence of a legally designated responsible party, no Physician's Order for Scope of Treatment (POST) form, or no signed admission forms/consents of any kind on the chart, she stated she had been waiting for Son #2 to return from vacation and had been unable to reach Son #1. She also pointed out the front sheet on the record had been changed and Son #2 and his wife were no longer entered as HCS designees. Review of the medical record on 07/14/14, revealed Employee #131 had contacted APS at 12:06 p.m. on 07/10/14 as stated. A note written by Employee #131 at 1:34 p.m. on 07/10/14, stated, SS (social services) spoke with resident's physician who stated that he has MPOA (Medical Power of Attorney) paperwork on resident. At 2:20 p.m. on 07/14/14, Employee #131, accompanied by the DON, produced a HCS form dated 07/07/14 and signed by Son #2 on 07/14/14 (today) appointing him HCS. She also had a copy of the MPOA form dated 07/03/2012 naming Son #1, which, per the time stamp, had been received via fax at 12:29, on 07/10/14. Employee #131 stated she had called a local attorney and he said if they could not reach the MPOA, the physician could revoke the MPOA due to the neglect allegation made to APS and re-assign the HCS to Son #2 because he was the successor representative on the MPOA document. The DON had no comment when informed Son #1, accompanied by his son, was in earlier and visited with the resident throughout lunch. Employee #131 did agree there had been no information from APS confirming the allegation investigation had been completed and/or substantiated; and there was no evidence of documentation by the physician of revocation of the MPOA, although he had signed the HCS form on 07/07/14. During an interview with Employee #131, the Administrator, and the DON at 2:15 p.m. on 07/15/14, the Administrator reported they had contacted Son #1 and he had immediately come into the facility and informed them he intended to remain the MPOA. He also authorized a DNR status for the resident. They acknowledged the resident had been in the facility since 07/06/14 (9 days) without a legally appointed responsible party.", "filedate": "2017-07-01"}
{"rowid": 7390, "facility_name": "ROSEWOOD CENTER", "facility_id": 515105, "address": "8 ROSE STREET", "city": "GRAFTON", "state": "WV", "zip": 26354, "inspection_date": "2013-08-15", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "PDFH11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to ensure a legally appointed healthcare decision-maker was in place for a resident the facility decided was unable to make her own health care decisions. This was found for one (1) of thirty-two (32) Stage 2 sample residents. Resident identifier: #2. Facility census: 62. Findings include: a) Resident #2 This resident's medical record was reviewed on 08/13/13 at 1:07 p.m. While reviewing the record, it was noted there were inconsistencies related to who was making healthcare decisions for this resident. This [AGE] year old resident was admitted to the facility on [DATE], transferred to another facility on 11/29/11, and was subsequently readmitted on [DATE]. Her [DIAGNOSES REDACTED]. She was determined by a physician to lack the capacity to make informed medical decisions on 06/28/13. Her Brief Interview for Mental Status (BIMS) score, as assessed on 07/02/13, was 14, indicating she was cognitively intact. (The highest possible BIMS score is 15.) An interview was conducted with the social worker (SW), Employee #18, on 08/14/13 at 9:29 a.m. She confirmed Resident #2 was determined to have capacity at the facility where she resided prior to her admission. The resident was determined to possess the capacity to make informed healthcare decisions by a physician. The SW said the resident had acted as her own decision-maker there. According the SW, since the resident was determined to lack capacity to make healthcare decisions upon her admission, a person needed to be selected to make health care decisions on the resident's behalf. An appointment of a Health Care Surrogate was necessary, but had not been completed. The resident's cousin was willing to assume this responsibility according to the social worker. In the meantime, Resident #2's choices related to refusal of care and other treatment were documented as being followed without question or counseling regarding the impact of those decisions, even though the facility had determined she was unable to make healthcare decisions for herself. Her cousin had already signed all consents and admission documents authorizing the facility to admit and treat Resident #2, although she had no legal basis for doing so. The administrator, Employee #33, was interviewed on 08/14/13 at 4:12 p.m. The situation regarding the lack of any legal authority to make medical decisions for Resident #2 was discussed. She confirmed Resident #2 was determined by her physician to lack the capacity to make medical decisions upon admission, but there was still no documented legal designation of any other person to make decisions on her behalf. The resident's cousin was permitted to sign all the admission documents and consents without the authority to do so. This had been the situation from admission on 06/27/13, until it was identified during the survey on 08/14/13.", "filedate": "2017-05-01"}
{"rowid": 8079, "facility_name": "EASTBROOK CENTER LLC", "facility_id": 515089, "address": "3819 CHESTERFIELD AVENUE", "city": "CHARLESTON", "state": "WV", "zip": 25304, "inspection_date": "2013-10-22", "deficiency_tag": 152, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "KE9711", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the resident's legal representative was permitted to make medical decisions on behalf of one (1) of five (5) residents reviewed. The health care surrogate (HCS) for Resident #66 was unaware of the facility's decision to transport the resident to an out of state facility for treatment of [REDACTED]. Resident identifier: #66. Facility census: 121. Findings include: a) Resident #66 Medical record review found the resident was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Upon admission to the facility, the resident had HCS which was appointed during her stay at the referring hospital. Further review of the medical record revealed the resident was transferred and admitted to an out of state hospital's psychiatric unit for treatment of [REDACTED]. On the day of discharge (09/30/13), only three (3) entries were recorded in the resident's computerized medical record. -- The first entry was written at 2:15 p.m., (Name of health care surrogate) aware of new order to send resident to (name of hospital) for evaluation. -- The second entry was made at 3:59 p.m. by a facility social worker, Employee #80 which stated, A referral was made to (name of facility), there are no openings at the current time, requested documents will be faxed for review. A referral was made to (another name of a facility) documents will be faxed for review. A referral was made to (name of a third facility) documents will be faxed for review. Two (2) of these three (3) referrals were made to out of state facilities. -- The third entry, on 09/30/13 was made at 4:12 p.m., (Name of ambulance service) here to transport resident to (name of the state). Resident and family aware. (Note: The resident's legal representative was not a family member.) On 10/21/13 at 12:05 p.m., the director of nursing (DON) was asked how the HCS was notified regarding the transfer of Resident #66. The DON stated the facility corresponded with the HCS surrogate by e-mail. She provided a copy of the e-mail correspondence on 09/30/13. The DON stated the resident had exhibited inappropriate sexual behaviors over the weekend which prompted the transfer on Monday, 09/30/13. The e-mail message sent to the HCS at 12:45 p.m. on 09/30/12 was, (Resident's initials) new order for psych consult at (name of hospital) in (name of state). The HCS was interviewed by telephone on 10/21/13 at 2:30 p.m. The HCS stated the e-mail did not explain the resident was being admitted to an out of state facility on 09/30/13. She said she believed a psych consult would be completed in house by a psychiatrist, as that was the procedure in the past. She was also unaware the resident was exhibiting any inappropriate sexual behaviors. The HCS stated she had been told the resident had a crush on a male resident. She did not believe a crush, was inappropriate. Further review of the medical record found Employee #60, a facility social worker, had contacted four (4) other area nursing homes in an attempt to make placement arrangements for Resident #66 on 07/31/13. According to the documentation in the medical record, the other facilities did not accept placement of the resident. Employee #60 was interviewed on 10/21/13 at 1:00 p.m. She stated the resident had displayed inappropriate sexual behaviors for some time, but she did not know the actual behaviors that occurred on 09/30/13 because she was not working that day. She stated she had made referrals to other nursing homes for the resident in July 2013, when the sexual behaviors started. Employee #60 was asked to provide verification the HCS was made aware of the placement arrangements and of the inappropriate sexual behavior exhibited by the resident. At the close of the survey on 10/22/13, no further information had been provided. Employee #80, another facility social worker, was interviewed on 10/22/13 at 2:48 p.m., regarding her note written on 09/30/13 at 3:59 p.m. She stated she was told in morning meeting on Monday, 09/30/13, the resident had exhibited sexual behaviors over the weekend and she needed to call some facilities for placement. She verified she did not contact the HCS regarding her efforts at placement. Employee #80 stated she was just calling other facilities because she was told to follow up on referrals made by another social worker. During the telephone interview, on 10/21/13 at 2:30 p.m., the HCS stated she was unaware of referrals being made to other facilities until she spoke with the DON via telephone on 10/02/13. She said she called the facility because the hospital had contacted her about Resident #66. She said she had just become aware the facility was also contacting out of state facilities for placement, and her HCS appointment would not even be recognized in an out of state facility. On 10/22/13, the DON and the administrator were interviewed at 9:30 a.m. The DON verified the facility could not produce evidence the HCS was notified the facility was seeking alternative placement at other facilities and she could not find evidence the HCS was notified of the resident's inappropriate sexual behaviors which the facility stated had occurred. The DON also acknowledged the facility had not documented the sexual behaviors exhibited by the resident that resulted in the resident's hospitalization .", "filedate": "2016-10-01"}
{"rowid": 8112, "facility_name": "OHIO VALLEY HEALTH CARE", "facility_id": 515181, "address": "222 NICOLETTE ROAD", "city": "PARKERSBURG", "state": "WV", "zip": 26104, "inspection_date": "2013-10-25", "deficiency_tag": 152, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "CYPC11", "inspection_text": "Based on record review and staff interview, the facility failed to follow the directives of a person acting on behalf of an incapacitated resident. The family and Medical Power of Attorney (MPOA) informed staff they did not want a resident to receive an influenza vaccination. The facility administered the influenza vaccine without having consent to do so. This was evident for one (1) of six (6) residents reviewed for the facility's annual influenza vaccination program. Resident identifier: #29. Facility census: 61. Findings include: a) Resident #29 Review of the medical record revealed that family members did not want Resident #29 to receive an influenza vaccine. On 07/22/13, the resident's Medical Power of Attorney (MPOA) signed an influenza immunization form. By signing, this form, they acknowledged having received educational materials on the risks and benefits that may result from accepting or declining the influenza vaccine. The MPOA did not sign consent giving permission for the resident to receive the vaccine. A nursing progress note, dated 08/16/13, was reviewed. The resident's family/MPOA called and spoke with the nurse. The MPOA requested that the orders for flu vaccine and pneumonia vaccine be discontinued. On 10/23/13 at 2:30 p.m., the Director of Nursing (DON) produced a copy of the Medications Administration History for October 2013. She verified that a nurse administered the influenza vaccine to the resident's left deltoid muscle on 10/08/13 at 11:00 a.m. A nursing progress note, dated 10/09/13, conveyed that a nurse called the spouse of the MPOA and told her that the resident had received the flu vaccine with no adverse reaction. During an interview with the DON, on 10/23/13 at 2:30 p.m., she acknowledged that the resident was given the flu vaccine without consent of the MPOA.", "filedate": "2016-10-01"}
{"rowid": 8435, "facility_name": "OAK RIDGE CENTER", "facility_id": 515174, "address": "1000 ASSOCIATION DRIVE", "city": "CHARLESTON", "state": "WV", "zip": 25311, "inspection_date": "2013-06-18", "deficiency_tag": 152, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "RXW311", "inspection_text": "Based on record review and staff interview, the facility failed to follow the instructions that were given for allowing a resident to be taken out of the facility without permission from the legal guardian. Resident #50 was identified as a protected person and had a court appointed guardian/conservator. Written instructions were provided to the facility to indicate who was allowed to take the resident out of the facility. The facility did not follow the instructions and allowed the resident to leave the facility with a person who was not authorized to take the resident out of the facility. The court appointed guardian was not made aware the resident had left the facility. This was true for one (1) of five (5) sampled residents. Resident identifier: #50. Facility Census: 70. Findings include: a) Resident #50 It was recorded in this resident's medical record this resident had been determined by the Court to be a protected person. The Court had appointed a legal guardian to make decisions on the resident's behalf on 09/24/07. A review of the medical record, on 06/18/13, revealed a note that Resident #50 was not to leave the facility with anyone in his family. According to the note, he was only to leave with his court appointed guardian or her husband, whose name was specified. During an interview with the Administrator (Employee #83), it was verified that Resident #50 went out of the facility on 06/06/13 with an unauthorized person and went to his legal guardian's house without permission from the legal guardian. The facility had no knowledge of him leaving the facility until he returned. It was confirmed the facility did not follow the instructions of the legal guardian and failed to notify the responsible party that the resident wanted to go out of the facility with someone other than the individuals she had specified. The facility also failed to follow practices for signing out residents when they leave the facility.", "filedate": "2016-06-01"}
{"rowid": 8640, "facility_name": "GOLDEN LIVINGCENTER - RIVERSIDE", "facility_id": 515035, "address": "6500 MACCORKLE AVENUE SW", "city": "SAINT ALBANS", "state": "WV", "zip": 25177, "inspection_date": "2011-08-17", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "5VE911", "inspection_text": "Based on record review and staff interview, the facility failed to ensure the individuals making financial decisions for two (2) of three (3) sampled residents had the legal authority to do so. Review of Resident #11's financial file found a family member was being permitted to act as the resident's financial power of attorney in the absence of documentation to demonstrate this individual had the legal authority to do so. The physician appointed a health care surrogate (HCS) to make health care decisions on behalf of Resident #2, and the facility permitted this individual to also make financial decisions on behalf of the resident; such authority is not conferred by State law to a HCS. Facility census: 89. Findings include: a) Resident #11 Review of the financial file for Resident #11 revealed there was no documentation to indicate the individual making financial decisions on behalf of this resident who had the legal authority to do so. There was notice in the file by the facility, asking a family member to provide the necessary paperwork to prove they were the resident's financial power of attorney, but no such documentation had been supplied as yet. -- b) Resident #2 Review of the financial file for Resident #2 revealed he had been making his own financial decisions at the time of admission, but his status had changed such that he was no longer able to do so. The physician appointed a HCS to make health care decisions on behalf of the resident, but State law does not confer the authority to a HCS to also make financial decisions. -- c) The above concerns were discussed with Employee #29 (the business office manager) at 1:05 p.m. on 8/10/11.", "filedate": "2016-04-01"}
{"rowid": 8752, "facility_name": "PINE LODGE", "facility_id": 515001, "address": "405 STANAFORD ROAD", "city": "BECKLEY", "state": "WV", "zip": 25801, "inspection_date": "2013-03-13", "deficiency_tag": 152, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "MS9D11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that for residents who had been determined to lack the capacity to make informed medical decisions, a legal surrogate was designated in accordance with State law to exercise the resident's rights to the extent provided by the law. This was found for two (2) of four (4) residents whose records were reviewed. Resident identifiers: #116 and #117. Facility census: 115. Findings include: a) Resident #116 The medical record of Resident #116 was reviewed on 3/11/13 at 3:40 p.m. Resident #116 was admitted to the facility on [DATE], and discharged on [DATE]. He was seventy (70) years old. His [DIAGNOSES REDACTED]. He was determined by a physician to lack the capacity to make informed healthcare decisions on 02/27/13. He was admitted to the facility for skilled therapy services designed to strengthen him, and improve his ability to assist with activities of daily living (ADLs) to allow him to return home with his son and daughter-in-law. There was an indication in the admission paperwork that a health care surrogate (HCS) had been appointed. Further review found a form entitled West Virginia Health Care Surrogate Designation, which had been faxed to the facility on [DATE] from the admitting hospital. The form indicated the resident's sister had consented over the telephone to act as the resident's HCS on 02/18/13. The cause of Resident #116's incapacity to make his own decisions was not completed. The expected duration of his incapacity to make his own decisions was not completed. The person that the physician intended to appoint as HCS was not named. There was a signature in the space marked attending physician, but the signature was not dated. During an interview, on 03/13/13 at 8:45 a.m., the administrator, Employee #38, stated that a new health care surrogate appointment form containing all the information required by the West Virginia Health Care Decisions Act ?16-30-1 should have been completed by the facility following the facility's determination upon admission that Resident #116 continued to lack the capacity to make informed health care decisions. b) Resident #117 The medical record of resident #117 was begun on 03/11/3 at 3:00 p.m. and continued on 3/12/13 at 8:59 a.m. Resident #117 was a fifty-nine (59) resident who was admitted to the facility on [DATE], and discharged on [DATE]. His [DIAGNOSES REDACTED]. Resident #117 was admitted following hospitalization for a fall resulting in a head injury. During the review of the medical record, questions arose regarding Resident #117's capacity to make informed medical decisions and also regarding sufficient appropriate provisions to ensure that an authorized decision maker was in place. Resident #117 signed his physician's orders [REDACTED]. He indicated his wishes for emergency medical interventions and end of life care on 03/07/12. He then signed all admission paperwork, including an authorization to provide medical treatment on 03/08/12. The attending physician determined the resident was incapable of making informed medical decisions on 03/08/12. There was no medical power of attorney (MPOA), health care surrogate (HCS) appointment, or any other evidence that a legal and appropriate decision maker was in place. Social services notes, dated 03/14/12, stated (typed as written): Resident was deemed incapable of making self-decisions by physicians but no reason given. Physician consulted to reevaluate. Resident has no MPOA or HCS on chart. A social services note dated three (3) months later, on 06/13/12, stated (typed as written): HCS completed and waiting for physician signature. No HCS was found in the medical record. After discussion regarding this issue on 03/12/13 at 3:47 p.m., the administrator presented a health care surrogate appointment form that had been completed on 02/03/12, while the resident was in the hospital. She said, and the FAX transmission date confirmed, that this form had never actually been in the record or available to staff, as it was just faxed to the facility on [DATE]. What was found in the medical record was a determination made at the hospital 26 days later on 02/29/12. This document indicated Resident #117 did possess the capacity to make informed medical decisions, which would have negated the health care surrogate's authority. The social worker for Resident #117, Employee #37, was interviewed on 03/12/13 at 2:40 p.m. He was asked about the HCS status of Resident #117 following his admission. He said he could not speak to that as he only began his employment at the facility in September 2012. He said he thought there was a surrogate form on the chart, but was not sure. The administrator, Employee #38, was interviewed on 03/12/13 at 3:47 p.m. She confirmed that she was not able to provide any additional documentation regarding the completion of a health care surrogacy form following the determination that Resident #117 lacked the capacity to make informed medical decisions on 03/08/12.", "filedate": "2016-03-01"}
{"rowid": 9081, "facility_name": "PUTNAM CENTER", "facility_id": 515070, "address": "300 SEVILLE ROAD", "city": "HURRICANE", "state": "WV", "zip": 25526, "inspection_date": "2013-02-21", "deficiency_tag": 152, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "RESW11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a person making health care decisions had the legal authority to do so under state law, ?16-30-1, the West Virginia Health Care Decisions Act. The facility allowed a person to make health care decisions prior to having documentation to support the person had the legal authority to do so for one (1) of four (4) sampled residents. Resident Identifier: # 94. Facility Census: 107. Findings include: a) Resident #94 Medical record review, conducted at 1:45 p.m. on 01/25/13, revealed a Durable Power of Attorney (DPOA) for Resident #94. The DPOA did not provide legal authority for the person named as the DPOA to make health care decisions for Resident #94, because it was not signed by Resident #94. Therefore it was not a legally binding document. If the DPOA had been signed by the resident and was legally binding it still did not contain a health care decision clause giving permission for the person to make health care decisions for Resident # 94. This document was placed on the medical record by the facility staff, therefore the facility felt it was a legally binding document. The facility staff was not aware the document was not signed by Resident #94, until it was pointed out during the by the survey. There were no other documents within the medical record which gave anyone the legal authority to make health care decisions for the resident. The medical record revealed a Physician order [REDACTED]. This form was signed by a person other than Resident #94 on 10/21/09. The person signing the form signed in the signature box labeled, Signature of Patient/Resident, Parent of Minor, or Guardian/MPOA Representative/Surrogate(Mandatory). Also contained in the medical record of Resident # 94 was a form titled, Resident admission agreement/consent to treatment. This form was also signed by the same person who signed the POST form. This form was also dated 10/21/09, on the line labeled Legal Representative. There was no documentation contained on the medical record giving the person signing these forms the authority to do so. The medical record review further revealed a Physician's Determination of Capacity dated 10/28/09 which revealed Resident #94 demonstrated incapacity to make medical decisions as of 10/28/09. This determination of capacity was completed one (1) week after the facility allowed someone else to sign the POST form and the consent for treatment. An interview was conducted with the Nursing Home Administrator (NHA), Employee #119, and the master's level social worker, Employee #73 at 2:10 p.m. on 01/24/13. They both reported they thought the resident had a Health Care Surrogate (HCS) appointed to make her health care decisions. They both confirmed the HCS appointment was not on the medical record at the time of the interview. They looked at the resident's financial file and was able to locate a HCS appointment for this resident. The HCS did appoint the person who had signed the POST form and the consent to treat, as the HCS decision maker for Resident #94. This HCS appointment was signed by the Physician on 10/28/09 which was one week after the facility allowed this person to make health care decisions for the resident. The NHA and Employee #73 both felt the resident may have had a HCS appointment prior to entering the facility, but was unable to provide evidence which would suggest they had seen the HCS appointment prior to allowing this person to make health care decisions for Resident #94. On 01/28/13 the NHA provided a HCS appointment document which appointed the person allowed by the facility to make health care decisions for Resident #94 as her HCS decision maker on 10/12/09. The NHA reported they contacted the hospital and they were able to fax her this document. The time and date the form was faxed was printed at the top of the page which was 01/24/13 at 6:06 p.m This document was received by the facility after the the presence of such a document was unable to be located in the facility. There was no evidence to suggest the facility had this document in their possession prior to allowing the now appointed HCS to make the medical decisions for this resident. Had the facility had this document in their possession they would not have reappointed the same person as HCS decision maker on 10/28/09.", "filedate": "2016-02-01"}
{"rowid": 9429, "facility_name": "CLAY HEALTH CARE CENTER", "facility_id": 515142, "address": "HC 75, BOX 153", "city": "IVYDALE", "state": "WV", "zip": 25113, "inspection_date": "2011-07-28", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TF5T11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview it was found that the Physician order [REDACTED]. This was evident for 1 (one) of 37 stage II sampled residents. Census: 57 residents currently in facility. Findings include: A) Resident #51 Review of the medical record for this resident revealed that there had been a previous POST form completed with a physician signature and date of 12/29/09. It stated the resident would want: Do Not Resuscitate (DNR), comfort measure only, antibiotics, IV (intravenous fluids)for a trial period and no tube feedings. Another POST form was noted which was dated by staff on 1/26/11. This document had listed that the resident would want DNR, no antibiotics, no IV, no tube feedings. It was not signed nor dated as to when the physician would have reviewed this information with the resident or responsible party and informed them of this change in treatment that would be provided. Spoke with director of nursing on 7/26/11 at mid afternoon regarding the lack of the signature and date by the physician. There was no further details submitted to the surveyor as of exit on 7/28/11", "filedate": "2015-11-01"}
{"rowid": 9596, "facility_name": "HILLCREST HEALTH CARE CENTER", "facility_id": 515117, "address": "P.O. BOX 605", "city": "DANVILLE", "state": "WV", "zip": 25053, "inspection_date": "2012-10-05", "deficiency_tag": 152, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "D8F011", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the West Virginia Code, the facility failed to ensure a third evaluation of the resident's ability to make health care decisions was completed after the facility obtained two conflicting statements regarding the resident's ability to make health care decisions. The unresolved conflict resulted in various individuals making health care decisions for the resident. This was true for one (1) of six (6) medical records reviewed for resident rights exercised by a representative. Resident identifier: #81. Facility census: 89. Findings include: a) Resident #81 Review of the medical record found the resident's physician had determined the resident demonstrated capacity to make medical decisions on 07/17/12. Further review of the medical record found the local Department of Health and Human Services (DHHR) had completed the admission paper work on 07/19/12, two (2) days after the resident's physician determined the resident had the capacity to make his own medical decisions. The DHHR had also completed a, West Virginia Physician order [REDACTED]. The admissions director, Employee #56, was interviewed at 10:00 a.m. on 10/2/12. He stated the resident had lacked capacity upon admission. On 10/02/12 at 10:25 a.m., the facility social worker, Employee #62, presented a physician's determination of capacity from a local hospital, dated 06/27/12, which determined the resident lacked capacity to make medical decisions and appointed the DHHR as the resident's health care surrogate. According to the West Virginia Code (16-30-22), .shall have two physicians, one of whom may be the attending physician, or one physician and a qualified psychologist, or one physician and an advanced nurse practitioner, certify that the principal has regained capacity. Further review of the physician's orders [REDACTED]. The director of nursing (DON), Employee #88, and the corporate nurse, Employee #89, were made aware of the above situation on 10/04/12 at 10:30 a.m. The DON stated she thought another physician had examined the resident and had found he had capacity to make medical decisions, but this physician had not documented the findings on a determination of capacity form. No further information / explanation was provided regarding the inconsistent contacting of either the DHHR, the resident, or a family member when changes in condition occurred.", "filedate": "2015-10-01"}
{"rowid": 9692, "facility_name": "OAK RIDGE CENTER", "facility_id": 515174, "address": "1000 ASSOCIATION DRIVE", "city": "CHARLESTON", "state": "WV", "zip": 25311, "inspection_date": "2010-01-07", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "9PJH11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to ensure each resident's health care decisions were made by the individual appointed by the resident. Additionally, determination of the resident's incapacity did not clearly indicate the nature of the incapacity. This was true for one (1) of thirteen (13) sampled residents. Resident identifier: #17. Facility census: 72. Findings include: a) Resident #17 1. Review of the resident's medical record found the resident had appointed Individual #1 as her first choice to be her medical power of attorney representative (MPOA). She had appointed Individual #2 as the successor MPOA should Individual #1 be unable, unwilling, or disqualified to serve. Further record review found Individual #2 had signed the physician's orders [REDACTED]. However, no evidence was found in the medical record indicating Individual #1 was unwilling or unable to serve, or that he had been disqualified. On the morning of 01/07/10, Employee #95 was asked whether something had happened to Individual #1, as Individual #2 had been making the resident's health care decisions. She said she did not know but would find the answer. At 9:20 a.m. on 01/07/10, Employee #95 said she had contacted Individual #2, who said she had been making the resident's health care decisions because Individual #1 had been working a lot of overtime. 2. This resident was admitted on [DATE]. A Physician Determination of Capacity had been completed on 12/10/09, by a physician other than the resident's primary physician. The form contained the following sentence: In my opinion this patient HAS ___ or LACKS ___ sufficient mental or physical capacity to appreciate the nature and implication of health care decisions. The physician placed a checkmark in the blank beside Lacks. In a section directing Please check the nature of the incapacitation as evidenced by:, the evaluator recorded: Disorientation to person, place, and time. The word place had been circled. There was no check placed by Inability to understand or make medical decisions. This was discussed with Employee #95, who agreed it appeared the physician had indicated the resident was disoriented to place, which would not necessarily mean she was unable to understand the implications of health care decisions.", "filedate": "2015-10-01"}
{"rowid": 9834, "facility_name": "GOLDEN LIVINGCENTER - RIVERSIDE", "facility_id": 515035, "address": "6500 MACCORKLE AVENUE SW", "city": "SAINT ALBANS", "state": "WV", "zip": 25177, "inspection_date": "2012-08-02", "deficiency_tag": 152, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "K6SZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to aenure a resident who was alert and oriented was provided the opportunity to make her own health care decisions. Resident #85 had expressed that she did not want cardiopulmonary resuscitation (CPR) and two days later, her medical power of attorney (MPOA) changed this decision without the legal authority to do so and without evidence the resident was involved in this decision. The resident's family was also permitted to sign her admission paperwork without evidence the resident was involved in her admission or in decisions regarding her care at this facility. This practice was evident for one (1) of nine (9) sampled residents. Resident identifier: #85. Facility Census: 84. Findings include: a) Resident #85 Resident #85 was admitted to the facility on [DATE]. Her advance directives were reviewed and it was determined she had appointed a medical power of attorney on [DATE], just two (2) days prior to her admission to this facility. At the time of this resident's admission, on [DATE], the resident completed a cardiopulmonary resuscitation (CPR) form to express her wishes if she were to suffer a [MEDICAL CONDITION], respiratory arrest, or if death was imminent. She directed the facility withhold CPR and all life saving measures. The resident signed this form along with her representative who she had appointed her MPOA. Review of the medical record found that this resident was examined by the physician on [DATE]. It was recorded in the history and physical that she was alert and oriented times four (x 4). There was no incapacity statement found in the medical record to establish this residtn was not able to make her own medical decision and to activate her medical power of attorney. Further review of the medical record found that on [DATE], the appointed MPOA completed and signed a new CPR form stating \"I want CPR\". This form did not have the resident's signature on it and was completed only by the family with no evidence the resident had been involved in this decision or was even aware her CPR status had been changed. The Director of Nursing (Employee #67) was interviewed on [DATE] at 9:00 a.m. She revealed that she could not find a capacity statement for this resident. She also verified the admission papers had been signed by the power of attorney without evidence there was legal authority to allow her to sign these forms and without evidence the resident had requested the family be allowed to do so. .", "filedate": "2015-08-01"}
{"rowid": 10023, "facility_name": "BARBOUR COUNTY GOOD SAMARITAN SOCIETY", "facility_id": 515116, "address": "216 SAMARITAN CIRCLE", "city": "BELINGTON", "state": "WV", "zip": 26250, "inspection_date": "2010-02-11", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "4T1611", "inspection_text": ". Based on medical record review and staff interview, the facility failed to ensure the rights of one (1) of twelve (12) sampled residents, who had been determined to lack capacity to make informed health care decisions, were exercised by an individual appointed in accordance with State law. The physician appointed two (2) individuals to serve jointly as Resident #49's health care surrogate (HCS); however, WV State Code 16-30-8 allows a physician to appoint only one (1) HCS. Additionally, the facility allowed a family member who had not been appointed to the role of HCS to make health care decisions on Resident #49's behalf. Facility census: 50. Findings include: a) Resident #49 Medical record review revealed the physician appointed two (2) persons to serve jointly as Resident #49's HCS, to make health care decisions for this resident. In addition, record review also revealed health care decisions were being made by the resident's mother, who was had not been appointed to serve as HCS. In an interview with the administrator and the person in charge of resident funds (Employee #5) at 2:15 p.m. on 02/10/10, they acknowledged understanding the State law only allows for the appointment of one (1) person to serve as HCS for an incapacitated individual, and they acknowledged the resident's mother was not the resident's legal representative. They state they would see that all staff was made aware of this. According to WV Code 16-30-8. Selection of a surrogate.: \"(a) If no representative or court-appointed guardian is authorized or capable and willing to serve, the attending physician or advanced nurse practitioner is authorized to select a health care surrogate.\" \"(b)(1) Where there are multiple possible surrogate decisionmakers at the same priority level, the attending physician or the advanced nurse practitioner shall, after reasonable inquiry, select as the surrogate the person who reasonably appears to be best qualified.\" This State law does not allow for the simultaneous appointment of more than one (1) person to serve jointly as HCS for an incapacitated individual. .", "filedate": "2015-07-01"}
{"rowid": 10115, "facility_name": "ELKINS REGIONAL CONVALESCENT CENTER", "facility_id": 515025, "address": "1175 BEVERLY PIKE", "city": "ELKINS", "state": "WV", "zip": 26241, "inspection_date": "2009-10-23", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "9ELI11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility failed to ensure the individual acting on behalf of an incapacitated resident had the legal authority to make health care decisions. The facility had not obtained documentation to validate the appointment of a health care surrogate for the resident. One (1) of eighteen (18) residents on the sample was affected. Resident identifier: #40. Facility census: 99. Findings include: a) Resident #40 The resident was admitted to the facility on [DATE]. According to documentation in the resident's medical record, a health care surrogate had been appointed for the resident. An individual, other than the resident, had signed documents regarding health care decisions. However, there was no evidence the health care surrogate appointment had been validated. On 10/21/09 at 4:00 p.m., the social worker (Employee #23), when asked whether a copy of the health care surrogate appointment had been obtained, said she had asked the appointed individual to bring in a copy, but he had yet to do so. It was suggested a copy might have been received with the documents provided by the hospital at the time of transfer. Employee #23 checked, but was unable to locate a copy of the surrogate appointment. On 10/22/09 at 8:10 a.m., Employee #23 provided a copy of the health care surrogate appointment that had been faxed to the facility at 8:09 a.m. that morning. The facility had not obtained verification of the health care surrogate appointment for nearly a month after the resident was admitted . .", "filedate": "2015-06-01"}
{"rowid": 10182, "facility_name": "MEADOWVIEW MANOR HEALTH CARE", "facility_id": 515141, "address": "41 CRESTVIEW TERRACE", "city": "BRIDGEPORT", "state": "WV", "zip": 26330, "inspection_date": "2009-10-08", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "XHIH11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure determinations of incapacity were documented in accordance with State law for two (2) of thirteen (13) sampled residents. One (1) resident's determination of incapacity did not indicate the expected duration of incapacity, nor was there evidence the physician informed this alert resident that a surrogate decision-maker would be acting on her behalf. Another resident's determination of incapacity also did not note the expected duration of incapacity. Resident identifiers: Resident identifiers: #18 and #36. Facility census: 59. Findings include: a) Resident #18 The medical record of Resident #18, when reviewed on 10/05/09, disclosed the resident's physician had, on 02/05/09, determined she lacked the capacity to understand and make her own informed medical decisions. The resident had been admitted to the facility on [DATE] and had posessed capacity until this time. The physician's documentation did not indicate this alert resident had been informed that her medical power of attorney representative (MPOA) would be making medical decisions of her behalf, as required by State law. The documentation also did not include the length of time the physician expected the resident to lack this capacity. b) Resident #36 The medical record of Resident #36, when reviewed on 10/05/09, disclosed the resident's physician had determined she lacked the capacity to understand and make her own informed medical decisions. The physician's documentation did not indicate this alert resident had been informed that her MPOA would be making medical decisions of her behalf, as required by State law. In an interview on 10/07/09 at 3:30 p.m., the director of nursing (Employee #69) agreed the was no evidence to reflect physician had informed the resident that her MPOA would be making her medical decisions, as required by State law. c) According to W.V.C. 16-30-7. Determination of incapacity.: \"(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. \"(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. \"(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. .", "filedate": "2015-06-01"}
{"rowid": 10580, "facility_name": "GRAFTON CITY HOSPITAL", "facility_id": 515057, "address": "1 HOSPITAL PLAZA", "city": "GRAFTON", "state": "WV", "zip": 26354, "inspection_date": "2009-07-30", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "OPXH11", "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 legal surrogate, of one (1) of thirteen (13) residents reviewed, exercised the resident's rights in accordance with State law. Resident #24 had designated a medical power of attorney representative (MPOA) to make health care decisions for her in the event she should lack the capacity to do so. The MPOA was making health care decisions on the resident's behalf, although there was no determination of incapacity in her record to reflect she was incapable of making these decisions for herself. Resident identifier: #24. Facility census: 60. Findings include: a) Resident #24 The medical record of Resident #24, when reviewed on 07/27/09, disclosed this [AGE] year old female had been admitted to the facility on [DATE], following hospitalization after a fall resulting in a subdural hematoma and cervical fracture. Review of the resident's admission documents, as well as the physician's orders [REDACTED]. The resident's medical record contained no document stating she herself did not have the capacity to make her own health care decisions. The facility's director of nursing (DON), when interviewed related to these findings on 07/29/09, confirmed that, although the resident was indeed unable physically and mentally to make her own decisions, there was no determination of incapacity completed by the attending physician for this resident. .", "filedate": "2015-01-01"}
{"rowid": 10605, "facility_name": "MONTGOMERY GENERAL HOSP., D/P", "facility_id": 515081, "address": "WASHINGTON STREET AND 6TH AVENUE", "city": "MONTGOMERY", "state": "WV", "zip": 25136, "inspection_date": "2011-09-30", "deficiency_tag": 152, "scope_severity": "E", "complaint": 1, "standard": 0, "eventid": "0VZD11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and review of State law, the facility failed to determine a resident's capacity according to State law (WVC 16-30 - West Virginia Health Care Decisions Act) for six (6) of eight (8) sampled residents. Resident identifiers: #38, #40, #17, #35, #9, and #5. Facility census: 38. Findings include: a) Residents #38, #40, #17, and #35 1. Resident #38 A review of Resident #38's medical record revealed the resident was determined to be incapacitated due to bilateral hearing impairment and dementia. - 2. Resident #40 A review of Resident #40's medical record revealed the resident was determined to be incapacitated due to dementia. - 3. Resident #17 A review of Resident #17's medical record revealed the resident was determined to be incapacitated due to dementia. The form was not dated as to when the determination of capacity had been made. - 4. Resident #35 A review of Resident #35's medical record revealed the resident was determined to be incapacitated due to dementia. - 5. According to WVC 16-30-7. \"Determination of incapacity. \"(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. \"(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ...\" - 6. On 09/28/11 at 12:12 p.m., an interview with the director of nursing (DON - Employee #169) and the social worker (SW - Employee #188) revealed the above residents' determinations of capacity were based on a medical [DIAGNOSES REDACTED]. Both employees agreed that, just because a resident was hard of hearing, this did not necessarily mean the resident lacked the capacity to understand and make informed health care decisions. -- b) Resident #9 1. Medical record review, on 09/28/11, revealed this resident's physician determined the resident did not possess the capacity to make health care decisions. The document signed by the physician contained no date of the determination. \"Dementia\" was written across the areas on the form on which documentation was supposed to include \"nature of incapacity\" and \"cause of incapacity\". (The documentation of \"dementia\" in itself did not provide a description of the how this condition impacted this resident's ability to make informed health care decisions.) - 2. According to WVC 16-30-7: \"(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. The section on the facility's form regarding this requirement required the indication of \"yes\" or a \"no.\" Neither \"yes\" or \"no\" was marked. - 3. During an interview on 09/29/11 at 10:30 a.m., the acting DON confirmed this determination of incapacity did not describe why the resident could not make her own health care decisions, did not contain a date, and did not indicate the resident had been informed of being deemed incapacitated to make health care decision by the physician. -- c) Residents #5 Medical record review, on 09/28/11, revealed this resident's physician determined the resident did not possess the capacity to make health care decisions on 11/23/10. \"Dementia\" was written across the areas on the form on which documentation was supposed to include \"nature of incapacity\" and \"cause of incapacity.\" (The documentation of \"dementia\" in itself did not provide a description of the how this condition impacted this resident's ability to make informed health care decisions.) During an interview on 09/29/11 at 10:30 a.m., the DON confirmed this resident's determination of incapacity did not describe why the resident could not make her own health care decisions. .", "filedate": "2015-01-01"}
{"rowid": 10680, "facility_name": "SUMMERS NURSING AND REHABILITATION CENTER LLC", "facility_id": 515170, "address": "JOHN COOK ROAD, PO BOX 1240", "city": "HINTON", "state": "WV", "zip": 25951, "inspection_date": "2011-09-13", "deficiency_tag": 152, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "8CVP11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the medical record and staff interview, the facility failed to assure documentation was obtained to verify who had authority to make health care decisions on behalf of the resident. On numerous occasions throughout the medical record of Resident #56, the facility referred to the resident's daughter as the resident's medical power of attorney representative (MPOA) and allowed her to make medical decisions for the resident; however, the medical record failed to contain any documentation showing the resident had designated the daughter as his MPOA. Furthermore, the facility also failed to obtain an evaluation of the resident's capacity to understand and make informed health care decisions when it was determined the resident had severe cognitive impairment. This was true for one (1) of ten (10) sampled residents. Resident identifier: #56. Facility census: 110. Findings include: a) Resident #56 Medical record review revealed this [AGE] year old male was admitted to the facility on [DATE]. Active [DIAGNOSES REDACTED]. Further review of the medical record found an admission minimum data set assessment (MDS) with an assessment reference date (ARD) of 02/13/11. The results of the brief interview for mental status (BIMS) contained in this MDS revealed a score of \"5\", indicating the resident's cognitive performance was severely impaired. A quarterly MDS, with an ARD of 07/28/11, revealed a BIMS score of \"9\", indicating the resident's cognitive performance was moderately impaired. (A BIMS score of \"0\" to \"7\" indicates severely impaired cognitive performance; a score of \"8\" to \"12\" indicates moderately impaired cognitive performance; and a score of \"13\" to \"15\" indicates a resident is cognitively intact.) The medical record contained no further documentation to reflect the facility had assessed the resident's cognitive status. The medical record also contained no documentation to reflect the physician had completed an assessment of the resident's capacity to make medical decision when the facility became aware of the resident's severely impaired cognitive performance as indicated by the results of the BIMS on 02/13/11. Further review of the medical record revealed an absence of documentation to reflect the resident had ever designated his daughter to serve as his MPOA. Additionally, there was no evidence to reflect the physician had appointed the daughter to serve as the resident's health care surrogate after having made a determination that the resident was unable to make his own informed health care decisions. On numerous occasions throughout the resident's stay the resident's daughter had been contacted and had been allowed to make medical decisions for the resident. The following are some examples of such occasions: - On 02/09/11, the daughter completed the admission agreement which dictated the responsibilities of the resident and facility as terms for the condition of the stay. - On 04/09/11, nursing staff had referred to the daughter as \"MPOA\" when she was called concerning the resident's new orders. - On 05/10/11, the daughter had been allowed to determine the resident should not endure surgical procedure for a hernia. - On 08/15/11, the daughter had been allowed to decide whether the resident could attend an appointment for an eye exam. - The daughter was listed as the contact person for the resident on the admission information. - A grievance / concern form, completed by the corporate social worker on 05/11/11, referred to the resident's daughter as the \"MPOA\". From all indications, the facility's staff believed the daughter was the resident's MPOA and contacted her to make medical decisions for the resident during his stay at the facility. During an interview with the director of nursing (DON) on the afternoon of 09/12/11, she was unable to locate documentation to prove the resident's daughter was legally appointed to serve as his health care decision maker. She verified the resident's capacity should have been evaluated by the resident's physician but could find no evidence this had been completed. On the morning of 09/13/11, the DON provided a capacity statement completed by the resident's physician on 09/12/11. The physician had determined the resident lacked capacity to make medical decisions due to early dementia and the lack of inability to process information. The physician also provided a written statement, dated 09/13/11, which contained the following information: \"(name of resident) was admitted to (name of facility) in February of 2011. I am confident that I did a Determination of Capacity at that time and that he was deemed incompetent.\" In summary: The facility failed to produce an evaluation of the resident's capacity to make health care decisions when they knew (or should have known) the resident had cognitive impairment. Further, the facility failed to verify that the daughter, who was allowed to make health care decisions, was the legally appointed individual designated to make medical decisions on behalf of the resident. .", "filedate": "2015-01-01"}
{"rowid": 10711, "facility_name": "GUARDIAN ELDER CARE AT WHEELING, LLC", "facility_id": 515002, "address": "20 HOMESTEAD AVENUE", "city": "WHEELING", "state": "WV", "zip": 26003, "inspection_date": "2009-08-20", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "S2JZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the determination of incapacity, for one (1) of twenty-one (21) sampled residents, was documented in accordance with State law. Resident #106's record lacked any information regarding the cause or nature of the incapacity as required by W.Va. Code 16-30-7(b). Additionally, there was no evidence the resident was notified of the determination of incapacity as required by W.Va. Code 16-30-7(c). Resident identifier: #106. Facility census: 138. Findings include: a) Resident #106 According to the medical record, the resident was admitted to the facility on [DATE]. A \"Physician's Determination of Capacity\" form, completed by the attending physician on 04/23/08, indicated the resident \"Demonstrates INCAPACITY to make medical decisions\" for a \"Short term\" duration. The form listed \"sequelae of [MEDICATION NAME] toxicity\" without additional explanation as to the nature or cause of the resident's incapacity. Additionally, no evidence could be found the physician informed this conscious resident of the determination of incapacity or of the fact that a surrogate decision-maker would be acting on the resident's behalf. During an interview with the administrator and the three (3) social workers at 2:40 p.m. on 08/19/09, they acknowledged, after reviewing the resident's determination of incapacity, the documentation was incomplete. b) Per W.Va. Code 16-30-7. Determination of incapacity. \"(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. \"(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. \"(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. .", "filedate": "2014-12-01"}
{"rowid": 10755, "facility_name": "TRINITY HEALTH CARE OF MINGO", "facility_id": 515069, "address": "100 HILLCREST DRIVE", "city": "WILLIAMSON", "state": "WV", "zip": 25661, "inspection_date": "2009-06-25", "deficiency_tag": 152, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "667111", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, a review of the West Virginia Health Care Decisions Act, and staff interview, the facility failed to ensure, for three (3) of thirteen (13) sampled residents, a legal surrogate was appointed in accordance with State law for residents lacking the capacity to understand and make their own informed health care decisions. Determinations of incapacity were made solely based on a [DIAGNOSES REDACTED]. Resident identifiers: #50, #33, and #47. Facility census: 75. Findings include: a) Resident #50 On 06/24/09 at approximately 2:00 p.m., review of Resident #50's medical record revealed a physician's determination of capacity form indicating Resident #50 lacked the capacity to understand and make informed health care decisions. However, the cause of the incapacity had not been recorded on the form. b) Resident #47 On 06/23/09, review of Resident #47's medical record revealed a physician's determination of capacity form indicating Resident #47 lacked the capacity to understand and make informed health care decisions due to having a [DIAGNOSES REDACTED]. c) Resident #33 Review of Resident #33's medical record, on 06/23/09, revealed the physician determined she lacked the capacity to understand and make her own health care decisions; however, the cause of her incapacity was not recorded. d) According to '16-30-7. Determination of incapacity., \"(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. \"(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. \"(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. .", "filedate": "2014-12-01"}
{"rowid": 10804, "facility_name": "MARMET CENTER", "facility_id": 515146, "address": "ONE SUTPHIN DRIVE", "city": "MARMET", "state": "WV", "zip": 25315, "inspection_date": "2009-09-25", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "7F5X11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility failed to ensure the rights of residents were exercised by an individual appointed in accordance with State law. One (1) resident, who been determined to lack capacity prior to admission, had a health care surrogate appointed while in the hospital. Documentation indicated some staff was aware of this; however, others were a party to completion of a medical power of attorney document (MPOA), which would not be valid as the resident had not been deemed to have the capacity to make the appointment. Additionally, the MPOA had been witnessed by two (2) facility staff members, which was prohibited by the facility's policy. Two (2) residents, who were found to have capacity, had health care decisions made by others. Three (3) of the fifteen (15) current residents on the sample were affected. Resident identifiers: #6, #81, and #46. Facility census: 86. Findings include: a) Resident #6 This resident was admitted to the facility on [DATE]. 1. Review of the resident's medical record found a document entitled \"Health Care Decision Making\" that listed the resident's representative as Individual A and noted he was the resident's health care surrogate (HCS). At the bottom of the document, \"Surrogate Decision Maker for Health Care\" was marked as being the resident's advance directive. A date of 08/17/09, initialed by Employee #58, had been entered as the date the HCS document had been obtained. A \"Physician order [REDACTED]. This form had been prepared by Employee #20, a registered nurse. This was further evidence some staff was aware the resident had previously had a health care surrogate appointed due to a determination of incapacity. 2. A copy of a \"State of West Virginia Medical Power of Attorney\" was also found in the resident's medical record. The form was dated 08/24/09 and signed by the resident. This form named Individual A as the resident's MPOA representative. There was no indication why the MPOA had been completed, given that the resident had a HCS appointed and needed only to be reviewed by the physician. 3. A \"Physician Determination of Capacity\" had been completed by the resident's physician on 08/25/09. The physician determined the resident lacked capacity to make health care decisions, because she lacked the capacity to appreciate the nature and implication of healthcare decisions. 4. To execute an MPOA, a resident must have capacity. This document had been completed, although her hospital records documented she lacked the capacity to make such an informed decision as this. Additionally, the day after it was signed, her attending physician at the facility also determined that she lacked capacity. 5. The MPOA, executed on 08/24/09, had been witnessed by facility staff - Employees #86 (the assistant director of nursing) and #89 (the food services director). The facility's policy entitled \"Health Care Decision Making\" includes: \"GHC (Genesis Health Care) staff will not act as witnesses to signing of any forms or documents concerning health care decision making .... \" 6. A copy of the HCS appointment from the hospital was found with the records the hospital had sent to the facility. There was also a \"Determination of Capacity\" form dated 08/05/09, where the physician had noted the resident demonstrated incapacity to make medical decisions based on his examination of her in the hospital. The incapacity was expected to be long term. 7. The social worker who had completed the \"Health Care Decision Making\" form (which noted the resident had a HCS) was not available. The director of nursing was asked if she was aware of what had prompted the completion of the MPOA document when the resident had a HCS from the hospital in place. She did not know why this had been done. She agreed the MPOA document would not have been valid, since the resident had determinations of incapacity before and after the MPOA document was executed. b) Resident #81 This resident's medical record contained a form entitled \"Consent for Treatment and Release of Information\". The form had the resident's name written on it and a date of 09/11/09. It was apparent this had been written by the same nurse (Employee #54) who also signed the form and dated her signature 09/11/09. The resident's MPOA representative had signed the document, which authorized medical care but also authorized disclosure of information to the resident's daughters, the resident's son, and two (2) in-laws. The determination of the resident's capacity was not completed until 09/15/09, at which time, he was determined to possess the capacity to make his own health care decisions. There was no indication why the resident's MPOA representative had signed the document, nor was there evidence the document had been reviewed with the resident to see whether he agreed. c) Resident #46 Medical record review, on 090/2/09, revealed this resident was admitted to the facility on [DATE]. Upon admission, the person whom this resident had appointed as her MPOA representative signed for the resident to be resuscitated in the event of cardiopulmonary arrest. There was no evidence of the resident's involvement in this decision. This was verified by the social worker at 4:00 p.m. on 09/22/09. At the time the MPOA signed for resuscitation, the resident had not been determined to lack the capacity to make informed health care decisions. In fact, on 09/09/09, the physician evaluated the resident and determined she did possess the capacity for medical decision making. .", "filedate": "2014-12-01"}
{"rowid": 10838, "facility_name": "MAPLES NURSING HOME", "facility_id": 515186, "address": "1600 BLAND STREET", "city": "BLUEFIELD", "state": "WV", "zip": 24701, "inspection_date": "2009-08-14", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "L59911", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, the facility failed to ensure the determination of capacity for a resident was made in accordance with Chapter 16, Article 30 of the West Virginia State Code, prior to allowing another individual to make health care decisions on behalf of the resident. The cause, nature, and duration of the incapacity were not identified for one (1) of the twelve (12) residents on the sample. Resident identifier: #28. Facility census: 48. Findings include: a) Resident #28 Review of the medical record for this resident found determinations of capacity dated 02/13/08 and 03/17/09. Both of the assessments identified the resident as lacking capacity to make health care decisions. The \"Physician's Determination of Capacity\" dated 02/13/08 had an \"X\" in the box by \"[MEDICAL CONDITION]\" in the section for \"Nature\". (\"[MEDICAL CONDITION]\" means the resident was unable to speak but would not necessarily mean the resident was unable to communicate and/or make medical decisions.) In the section for the cause of the incapacity, \"ASCVD\" ([MEDICAL CONDITION] cardiovascular disease) had been written. Again, this [DIAGNOSES REDACTED]. Additionally, the box by the section indicating the resident had been informed that someone else would be making her health care decisions was not checked. On the same form, another section for \"Periodic Capacity Review\" had been completed on 03/17/09. An \"X\" had been placed in the box by \"Demonstrates INCAPACITY to make medical decisions.\" It had not been marked to indicate the resident was informed of the decision, and nothing had been checked or written for the nature and cause of the incapacity. The West Virginia Health Care Decisions Act, ?16-30-7. Determination of incapacity., states: \"(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. \"(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. \"(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. .", "filedate": "2014-12-01"}
{"rowid": 10864, "facility_name": "GLEN WOOD PARK, INC.", "facility_id": 515028, "address": "1924 GLEN WOOD PARK ROAD", "city": "PRINCETON", "state": "WV", "zip": 24740, "inspection_date": "2009-12-11", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "IPRG11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure one (1) of eleven (11) residents received a re-evaluation in their capacity status after a determination of short term incapacity had been made in 02/06/09. Resident identifier: #51. Facility census: 61. Findings include: a.) Resident #51 On 12/08/09 at approximately 9:30 a.m., medical record review for Resident #51 revealed she lacked the capacity to understand and make her own medical decisions. This determination occurred on 02/06/09, at which time the physician selected \"short-term\" for the duration incapacity and listed [MEDICAL CONDITION] cardiovascular disease as the cause. The physician identified as the nature of incapacity that the resident could not process information. The physician's determination of capacity form allowed for periodic capacity review; however, the facility had not completed the periodic review for this resident. On 12/08/09 at approximately 9:45 a.m., Employee #87 (registered nurse) indicated the resident received treatment from a psychiatrist who comes to the facility. She provided copies of the psychiatrist's progress notes which reflected no change in the resident's mental capacity. On 12/08/09, the physician re-evaluated the resident, at which time he determined the resident now possessed the capacity to understand and make her own medical decisions. .", "filedate": "2014-11-01"}
{"rowid": 10943, "facility_name": "HAMPSHIRE CENTER", "facility_id": 515176, "address": "260 SUNRISE BOULEVARD", "city": "ROMNEY", "state": "WV", "zip": 26757, "inspection_date": "2009-06-18", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "HO2T11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ascertain a capacitated resident's wishes with respect to advance directives, allowed a medical power of attorney representative (MPOA) to make a health care decision on behalf of the resident without the legal authority to do so, and failed to identify and resolve conflicts between physician's orders [REDACTED]. Resident identifier: #4. Facility census: 61. Finding include: a) Resident #4 Review of Resident #4's medical record, on 06/17/09, revealed she was admitted to the facility on [DATE], with admitting orders signed by the physician for \"Advance Directives: DNR (do not resuscitate).\" Review of the \"Physician Determination of Capacity\", dated 01/11/09, revealed the resident had the capacity to understand and make her own informed health care decisions. The \"staff member involved\" with the completion of Resident #4's Advanced Directive Acknowledgment Form (Employee #63) marked an \"X\" at Item 6 indicating, \"Do not perform cardiopulmonary resuscitation\", and recorded, \"Per conservation with POA (power of attorney) 01/09/09 2:50 PM.\" There was no signature of the form from the person making this health care decision on behalf of Resident #4, and there was no indication that Resident #4, who had the capacity to make this decision herself, was consulted regarding this matter. The \"physician acknowledgement\" of the form was signed by the physician on 01/09/09. Review of the resident's history and physical, dated and signed by the physician on 01/12/09 at 3:50 p.m., revealed: \"CODE STATUS: FULL RESUSCITATION in the event of cardiopulmonary arrest, including intubation with mechanical ventilation and/or cardioversion pending her POST form and official DNR status. Will get further details from the long-term care unit.\" Review of the Physician order [REDACTED]. The form had been signed by the resident's MPOA - not the resident, and the MPOA's signature was not dated. The physician had signed and dated the form on 01/18/09. Interview with the director of nursing (DON), on the afternoon of 06/17/09, confirmed there was conflicting information regarding the resident's advances directives. The DON said the facility would need to ascertain the resident's desires with respect to resuscitation status and honor her wishes. .", "filedate": "2014-11-01"}
{"rowid": 11021, "facility_name": "HEARTLAND OF KEYSER", "facility_id": 515122, "address": "135 SOUTHERN DRIVE", "city": "KEYSER", "state": "WV", "zip": 26726, "inspection_date": "2009-02-05", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "53ZE11", "inspection_text": "Based on record review and staff interview, the facility failed to assure a resident, who had been determined to lack the capacity to understand and make informed healthcare decisions, had his decisions made by a legal surrogate designated in accordance with State law. The facility had Resident #92 sign an informed consent form authorizing the administration of the influenza vaccine, even though he had been determined to lack the capacity to make such healthcare decisions. Resident identifier: #92. Facility census: 121. Findings include: a) Resident #92 Medical record review revealed the attending physician determined Resident #92 lacked the capacity to understand and make healthcare decisions on 07/28/08. This determination was validated by a second determination made by a psychologist on 08/01/08. Further record review revealed Resident #92 had signed an informed consent form authorizing the administration of the influenza vaccine on 10/22/08. No other signature was on the form. During an interview with the social worker at 11:45 a.m. on 02/04/09, she acknowledged, after reviewing the chart, that Resident #92 should not have been asked to sign this form, as the resident did not have the capacity to understand and make healthcare decisions at that time. (Note: After the fact, on 11/19/08, the resident's attending physician reversed this and determined the resident had the capacity to formulate healthcare decisions. However, at the time the resident signed the vaccination consent form, he did not.) .", "filedate": "2014-09-01"}
{"rowid": 11048, "facility_name": "VALLEY CENTER", "facility_id": 515169, "address": "1000 LINCOLN DRIVE", "city": "SOUTH CHARLESTON", "state": "WV", "zip": 25309, "inspection_date": "2009-06-25", "deficiency_tag": 152, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "OJEL11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed, for four (4) of twenty-eight (28) sampled records, to ensure legal surrogates were designated in accordance with State law for residents who have been determined to lack the capacity to understand and make their own health care decisions. Additionally, the facility failed to ensure the correct legal surrogate was identified in the medical record and contacted when health care decisions needed to be made. Resident identifiers: #3, #113, #131, and #19. Facility census: 128. Findings include: a) Resident #3 Medical record review, completed on 06/24/09, revealed the face sheet (demographic sheet) identified the resident's son was his medical power of attorney representative (MPOA). Review of the resident's MPOA document revealed the wife was the primary MPOA and the son was the successor MPOA. Further review revealed, on 11/19/08, the facility sent a notice to the resident's son, informing him of an upcoming care plan meeting. When interviewed on 06/24/09 at 11:20 a.m., the social worker (Employee #22) identified that the correct legal representative was the wife and the medical record face sheet was incorrect. Shortly after this interview, the face sheet was corrected. b) Resident #113 Medical record review, on 06/23/09, revealed Resident #113 was determined by his physician to lack capacity to make an informed choice regarding medical decisions on 03/27/09. Documentation on the form entitled \"Physician Determination of Capacity\" stated the resident lacked capacity due to a \"[MEDICAL CONDITION]\" ([MEDICAL CONDITION] - stroke). The determination of incapacity was based solely on a medical condition and did not provide information to describe what components of the disease interfered with his ability to understand and make informed health care decisions. The facility's director of nursing (DON - Employee #82), when provided this information on 06/25/09, was unable to provide any additional documentation by the resident's physician to describe the nature of the resident's incapacity. c) Resident #131 Closed medical record review, on 06/25/09, revealed Resident #131 was determined by his physician to lack capacity to make an informed choice regarding medical decisions on 02/27/09. Documentation on the form entitled \"Physician Determination of Capacity\" stated the resident lacked capacity due to the [DIAGNOSES REDACTED]. The determination of incapacity was based solely on a medical condition and did not provide information to describe what components of the disease interfered with his ability to understand and make informed health care decisions. The DON,when provided this information on 06/25/09, was unable to provide any additional documentation by the resident's physician to describe the nature of the resident's incapacity. d) Resident #19 Medical record review for Resident #19 revealed the physician's determination of capacity stated Resident #19 demonstrated incapacity to understand and make informed medical decisions and indicated, with a check mark, the [DIAGNOSES REDACTED]. There was NO further information regarding cause or nature, as required by State law. During an interview with the social worker (Employee #128) at 11:00 a.m. on 06/24/09, he confirmed the physician had not filled in all the required information on the determination of capacity form. e) Per W.Va. Code 16-30-7. Determination of incapacity: \"(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. \"(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. \"(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. .", "filedate": "2014-09-01"}
{"rowid": 11116, "facility_name": "NEW MARTINSVILLE CENTER", "facility_id": 515074, "address": "225 RUSSELL  AVENUE", "city": "NEW MARTINSVILLE", "state": "WV", "zip": 26155, "inspection_date": "2009-04-30", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "6TSD11", "inspection_text": "Based on record review and staff interview, the facility failed to ensure that the persons making healthcare decisions for two (2) of thirteen (13) sampled residents, who had been determined to lack the capacity to make such decisions for themselves, were appointed in accordance with State law. Resident identifiers: #45 and #60. Facility census: 101. Findings include: a) Resident #45 A review of Resident #45's medical record revealed a copy of a document appointing the resident's son as her medical power of attorney representative (MPOA). Review of the resident's advance directives, consents for vaccination, and other legal documents revealed these healthcare decisions had been made by the resident's daughter as evidenced by her signatures on these documents. During an interview with the director of nursing (DON) at 5:15 p.m. on 04/28/09, she stated the son was the MPOA of record, but the facility accepted the daughter's signature because she was the one who came in most often. b) Resident #60 A review of Resident #60's medical recordrevealed the individual who gave consent for a do not resuscitate order and for use of psychoactive medications, and who made other healthcare decisions for Resident #60 was not the person designated by the resident to serve as MPOA. During an interview with the DON at 5:15 p.m. on 04/28/09, she acknowledged that the person making the resident's healthcare decisions was not the resident's legally appointed MPOA.", "filedate": "2014-08-01"}
{"rowid": 11154, "facility_name": "EMERITUS AT THE HERITAGE", "facility_id": 5.1e+153, "address": "RT. 4, BOX 17", "city": "BRIDGEPORT", "state": "WV", "zip": 26330, "inspection_date": "2009-08-12", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "OCKG11", "inspection_text": "Based on record review and staff interview, the facility allowed a resident to sign legal documents for health care decisions on the same day the resident's physician determined he did not possess the capacity to understand and make informed health care decisions and no one had been designated to serve as health care surrogate for the resident. Additionally, the physician failed to record the cause and duration of Resident #50's incapacity. This was evident for one (1) of thirteen (13) sampled residents. Resident identifier: #50. Facility census: 50. Findings include: a) Resident #50 Record review revealed Resident #50 had a determination of incapacity statement signed by his attending physician at the facility. Record review also revealed that, on the same day the incapacity statement was signed by the physician, Resident #50 had signed the following documents: acknowledgment for bed rail use; acknowledgment of resident rights and privacy notice; immunization acknowledgment for declination of influenza vaccine; advance directives acknowledgment form; and permission to release information form. Interview with the social worker (Employee #8), on 08/12/09 at 2:00 p.m., revealed the resident had recently been admitted to the facility on her day off; he was accompanied by one (1) of his children. Employee #8 said, on the following day, she contacted one (1) of his children, who agreed to come in that day and speak with her, but the daughter did not appear. The next day, the physician assessed Resident #50 and determined he lacked the capacity to understand and make health care decisions. Employee #8 spoke her plans to have a yet-to-be assigned health care surrogate co-sign his legal documents, and she was in the process of making phone calls and going down the long list of family members to identify who was willing and able to serve as his health care surrogate. Interview with the social worker, on 08/12/09 at approximately 6:00 p.m., revealed she was still in the process of calling family members to determine who was able and willing to be the resident's health care surrogate, noting that it was a very large family which made the process more difficult. She explained that, prior to his admission to the facility, the transferring facility led her to believe the resident had capacity. Also at this time, it was brought to the attention of staff that the physician did not record the cause(s) of his incapacity. Employee #8 said the physician wrote the cause was \"to be determined\". Review of Resident #50's determination of incapacity form found physician documentation indicating the duration of his incapacity was \"to be determined\" (as to whether it was short term or long term), and nothing was recorded to address the cause of his incapacity. .", "filedate": "2014-08-01"}
{"rowid": 11211, "facility_name": "TEAYS VALLEY CENTER", "facility_id": 515106, "address": "590 NORTH POPLAR FORK ROAD", "city": "HURRICANE", "state": "WV", "zip": 25526, "inspection_date": "2009-12-03", "deficiency_tag": 152, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TDS111", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to identify the nature of incapacity for one (1) of twenty-one (21) sampled residents determined by the physician to lack the ability to understand and make informed health care decisions. Resident identifier: #3. Facility census: 116. Findings include: a) Resident #3 Review of Resident #3's determination of incapacity statement, dated 10/28/09, revealed the physician identified the resident lacked decision-making capacity due to the [DIAGNOSES REDACTED]. During interview with the director of nursing (DON) the morning of 12/02/09, she stated the facility's practice is for the physician to note not only the [DIAGNOSES REDACTED]. When informed of Resident #3's incapacity statement, which noted only the diagnosis, she said she would bring this to the physician's attention for correction. According to W.V.C. 16-30-7. Determination of incapacity.: \"(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. \"(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ...\" .", "filedate": "2014-07-01"}
{"rowid": 11332, "facility_name": "GOLDEN LIVINGCENTER - MORGANTOWN", "facility_id": 515049, "address": "1379 VAN VOORHIS RD", "city": "MORGANTOWN", "state": "WV", "zip": 26505, "inspection_date": "2010-12-28", "deficiency_tag": 152, "scope_severity": "D", "complaint": null, "standard": null, "eventid": "OYFI11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to verify that a surrogate decision-maker had the necessary authority to act on behalf of a resident who had been determined to lack the capacity to make healthcare decisions, for one (1) of six (6) sampled residents. Resident identifier: #23. Facility census: 89. Findings include: a) Resident #23 A review of Resident #23's medical record revealed a [AGE] year old female who was originally admitted to the facility on [DATE], and who had been determined to lack the capacity to make healthcare decisions by her attending physician on 08/21/08. The face sheet in the resident's record indicated the resident had designated an individual to serve as her medical power of attorney representative (MPOA), but there was no copy of this document in the record. Social service notes, dated 12/13/10, stated the resident's sister had been appointed to serve as her health care surrogate (HCS), and documentation elsewhere in the record indicated this HCS was making healthcare decisions for the resident. No record of the appointment of a HCS by the resident's attending physician was located in the record. During an interview with the social worker (Employee #5) at 10:40 a.m. on 12/28/10, she verified, after review of the resident's medical record and her office records, that there was no record of a legal representative. She speculated it had been misplaced at some point. .", "filedate": "2014-04-01"}
{"rowid": 11505, "facility_name": "MONTGOMERY GENERAL HOSP., D/P", "facility_id": 515081, "address": "WASHINGTON STREET AND 6TH AVENUE", "city": "MONTGOMERY", "state": "WV", "zip": 25136, "inspection_date": "2009-05-29", "deficiency_tag": 152, "scope_severity": "D", "complaint": null, "standard": null, "eventid": "E5O711", "inspection_text": "Based on medical record review, and staff interview, the facility failed to assure the right to make medical decisions for one (1) of ten (10) sampled residents was exercised in accordance with State law (the West Virginia Health Care Decisions Act). The facility allowed a health care surrogate (HCS) to transfer decision-making authority to a different family member when the HCS was unavailable. Resident identifier: #4. Facility census: 29. Findings include: a) Resident #4 Review of Resident #4's medical record found the treating physician determined the resident lacked capacity to understand and make informed medical decisions on 04/17/09. The physician appointed Family Member #1 to act as the resident's HCS. Further review found a handwritten, notarized document which appeared to be authored by Family Member #1, transferring the health care decision-making authority to Family Member #2 in the event Family Member #1 could not be reached. On 05/28/09 at 1:00 p.m., the document was shown to two (2) facility nurses (Employees #24 and #27). Each was asked what they would do if Family Member #1 could not be reached to make a health care decision. Both stated that, because the document was notarized, they would contact Family Member #2 to make health care decisions. Review of section 16-30-8 (a) of the West Virginia Health Care Decisions Act found the following language, \"When a person is or becomes incapacitated, the attending physician or the advanced nurse practitioner with the assistance of other health care providers as necessary, shall select, in writing, a surrogate.\" The facility allowed a HCS to transfer medical decision-making authority to another individual in violation of the West Virginia Health Care Decisions Act. Only the attending physician or advanced nurse practitioner may select a surrogate decision-maker. .", "filedate": "2014-01-01"}
{"rowid": 6917, "facility_name": "ELDERCARE HEALTH AND REHABILITATION", "facility_id": 515065, "address": "107 MILLER DRIVE", "city": "RIPLEY", "state": "WV", "zip": 25271, "inspection_date": "2014-10-08", "deficiency_tag": 153, "scope_severity": "B", "complaint": 1, "standard": 0, "eventid": "KVTV11", "inspection_text": "Based on review of the facility's policies and procedures, the facility failed to ensure the policies established for accessing medical records was in compliance with this regulation. The current facility policy had the potential to result in residents and/or the legal representative being denied access to medical records within 24 hours (excluding weekends and holidays) as required. This practice had the potential to affect any resident/responsible party who exercised the right to access clinical records. Facility Census: 81. Findings include: a) Review of the facility's policy titled Request for Medical Records, last reviewed 2013, revealed in section 6, . the documents should be produced within five (5) days of receipt of the notification that the request for a medical record is valid.", "filedate": "2017-10-01"}
{"rowid": 11423, "facility_name": "HEARTLAND OF BECKLEY", "facility_id": 515086, "address": "100 HEARTLAND DRIVE", "city": "BECKLEY", "state": "WV", "zip": 25801, "inspection_date": "2010-11-02", "deficiency_tag": 153, "scope_severity": "D", "complaint": null, "standard": null, "eventid": "U2Q611", "inspection_text": ". Based on a review of the State Board of Review hearing notice, staff interview, family interview, and a review of a Release of Medical Record form, the facility failed to ensure a resident or his / her legal representative had the right, upon an oral or written request, to access all records pertaining to his/her stay at the facility, including current clinical records, within twenty-four (24) hours (excluding weekends and holidays) of receipt of the request. This occurred for one (1) of eleven (11) residents included in the sample. Resident identifier: #162. Facility census: 150. Findings include: a) Resident #162 During a telephone interview on 11/01/10 at 7:30 p.m., Resident #162's legal representative reported the facility did not allow access to the resident's medical record for review prior to an appeal for discharge hearing with the State Board of Review at 1:00 p.m. on 09/27/10. The representative reported having called the facility on 09/23/10 or 09/24/10 and leaving a voice message for the assistant administrator, asking to review the information the facility was going to use in the hearing. She said she was not provided the information prior to the hearing. During an interview on 11/02/10 at 11:00 a.m., the assistant administrator reported the request was made on 09/24/10 (a Friday) and, at that time, the information was being gathered by the facility administrator for the hearing. He said the information was not available for review until the hearing at 1:00 p.m. on 09/27/10. Review of the hearing notice, dated 09/20/10, found a second page with a section titled, \"You Have the Right To:\" The first item under this title stated, \"1. Examine all documents and manual sections to be used at the hearing, both before, during, and after the hearing. Please call the nursing home if you wish to look at the evidence before the hearing.\" The administrator, who was interviewed on 11/02/10 just after the assistant administrator, stated the resident's legal representative did not ask to review the resident's records until after the hearing on 09/27/10, and she produced a release signed by the resident's legal representative on that date. .", "filedate": "2014-03-01"}
{"rowid": 827, "facility_name": "DUNBAR CENTER", "facility_id": 515066, "address": "501 CALDWELL LANE", "city": "DUNBAR", "state": "WV", "zip": 25064, "inspection_date": "2017-03-22", "deficiency_tag": 154, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "ZQ9211", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and record review it was determined the facility failed to ensure two (2) of five (5) residents reviewed for unnecessary medications who received psychoactive medications were informed of the risks and benefits of psychoactive medications. Failure to provide residents and/or the legal representative information regarding psychoactive medications placed the residents at risk to not be fully informed about their care and potential alternate treatment options. Resident identifiers: #35 and #113. Facility census: 85. Findings include: a) Resident #35 Review of physician orders, on 03/21/17 at 10:15 a.m., revealed Resident #35 received the anti-psychotic medication, [MEDICATION NAME], and the anti-depressant medication, [MEDICATION NAME], daily since 09/09/16. On 03/21/17 at 10:25 a.m., review of the Minimum Data Set (MDS) with an Assessment Reference Date of 02/04/17 revealed the resident had moderately impaired cognitive skills. In an interview, on 03/21/17 at 11:35 a.m., Resident #35 was unable to state any of the medications she received nor what she took them for. Review of the resident's record, on 03/21/17 at 10:43 a.m., revealed a paper form entitled Psychotherapeutic Medication Administration Disclosure. The form included different classifications of psychoactive medications, their benefits, adverse reactions and special concerns for staff to select based on the resident's assessed care needs. While someone had circled the anti-psychotic medication [MEDICATION NAME], the form failed to identify the anti-depressant [MEDICATION NAME]. There were no signatures from the resident, the resident's representative, or facility staff, nor was there any indication verbal consent was obtained. There was no date on the form. In an interview, on 03/21/17 at 2:25 p.m., the Assistant Director of Nursing (ADON) #79 stated the hard copy of the Medication Administration Disclosure should be in the chart under the consent tab. She explained this was the facility's evidence the resident, or their representative, was informed about the use of the medication and it's risks and benefits. She reviewed the record, determined the only copy in it was blank, and stated she would check the thinned chart. She explained the admitting nurse, or the nurse who obtained the physician's orders [REDACTED]. At 2:35 p.m. ADON #79 returned and stated she reviewed the thinned chart and progress notes and was unable to locate any indication the resident or the resident's representative had been provided information regarding the use of, including risks and benefits, of the [MEDICAL CONDITION] medications. b) Resident #113 Review of physician orders, on 03/21/17 at 1:35 p.m., revealed Resident #113 received the anti-depressant [MEDICATION NAME], since 05/04/16. The orders also indicated the resident received the anti-psychotic medication [MEDICATION NAME], since 05/03/16, with a decrease in dose on 12/14/16 and an increase back to the original dose on 12/19/16. Review of the MDS with an ARD of 03/07/17, on 03/21/17 at 2:00 p.m., revealed the resident had severely impaired cognitive skills. In an interview, on 03/21/17 at 11:35 a.m., Resident #113 was unable to state any of the medications she received nor was she able to report what she took them for. Review of the resident's record, on 03/21/17 at 2:15 p.m., revealed a blank Psychotherapeutic Medication Administration Disclosure. The form had the resident's name written on it, but did not identify the classification of the medications, the benefits, adverse reactions or special concerns related to these medications. The form did not indicate whether the resident, or the resident's representative, had been provided this information. In an interview on 03/21/17 at 2:25 p.m., the ADON #79 reviewed the record and determined the only copy in it was blank. She stated, Well, she is a ward of the state, so. When asked if that meant the facility would not provide information about the medication to the resident's representative, she said, Well, no. She then stated she would check the resident's thinned record. At 2:35 p.m., she returned and stated she was unable to locate any indication the resident's representative had been provided information regarding the risks and benefits of the [MEDICAL CONDITION] medications.", "filedate": "2020-09-01"}
{"rowid": 2612, "facility_name": "WILLOW TREE HEALTHCARE CENTER", "facility_id": 515156, "address": "1263 SOUTH GEORGE STREET", "city": "CHARLES TOWN", "state": "WV", "zip": 25414, "inspection_date": "2017-08-17", "deficiency_tag": 154, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "OM4311", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to inform the responsible parties of the risks and benefits of receiving psychopharmacological medications in advance of administering them to cognitively impaired residents. This affected two (2) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #46, and #118. The facility census was 101. Findings include: a) Resident #46 On 08/17/17 at 9:32 a.m., review of the resident's medical record revealed [REDACTED]. Review of current physician orders [REDACTED]. Review of the medical record on 08/17/17 at 11:15 a.m. revealed Resident #46 lacked capacity to make her own medical decisions and her daughter was indicated as the resident's responsible party and emergency contact. Concurrent review of the resident's plans of care revealed a current plan of care with a revision dated of 03/29/17 for the resident's use of [MEDICAL CONDITION] drug for dementia. The care plan problem stated the use of [MEDICAL CONDITION] drug use placed the resident at risk for drug related [MEDICAL CONDITION], gait disturbance, cognitive impairments, behavior impairment, activities of daily living decline, decline in appetite, and abnormal involuntary movements. The care planned interventions included antipsychotic side effects list #1 not limited to: [DIAGNOSES REDACTED]: [DIAGNOSES REDACTED] (stiffness of neck), [MEDICATION NAME] symptoms: dry mouth, blurred vision, constipation, [MEDICAL CONDITIONS], sedation/drowsiness, increased falls/dizziness, cardiac abnormalities ([MEDICAL CONDITIONS], irregular heart rate), anxiety/agitation, blurred vision, sweating/rashes, headache, [MEDICAL CONDITION]/hesitancy, pseudo-parkinsonism: cogwheel rigidity, bradykinesia, tremors, appetite change/weight change. Educate resident/family/POA about risk versus benefits of medication/side effects/adverse effects. Further review of the medical record found no evidence the resident's responsible party was educated/informed about the risk versus benefits of the resident's use of the [MEDICAL CONDITION] medications. Interview on 08/17/17 at 10:30 a.m. with the Director of Nursing verified there was no evidence Resident #46's responsible party was educated/informed about the risk versus benefits of the resident's use of the [MEDICAL CONDITION] medications and had given consent for the continued use of the medications. b) Resident #118 Review on 08/16/17 at 1:54 p.m. of the resident's medical record revealed the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Concurrent review of current physician orders [REDACTED]. Review of the medical record on 08/16/17 at 1:57 p.m. revealed Resident #118 lacked capacity to make her own medical decisions and her granddaughter was indicated as the resident's responsible party and emergency contact. Concurrent review of the resident's plans of care on revealed a current plan of care with an initiation date of 11/09/16 for the resident's use of an anti-depressant. The care plan interventions included to administer medications as ordered. (MONTH) cause day time drowsiness, confusion, loss of appetite in the morning, increased risk of falls and fractures, dizziness. Observe for possible side effects. Further review of the resident's plans of care revealed a plan of care for the resident's use of use of [MEDICAL CONDITION] drugs. The plan of care identified the medication placed the resident at risk for drug related [MEDICAL CONDITION], gait disturbance, cognitive impairments, behavior impairment, activities of daily living decline, decline in appetite and abnormal involuntary movements. Interventions with initiation date of 03/22/17 stated sedative/hypnotic side effects not limited to: [DIAGNOSES REDACTED]: [DIAGNOSES REDACTED] (stiffness of neck), [MEDICATION NAME] symptoms: dry mouth, blurred vision, constipation, [MEDICAL CONDITIONS], sedation/drowsiness, increased falls/dizziness, cardiac abnormalities ([MEDICAL CONDITIONS], irregular heart), anxiety/agitation, blurred vision, sweating/rashes, headache, [MEDICAL CONDITION]/hesitancy, weakness and hangover effect. Educate resident/family/POA about risk vs benefits of medication/side effects/adverse effects. Further review of the medical record found no evidence the resident's responsible party was educated/informed about the risk versus benefits of the resident's use of the [MEDICAL CONDITION] medications. Interview on 08/17/17 at 10:30 a.m. with the Director of Nursing verified there was no evidence Resident #118's responsible party was educated/informed about the risk versus benefits of the resident's use of the [MEDICAL CONDITION] medications and had given consent for the continued use of the medications", "filedate": "2020-09-01"}
{"rowid": 3893, "facility_name": "HARPER MILLS", "facility_id": 515086, "address": "100 HEARTLAND DRIVE", "city": "BECKLEY", "state": "WV", "zip": 25801, "inspection_date": "2016-09-23", "deficiency_tag": 154, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0MB311", "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 ensure Resident #170 was given information in advance sufficient enough for her to make a knowledgeable health care decision in regards to a fluid restriction which her attending physician at the hospital (who was also her attending physician at the facility) had recommended upon her discharge from the hospital on [DATE]. This was true for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT]. Resident Identifier: #170. Facility Census: 178 Findings include: a) Resident #170 A review of Resident #170's medical record at 9:00 a.m. on 09/23/16, found a discharge summary completed by Resident #170's attending physician while she was at the hospital. The discharge summary completed on 08/22/16 included her attending physician recommended a fluid restriction due to her status as a [MEDICAL TREATMENT] patient and her [DIAGNOSES REDACTED]. The same physician was also her attending physician at the facility. During an interview with the corporation's Chief Medical Officer Medical Doctor (CMO-MD) #271 at 10:20 a.m. on 09/23/16, when asked why Resident #170, a [MEDICAL TREATMENT] patient, was not ordered a fluid restriction upon her return from the hospital on [DATE], he replied not every one on [MEDICAL TREATMENT] needed a fluid restriction. He indicated that people in the community very seldom ever restrict their fluid. He proceeded to state the risk and benefits related to not watching her fluid intake was explained to the resident, but she was alert and orientated and able to make her own decisions. Therefore, she had the right refuse the fluid restriction which is why she was not currently ordered a fluid restriction. CFO-MD #271 was then asked if the conversation explaining the risk and benefits related to her refusal of a physician recommended fluid restriction was documented in her medical record. He informed the surveyor that this information did not need to be in the medical record because she was alert and orientated and able to make her own decisions. Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities found the following, 483.10(d)(2) - The resident has the right to be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect the resident's well-being; Interpretive Guidelines 483.10(d)(2) Informed in advance means that the resident receives information necessary to make a health care decision, including information about his/her medical condition and changes in medical condition, about the benefits and reasonable risks of the treatment, and about reasonable available alternatives. At 4:04 p.m. on 09/23/16 the NHA was asked to provide any information that showed Resident #170 was informed about the physician recommended fluid restriction. The Director of Nursing (DON) was also asked at 5:16 p.m. on 09/23/16 to provide the same information. The DON stated she would check with the NHA and let us know. At 5:30 p.m. on 09/23/16, the medical records director reported the DON had told her to let the surveyors know there was no documentation in the medical record related to Resident #170's recommended fluid restriction. During an interview at 4:15 p.m. on 09/23/16, when asked if anyone at the facility had ever talked to her about a fluid restriction Resident #170 said a doctor, who she described as CMO - MD #271, had just been in a little while ago and asked her about a fluid restriction. She stated, I told him that I would not mind being on a fluid restriction if it was what was best for me. She then stated, Then he (she was referring to CMO - MD #271) said not to worry about it because I really did not need one. She then stated, I just want to do what is best for me. When asked if anyone at the facility had ever spoken with her about a fluid restriction prior to that time she stated, No that was the first time they ever mentioned it. On 09/23/16 Resident #170's attending physician declined to be interviewed by the surveyor. The NHA indicated that he was going out of town and was too busy to talk to us.", "filedate": "2020-04-01"}
{"rowid": 5100, "facility_name": "RALEIGH CENTER", "facility_id": 515088, "address": "1631 RITTER DRIVE", "city": "DANIELS", "state": "WV", "zip": 25832, "inspection_date": "2015-04-10", "deficiency_tag": 154, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "CRGX11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for resident rights was informed of his health status and needs. The resident's daughter, and not the resident, who had capacity to make health care decisions, was informed of the resident's health status. Resident identifier: #76. Facility census: 66. Findings include: a) Resident #76 On 04/06/15 at 11:04 a.m., the resident voiced concerns that staff did not involve him in his plan of care. He stated, I want my daughter involved and notified; however, I want to be notified first. Medical record review, on 04/06/15 at 1:20 p.m., found Resident #76 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. On 11/29/14, Resident #76's attending physician determined he had capacity to make informed health care decisions. Review of nurse's notes since admission found Resident #76's daughter was notified of his condition instead of the resident. An interview with Employee #42, Director of Admissions (DOA) and Employee #59, Social Services (SS), on 04/08/15 at 1:15 p.m., confirmed Resident #76 should be notified and involved in his plan of care. On 04/08/15 at 2:00 p.m., after intervention during the survey, Employee #42 spoke with Resident #76. The resident voiced his concern of not being allowed to be involved in his plan of care. In-service documentation, provided on 04/08/15, confirmed Resident #76 had capacity to make health care decisions and wished to actively participate in his care process.", "filedate": "2019-03-01"}
{"rowid": 5644, "facility_name": "PIERPONT CENTER AT FAIRMONT CAMPUS", "facility_id": 515155, "address": "1543 COUNTRY CLUB ROAD", "city": "FAIRMONT", "state": "WV", "zip": 26554, "inspection_date": "2015-07-29", "deficiency_tag": 154, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "DSPZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, family interview, and staff interview, the facility failed to ensure the responsible party of a resident with a severe decline in health status was given information about the resident's reasonable available alternatives; including the option of palliative care. Resident identifier: 98. Facility census: 99. Findings include: a) Resident #98 A review of the clinical record revealed Resident #98 was a [AGE] year-old male initially admitted to the facility on [DATE]. He was determined by his physician to lack the capacity to make health care decisions and his brother was his medical power of attorney (MPOA). Resident #98 was designated to be a Full Code, meaning he was to be resuscitated should he stop breathing or his heart stop. His present [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED].#217 at 10:15 a.m. on 07/22/15. The resident had multiple hospitalization s in (YEAR). When discharged to the hospital on [DATE], his skin was clear with no pressure ulcers. On readmission on 04/02/15, his admission physical indicated [MEDICAL CONDITION] of his lower extremities, but no evidence of pressure ulcers. A Significant Change comprehensive assessment was completed on 04/09/15. An entry in the clinical record by NP #217 on 05/21/15, indicated the resident had multiple unstageable pressure wounds. His last readmission was 07/08/15 and although there was no terminal [DIAGNOSES REDACTED]. The record on readmission indicated Resident #98 was a Full Code. The record indicated Resident #98 now had 1 unstageable and 11 deep tissue injuries (DTIs) and the treatment goal stated by the NP/Physician was, Expectation is for non-healing with goal to prevent worsening of wounds. The care plan meeting notes from 07/19/15, indicated he was a full code; had recent cognitive changes and scored 0/15 on his brief interview for mental status (BIMS); and was refusing oral intake. There was no evidence of any discussion of the resident's status with the MPOA. During an interview with the resident's brother/MPOA at 9:35 a.m. on 07/21/15, he said he knew the resident had been getting worse for the past few months. When asked what the plan of care was at present, he stated they wanted him to eat more and be able to get out of bed more. The resident, observed during the conversation was very frail and thin, with pale skin. He was lying on one side with his knees drawn up. He was awake but did not respond when spoken to. During an interview with Social Worker (SW) #145 at 2:00 p.m. on 07/23/15, she was asked if there had been a discussion with the MPOA about changing the code status, or about the use of palliative care or Hospice when the resident's health status deteriorated. She stated she had no knowledge of this and referred to SW #154, who was unavailable at that time. At 10:50 a.m. on 07/27/15, SW #154 was interviewed and also asked the same questions. She stated she had spoken to the MPOA and he had refused hospice, but would have to review her notes. At 11:45 a.m. SW #154 returned after reviewing the record and stated she had been unable to find written evidence of the MPOA being informed of available palliative or hospice care. At 4:30 p.m., on the same day, SW #154 stated she had informed the resident's brother/MPOA of the option of hospice/palliative care and had entered it into the record.", "filedate": "2018-09-01"}
{"rowid": 5711, "facility_name": "CLARY GROVE", "facility_id": 515039, "address": "209 CLOVER STREET", "city": "MARTINSBURG", "state": "WV", "zip": 25404, "inspection_date": "2014-11-19", "deficiency_tag": 154, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "H5V711", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, resident interview, and staff interview, the facility failed to ensure a resident was fully informed in language that she could understand of her total health status, including but not limited to, her medical condition and, in advance, about care and treatment and of any changes in that care or treatment that may affect her well-being. The facility failed to inform a resident they documented as having the capacity to make informed medical decisions that they had honored her medical power of attorney's decision to change her treatment to comfort measures only. This was found for one (1) randomly reviewed resident. Resident identifier: #147. Facility census: 110. Findings include: a) Resident #147 The medical record review for Resident #147, on 11/12/14 at 1:20 p.m., revealed she was most recently admitted to the facility on [DATE] and subsequently re-admitted on [DATE]. She was determined by a physician to possess the capacity to make informed medical decisions on 05/07/14. b) A physician's determination of capacity completed at the acute- care hospital on [DATE] just prior to resident #147's admission to the facility stated she possessed the capacity to make informed medical decisions. The initial determination of capacity made after her admission to the facility was on 05/05/14 and determined she lacked the capacity to make informed medical decisions, and the duration of her incapacity was long term. There was no nature or cause of her incapacity recorded. Another determination of capacity was completed at the facility on 05/07/14 as a periodic capacity review. Besides the reasons provided on the form for capacity review, which were Significant Change, Annual, and Readmission, a fourth reason, Tiebreaker, had been hand-written and was checked. This tiebreaker assessment determined she possessed the capacity to make informed medical decisions. There were no other physician's determinations of capacity found in the medical record. c) Pertinent progress notes were found as follows: -- The social service note dated 05/09/2014 at 8:07 a.m. stated: Resident admitted to facility from (acute care hospital) on 05/03/14. Resident is a DNR (do not resuscitate) and has a DNR order, DPOA, and LW posted on her chart. Resident has capacity and is oriented to person, place, time, and situation. Resident refused to participate in MDS/SW assessment(s). Resident's PHQ-9-OV score is 2. Resident receives an ATA medication with no reported adverse reactions. Resident is short term in the facility and will return to (assisted living facility) after completion of nursing/rehab goals. Resident's PCP is Dr. (name). Care plan reviewed/revised as needed. -- 06/12/2014 11:05 a.m. social services note stated: SW met with resident's daughter/POA and son in law, (name) and (name), to talk about placement plans for this resident. Resident is not appropriate to return to (assisted living facility) due to her high level of care needs. (medical power of attorney) has requested that resident remain in the facility for LTC. Facility is able to offer resident a LTC bed at this point in time, family accepted offer. (Son-in-law and daughter) then met with the business office to discuss the financial side of things involved with the transition. -- 07/14/2014 2:44 p.m. nutrition/weight Note: Call placed to resident's DPOA (durable power of attorney)/daughter, (name) notifying of 65 weight loss within one month and noted meal refusals. Per (name), she has noted that her mother does not seem to be interested in eating her usual favorites that she herself has brought in for resident, she states that she believes her mother has given up and states that she is agreeable to her mother being evaluated by psychiatrist if ordered by MD. Spoke with PA-C (physician's assistant) in facility notifying him of conversation with daughter and order received for psych evaluation due to noted weight loss with declination of meals. (Name) notified of same. -- 07/15/2014 3:18 p.m. social services note: SW met w/POA (name) to complete POST (physician orders [REDACTED]. POST form completed with following options: comfort measures, no IV fluids, no feeding tube. Resident is a DNR. Hospice offered and declined at this time. (Name) states she will notify SW if she changes her mind. POST out for MD signature. (Name) also informed SW that if resident should pass while in facility to have body sent to (Name)'s funeral and they have instructions to send body to funeral home in (another state). -- 07/16/2014 8:54 a.m. social services note: POA (power of attorney) also stated psych. (psychiatric) consult not necessary at this time. -- 07/16/2014 1:46 p.m. social services note: POST form signed by MD. POA aware. -- 07/18/2014 5:16 p.m. general progress note: Dr. (name) PA, (name) in to see resident and dc'd meds. and put resident on comfort measures. POA, (name) made aware. No pain or distress made aware. 08/6/2014 12:35 Care Plan Progress Note: Significant change. Weight loss, hand fed, incontinence, refusals to eat, behaviors. Alert. She has no hearing, communication problems. No vision impairment with glasses. When staff speaks with her she answers with curt, sharp almost angry sound in voice and does not care to carry on a conversion with them. Episodes of refusing 5 meals during ARD. ADL status verified by speaking with staff, observation, review of P[NAME]. Due to issues with screw in her hip per note of 6/19/14 she is a hoyer lift for transfers. She has episodes of yelling out, and at times does not know what she wants. She prefers to be in bed most of the time. Therapies discontinued. She is not motivated to assist with ADLs. Incontinent of urine and stool. Most medications have been discontinued without adverse effect. No pain per resident. No falls. Her dentures are loose and per resident not using them. When asked if she would like to see a dentist her response was as follows. They don't fit anymore and I ain't spending no D--- money on them No pressure areas. Excoriation under breast (pink currently, slightly damp. Use of prn antianxiety medication. Displays episodes of yelling out, and verbalizes increased anxiety. No adverse effects noted. --08/7/2014 8:00 a.m. Social Services Note: Resident is a significant change. Please refer to assessments for details. Resident is a DNR (do not resuscitate) hand has a DNR order, DPOA, POST form, and LW (living will) on her chart. Resident has capacity and is oriented to person and place. Her BIMS (brief interview for mental status) score is 3 and PHQ-9 (patient health questionnaire) score is 0. Resident is LTC (long term care) in facility r/t (related to) physical care needs. Care plan reviewed/revised as needed. 08/27/2014 16:34 Social Services Note: Alerted to the fact that resident was yelling at/with roommate's spouse. SW offered resident a room change because she does not like the fact that her roommate rambles without reason at times. SW offered resident a room change but she refused a move at this time. SW explained that if she is not getting along with her roommate she always has the right to move. Resident again refused to move. Resident stated that she agrees to be cordial with roommate and spouse from this point forward. SW stated that if she changes her mind and would like to move rooms to please alert staff. Resident agreed to do so. d) There was no documentation found to suggest Resident #147 had ever expressed she now wished to defer all decisions regarding her care to her medical power of attorney. e) Resident #147 was interviewed on 11/18/14 at 1:00 p.m. She was asked if anyone had spoken to her about her wishes for her continued care and advance directives. She replied absolutely not. f) Staff interviews 1. A member of the activities staff was interviewed on 11/18/14 at 11:47 a.m. they were asked about their interactions with resident #147 during documented one to one visits for socialization. They said they felt resident #147 understood the intent of conversation and questions during their visits. Although she occasionally refused to engage in conversations, when she did, she understood what was being communicated and answered questions appropriately. 2. The administrator was interviewed on 11/18/14 at 2:40 p.m. The situation regarding Resident #147 was discussed. She expressed understanding about the issues, including apparent contradictions in the record regarding Resident #147's capacity status, and agreed that if there is no additional evidence available, there is a concern with the resident's right to be informed of a change in her capacity, the recognized decision maker, and/or of her complete medical condition. No further documentation was presented during the survey. Although the medical record continues to show Resident #147 has the capacity to make informed medical decisions, the facility has honored the medical power of attorney's decisions placing her on comfort measures only, declining hospice care, and canceling an appointment for a psychiatric consultation.", "filedate": "2018-08-01"}
{"rowid": 6078, "facility_name": "RIVER OAKS", "facility_id": 515120, "address": "100 PARKWAY DRIVE", "city": "CLARKSBURG", "state": "WV", "zip": 26301, "inspection_date": "2014-01-24", "deficiency_tag": 154, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "ZW4411", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to fully inform residents who had been determined to possess the capacity to act as their own decision-maker, in a language that he or she could understand, of identified concerns regarding his or her total health status, including their cognitive status and psychosocial status as initiated in their individualized care plans. Residents were not informed of care plans established for behaviors. This was found for four (4) of four (4) residents who had voiced multiple documented complaints during 2013. Resident identifiers: #19, #62, #25, and #57. Facility census: 100. Findings include: a) Review of complaints, concerns, and abuse/neglect reporting began on 01/08/13 at 9:00 a.m. This review was continued and expanded on 01/20/14 as part of the extended survey protocol. 1) Resident #19 Review of the complaint/concern files identified this resident had thirty (30) documented concerns in 2013 to date. According to the documentation regarding these issues, the facility had attempted to resolve all of the resident's issues. The facility had not dismissed any of the resident ' s concerns as being unfounded or untrue. The high number of concerns filed by this resident prompted review of her medical record. This review the resident's physician had determined she possessed the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score, as assessed on 12/17/13, was 15, indicating she was cognitively intact. She was acting as her own decision-maker. Review of her care plan, on 01/16/13 at 1:00 p.m., found she had a focus item for being at risk for changes in behavior problems related to making false accusations towards staff. The goal for this problem was (typed as written), Will remain free of behavioral disturbances daily thru next review. Interventions implemented toward meeting this goal were (typed as written): 1. Anticipate needs and provide care as able. 2. Provide emotional support as needed. Further review of the resident's medical record found there were no behaviors identified on the resident's minimum data set assessments. There was no evidence of any targeted behaviors being quantitatively monitored. There was no evidence of any behaviors, other than the frequency of her complaints. The record review found no basis for establishing the goal of (typed as written), Will remain free of behavioral disturbances daily thru next review. b) Following the review of Resident #19's medical record, patient liaison, Employee #176, was asked on 01/20/14 at 11:48 a.m., to provide a listing of residents who had voiced the most complaints and concerns in 2013. She provided the requested information a short time later, which indicated the following: 1) Resident #62 This resident had eleven (11) complaints/concerns/grievances documented. Resident #62 had been determined by a physician to possess the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score as assessed on 01/09/14 was 15, indicating she was cognitively intact. She was acting as her own decision-maker. She was currently president of the resident council. Review of her care plan, on 01/16/13 at 1:10 p.m., found she had a focus item for being at risk for behavior symptoms related to fabrications of staff refusing care/frequently making accusations toward staff and other residents. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer medications per physician order. 2. Observe for mental status/behavior changes when new medication started or with changes in dosage. 3. Resident refuses psychiatric evaluation. 4. Use consistent approaches when giving care. 2) Resident #25 A review of the closed medical record for Resident #25 revealed she had been determined by a physician to possess the capacity to make informed medical decisions. This was verified in each of her care plan meeting minutes 07/24/13,08/08/13, and 10/16/13). She had scored 15/15 on the BIMS (Brief Interview for Mental Status) on 10/18/13. She was her own decision-maker during her stay at the facility. A review of the Concern Report files revealed Resident #25 had nine (9) grievances documented during her admission at the facility from 07/23/13 to 11/08/13. Review of the complaints and concerns found that the facility had attempted to resolve all of the issues. None had been dismissed as being unfounded or untrue. A review of her care plan, at 1:37 p.m. on 01/16/13, found she had a focus item for being noted to make false accusations towards staff related to [MEDICAL CONDITIONS]. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer medications per physician order. 2. Observe for mental status/behavior changes when new medication started or with changes in dosage. 3. Use consistent approaches when giving care. Medical record review found that although she had a care plan focus item related to being at risk for behaviors due to making false allegations or fabrications, there was no evidence of behaviors documented on the resident ' s comprehensive assessments (MDS) or any other systematic behavior monitoring that caused these focus items to be triggered for inclusion in their care plans. The only progress note in the entire record alluding to behaviors was the following on 10/18/13, which was the initiation date of the care plan for this focus, (typed as written) Nurse was standing outside of room passing medications when resident call light came on. Nurse finished passing pills that were already started. Nurse answered call light. Resident states, ' Its about time my call light has been on for an hour. ' Nurse explained to resident that she was standing outside of the room when the call light came on but I would be glad to assist her in repositioning. Resident states, ' You are just like everyone else, liars. ' Will continue to monitor. There was no entry in any of the physician's progress notes suggesting the presence of any behaviors. An interview was conducted with acting social services director, contracted Employee #44 on 1/21/14 at 11:50 a.m. She was identified by the Administrator, Employee #120 as the person responsible for facilitating resident care plan meetings. She was asked about general procedures during care plan conferences when a resident acting as their own decision-maker was in attendance, specifically if each focus item would be discussed with the resident. She said each department would in turn bring up all the items on their section of the care plan for discussion, and confirmed that, if an issue was significant enough to be initiated as a focus area on the care plan, it would be discussed during the conference with the responsible party. There was no evidence of behaviors being discussed in any of her care plan meeting minutes (07/24/13, 08/08/13, and 10/16/13) and her daughter had been in attendance at two (2) of the meetings. 3) Resident #57 This resident had eight (8) complaints/concerns/grievances documented. Resident #57 had experienced a recent significant change of condition and was determined by her physician to lack the capacity to make informed medical decisions on 12/27/13 due to illness/early dementia. Prior to that determination, she had acted as her own responsible party throughout her residency in 2013. Her Brief Interview for Mental Status (BIMS) score, as assessed on 11/27/13 was 15, indicating she was cognitively intact. Review of her care plan on 01/16/13 at 1:42 p.m. found she had a focus item for being at risk for behavior symptoms such as making false accusations towards staff and family related to mental illness and [MEDICAL CONDITION]. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer meds per physician orders, observe for effectiveness and side effects such as but not limited to dizziness, drowsiness, and falls. 2. If resident exhibits inappropriate behaviors, speak in a soft, calm tone, attempt to redirect, and encourage resident to express herself in a more appropriate manner. 3. Observe for mental status/behavior changes when new medication started or with changes in dosage. 4. Use consistent approaches when giving care. c) Review found each of these residents had care plan focus items related to being at risk for behaviors due to making false allegations or fabrications, although none of them had evidence of behaviors documented on their comprehensive assessments (MDS) or any other systematic behavior monitoring that caused these focus items to be triggered for inclusion in their care plans. d) In an interview with the acting social services director, contracted Employee #44, on 01/21/14 at 11:50 a.m. (she was identified by administrator, Employee #120, as the person responsible for facilitating resident care plan meetings), she was asked about general procedures during care plan conferences when a resident acting as their own decision-maker was in attendance, specifically if each focus item would be discussed with the resident. She said each department would in turn bring up all the items on their section of the care plan for discussion, and confirmed that, if an issue was significant enough to be initiated as a focus area on the care plan, it would be discussed during the conference with the responsible party. It was then discussed that review had found those residents having the most complaints all had care plan focus items bringing their credibility into question. She was asked if the focus item related to making false allegations or fabrications had been discussed with these residents. She said they had not.", "filedate": "2018-05-01"}
{"rowid": 6420, "facility_name": "PRINCETON CENTER", "facility_id": 515028, "address": "1924 GLEN WOOD PARK ROAD", "city": "PRINCETON", "state": "WV", "zip": 24740, "inspection_date": "2015-03-06", "deficiency_tag": 154, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "S2LQ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to inform one (1) of five (5) sampled residents of the healthcare status and treatment which necessitated medication changes. Resident #54 was receiving two (2) medications used to treat sexual behaviors. These medications had dosage adjustments of which Resident #54 was not informed. Resident Identifier: #54 Facility Census: 68. Findings Include: a) Resident #54 Review of Resident #54's medical record, at 3:17 p.m. on 03/03/15, found the resident had capacity to make medical decisions. The medical record contained one (1) capacity statement completed by the attending physician. The capacity statement indicated Resident #54 had the ability to appreciate the nature and implications of a health care decision, to make an informed choice regarding the alternatives presented, and to communicate the choice in an unambiguous manner. This form was completed on 05/31/14 and was still in effect at the time of this review. Further review of Resident #54's medical record found a physician's orders [REDACTED]. The nurse progress notes were reviewed. A note, dated 02/16/15, indicated Resident #54's spouse was notified of the medication change. There was no evidence in the medical record to suggest Resident #54 was notified of this medication change or was informed of the reason the medications were ordered and provided. Interview with the Director of Nursing (DON), at 12:23 p.m. on 03/06/15, confirmed there was no evidence to suggest Resident #54 was informed of the medication change on 02/16/15. She said staff called the spouse, but there was no evidence the resident was informed. The DON stated the physician was going to review the resident's capacity; however, at the time of the medication changes the resident was determined capable of making medical decisions.", "filedate": "2018-03-01"}
{"rowid": 8217, "facility_name": "HILLTOP CENTER", "facility_id": 515061, "address": "PO BOX 125", "city": "HILLTOP", "state": "WV", "zip": 25855, "inspection_date": "2013-07-25", "deficiency_tag": 154, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "1LKT11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to accurately inform the family and resident of the total health status related to antibiotic use for one (1) of three (3) residents reviewed for the use of antibiotics. The facility notified the resident and family member the resident was receiving the antibiotic [MEDICATION NAME] for a urinary tract infection. The resident was actually receiving the antibiotic for another diagnosis. He did not have a urinary tract infection at the time this antibiotic was ordered. Resident identifier: #114. Facility census: 112. Findings include: a) Resident #114 Review of the medical record, on 07/24/13, identified a physician's orders [REDACTED].#90 (licensed practical nurse - LPN) dated 06/29/13. The physician's orders [REDACTED]. Further review of the medical record found a general note written by Employee #90 (LPN), on 06/29/13 at 19:12, stating the family was notified this resident was ordered [MEDICATION NAME] for a urinary tract infection. During an interview conducted on 07/24/13 at 3:11 p.m., Employee #137 (family nurse practitioner), revealed she did not order [MEDICATION NAME] for a urinary tract infection. She stated, The [MEDICATION NAME] was ordered for results of a chest-x-ray called to me on 06/29/13, by the facility. Employee #137 also stated, I wouldn't have ordered [MEDICATION NAME] for a urinary tract infection. Review of the medical record identified a chest x-ray, dated 06/29/13, with the following impression: Under ventilated lungs, mild cardiomegaly, ill-defined densities left lung base could represent atelectasis or mild consolidation, recommend follow up.", "filedate": "2016-07-01"}
{"rowid": 9546, "facility_name": "HARPER MILLS", "facility_id": 515086, "address": "100 HEARTLAND DRIVE", "city": "BECKLEY", "state": "WV", "zip": 25801, "inspection_date": "2009-11-20", "deficiency_tag": 154, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "5V2011", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to inform one (1) of twenty-one (21) sampled residents of the potential risks and available alternative treatments relating to bladder elimination. An alert and oriented resident, whose indwelling Foley urinary catheter continued to be used at her request (beyond the time-limited physician's orders [REDACTED]. Resident identifier: 25. Facility census: 157. Findings include: a) Resident #25 Resident #25's medical record, when reviewed on 11/19/09 at 1:30 p.m., revealed a [AGE] year old female who was admitted to the facility on [DATE]. The resident was alert and oriented and had been determined by her physician to possess the capacity to understand and make informed healthcare decisions. The resident was on bedrest due to a fall at home resulting in fractures to the lumbar spine. The physician ordered an indwelling Foley urinary catheter for seven (7) days on 11/01/09 due to excoriation. Resident #25, when observed in bed at 1:45 p.m. on 11/19/09, had in place an indwelling urinary catheter. The resident, when interviewed, reported she did not want the catheter removed until she was off of bedrest and able to ambulate. The director of nurses (DON - Employee #165), when interviewed on 11/20/09 at 3:15 p.m., reported it was the resident's choice to keep the catheter. However, the DON did acknowledge the facility failed to inform the resident of potential risks of continuing to use an indwelling catheter over an extended period of time or alternative treatments available.", "filedate": "2015-10-01"}
{"rowid": 10569, "facility_name": "HEARTLAND OF MARTINSBURG", "facility_id": 515039, "address": "209 CLOVER STREET", "city": "MARTINSBURG", "state": "WV", "zip": 25404, "inspection_date": "2009-10-29", "deficiency_tag": 154, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0YSZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to fully inform one (1) of twenty (20) sampled residents, who had been determined by his physician to have the capacity to make his own healthcare decisions, of his rights as a resident, his healthcare status and the treatment interventions planned, and/or his discharge planning arrangements. Resident identifier: #62. Facility census: 114. Findings include: a) Resident #62 A review of the medical record revealed Resident #62 was a [AGE] year old male with [DIAGNOSES REDACTED]. He was admitted to the facility on [DATE]. His attending physician determined he lacked the capacity to make his own informed healthcare decisions on 04/13/09, and assigned his niece as his health care surrogate (HCS). The social services note, written by the social worker (SW - Employee #80) on 09/29/09, recorded the resident's niece came to the facility on this date and stated that, for health reasons, she could no longer serve as the resident's HCS. She was advised the facility would seek a HCS from WV DHHR. There was also evidence that a 30-day notice of discharge had been mailed to the HCS on or about 09/24/09, although she reported to the SW she had not received it. On 10/06/09, the resident's attending physician determined the resident now demonstrated the capacity to make his own informed healthcare decisions. All social services notes, progress notes, and nurses' notes after that date were reviewed, but there was no evidence that the resident had his care plan (especially his discharge plan) or his rights explained to him. During the general tour at 3:30 p.m. on 10/19/09, this resident approached the surveyor and asked if there was any rule about the sharing of the television in his room; he also asked the surveyor to find out why he had not been discharged yet. At 11:20 a.m. on 10/20/09, the resident was interviewed about his healthcare status. He said he was sick a few months ago but was well now and ready to go home. He could not relate to the surveyor any healthcare instructions and said that his niece took care of everything. During an interview with the social worker (Employee #80) at 9:45 a.m. on 10/21/09, she acknowledged the resident had not \"formally\" been included in any care discussions since he had been declared to have capacity and that the niece had formally rescinded her agreement to act as HCS for the resident. There was no evidence in the record that the resident had been informed of his rights, his code status, or that the facility has issued a 30-day notice of discharge. .", "filedate": "2015-01-01"}
{"rowid": 10783, "facility_name": "HEARTLAND OF CLARKSBURG", "facility_id": 515120, "address": "100 PARKWAY DRIVE", "city": "CLARKSBURG", "state": "WV", "zip": 26301, "inspection_date": "2011-08-02", "deficiency_tag": 154, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "H4MU11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, physician interview, and family interview, the facility failed to ensure the responsible party of one (1) of five (5) sampled residents, who lacked capacity to understand and make informed healthcare decisions, was informed in advance about a change in care that may affect the resident's well-being. The facility did not receive approval from Resident #72's health care surrogate (HCS) before discontinuing the resident's medication, labs and diagnostic tests, and weights. Facility census: 106. Findings include: a) Resident #72 Record review revealed Resident #72 was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident weighed 88 pounds (#) on admission, and his current weight on 08/02/11 was 98#. -- On 06/23/11, a physician's orders [REDACTED]. Resident refusal.\" -- An interview with the social worker, on 08/02/11 at 11:35 a.m., revealed the social worker had no knowledge of the resident not receiving his medication, labs and diagnostic tests, and weights. She was not aware that the resident was refusing to take his medication and was refusing to be weighed. She also stated, \"I was unaware that the HCS was not returning the calls to the nursing staff about his (the resident's) refusal to take his medication and refusing to be weighed.\" -- An interview with the director of nursing (DON), on 08/02/11 at 10:00 a.m., revealed the resident was refusing to take his medication and refusing to be weighed. She stated, \"The HCS was notified multiple times and did not return the calls.\" She further stated, \"When a resident is refusing to take their medication and refusing to be weighed, it is my practice to have the physician discontinue the medication and weights.\" -- An interview with the physician, on 08/02/11 at 2:00 p.m., revealed the physician was unaware that the resident's HCS was not informed of the medications and the weights discontinued. She stated, \"Put me through to the charge nurse, and I will get the ball rolling to change the HCS if necessary.\" -- An interview with the resident's HCS, on 08/02/11 at 2:15 p.m., revealed she could not remember if she had returned a call to approve the discontinuation of the medications and weights. She reported she was unaware that she was responsible for making the decisions concerning the resident's medical needs. She stated, \"I now understand my responsibilities concerning (Resident #72's) health needs and want to remain his HCS.\" .", "filedate": "2014-12-01"}
{"rowid": 10944, "facility_name": "GREENBRIER MANOR", "facility_id": 515185, "address": "ROUTE 2, BOX 159A", "city": "LEWISBURG", "state": "WV", "zip": 24901, "inspection_date": "2009-05-22", "deficiency_tag": 154, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "T34S11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, review of the facility's policy regarding cardiopulmonary resuscitation (CPR), and staff interview, the facility failed to ensure residents were fully informed in advance of care or treatment that might affect their well-being. Resident #94's medical record included a Physician order [REDACTED]. There was no evidence the resident / responsible party had been made aware of the facility's policy. One (1) of eight (8) residents whose closed record was reviewed was affected. Resident identifier: #94. Facility census: 86. Findings include: a) Resident #94 Review of the resident's medical record found a POST form had been completed by the resident's medical power of attorney representative (MPOA) on [DATE]. The MPOA had checked the POST form, indicating the resident was to be resuscitated. Further review of the medical record found an entry, dated [DATE] at 3:00 a.m., recording, \"Called to residents (sic) room by staff at 12:30 AM (sic) No pulse - radial/carotid. No respirations. Skin cold to touch. Pupils fixed / dilated /c (with) pupil indented. Tem (temperature) 87.2 (degree mark) F....\" The note continued, and the MPOA was quoted as saying, \"I spent a long time with her a couple of days ago and I have been expecting this.\" No attempts were made to provide CPR. The director of nursing (DON), when interviewed regarding these findings at 7:45 a.m. on [DATE], stated they have night time briefs so staff do not have to disturb residents so often. She said staff does not go in and check to see whether residents are still breathing every two (2) hours, as this would disturb the sleeping residents. The DON said this resident had been stiff when she was found, and the resident's death was \"very unexpected\". The DON was asked whether there was a policy regarding when CPR would be provided. Shortly after, she provided a copy of the facility's policy entitled \"Cardiopulmonary Resuscitation.\" The policy included, \"Cardiopulmonary resuscitation (CPR) will be instituted in cases of witnessed cessation of cardiac and/or [MEDICAL CONDITION] function until advanced cardiac life support is available on any resident who does not have a 'Do Not Resuscitate' order.\" (The policy did not have a date, so it could not be ascertained whether it had been in place in 2005.) When asked whether residents or their responsible parties were informed of this when they completed the POST form, the DON said the social workers explain this when the POST form is signed. Approximately one (1) hour later, Employee #51 (a facility social worker) was asked about what she told people when they were deciding how to fill out the POST form. She provided a thorough explanation but did not mention the facility's CPR policy. When specifically asked about this policy, she said she was not aware of it. She added that, fortunately, she had not had admitted anyone who had wanted CPR. It was suggested she obtain a copy of the policy. .", "filedate": "2014-11-01"}
{"rowid": 11148, "facility_name": "EMERITUS AT THE HERITAGE", "facility_id": 5.1e+153, "address": "RT. 4, BOX 17", "city": "BRIDGEPORT", "state": "WV", "zip": 26330, "inspection_date": "2009-08-12", "deficiency_tag": 154, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "OCKG11", "inspection_text": "Based on medical record review and staff interview, the facility failed to ensure one (1) of thirteen (13) sampled residents was fully informed in advance of medication changes. Resident #8 was determined to possess the capacity to make her own health care decisions, but a note in the resident's medical record indicated her daughter, who was not a legally designated health care surrogate, was to be informed of medication changes before the resident was. Facility census: 50. Findings include: a) Resident #8 Resident #8 was an alert and oriented resident who had been determined by her physician to possess the capacity to understand and make her own health care decisions. Review of Resident #8's medical record found the following statement dated 02/24/09 and signed by the former director of nursing: \"Nurses: Please contact (name) before ordering new medications for (Resident #8). She would like to talk it over with her mother first. The above is not to be discussed with (Resident #8).\" A review of the statement with the current director of nursing, on 08/12/09 at 2:00 p.m., found the director of nursing was unaware of the note in the resident's medical record. .", "filedate": "2014-08-01"}
{"rowid": 11218, "facility_name": "HEARTLAND OF KEYSER", "facility_id": 515122, "address": "135 SOUTHERN DRIVE", "city": "KEYSER", "state": "WV", "zip": 26726, "inspection_date": "2011-03-16", "deficiency_tag": 154, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "81RJ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility did not inform the legal representatives of three (3) of five (5) sampled residents when changes were made to their care and/or treatment. Resident identifiers: #73, #85, and #8. Facility census: 116. Findings include: a) Residents #73, #85, and #8 A review of MEDICATION ORDERS FOR [REDACTED]. 1. Resident #73 Record review revealed a physician's orders [REDACTED].\" On 12/08/10, another physician's orders [REDACTED]. Each physician's telephone order form contained a place for the nurse to record the name of the family member who was notified of the new order; these areas were blank on the above telephone orders. - 2. Resident #85 Record review revealed a physician's orders [REDACTED]. Each physician's telephone order form contained a place for the nurse to record the name of the family member who was notified of the new order; this area was blank on the above telephone order. - 3. Resident #8 Record review revealed a physician's orders [REDACTED]. Each physician's telephone order form contained a place for the nurse to record the name of the family member who was notified of the new order; this area was blank on the above telephone order. -- b) An interview with the administrator, on 03/16/11 at 9:30 a.m., revealed the nurses were all educated to notify families of residents when a change was made in medications. .", "filedate": "2014-07-01"}
{"rowid": 2435, "facility_name": "HIDDEN VALLEY CENTER", "facility_id": 515147, "address": "422  23RD STREET", "city": "OAK HILL", "state": "WV", "zip": 25901, "inspection_date": "2017-06-30", "deficiency_tag": 155, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "45HC11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure Resident #133 was afforded the right to request, refuse, and/or discontinue treatment, and to formulate an advance directive. Resident #133 was determined to have capacity to make medical decisions, however; his caregiver had signed all his admission paperwork for admission and treatment at the facility. This was true for one (1) of one (4) residents reviewed for the care area of Choices during Stage 2 of the Quality Indicator Survey. Resident identifier: #133. Facility census: 76. Findings include: a) Resident #133 A review of Resident #133's medical record, at 1:12 p.m. on 06/28/17, found the resident was [AGE] year old resident with an admission date of [DATE]. Consent for treatment and release of information found in medical records was signed by Resident #133's Medical Power of Attorney (MPOA) on 04/07/17. Review of the record found a Physician's Determination of Capacity dated 04/08/17 which indicated Resident #133 was capacitated to make medical decisions. Contained in Resident #133's medical record was a form titled, Resident Representative Designation which allows the representative on behalf of patient to sign the for purposes of nursing facility admission. This form was signed by Resident #133's MPOA on 04/11/17. Resident #133 did not sign this form. Review of Resident #133's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/12/17, found Resident #133's Brief Interview of Mental Status (BIMS) score was 14. This score indicates Resident #133 was cognitively intact. Further review of the record found no evidence to suggest the decisions made by Resident #133's MPOA were ever discussed with Resident #133. An interview with the Admission Director, at 10:26 a.m. on 06/29/17, confirmed she completed the admission form with Resident #133's MPOA on 04/07/17 and 04/08/17. She stated, what typically happens we have an admission meeting and the resident is involved in the process if they have capacity. She then reviewed Resident #133's record and stated, It looks like it was not documented the resident was involved in the decisions and wishes of his care. An interview, on 06/29/17 at 11:30 a.m., with Acting Administrator, when the medical records for Resident #133 was reviewed. She confirmed there was no evidence Resident #133 was involved in his medical decisions. No further information was provided.", "filedate": "2020-09-01"}
{"rowid": 2795, "facility_name": "WAYNE NURSING AND REHABILITATION CENTER", "facility_id": 515168, "address": "6999 ROUTE 152", "city": "WAYNE", "state": "WV", "zip": 25570, "inspection_date": "2017-05-05", "deficiency_tag": 155, "scope_severity": "D", "complaint": 1, "standard": 1, "eventid": "43JR11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, resident interview and staff interview, the facility failed to ensure Resident #9 was afforded the right to execute an advanced directive. Resident #9 was determined to have capacity to make medical decisions, however; her son had signed her Physician order [REDACTED]. Resident identifier: #9. Facility census: 55. Findings include: a) Resident #9 A review of Resident #9's medical record, at 1:12 p.m. on [DATE], found this [AGE] year old resident was admitted to the facility on [DATE]. Contained in Resident #9's medical record was a form titled, Authority to act on behalf of patient for purposes of nursing facility admission. This form was signed by Resident #9 on [DATE] and gave her son permission to act as her representative for the purpose of executing the admission agreement. Further review of the record found a POST form signed by Resident #9's son which was also dated [DATE]. This form indicated Resident #9 was designated as Do Not Resuscitate (DNR) with limited additional interventions with Intravenous Fluids for a trial period and no feeding tube. This form was not signed by Resident #9. Further review of the record found a Physician's Determination of Capacity dated [DATE] which indicated Resident #9 was capacitated to make her own medical decisions. Review of Resident #9's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], found Resident #9's Brief Interview of Mental Status (BIMS) score was 15. This score indicates Resident #9 was cognitively intact. Further review of the record found no evidence to suggest the decisions made by Resident #9's son on her POST form were ever discussed with Resident #9. During an interview with Resident #9 at 10:21 a.m. on [DATE], when asked, Has any one here ever talked to you about your wishes for CPR (Cardiopulmonary Resuscitation) and the use of other life sustaining measures? Resident #9 stated, No they have never talked to me about any of that. She further stated, I am against feeding tubes I don't think I would want one of them to prolong my suffering. An interview with the Social Services Supervisor (SSS), at 10:26 a.m. on [DATE], confirmed she completed the POST form with Resident #9's son on [DATE]. She stated, what typically happens if the resident is capacitated the POST form would be reviewed with the resident to make sure it accurately reflected their decisions in regards to advance directives. She then reviewed Resident #9's record and stated, It looks like I did not follow up with her. She indicated, she must have just missed this and she would follow up with the resident today and clarify the POST form decisions with her.", "filedate": "2020-09-01"}
{"rowid": 3468, "facility_name": "CABELL HEALTH CARE CENTER", "facility_id": 515192, "address": "30 HIDDEN BROOK WAY", "city": "CULLODEN", "state": "WV", "zip": 25510, "inspection_date": "2017-09-21", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "ITHZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of four (4) resident's reviewed for the care area of choices was afforded the right to refuse a shower without receiving a [MEDICAL CONDITION] medication. Resident identifier: #25. Facility census: 83. Findings include: a) Resident #25 Review of the resident's Medication Administration Record, [REDACTED] [MEDICATION NAME] 0.5 milligrams (mgs) by mouth, as needed (PRN), every 24 hours for aggressive behavior, anxious mood/behavior related to unspecified dementia with behavioral disturbances, give before shower due to frequent refusal of care. Further review of the MAR found the resident had received the PRN [MEDICATION NAME] on 07/25/17, 08/23/17 and 09/03/17. An interview with the director of nursing (DON) at 2:10 p.m. on 9/20/17, found the resident had received the medication on 07/25/17, 08/23/17, and 09/03/17 for aggressive behaviors with non-pharmacological interventions prior to administration. Although the medication had not been administered for refusal of a shower, the DON confirmed the potential still existed for the resident to receive the medication if she refused a shower. The DON said the resident had the right to refuse her showers. She said she was going to call the doctor and get a new order as the current order, should have never been written this way.", "filedate": "2020-09-01"}
{"rowid": 3875, "facility_name": "SUMMERSVILLE REGIONAL MEDICAL CENTER", "facility_id": 515029, "address": "400 FAIRVIEW HEIGHTS ROAD", "city": "SUMMERSVILLE", "state": "WV", "zip": 26651, "inspection_date": "2016-11-18", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TJMH11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to ensure Resident #52 was afforded the right to have her advance directives incorporated into her treatment regimen, failed to communicate this choice to the Interdisciplinary Team (IDT), and failed to ensure that when the resident experienced a severe weight loss, her treatment reflected this choice. Resident identifier: #52. Facility Census: 52. Findings include: a) Resident #52 Review of Resident #52's medical records on 11/17/16 at 10:00 a.m. found the resident was admitted to the facility on [DATE]. A West Virginia Physician order [REDACTED]. A review of Resident #52's medical record at 9:11 a.m. on 11/17/16, found the following recorded weights (All weight loss/gain Percentages calculated using the following formula % of body weight loss = (usual weight - actual weight)/(usual weight) x 100.): -- Date of admission 01/20/16 - 172.4 pounds (lb) -- 01/31/16 - 169 lbs. -- 02/02/16 - 169 lbs. -- 02/09/16 - 167 lbs. -- 02/15/16 - 168 lbs. -- 02/23/16 - 174 lbs. -- 03/01/16 - 175 lbs. -- 04/01/16 - 176 lbs. -- 05/03/16 - 170 lbs. -- 06/06/16 - 168 lbs. -- 07/05/16 - 165 lbs. -- 07/07/16 - 165 lbs. -- 07/11/16 - 165 lbs. -- 08/02/16 - 161 lbs. -- 09/08/16 - 152 lbs. -- 10/03/16 - 149 lbs. -- 11/01/16 - 148 lbs. From 08/02/16 through 09/08/16, Resident #52 lost 9 lb or 5.6% (percent) in 30 days - a severe weight loss in 30 days. From 06/06/16 through 09/08/16, Resident #52 lost 16 lb or 9.5% in 90 days - a severe weight loss 90 days. From 03/01/16 through 09/08/16 Resident #52 experienced a 23 lb or 13.1% in 180 days - a severe weight loss in 180 days. Guidance to Surveyors related to suggested parameters for evaluating significance and unplanned and undesired weight loss, found in Appendix PP of the CMS (Centers for Medicare and Medicaid Services) State Operations Manual contained the following: Interval Significant Loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5% Greater than 7.5% 6 months 10% Greater than 10 % Review of Resident #52's meal intake percentages found her intakes were poor and inadequate at 1-25% meals consumed and 240 milliliters (ml) to 480 ml of fluids consumed in 24 hours. Review of the Medication Administration Record [REDACTED]. On 11/04/16 at 2:46 p.m., the dietary manager noted, The residents current weight is 148 lbs., in which is a significant weight loss of 13 lbs. or 8.1% in 90 days, 22 lbs. or 12.9% in 180 days. Resident simply refuses to eat, refuses to let staff feed her, refuses care on a daily basis. Dietician recommended changing Health shakes two times a day to Ensure/[MEDICATION NAME] two times daily in hopes resident will consume Ensure. Resident may need a failure to thrive diagnosis. Nurse to discuss this with the physician. To continue to monitor intake, weights and condition changes. No further progress notes were found to indicate the physician was aware of Resident #52's weight loss and Resident #52's desire to have a feeding tube as directed in her POST form. Review of Resident #52's physician's progress notes showed the physician saw the resident on 09/27/16 and 10/25/16 with no mention of weight loss. Interview with the registered dietitian on 11/17/16 at 2:15 p.m., found the resident had had a significant weight loss. She further communicated she did not feel the resident was a candidate for a feeding tube due to [MEDICAL CONDITION] and it was contraindicated. She also stated the resident's weight should be monitored on a weekly weight when a significant weight loss was determined. She confirmed Resident #52 remained on monthly weights. On 11/17/16 at 3:25 p.m., the Director of Nursing was informed of the resident ' s significant weight loss. She was asked to provide information concerning the physician's notification of weight loss and the resident's wish of the resident to have a feeding tube as directed in the POST form. As of the exit of the survey on 11/18/16 at 1:00 p.m. no further information was provided.", "filedate": "2020-04-01"}
{"rowid": 3894, "facility_name": "HARPER MILLS", "facility_id": 515086, "address": "100 HEARTLAND DRIVE", "city": "BECKLEY", "state": "WV", "zip": 25801, "inspection_date": "2016-09-23", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "0MB311", "inspection_text": "Based on record review and staff interview, the facility failed to establish and maintain policies about a resident's right to refuse treatment. This had the potential to affect all residents currently residing at the facility. Facility Census: 178. Findings Include: a) Policy In the early afternoon of 09/23/16, the Assistant Nursing Home Administrator (ANHA) was asked to provide the facility's policy and/or procedures which were followed when a resident wished to exercise their right to refuse treatment. At 2:44 p.m. on 09/23/16, the ANHA and Nursing Home Administrator (NHA) both confirmed the facility did not have a policy in regards to the residents' right to refuse treatment. They provided the facility's advance directive policy. This policy did include the following statement, Prior to or upon admission of a resident to the facility, the Social Service Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate and advance directive. The remaining eight (8) statements contained in the policy were solely directed to written advanced directives such as medical power of attorney or a living will, and not the right to accept or refuse medical treatment. At approximately 3:00 p.m. on 09/23/16, the Admissions Coordinator #77 was asked to provide what written information was given to residents upon admission to the facility in regards to advance directives and their right to accept and/or refuse medical treatment other than an advance directive. She referred to the facility's Admission Information Packet pages 14 - 26. The information contained on these pages specifically related to the creation of and the authority of written advance directives such as a Medical Power of Attorney or Living Will. It did not include any information pertaining to the residents' right to accept or refuse medical treatment other than the creation of a written advance directive. At 4:04 p.m. on 09/23/16, while reviewing these findings, the NHA was again asked to provide any written policies or procedures related to the residents' right refuse treatment. As of the time of exit, at approximately 7:15 p.m. on 09/23/16, no further information had been provided.", "filedate": "2020-04-01"}
{"rowid": 4697, "facility_name": "BERKELEY SPRINGS CENTER", "facility_id": 515137, "address": "456 AUTUMN ACRES ROAD", "city": "BERKELEY SPRINGS", "state": "WV", "zip": 25411, "inspection_date": "2016-04-06", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TULX11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to formulate a plan of care with written policies and procedures to provide cardiopulmonary resuscitation (CPR) to residents on the 500 hall/memory care unit; a separate unit isolated from other parts of the building. Staff were unaware of the location of emergency equipment and/or the planned procedure to call for additional staff in the event of a cardiac and/or respiratory emergency. This was found for two (2) of seven (7) residents with advanced directives for CPR residing on the memory care unit. Resident identifiers: #76 and #94. Facility census: 92. Findings include: a) Resident #76 Review of Resident #76's medical record on [DATE] at 11:00 a.m. revealed the West Virginia Physician order [REDACTED]. The resident's care plan with a revised date of [DATE], included, Resident has multiple cardiac issues; CAD ([MEDICAL CONDITION]),[MEDICAL CONDITION](hypertension), [MEDICAL CONDITIONS], stenosis of carotid artery. However, care plan did not reflect the resident's resuscitation status. b) Resident #94 Resident #94's medical record, reviewed on [DATE] at 11:30 a.m., found Resident #94's POST form, signed by her daughter/power of attorney (POA) on [DATE], identified the resident was to receive resuscitation with full interventions. c) Random observations of the unit on [DATE], and on [DATE] at 2:00 p.m., revealed no emergency equipment or written procedures for staff to follow in the event of a cardiopulmonary emergency. d) During an interview on [DATE] at 11:00 a.m. Registered Nurse (RN) #92 reported the 500 hall/memory care unit currently housed seven (7) residents and was staffed every shift by two (2) people - a nurse and a nurse aide (NA). She was unaware of any stairs connecting this unit to the remainder of the building and reported all staff must enter the unit from outside of the building. RN #92 reported Residents #76 and #94 had advanced directives requiring resuscitation with full interventions. When asked about the location of the crash cart and/or emergency supplies, RN #92 acknowledged there was no crash cart and/or emergency supplies for resuscitation on the 500 hall/memory care unit at that time. The future unit director, RN #100, was working on these. In the event of an emergency they would have to call upstairs for assistance. When asked if there was a specific number identified to guarantee someone would answer the phone in the event of an emergency she replied No. The minimum data set (MDS) nurse/director of the memory care unit, RN #100, interviewed on [DATE] at 1:15 p.m., said a crash cart was ordered, but there were currently no resuscitation supplies available on the 500 hall/memory care unit. In addition, she was unaware of any connecting stairs and reported the only way to enter the unit was from the outside of the building. Dietary Aide #101, during an interview on [DATE] at 3:11 p.m., reported there were no stairs and the only access to the 500 hall/memory care unit was from the outside of the building. It was later learned that there was a stairway, but staff working on the unit were not aware of the stairs. Nurse Consultant #136 reported there was no CPR policy for the staff to follow during an interview on [DATE] at 5:30 p.m.", "filedate": "2019-08-01"}
{"rowid": 5101, "facility_name": "RALEIGH CENTER", "facility_id": 515088, "address": "1631 RITTER DRIVE", "city": "DANIELS", "state": "WV", "zip": 25832, "inspection_date": "2015-04-10", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "CRGX11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review, and resident interview, the facility failed to ensure two (2) of two (2) sample residents, reviewed for the care area of choices during Stage 2 of the survey, were afforded the right to formulate an advanced directive. The facility determined each of the residents had capacity to make health care decisions; however, a family member for each resident signed their Physician order [REDACTED]. Resident Identifies: #32 and #83. Facility Census: 66. Findings Include: a) Resident #32 A review of Resident #32's medical record, at 9:04 a.m. on [DATE], found she was admitted to the facility on [DATE]. Review of the resident's admission information found Resident #32 signed all admission paperwork on [DATE]. Further review of the medical record found a Physician Determination of Capacity completed by Resident #32's attending physician on [DATE]. This form indicated Resident #32 was able to make her own informed medical decisions. The medical record contained a POST form which indicated Resident #32 was not to receive cardiopulmonary resuscitation (CPR). The form also noted she was to receive intravenous fluids and a feeding tube for a defined trail period only. The POST form was signed by Resident #32's daughter on [DATE]. Licensed Practical Nurse (LPN) #36 assisted Resident #32's daughter in completing this form on [DATE], as indicated by the LPN's signature on the back of the POST form. The form went into effect on [DATE], when Resident #32's attending physician signed the form making it a physician's orders [REDACTED].>The medical record contained no evidence indicating Resident #32's wishes for CPR, use of IV fluids, and use of a feeding tube were ever discussed with her. An interview with the Director of Admissions (DOA) #42, at 1:20 p.m. on [DATE], confirmed Resident #32 had capacity to make medical decisions. She stated the POST form should have been completed by Resident #32 and not her daughter. The DOA was unable to provide any information to indicate these decisions were ever discussed with the resident. She stated she would complete a new POST form with Resident #32 as soon as possible. At 3:00 p.m. on [DATE], DOA #42 provided a new POST form completed by Resident #32. This POST form indicated the resident was not to have CPR, was to only have IV fluids for a defined trial period. and was not to have a feeding tube. The resident's wishes in regards to a feeding tube conflicted with the previous POST form completed by her daughter. b) Resident #83 A review of Resident #83's medical record, at 9:14 a.m. on [DATE], found he was admitted to the facility on [DATE]. Review of the resident's admission information found Resident #83 signed all admission paperwork on [DATE]. Further review of the medical record found a Physician Determination of Capacity completed by Resident #83's attending physician on [DATE]. This form indicated Resident #83 was able to make his own informed medical decisions. Resident #83's medical record contained a POST form which indicated he was to receive CPR, and a feeding tube and IV fluids long term if needed. The POST form was signed by Resident #83's daughter on [DATE]. Registered Nurse (RN) #41 assisted Resident #83's daughter in completing this form on [DATE], as indicated by the RN's signature on the back of the form. The form went into effect on [DATE], when Resident #83's attending physician signed the form making it a physician order. The medical record contained no evidence indicating Resident #83's wishes for CPR, use IV fluids, and use of a feeding tube were ever discussed with him. An interview with Resident #83, at 11:30 a.m. on [DATE], revealed facility staff had never spoken with him about his wishes in regards to CPR. He stated, That topic of conversation has never come up with anyone. An interview with DOA #42 and Social Service Director (SSD) #59, at 12:51 p.m. on [DATE], confirmed Resident #83 should have signed his own POST form. SSD #59 stated she had reviewed his code status on his quarterly and admission assessments, but failed to notice Resident #83 had not signed his own POST form. She stated she would have to complete a new POST form with Resident #83. At 4:30 p.m. on [DATE], a POST form dated [DATE] was provided by SSD #59. This form indicated Resident #83 was to receive CPR, and was only to receive IV fluids and a feeding tube for a defined trial period only. His wishes in regards to IV fluids and feeding tube conflicted with the form completed by his daughter. c) Healthcare Decision Making Policy A review of the Facility's Health Care Decision Making policy on [DATE], found the following, .9. Upon admission, quarterly, and with a change in condition, the physician, in collaboration with designated center staff, will meet with the patient or health care decision maker to complete or review advance directives . and define and clarify medical issues .", "filedate": "2019-03-01"}
{"rowid": 5185, "facility_name": "EAGLE POINTE", "facility_id": 515159, "address": "1600 27TH STREET", "city": "PARKERSBURG", "state": "WV", "zip": 26101, "inspection_date": "2016-03-03", "deficiency_tag": 155, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "MTOL11", "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's right to refuse treatment. Resident #5 was given [MEDICATION NAME] ([MEDICATION NAME]) (an atypical antipsychotic medication) although the resident's son did not want the medication given until he read about the drug. This was true for one (1) of three (3) residents reviewed for unnecessary medications during a complaint survey. Resident identifier: #5. Facility census: 125. Findings include: a) Resident #5 Review of Resident's #5's medical records on 03/03/16 beginning at 9:00 a.m., revealed a physician's orders [REDACTED]. A nursing note, dated 07/19/15, revealed the facility called the resident's son, . to see if he wanted [MEDICATION NAME] (same as [MEDICATION NAME]) started. He stated that he would read up on it at home and sign it if he wanted to start the medications when he is in to visit again. I told him I would place the psychotic medication informed consent in her chart for him to sign if he decided to have his mother take it. The Medication Administration Record [REDACTED]. A physician's orders [REDACTED]. An additional physician order [REDACTED]. [MEDICATION NAME] was administered to Resident #5 on three (3) occasions after the resident's son verbally indicated he wanted the antipsychotic medication held until further notice. On 03/03/16 at 2:20 p.m., the director of nursing stated the mediation was given, held, and discontinued according to physician orders.", "filedate": "2019-03-01"}
{"rowid": 5242, "facility_name": "PINEY VALLEY", "facility_id": 515122, "address": "135 SOUTHERN DRIVE", "city": "KEYSER", "state": "WV", "zip": 26726, "inspection_date": "2015-08-06", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "SMTQ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure the accuracy and clear intent of end of life decisions. The facility physician's orders did not reflect the resident's desire to be a do not resuscitate status in a timely manner. Two different sets of West Virginia Physician Orders for Scope and Treatment (POST) were in the medical record. This practice had the potential to affect one (1) of twenty five (25) stage 2 residents. Resident identifier: #174. Facility census 117. Findings include: a) Resident #174 Resident #174 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A closed record review performed [DATE] at 3:00 p.m. found she had a physician's order on the date of her admission declaring her a full code status. She filled out a Physician Orders for Scope and Treatment (POST) form twice since her admission requesting to be a do not attempt resuscitate (DNR) status, once on [DATE] and again on [DATE]. There was no physician's order in the medical record designating the resident as a DNR status until the following monthly orders for (MONTH) (YEAR). This matter discussed with the director of nursing (DON), on [DATE] at 9:30 a.m., revelaed the pharmacy received a facsimile of the change in code status, but no evidence of a physician's order in the medical record changing the code status of the resident from [DATE] until [DATE]. During an interview with Social Worker #105 on [DATE] at 9:00 a.m. she said after a POST form is completed, a physician's order is written for DNR if that is what is designated on the POST. She also said a red dot is put on the back (spine) of the hard chart and also a red page stating DNR is placed in the medical record when a resident is of DNR status. Review of HCR Healthcare, LLC procedure for EMERGENCY MANAGEMENT for code status identification, last revised ,[DATE] finds implementation of a color-coded cover sheet may be used to assist with easy access of information. the red sheet signifies no code or no CPR status. Review of the closed record on [DATE] at 9:15 a.m. found no red dot or red sheet in the record. The record review of Resident #174 revealed two (2) POST forms had been completed and signed by both the resident and physician with different wishes expressed in regards to medically administered fluids and nutrition. The first POST completed by the resident was dated on [DATE] and requested intravenous fluids for a trial period of no longer than 1 month. This POST was signed by the physician [DATE]. The second POST completed by the resident and dated [DATE] and it did not designate a length of time for trial of intravenous fluids. It did, however, indicate the resident requested no feeding tube. This form included the signature of the physician on [DATE]. During an interview with social worker #105 on [DATE] at 9:00 a.m. she said because the first POST filled out by the resident [DATE] was actually signed by the physician after the second POST form was completed, the original POST would be the one honored by the facility. She agreed that the resident's wishes last expressed on the POST filled out on [DATE] would not be honored because the physician had signed the first POST on [DATE] after the second POST, [DATE]. She said We usually pull them and put them (the POST forms) in medical records if a new one is completed, but this one must have gotten missed. Instructions for Review of the POS [REDACTED]. If this form is to be voided, write the word VOID in large letters on the front of the form.", "filedate": "2019-02-01"}
{"rowid": 5335, "facility_name": "ROANE GENERAL HOSPITAL", "facility_id": 515099, "address": "200 HOSPITAL DRIVE", "city": "SPENCER", "state": "WV", "zip": 25276, "inspection_date": "2015-10-21", "deficiency_tag": 155, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "4PJF11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to accurately and consistently incorporate the resident's choices regarding Advance Directives into the clinical record for seven (7) of fourteen (14) residents reviewed. Resident identifiers: #35, #9, #3, #26, #4, #21, and #29. Facility census: 29. Findings include: a) Resident #35 A review of Resident #35's clinical record, at 1:30 p.m. on 10/20/15, revealed the resident was [AGE] years old and was admitted to the facility on [DATE]. Resident #35 was determined by the physician to lack capacity to form her own health care decisions, and the record indicated Resident #35 had appointed a medical power of attorney (MPOA). The resident admission record front sheet indicated, under a section entitled Advanced Directives, that no advanced directives were selected for Resident #35. Further review of the record revealed a Physician Orders for Scope of Treatment (POST) form signed and completed on 03/06/14. In addition, the admission orders [REDACTED]. These findings were reviewed with Social Worker #37 at 2:20 p.m. on 10/20/15. Social Worker #37 acknowledged the statement on the admission record was an error and provided evidence of discussion of the DNR decision with the MPOA at the time of admission to the facility. She agreed the front sheet of the clinical record should reflect that choice and said she would have this corrected. A review of the facility policy entitled: Documentation of Advance Directives, provided by the Social Worker, indicated the existence of the advanced directive was to be entered into the record by the admissions department. If not present at admission, the policy stated, The unit clerk shall follow-up with the patient within 24 hours to secure a copy of the advance directive and will continue to do so during the admission until patient disposition, and This will be scanned to the record by the unit clerk. b) Resident #9, #3, #26, #4, and #21 Further review revealed the same findings for Resident #9, #3, #26, #4, #21, and #29. During an interview with the Social Worker #37, at 3:05 p.m. on 10/20/15, she stated she had reviewed the records of the identified residents, and the same entry had been entered on the front sheets of the clinical record at admission and never updated. During an interview with the director of nurses, at 11:00 a.m. on 10/21/15, she agreed the record should not include conflicting information for communicating the residents' choices to the interdisciplinary team.", "filedate": "2019-01-01"}
{"rowid": 5456, "facility_name": "LOGAN CENTER", "facility_id": 515175, "address": "55 LOGAN MINGO MENTAL HEALTH CENTER ROAD", "city": "LOGAN", "state": "WV", "zip": 25601, "inspection_date": "2015-06-22", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "N2E611", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of choices during the Quality Indicator Survey (QIS), was afforded the right to have her advance directive incorporated into her care and treatment. The resident indicated on her POST form, she did not want a feeding tube; however, a feeding tube was inserted. Resident Identifier: #67. Facility Census: 62. Findings include: a) Resident #67 Feeding Tube Resident #67's POST form, reviewed at 9:46 a.m. on 06/17/15, also revealed the resident indicated No feeding tube. Under section C titled: Medically administered fluids and nutrition: Oral fluid and nutrition must be offered as tolerated, an X was placed in the box beside, No feeding Tube, indicating the resident's wish to not have a feeding tube. According to information on the POST form, LPN #6 assisted the resident in completing the form on 12/20/14. The resident's medical record contained a Physician Determination of Capacity, completed on 12/30/14, by Licensed Psychologist #77. This form indicated Resident #67 lacked capacity to make healthcare decisions due to Multiple Infarct Dementia, cognitive loss, inappropriate answers to questions, and inability to understand or make medical decisions. Licensed Psychologist #77 indicated the incapacity would be short term in nature and would likely improve as the resident's medical condition improved. Also contained in Resident #67's medial record, was a medical power of attorney (MPOA) form, completed by Resident #67 on 08/26/13, appointing her niece as her MPOA. Additional review of the medical record found a physician's progress note dated 04/13/15, which contained the following text (typed as written): Spoke with MPOA and agreed for PEG (Percutaneous endoscopic gastrostomy) placement with (Name of local Physician) ASAP (as soon as possible). Resident #67's medical record contained information which indicated the resident had a gastrostomy tube ([DEVICE]) placed at a local hospital on [DATE]. An interview with the Director of Nursing (DON), at 11:24 a.m. on 06/17/15, confirmed Resident #67 had a [DEVICE] inserted on 04/15/15. When asked why the resident's directive for No feeding tube on the POST form was not honored, the DON stated the resident did not fully understand the form when it was completed with her on 12/20/14. She said she felt Resident #67 did not fully comprehend the form. The DON was unable to answer, when asked if the resident's wishes were honored. An interview with Resident #67's attending physician, at 11:32 a.m. on 06/17/2015, revealed Resident #67 needed the feeding tube because her wounds were getting worse, she was losing weight, and she was refusing to eat. He stated he talked to Resident #67's MPOA, who was in agreement with having the tube inserted. When asked why the MPOA was allowed to make a decision contrary to the resident's wishes, the physician stated, I don't really think she was capacitated when she completed the POST form. He stated he wanted to wait for the psychologist to review her capacity because of her [DIAGNOSES REDACTED]. The physician said later, the information the resident provided was found inaccurate. When asked why the resident was sent for a feeding tube when her POST form indicated she did not want one, he stated, She knew what she was going for she could have refused to go to the appointment if she did not want it.", "filedate": "2019-01-01"}
{"rowid": 5526, "facility_name": "MCDOWELL NURSING AND REHABILITATION CENTER", "facility_id": 515162, "address": "150 VENUS ROAD", "city": "GARY", "state": "WV", "zip": 24836, "inspection_date": "2015-11-19", "deficiency_tag": 155, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "TPT811", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to afford Resident #99 the right to formulate an advanced directive. This was found for one (1) of five (5) sampled residents. Resident #99 was deemed to have capacity to make medical decisions; however, the facility allowed someone other than the resident to make decisions in regards to his advanced directives and/or refusals of treatment. Resident identifier: #99. Facility census: 98. Findings include: a) Resident #99 A review of Resident #99's medical record, at 1:10 p.m. on [DATE], found a Physician's Determination of Capacity completed by Resident #99's attending physician on [DATE]. This form indicated Resident #99 maintained capacity to make his own healthcare decisions. Further review of the record found a West Virginia Physician order [REDACTED].#99's attending physician on [DATE]. This form indicated Resident #99 was to receive cardiopulmonary resuscitation (CPR) in the event he would need it. This form was signed by another person, not the resident. There was no indication the resident was consulted about this decision or had asked for another person to sign on his behalf. The person who signed the POST form also signed a Psychoactive Medication Informed Consent form and an Informed Refusal of Treatment consent form on behalf of Resident #99. These forms were signed on [DATE], again with no evidence of input by the resident. An interview with Social Service Director (SSD) #21 and Social Worker (SW) #55, at 3:13 p.m. on [DATE], confirmed Resident #99 was deemed to have capacity to make healthcare decisions on [DATE] by his attending physician. SSD #21 and SW #55 indicated that until the attending physician saw the resident and made a determination of incapacity, the capacity of a resident who was alert and orientated should be assumed. They stated even though Resident #99 was somewhat confused on admission, his capacity should have been assumed. SSD #21 confirmed another person should not have signed the referenced forms because the resident's capacity was presumed and he had the right to make the decisions in regards to CPR, psychoactive medication use, and any refusals of treatment he chose.", "filedate": "2018-11-01"}
{"rowid": 5645, "facility_name": "PIERPONT CENTER AT FAIRMONT CAMPUS", "facility_id": 515155, "address": "1543 COUNTRY CLUB ROAD", "city": "FAIRMONT", "state": "WV", "zip": 26554, "inspection_date": "2015-07-29", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "DSPZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to ensure the responsible party of a resident with a severe decline in health status was given information about the resident's rights regarding cardiopulmonary resuscitation and the facility's policies regarding exercising these rights. Resident identifier: #98. Facility census: 99. Findings include: a) Resident #98 A review of the clinical record revealed that Resident #98 was a [AGE] year old male initially admitted to the facility on [DATE]. He had been determined by his physician to lack the capacity to make health care decisions and his brother was indicated as his MPOA (Medical Power of Attorney). He was designated to be a Full Code. His present [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED].#217 at 10:15 a.m. on 07/22/15. The resident had multiple hospitalization s in (YEAR). When discharged to the hospital on [DATE], his skin was clear with no pressure ulcers and on readmission on 04/02/15, his admission physical indicated [MEDICAL CONDITION] of his lower extremities, but no evidence of pressure ulcers. A Significant Change comprehensive assessment was completed on 04/09/15. An entry in the clinical record by NP #217 on 05/21/15, indicated the resident had multiple unstageable pressure wounds. His last readmission was 07/08/15 and although there was no terminal [DIAGNOSES REDACTED]. The record on readmission indicated Resident #98 was a Full Code. The record indicated Resident #98 now had 1 unstageable pressure ulcer and 11 DTI's (deep tissue injury) and the treatment goal stated by the NP/Physician stated, Expectation is for non-healing with goal to prevent worsening of wounds. The care plan meeting notes from 07/19/15, indicated he was a Full Code; had recent cognitive changes and scored 0/15 on his BIMS (brief interview for mental status); and was refusing oral intake. There was no evidence of any discussion of the resident's status with the MPOA. During an interview with the resident's brother/MPOA at 9:35 a.m. on 07/21/15, he said he knew the resident had been getting worse for the past few months and when asked what the plan of care was at present; he stated they wanted him to eat more and be able to get out of bed more. The resident, observed during the conversation was very frail and thin, with pale skin. He was lying on one side with his knees drawn up. He was awake but did not respond when spoken to. During an interview with Social Worker (SW) #145 at 2:00 p.m. on 07/23/15, she was asked if there had been a discussion with the MPOA about changing the Code status or about the use of palliative care or Hospice when the resident's health status deteriorated. She stated she had no knowledge of this and referred to SW #154, who was unavailable at that time. At 10:50 a.m. on 07/27/15, SW#154 was interviewed and also asked the same questions. She stated she had spoken to the MPOA and he had refused to change the Code status, but would have to review her notes. At 11:45 a.m. SW #154 returned after reviewing the record and stated she had been unable to find written evidence of discussing the Code status with the MPOA. At 4:30 p.m., on the same day, SW #154 stated she had re-explained Advanced Directives to the resident's brother/MPOA and had entered that into the record.", "filedate": "2018-09-01"}
{"rowid": 5712, "facility_name": "CLARY GROVE", "facility_id": 515039, "address": "209 CLOVER STREET", "city": "MARTINSBURG", "state": "WV", "zip": 25404, "inspection_date": "2014-11-19", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "H5V711", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to involve the resident in formulating an advance directive. A medical power of attorney (MPOA) and physician filled out paperwork designating a resident as Do Not Resuscitate (DNR) without discussing the matter with the resident. This is true for one (1) randomly reviewed resident. Resident identifier: #211. Facility census: 110. Findings include: a) Resident #211 An interview conducted with the social worker occurred on [DATE] at 4:00 p.m. Two (2) surveyors witnessed this interview. The social worker stated Resident #211 was readmitted to the facility in (MONTH) 2014 and he no longer had capacity. The social worker said the medical power of attorney (MPOA) was who she contacted for issues such as care planning. A medical record review was performed, on [DATE] at 10:00 a.m., where a note was found written by the social worker. The note dated [DATE] stated Resident is a do not resucitate DNR and has a DNR order, MPOA, durable power of attorney (DPOA), and living will (LW) posted on his chart. Resident lacks capacity and is oriented to person, place and time. Resident's brief interview of mental status (BIMS) is 13 . According to the Minimum Data Set (MDS) completed with an assessment reference date (ARD) of [DATE], the resident had a BIMS of 13. This score means cognitively intact. The resident also had a capacity statement on the chart stating he had capacity, signed and dated by a physician on [DATE]. The medical record contained a physician prescription stating DNR signed and dated by a physician on [DATE]. There was also a Release of Liability for Withholding of Life Prolonging Interventions filled out by the resident's MPOA requesting to withhold CPR on [DATE]. This form was not signed and dated by the physician until [DATE], the same date the resident was determined to have capacity. On [DATE] at 10:30 a.m. an interview was held with the resident regarding his wishes for life prolonging measures. He stated no one has discussed this with him and also I think CPR (cardiopulmonary resuscitation) would be good! This matter was then discussed with the social worker on, [DATE] at 10:45 a.m., and she could not find evidence that the matter of life prolonging measures was ever discussed with the resident prior to the DNR order being written.", "filedate": "2018-08-01"}
{"rowid": 5827, "facility_name": "ROSEWOOD CENTER", "facility_id": 515105, "address": "8 ROSE STREET", "city": "GRAFTON", "state": "WV", "zip": 26354, "inspection_date": "2015-01-29", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "3O8G11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure one (1) of twenty-three (23) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS) was afforded the right to refuse treatment. The resident desired a code status of Do Not Resuscitate (DNR); however, cardiopulmonary resuscitation (CPR) was performed on the resident. Resident identifier: #56. Facility Census: 67. Findings Include: a) Resident #56 Review of medical records, on [DATE] at 9:00 a.m., revealed Resident #56 was admitted on [DATE] and died on [DATE]. The medical record contained a Pre-admission Report Sheet which listed the resident as a DNR. Handwritten notes from the hospital discharge report also designated the resident as a DNR. A nursing progress note, dated [DATE] at 08:45 a.m., by Employee #100 included, Unable to get B/P, pulse or resp. at this time. Unable to verify post (POST - physician's orders [REDACTED]. Dr. (physician name) entered facility and called to res. room. Orders received to initiate CPR until post verified. CPR initiated by nursing staff. Review of the resident's interim care plan, dated [DATE], showed the advance directives section was blank and not filled out. The interim care plan is the method nursing staff use to be aware of each resident's immediate needs. On [DATE] at 4:35 p.m., the Social Worker (SW) said, The interim care plan should be completed by the admitting nurse. The SW reviewed the interim care plan for Resident #56 and confirmed the advanced directive section was not completed, but should have been completed by the admitting nurse. On [DATE] at 5:05 p.m., interview with Employee #53, a registered nurse (RN), revealed this was the nurse who admitted Resident #56 to the facility on [DATE] at 10:22 p.m. The nurse confirmed the advance directive section of the interim care plan should have been filled out upon the resident's admission. Employee #53 said he/she must have been missed filling out that section when completing the physician's orders [REDACTED].", "filedate": "2018-07-01"}
{"rowid": 5860, "facility_name": "HILLCREST HEALTH CARE CENTER", "facility_id": 515117, "address": "462 KENMORE DRIVE", "city": "DANVILLE", "state": "WV", "zip": 25053, "inspection_date": "2014-11-17", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "LO0C11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, and policy review, the facility failed to allow one (1) of four (4) Stage 2 residents reviewed for the care area of choices, the right to formulate an advanced directive related to cardiopulmonary resuscitation (CPR). After Resident #89 regained the capacity to make her own healthcare decisions, the facility failed to provide the resident the right to choose whether or not she wanted to receive CPR should it be necessary. Resident identifier: #89. Facility census: 87. Findings Include: a) Resident #89 Review of the resident's medical record at 10:08 a.m. on [DATE], revealed she was admitted to the facility on [DATE], at which time she lacked capacity to make healthcare decisions. Her son was appointed as her health care surrogate (HCS). The medical record contained a physician's orders [REDACTED]. The POST form indicated Resident #89 was to receive CPR in the event she would need it. Additional review of the medical record revealed a physician's determination of capacity completed by Resident #89's attending physician on [DATE]. This form indicated Resident #89 demonstrated capacity to make medical decisions. There was no evidence in the medical record to indicate the facility had ever discussed with Resident #89 her wishes in regards to CPR after she regained her capacity to make health care decisions on [DATE]. In an interview with Resident #89 at 11:27 a.m. on [DATE], she was asked if any one at the facility had ever discussed with her what her choices in regards to CPR would be. Resident #89 replied, No honey, they have never talked to me about that. I would want it because I want to live as long as possible, wouldn't you? An interview with the Social Service Supervisor (SSS), at 1:08 p.m. on [DATE], revealed if a resident was incapacitated upon admission to the facility, but then regained capacity at a later date, a new POST form should be completed with the resident to reflect his/her choice, not the choices of the health care decision maker. The SSS was asked if Resident #89 was afforded the right to complete a new POST form when she regained capacity on [DATE]. The SSS reviewed the medical record and indicted there was never a new POST form completed with Resident #89 and she would have to go speak with the resident and complete a new form. The SSS stated, they discussed CPR in the quarterly care plan meetings, but they never completed a new post form with Resident #89. The facility's advance directive operations policy was reviewed at 12:30 p.m. on [DATE]. The policy contained the following statements in regards to advance directives, .10. At least annually and following any changes or revocations to the documents, the Interdisciplinary Team (IDT) will review his/her advance directives with the patient to ensure that such directives are still the wishes of the patient. Such reviews will be recorded in the patients clinical record. The IDT shall be responsible to ensure that the patient's current plan of care reflects the patient's expressed directives for treatment. Review of the care plan meeting notes for Resident #89 for the previous year revealed no mention of Resident #89's wishes in regards to CPR. The facility was unable to provide any evidence from Resident #89's clinical record to indicate the facility had reviewed the POST form with Resident #89 since she regained capacity on [DATE].", "filedate": "2018-07-01"}
{"rowid": 6079, "facility_name": "RIVER OAKS", "facility_id": 515120, "address": "100 PARKWAY DRIVE", "city": "CLARKSBURG", "state": "WV", "zip": 26301, "inspection_date": "2014-01-24", "deficiency_tag": 155, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "ZW4411", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure four (4) of thirty-four (34) sample residents were afforded the right to formulate an advance directive. The facility failed to clarify and periodically review existing advance directives. Advance directives were not accurately documented to effectively communicate the resident's choices to the direct care staff should the need to implement, or not implement, cardiopulmonary resuscitation (CPR) arise. Resident identifiers: #114, #130, #99, and #5. Facility census: 100. Findings include: a) Resident #114 A medical record review was conducted on [DATE]. Resident #114 had a FULL CODE sticker on his condition alert tab in the chart. A green page in the chart stated Full Code. The monthly physician's orders [REDACTED]. (A full code would mean the facility would attempt to resuscitate the resident.) The resident's West Virginia Physician order [REDACTED]. The POST form was signed by the medical power of attorney on [DATE], and was signed by the physician on [DATE]. The information on the POST form was not transferred to the remainder of the medical record. b) Resident #130 Resident #130 was admitted to Hospice services on [DATE]. A copy of a physician's prescription on the medical record stated Please make patient DNR (do not resuscitate) dated [DATE]. This information was not updated in the medical record. His condition alert tab stated FULL CODE. A green page in the medical record stated Full Code. A sticker was placed on this page stating, Do Not Thin From Chart. A physician's orders [REDACTED]. No POST form was in the medical record. c) Resident #99 The condition alert tab in the medically record of Resident #99 did not address the code status of Resident #99. A Medical Power of Attorney, notarized [DATE], stated Do Not Resuscitate. The physician's orders [REDACTED]. No POST form was present. This medical record provided conflicting information in regards to the resident's choice of code status. d) Resident #5 A POST form, signed by the physician on [DATE], was marked Do Not Resuscitate. The physician's orders [REDACTED]. The condition alert tab, which was intended as a reference for staff, had a sticker stating FULL CODE. e) Staff interviews were held on [DATE] at 12:00 p.m. with the licensed nurses on duty. Employee #151, an agency Licensed Practical Nurse (LPN), stated she relied on the sticker on the Condition Alert tab as a reference in an emergent situation regarding the resident's condition Employee #69, LPN, stated she also referred to the sticker on the Condition Alert tab. Another LPN, Employee #110, stated she looked for a red or green paper in the chart to let her know the code status of a resident and compared it to the POST form. Employee #52, LPN, stated she looked on the Condition Alert tab and compared it to the POST form. The conflicting information found in the medical record and among staff members in regards to code status was discussed with the Administrator, Employee #120, and the Director of Care Delivery, Employee #124, Registered Nurse (RN) on [DATE] at 1:00 p.m. They acknowledged there was conflicting information in the residents' medical records. A policy, revised ,[DATE], was provided titled, Emergency Management code status identification. This policy stated, Review and documentation of new physician orders [REDACTED]. Employee #120 stated a new process was going to be put into place effective immediately due to the breakdown of the current system.", "filedate": "2018-05-01"}
{"rowid": 6290, "facility_name": "PINEY VALLEY", "facility_id": 515122, "address": "135 SOUTHERN DRIVE", "city": "KEYSER", "state": "WV", "zip": 26726, "inspection_date": "2014-04-15", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "ZU6S11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, interviews with the contracted facility staff, and interview with the resident's medical power of attorney, the facility failed to ensure a resident's rights were honored for one (1) of twenty-nine (29) residents reviewed in Stage 2 of the Quality Indicator Survey. The resident received anticoagulant therapy at the [MEDICAL TREATMENT] center. His medical record indicated he did not want anticoagulant therapy due to religious beliefs. Resident identifier: #169. Facility census: 105. Findings include: a) Resident #169 A medical record review, completed on 04/14/14 at 9:00 a.m., revealed Resident #169 received [MEDICAL TREATMENT] services. The current care plan indicated the facility would coordinate care with the [MEDICAL TREATMENT] center. A hospital discharge summary, dated 03/08/14, noted the resident did not receive anticoagulation therapy related to his religious beliefs. In addition, a physician's progress note included, (name of religion) . no anticoagulant therapy. During an interview with the medical power of attorney, on 04/14/14 at 4:30 p.m., she conveyed Resident #169's religious preferences were very important to him. She confirmed he did not want anticoagulant therapy. Upon inquiry, she related she was unaware of the [MEDICAL TREATMENT] process. She said the [MEDICAL TREATMENT] center had spoken with her, but she did not know how the process worked. An interview with [MEDICAL TREATMENT] staff, on 04/14/14 at 5:30 p.m., revealed they were not aware of the resident's refusal of anticoagulant therapy. Staff member #182, a registered nurse (RN) and Staff member #183 (RN) said information regarding the resident's preference for refusal of anticoagulant therapy was not conveyed to them. Employee #183 said communication with the facility was usually limited to communication forms. In addition, the [MEDICAL TREATMENT] center staff related they were not invited, and had never participated in the facility's care plan process. Employee #182 explained options, other than [MEDICATION NAME], were available for the resident, such as saline flushes. Review of the agreement between the facility and the outpatient [MEDICAL TREATMENT] services revealed the facility would make the necessary individual resident clinical records available as necessary for the [MEDICAL TREATMENT] center to furnish its services. The director of care delivery (DCD), Employee #101, was interviewed on 04/15/14 at 8:30 a.m. regarding what pertinent information was shared with the [MEDICAL TREATMENT] center. She said the information provided to the [MEDICAL TREATMENT] center consisted of a copy of the Medication Administration Record, [REDACTED]. There was no evidence the hospital discharge summary, dated 03/08/14, which noted the resident did not receive anticoagulation therapy related to his religious beliefs, or the physician's progress note which included (name of religion) . no anticoagulant therapy were shared with the [MEDICAL TREATMENT] center. Upon exit, the facility had provided no evidence to indicate an attempt was made to ensure Resident #169's right to refuse treatment in regards to religious preferences was honored.", "filedate": "2018-04-01"}
{"rowid": 6331, "facility_name": "DAWN VIEW CENTER", "facility_id": 515163, "address": "PO BOX 686", "city": "FORT ASHBY", "state": "WV", "zip": 26719, "inspection_date": "2014-07-09", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "2M0C11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident who had been determined by her attending physician to have the capacity to make her own healthcare decisions was provided with appropriate information and/or involved in the formulation of her advance directive. She was one (1) of a total of thirty-one (31) residents (both with and without capacity) in the sample reviewed. Resident identifier: #29. Facility census: 66. Findings include: a) Resident #29 A review of Resident #29's medical record revealed she was admitted on [DATE]. At that time, her attending physician deemed she had the capacity to form her own healthcare decisions. There was no evidence in the record stating she wished another individual to make her decisions. She had a Full Code (wanted to be resuscitated and have all life saving measures implemented) decision documented on admission. The resident's Physician order [REDACTED]. The form indicated the decision was explained to only MPOA (medical power of attorney), and was signed by the daughter (MPOA). There was no indication in the record the resident was involved in the decision or that it had been explained to her. During an interview with the director of nurses (DON) and the Social Worker (SW), at 2:00 p.m. on 06/30/14, the DON verified the resident was alert and oriented, and was able to make her needs known. The Social Worker said he remembered the daughter attending a care plan meeting and requesting a change to the DNR status, but he did not remember the resident being present. The SW returned at 2:20 p.m. on 06/30/14, after reviewing the entire record and acknowledged there was no documentation of a request by the resident instructing anyone to sign for her or that she was aware of the change in her code status. The care plan was revised to DNR status on 04/29/14, and included a nursing intervention stating, Inform (Resident #29) and/or healthcare decision maker of any change in status or care needs and Provide (Resident #29)/healthcare decision maker with sufficient information to make an informed decision.", "filedate": "2018-04-01"}
{"rowid": 6889, "facility_name": "CABELL HEALTH CARE CENTER", "facility_id": 515192, "address": "30 HIDDEN BROOK WAY", "city": "CULLODEN", "state": "WV", "zip": 25510, "inspection_date": "2014-01-23", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "ONTQ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview and policy review, the facility failed to allow two (2) of three (3) Stage 2 residents reviewed for choices, the right to formulate an advanced directive related to Cardiopulmonary Resuscitation (CPR). Both residents were determined to have capacity to make medical decisions upon their admission to the facility. The facility allowed each resident's appointed Medical Power of Attorney to sign their Physician order [REDACTED]. Resident identifiers: #53 and #32. Facility Census: 85. Findings Include: a) Resident #53 Resident #53's medical record was reviewed at 10:24 a.m. on [DATE]. This review revealed the resident was admitted to the facility on [DATE]. The review also revealed a determination of capacity, completed on [DATE], which indicated the resident had capacity to make medical decisions. The resident's medical record contained a POST form dated [DATE]. This form indicated the resident was to receive CPR should she need it. The form was signed by Resident #53's appointed Medical Power of Attorney. The date this form was signed by the MPOA was left blank. The physician signed the POST form, making it an order, on [DATE]. Resident #53 was interviewed at 11:30 a.m. on [DATE]. When asked if she would want CPR should she need it, she replied, I would not want to have CPR. No one here has ever asked me about CPR, but I know I would not want to have it. She further stated, I would want to tell my son before I made any final decisions just to let him know what my plan was. The facility's Notification of Advance Directives policy was reviewed on [DATE] at 11:00 a.m This review revealed the following: The health care center informs and presents written materials to the residents who are admitted pertaining to their legal rights and decisions about medical care. These rights include the right to accept or refuse medical or surgical treatment, the right to choose to receive cardiopulmonary resuscitation, and the right to formulate advanced directives such as living will (declaration to physicians, power of attorney for health care, or health care surrogate The Social Service Director job description was reviewed on [DATE] at 9:15 a.m. This review revealed the following key responsibility related to resident rights under the heading, Key Responsibilities . 9. Acts as resident/family advocate and ensures the resident is knowledgeable in and exercises his/her rights. Employee #88, Social Service Director, was interviewed at 02:24 p.m. on [DATE]. She stated if Resident #53 had capacity, she should have signed her own POST form. The Social Service Director confirmed Resident #53 was not afforded her right to formulate an advanced directive related to CPR. The Social Service Director stated she was aware it was Resident #32's right to formulate an advance directive, but was not aware Resident #32 had not signed her own POST form. The Social Service Director stated, To my recollection I have never talked to this resident about CPR. She confirmed she was unaware Resident #53 had not signed her own POST form. b) Resident #32 Resident #32's medical record was reviewed at 10:00 a.m. on [DATE]. This review revealed the resident was admitted to the facility on [DATE]. The review also revealed a determination of capacity, completed on [DATE], which indicated the resident had capacity to make medical decisions. The Resident's medical record contained a POST form dated [DATE]. This form indicated the resident was not to receive CPR. The form was signed by the resident's appointed Medical Power of Attorney on [DATE]. The MPOA was not in effect because Resident #32 had capacity to make medical decisions at the time the MPOA signed the form. The facility's Notification of Advance Directives policy was reviewed at [DATE] at 11:00 a.m. This review revealed the policy included, The health care center informs and presents written materials to the residents who are admitted pertaining to their legal rights and decisions about medical care. These rights include the right to accept or refuse medical or surgical treatment, the right to choose to receive cardiopulmonary resuscitation, and the right to formulate advanced directives such as living will (declaration to physicians, power of attorney for health care, or health care surrogate. An interview was conducted with Employee #88, Social Service Director, at 12:13 p.m. on [DATE]. She stated if Resident #32 had capacity, she should have signed her own POST form. The Social Service Director confirmed Resident #32 was not afforded the right to formulate an advanced directive, related to choosing whether or not to receive CPR. The Social Service Director stated she was aware it was Resident #32's right to formulate an advance directive, but was not aware Resident #32 had not signed her own POST form. The Social Service Director stated, Since they have a dementia diagnosis, staff is assuming they do not have decision making ability and is just letting the decision maker sign the forms on admission. When asked to describe the typical process for establishing a POST form, the Social Worker stated, The practice is typically if the resident seems with it they will allow the resident to sign the forms otherwise they will wait until the doctor determines the resident's capacity.", "filedate": "2017-11-01"}
{"rowid": 6989, "facility_name": "EAGLE POINTE", "facility_id": 515159, "address": "1600 27TH STREET", "city": "PARKERSBURG", "state": "WV", "zip": 26101, "inspection_date": "2013-12-18", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "EUXT11", "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 ensure a resident was afforded the right to formulate an advanced directive. This was found for one (1) of four (4) sample residents reviewed for the care area of choices during Stage 2 of the survey. The resident's code status was determined by a medical decision maker during a time the resident did not have capacity to make medical decisions. The code status was not reevaluated with the resident when she regained capacity to make health care decisions. Resident Identifier: #91. Facility Census: 130. Findings Include: a) Resident #91 Resident #91's medical record was reviewed at 1:00 p.m. on 12/17/13. This review revealed two (2) Physician's Determination of Capacity forms. The first form was dated 12/04/13 and determined the resident had capacity to make medical decisions. The second form was dated 12/07/13, and also determined the resident had capacity to make medical decisions. The record also contained a social service progress note, dated 12/11/13, written by Employee #62, Social Worker. This note revealed Resident #91 was reevaluated for capacity because she had scored a 15 on her latest Brief Interview for Mental Status (BIMS). She indicated Resident #91 was reevaluated by two (2) physicians and had regained her ability to make medical decisions. Further review of Resident #91's medical record revealed a Do Not Resuscitate form. This form contained the following paragraph, I, the undersigned resident or duly authorized legal representative, have made a decision regarding resuscitation in the event that I (the above named resident) am discovered without respiration or pulse. The affected resident or legal representative wishes that medical personnel in attendance would NOT initiate cardiopulmonary resuscitation. I understand I may revoke these directions at any time. This form contained Resident #91's name. It was signed by her Legal Representative on 09/26/12. At the time the form was signed by the legal representative, Resident #91 did not have capacity to make healthcare decisions. A physician's orders [REDACTED]. There was no indication the facility reviewed the Do Not Resuscitate order with Resident #91 when she regained capacity to make medical decisions on 12/07/13. Resident #91 was interviewed at 2:15 p.m. on 12/17/13. She stated no one had ever talked to her about Cardiopulmonary Resuscitation. Employee #62, Social Worker, was interviewed at 2:35 p.m. on 12/17/13. She stated she had not reviewed Resident #91's advance directives with her since she regained capacity to make health care decisions. She confirmed the resident's Do Not Resuscitate status was something she should have reevaluated with the resident when the resident regained capacity to make medical decisions. .", "filedate": "2017-09-01"}
{"rowid": 7172, "facility_name": "PINEY VALLEY", "facility_id": 515122, "address": "135 SOUTHERN DRIVE", "city": "KEYSER", "state": "WV", "zip": 26726, "inspection_date": "2014-07-16", "deficiency_tag": 155, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "1X1U11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to determine on admission whether a resident, who had been determined by her attending physician to lack the capacity to form her own health care decisions, had an advance directive formulated by the appropriate legal representative and in compliance with State requirements regarding advance directives. This decision applied to one (1) of nine (9) residents reviewed during the investigation of a complaint. Resident identifier: #61. Facility census: 104. Findings include: a) Resident #61 A review of the medical record revealed Resident #61 was a [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital. Her [DIAGNOSES REDACTED]. She also had deep tissue injury to both feet, right hip, coccyx, both ears, and left hip. The 5 foot, 4 inch tall resident weighed 90.2 pounds on admission. Both the physician who discharged the resident from acute care and the attending physician at the nursing home, who was the resident's prior family physician, determined the resident lacked the capacity to process the information needed to form her healthcare decisions. A review of the hospital records forwarded to the facility revealed the resident had been referred to Adult Protective Services (APS) on admission to the hospital ([DATE]) because of suspected elder abuse neglect. A Forensic Nurse Examiner Consult completed on [DATE], revealed, . patient is confused, does know her name and that she lives in (name of town/city). The Nurse affirmed an APS referral had been made. She also indicated the hospital Social Worker had informed them the resident's Son #1, who was indicated to be the responsible party, had agreed to nursing home placement. The Discharge Instructions from the hospital included, Resuscitation Status: No CPR (cardiopulmonary resuscitation), . A form entitled (Name of other state) Medical Orders for Life - Sustaining Treatment (_OLST) accompanied the resident. It indicated the resident's surrogate was the basis for the orders which included DNR (do not resuscitate), but there was no evidence the resident had a legal surrogate and the form stated, It is valid in all health care facilities and programs throughout (name of other state.) Furthermore, there was no signature of the resident and/or legally responsible party on the form. Resident #61 was admitted to the facility on [DATE]. The nurses' notes indicated she arrived via ambulance and indicated notification of Son #2 and his wife. There was no evidence of attempt to contact Son #1. The nurses' notes revealed Son #1 was in to visit the resident on the evening of her admission ([DATE]). During a review of the clinical record for Resident #61 at 9:00 a.m. on [DATE]. a full-sized red paper was observed on opening the chart stating she was Do Not Resuscitate (DNR) status. Further review failed to reveal documented evidence of a physician's orders [REDACTED].#61. The resident had been deemed to lack the capacity to form her own health care decisions by the attending physician, who had also written an order for [REDACTED]. During an interview with Employees #119 and #131 (both Licensed Social Workers) at 10:00 a.m. on [DATE], they were asked to provide evidence that Resident #61 had a legally appointed health care surrogate. Employee #131 stated the daughter-in-law was making decisions, but she acknowledged the absence of a HCS document, and stated Son #2 and his wife had gone on vacation and said they would take care of that on their return. When asked about the status of Son #1, they stated they had been unable to reach him and he had not contacted them, but there was no supporting evidence of the attempts. A review of the entire record revealed only one (1) entry of an attempt to reach Son #1 since admission, and it was by the DON (director of nurses) on [DATE]. At 11:35 a.m. on [DATE], Resident #61 was observed meeting her son (Son #1) in the hall next to the South Nurses' Station. Both were happy to see the other and greeted each other warmly. Both were being pushed in wheelchairs. They continued to the dining room and were observed sitting next to each other during the meal where he stayed to visit her while she ate. During an interview with Employee #131 at 2:00 p.m. on [DATE], she stated she had contacted APS and confirmed an investigation was pending. She had also contacted the attending physician who informed her he was the family doctor for both the resident and Son #1, who was also sick. When asked why there was still no evidence of a legally designated responsible party, no POST form, or no signed admission forms/consents of any kind on the chart; she stated she had been waiting for Son #2 to return from vacation and had been unable to reach Son #1. She also pointed out the front sheet on the record had been changed and Son #2 and his wife were no longer entered as HCS designees. Employee #131 was asked for evidence the DNR decision had been made by a legally designated responsible party since her chart was flagged to indicate she was not to be resuscitated. She stated the physician had written a DNR order and produced the _OLST document. She admitted she had not discussed the resident's DNR status with any family member. A note written by Employee #131 at 1:34 p.m. on [DATE], stated, SS (social services) spoke with resident's physician who stated that he has MPOA (Medical Power of Attorney) paperwork on resident. At 2:20 p.m. on [DATE], Employee #131, accompanied by the DON produced a HCS form dated [DATE] and signed by Son #2 on [DATE] (today) appointing him HCS. She also had a copy of the MPOA form dated [DATE] naming Son #1, which, per the time stamp, had been received via fax at 12:29 p.m. on [DATE]. Employee #131 stated she had called a local attorney and he said if they couldn't reach the MPOA, the physician could revoke the MPOA d/t the neglect allegation made to APS and re-assign the HCS to Son #2 because he was the successor representative on the MPOA document. They had no comment when informed Son #1, accompanied by his son, was in earlier and visited with the resident throughout lunch. Employee #131 did agree there had been no information from APS confirming the allegation investigation had been completed and/or substantiated; and there was no evidence of documentation by the physician of revocation of the MPOA, although he had signed the HCS form on [DATE]. The resident's chart continued to indicate she was DNR status at 3:00 p.m. on [DATE]. During an interview with Employee #131, the Administrator, and the DON at 2:15 p.m. on [DATE], the Administrator reported they had contacted Son #1 and he had immediately given them a verbal authorization for the DNR status which was witnessed by two staff members. He then came directly to the facility and informed them he intended to remain the MPOA.", "filedate": "2017-07-01"}
{"rowid": 9033, "facility_name": "DUNBAR CENTER", "facility_id": 515066, "address": "501 CALDWELL LANE", "city": "DUNBAR", "state": "WV", "zip": 25064, "inspection_date": "2013-03-14", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "RKHC12", "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 assist two (2) of three (3) residents, reviewed for decision making, to formulate an advance directive, stating their desire to receive or not to receive cardiopulmonary resuscitation (CPR). Resident #193's wishes were to receive CPR if she was found to have no pulse, respirations and/or blood pressure. This was not assessed by the facility. She had a physician's orders [REDACTED]. Resident #217 had a Physician order [REDACTED].#217. The form was signed by her medical power of attorney (MPOA); however the resident still maintained capacity to make medical decisions. Resident identifiers: #193 and #217. Facility Census: 113 Findings Include: a) Resident #193 A medical record review was completed at 9:20 a.m. on [DATE]. This review revealed the resident had an order for [REDACTED]. The resident was readmitted to the facility from an acute care hospital on [DATE]. A care plan conference summary sheet was reviewed. It noted the resident wanted to be a Full Code. This indicated the resident wanted to have CPR initiated should it be needed. This summary was signed by Employee #36, a Registered Nurse (RN), minimum data set (MDS) Coordinator, Employee #51, Social Worker, a Licensed Physical Therapy Assistant, a Certified Occupational Therapy Assistant, and Resident #193. The resident's care plan was also reviewed. The care plan contained the following problem, The resident desires to be a DNR. The goal contained on the care plan was, DNR will be honored upon absence of pulse, respirations, and/or blood pressure. The care plan contained the following interventions. 1. Verify the absence of apical pulse, respirations, and/or blood pressure. 2. Notify Physician. 3. Notify Family. Additional review of the medical record revealed a hospital discharge summary, dated [DATE], which contained the following statements: It was questioned whether or not the son would request comfort care. He did make her a do not resuscitate, do not intubate. The medical record contained a Physician's Determination of Capacity, dated [DATE], which identified the resident demonstrated the capacity to make healthcare decisions. Finally, the medical record did not contain any evidence to suggest Resident #193 ever told facility staff she had a desire to have a DNR order. At 9:45 a.m. on [DATE], a resident interview was conducted with Resident #193. The resident was alert and orientated to time, place, and person. She was able to answer questions appropriately. She was asked if she had told the facility what her wishes were in regards to CPR. She stated, I have never really thought about whether or not I would want CPR. She further stated, I have never told anyone here that I did not want CPR. She stated, No one has ever asked me that before. At 9:52 a.m. on [DATE], Employee #108, Licensed Practical Nurse (LPN) and Employee #90, Registered Nurse (RN) were interviewed. They were asked how they determined whether or not to initiate CPR on a resident. They both confirmed they looked at the resident's Condition Alert sheet in the front of the chart for a DNR sticker. They stated if there was no sticker, they then looked at the resident's POST form. If there was no POST form, they reported they would look at the physician's orders [REDACTED].>At 10:00 a.m. on [DATE], Employee #51, the social worker, was interviewed. She stated the resident was a Full Code. She referred to the care plan conference summary sheet dated [DATE]. She confirmed she had not discussed this with the resident since her return from the hospital. She confirmed the resident had a physician's orders [REDACTED]. Employee #51 confirmed the resident had not signed any paperwork at the facility to indicate she would want to be a DNR. Employee #51 also confirmed the resident had a DNR care plan. At 10:22 a.m. on [DATE], Employee #108, an LPN, was asked to review the medical record of Resident #193 and to indicate if he would perform CPR on the resident should she have an absence of pulse, respirations and/or blood pressure. The LPN reviewed the medical record and indicated he would not perform CPR on this resident because she had a physician's orders [REDACTED]. At 10:25 a.m. on [DATE], Employee #46, an RN, was asked to review the medical record of Resident #193 and to indicate if she would perform CPR on this resident should she have an absence of pulse, respirations and/or blood pressure. The RN reviewed the medical record and stated she would not perform CPR on this resident because she had a physician's orders [REDACTED]. Employee #72, RN, Director of Nursing (DON), was interviewed at 10:30 a.m. on [DATE]. She was asked to review the medical record of Resident #193 and to indicate if she would perform CPR on this resident if there was an absence of pulse, respirations, and/or blood pressure. She stated she would perform CPR on this resident because she did not have a DNR sticker on her condition alert page in the front of her chart. The DON then reviewed the chart with the surveyor and confirmed the resident had a physician's orders [REDACTED]. She also confirmed the absence of a POST form and of a DNR sticker on the condition alert form at the front of the resident's medical record. At 10:35 a.m. on [DATE], Employee #37, the social worker, reported the facility contacted the acute care hospital and now had a form which the resident had signed while in the hospital. Employee #37 also reported, Employee #51 had spoken with Resident #193 and completed a POST form. The resident indicated to Employee #51 she wanted CPR should it be needed. The POST form was completed to reflect the resident's wishes regarding end of life care. Later in the afternoon of [DATE], Employee #37 provided a copy of a Do not Resuscitate and Limited Resuscitation orders (DNR) form. This form was completed at the acute care hospital on [DATE]. The form was faxed to the facility at 12:31 p.m. on [DATE]. This form was not signed by Resident #193. It was instead signed by her MPOA. The form was also not signed by a physician which meant it was not a valid physician's orders [REDACTED].>The facility's Advance Directives policy was reviewed at 8:00 a.m. on [DATE]. The policy states, The Social Services Director/Designee assists the resident or legal representative with any questions regarding Advanced Directives at the time of admission by providing them the Advance Directive booklet as applicable. The policy further stated, The Social Services Director/designee periodically provides education related to Advance Directives. At any time the resident who wishes to initiate or change an advance directive, the Social Service Director/designee directs the resident or legal representative to the appropriate resource(s). Upon further review of the Advance Directives policy the following procedure was identified if the resident or legal representative chooses to request a DNR. Documented discussion between the resident or legal representative regarding the request for DNR, which may include signed Request for Do Not Initiate CPR or state specific DNR Consent completed by the resident or legal representative This information was not contained on Resident #193's medical record. The policy also stated, An advanced directive label is placed on the Condition alert tab within the medical record reflecting the resident's choice. This information was not contained on the resident's medical record. b) Resident #217 A review of Resident #217's medical record was completed at 8:30 a.m. on [DATE]. This review revealed the resident had a Physician's Determination of Capacity dated [DATE]. This form indicated Resident #217 demonstrated the capacity to make health care decisions. Further review revealed a POST form which indicated the resident desired to be a DNR. This form indicated this was discussed with the resident's medical power of attorney (MPOA). The form was also signed by the resident's MPOA and not the resident. This form was signed by the MPOA on [DATE] and by the physician [DATE]. The form indicated Employee #51 assisted the MPOA in completing this form. An interview with Employee #51, the social worker, was completed at 9:20 a.m. on [DATE]. Employee #51 stated the resident could not see at all and this was why the resident did not sign the POST form. The social worker reported she did talk to the resident about the POST form, but that the MPOA had signed the form. She reported the resident understood what the POST form was and the resident wanted to be a DNR. The social worker wrote a note, on [DATE], which contained the following information in regards to Resident #217: Resident is alert and orientated, but she has her niece (nieces name) as her MPOA to make all decisions for her. The note further states, . She does not have many hobbies as she can not see and/or hear. Completed post form with MPOA, she is a DNR nurse notified . At 9:36 a.m. on [DATE], Resident #217 was interviewed. Resident #217 confirmed she wanted to be a DNR. She stated she did not want to have CPR. She stated she did not recall anyone ever discussing this with her. The resident confirmed she did not see well, but she stated she could see well enough to sign a paper if someone will show her where to sign. She reported she signed some paperwork when she first came to the facility and they just showed her where to sign and read her the information. An additional medical record review was completed at 10:00 a.m. on [DATE]. This review revealed an Admission Agreement which was signed by Resident #217 on [DATE]. This form was also signed by Employee #60, an admissions employee. There was also a Representative Designation form contained on the medical record which indicated, Resident/Patient completing admission paperwork. No Representative Designated. .", "filedate": "2016-02-01"}
{"rowid": 9141, "facility_name": "CAREHAVEN OF PLEASANTS", "facility_id": 515191, "address": "PO BOX 625", "city": "BELMONT", "state": "WV", "zip": 26134, "inspection_date": "2012-04-26", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "JRXZ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, and record review, the facility failed to ensure one (1) of thirty-three (33) residents was provided the opportunity to exercise his right to refuse treatment. The resident was given a thirty (30) day notice for refusing care and treatment without evidence the facility assessed the reason's for the refusals and without evidence alternative treatments and/or times for treatments were offered. Resident identifier: #78. Facility census: 61. Findings include: a) Resident #78. Review of the medical record found several occasions when Resident #78 refused care and treatment. No evidence could be found the facility investigated why the resident refused care and treatment. Resident #78 was admitted to the facility on [DATE]. The admission [DIAGNOSES REDACTED]. During an interview with the resident, on 04/23/12 at 3:00 p.m., it was learned the resident did not like the type of solution used to treat his wounds. The resident stated, It's a bleach solution and [MEDICAL CONDITION] nose. The treatment was ordered twice a day. The resident stated he was not going to let the facility use Dakins solution twice a day. According to Employee #97 (treatment nurse), during an interview on 04/25/12 at 9:14 a.m., Resident #78 had voiced his opinion of the Dakins solution to her. She stated, He is non-compliant with a twice a day treatment. She further added she contacted the wound care center, but they would not change the treatment. Employee #97 was asked whether she had contacted the attending physician to get the treatment changed. She stated, He will not go against the wound care center. She stated at one time they had used a patch which only had to be changed every three (3) days, and the resident was more compliant with this treatment. No evidence could be found the physician was aware of Resident #78 having difficulty with the current treatment. Additionally, no evidence could be found the facility alerted the physician to why Resident #78 was refusing treatments. During the interview with Resident #78 on 04/23/12 at 3:00 p.m., the resident stated he liked to stay up all night and watch television and slept during the day. This was also a reason he refused treatments, as they were scheduled at times which were inconvenient for him. No evidence could be found the facility made arrangements to work treatments around Resident #78's schedule. On 04/11/12, the facility issued Resident #78 a thirty (30) day notice stating they had no choice, but to give him a thirty (30) day notice related to his refusals of care and treatment. The letter further stated the facility would look for alternative placement that better suited the resident. During an interview with Employee #100 (administrator), on 04/24/12 at 5:57 p.m., he stated the facility had several meetings with Resident #78, but did not have documentation related to these meetings. He further added Resident #78 may have stated he did not want to go to another nursing home. During an interview, on 04/24/12 at 5:57 p.m., Employee #100 was asked for information related to education provided to Resident #78 on the risks and benefits of treatment. He stated, I'm sorry, it's not documented. On 04/24/12 at 3:37 p.m., Employee #78 (social worker/admission coordinator) was asked if he had met with Resident #78 related to his care and treatment. He stated, No, I have not had a lot of contact with him. He further added he was present when the facility gave Resident #78 a thirty (30) day notice for refusal of care. Review of the social worker notes identified only three (3) notes written from 02/14/12 thru 04/23/12. On 02/29/12, Employee #78 wrote a note stating the following, Had been refusing care related to pain, but this has been corrected and he is participating more now. According to the social service note dated 02/29/12 Resident #78 was having no issues at that time.", "filedate": "2016-02-01"}
{"rowid": 9636, "facility_name": "BRIGHTWOOD CENTER", "facility_id": 515128, "address": "840 LEE ROAD", "city": "FOLLANSBEE", "state": "WV", "zip": 26037, "inspection_date": "2009-12-17", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "6HX711", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, Hospice staff interview, and observation, the facility failed, for one (1) of eighteen (18) residents sampled, to allow refusal of treatment. The resident, who was also under the care of Hospice services, had requested through her medical power of attorney representative (MPOA) via the Physician order [REDACTED]. IV fluids had continued for a period of at least twenty-nine (29) days following the resident's hospitalization and return to the facility, with no evidence the facility recognized the right to refuse them and/or worked in conjunction with her physician and the Hospice agency to discontinue the IV fluids. Resident identifier: #13. Facility census: 105. Findings include: a) Resident #13 The medical record of Resident #13, when reviewed on 12/15/09, disclosed this [AGE] year old female had resided at the facility since 12/22/04. Her medical [DIAGNOSES REDACTED]. She had returned to the facility from her most recent hospitalization on [DATE], having been admitted to the hospital with [REDACTED]. On 12/08/09, the resident's attending physician wrote an order for [REDACTED]. The resident's medical record, when further reviewed, revealed she did not have the capacity to make her own medical decisions, as determined by her attending physician on 09/02/08. The most recent minimum data set (MDS), with an assessment reference date of 11/26/09, in the area of Cognitive / Decisionmaking described this resident as 3, severely impaired, rarely / never made decisions. The record disclosed a POST form which stated, This is a physician's orders [REDACTED]. Any section not completed indicates full treatment for [REDACTED]. All areas of the POST form were completed on 12/10/08, with the resident's MPOA signature noted in Section F. The document was reviewed on 11/30/09 with no changes noted. The form requested under Section A - Do Not Attempt Resuscitation; under Section B - Comfort Measures; under Section C - Antibiotics; and under Section D - IV fluids for a defined trial period. In Section E, it was noted these were discussed with MPOA, and under The Basis for These Orders Is was marked Patient's best interests (patient preferences unknown). The resident's medical record did not contain a Living Will document. Observation, during a wound care treatment on the afternoon of 12/15/09, found the resident was receiving an infusion of IV fluids. The infusion was [MEDICATION NAME], and it was infusing at forty (40) cc/per hour. [MEDICATION NAME], according to RxList Inc., the Internet Drug List at www.rxlist.com, is a sterile, nonpyrogenic, moderately hypertonic intravenous injection containing [MEDICATION NAME], a nonprotein energy substrate and maintenance electrolytes. [MEDICATION NAME] is indicated for peripheral administration in adults to preserve body protein and improve nitrogen balance in well-nourished, mildly catabolic patients who require short-term [MEDICATION NAME] nutrition. The source of the implementation of the IV fluids was found to be a physician's orders [REDACTED]. The resident was non-responsive during the wound care, even when turned from side to side by staff. When questioned as to the palliative purpose of the infusing fluids, the nurse completing treatment (Employee #113) stated she wasn't sure. When asked if the fluids had prevented a further decline in the resident's condition, the nurse stated, No. The facility's director of nurses (DON - Employee #99, when interviewed related to this observation on 12/15/09 at approximately 3:00 p.m., stated she did not know if the resident's MPOA had been contacted related to the continuation of the IV fluids at the time of re-admission from the hospital or at the time of the admission to Hospice Services. She did recall there had been discussion about the IV fluids among staff. Return to the medical record divulged a social services note, dated 11/30/09, stating, POST form discussed with Daughter / MPOA on 11/30/09 (sic) with no changes. This note also stated the resident has been exhibiting behaviors of refusing / spitting out meals and medications. The social worker (Employee #140), when interviewed on the morning of 12/16/09, was asked if she was aware the resident's current care was in contradiction with the POST form with respect to the continued administration of IV fluid infusion. The social worker stated that, during the care plan meeting for this resident on 12/08/09, when the resident's MPOA and Hospice nurse were present, Hospice staff had indicated they would address this situation. She made no mention of the issue being addressed at the time of the resident's re-admission to the facility on [DATE], or at the time of the documented Review of the POS [REDACTED] On 12/16/09 at 9:30 a.m., a Hospice nurse (Employee #142) was visiting the resident in her room. This nurse was questioned as to if Hospice staff had attempted to contact the resident's MPOA about the continued infusion of IV fluids, in light of her noted desires on the resident's POST form. It had now been eight (8) days since Hospice had become involved in the resident's care. The Hospice nurse stated he thought someone had tried to contact the MPOA with no success and that he had just met the resident for the first time. He further stated the physician had been contacted by facility staff the previous evening (on 12/15/09), following questioning by this surveyor, and he wanted the IV fluids to continue. The Hospice nurse could give no reason for the continued use of IV fluids and could not describe any palliative purpose the IV fluids may be serving. The Hospice nurse also stated that discontinuing the fluids was the decision of the resident's attending physician. When asked if the Hospice medical director might not intervene in a situation similar to this, the Hospice nurse responded, No. The Hospice nurse then described the resident's attending physician as sometimes being hesitant to act upon recommendations by Hospice staff. Later on this same day at approximately 2:00 p.m., the Hospice nurse informed this surveyor that the resident's MPOA had been contacted and her desire was to discontinue the IV fluid infusion. He stated a request for that order had been communicated to the attending physician. According to Hospice Philosophy, as noted by the Hospice Patient's Alliance and found at www.hospicepatients.org/hospic28.html, When appetite declines and your loved one is refusing food, it's quite difficult to accept. We all know that you have to eat to live, but what many of us don't know is that if your body can't process the food because of a terminal illness, forcing nutrition in will not prolong life. There is a natural process in the dying: decreased appetite, decreased thirst, gradual withdrawal from the concerns of this world and focus on concerns about death and taking care of 'unfinished business' with family. The refusal of food / nutrition, according to Hospice Philosophy, is a normal part of the dying process. At the time of the resident's admission to Hospice, the resident's MPOA, with the resident's best interest in mind, agreed to accept the Hospice philosophy. Review of the documents on the resident's medical record that had been provided to the MPOA at the time of admission disclosed a document entitled Section C: Bill of Rights. This document stated, Consistent with state laws, the patient's family or guardian may exercise the patient's rights when the patient is unable to do so. Hospice organizations have an obligation to protect and promote the rights of their patients. There was no evidence, through record review or staff interview, that the facility had made efforts to coordinate with the resident's MPOA, the Hospice Agency, and the resident's attending physician to effectively honor the desire for IV fluids only for defined trial period. There was no documentation of a plan to discontinue the IV fluids, a defined time period for their use was not designated, and there was no documented purpose for their use in providing palliative / comfort care to the resident. At the time of exit from the facility at 10:00 a.m. on 12/17/09, the IV fluids continued to infuse for this resident.", "filedate": "2015-10-01"}
{"rowid": 9878, "facility_name": "DUNBAR CENTER", "facility_id": 515066, "address": "501 CALDWELL LANE", "city": "DUNBAR", "state": "WV", "zip": 25064, "inspection_date": "2013-05-17", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "RKHC12", "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 assist two (2) of three (3) residents, reviewed for decision making, to formulate an advance directive, stating their desire to receive or not to receive cardiopulmonary resuscitation (CPR). Resident #193's wishes were to receive CPR if she was found to have no pulse, respirations and/or blood pressure. This was not assessed by the facility. She had a physician's orders [REDACTED]. Resident #217 had a Physician order [REDACTED].#217. The form was signed by her medical power of attorney (MPOA); however the resident still maintained capacity to make medical decisions. Resident identifiers: #193 and #217. Facility Census: 113 Findings Include: a) Resident #193 A medical record review was completed at 9:20 a.m. on [DATE]. This review revealed the resident had an order for [REDACTED]. The resident was readmitted to the facility from an acute care hospital on [DATE]. A care plan conference summary sheet was reviewed. It noted the resident wanted to be a \"Full Code.\" This indicated the resident wanted to have CPR initiated should it be needed. This summary was signed by Employee #36, a Registered Nurse (RN), minimum data set (MDS) Coordinator, Employee #51, Social Worker, a Licensed Physical Therapy Assistant, a Certified Occupational Therapy Assistant, and Resident #193. The resident's care plan was also reviewed. The care plan contained the following problem, \"The resident desires to be a DNR.\" The goal contained on the care plan was, \"DNR will be honored upon absence of pulse, respirations, and/or blood pressure.\" The care plan contained the following interventions. \"1. Verify the absence of apical pulse, respirations, and/or blood pressure. 2. Notify Physician. 3. Notify Family.\" Additional review of the medical record revealed a hospital discharge summary, dated [DATE], which contained the following statements: \"It was questioned whether or not the son would request comfort care. He did make her a do not resuscitate, do not intubate.\" The medical record contained a Physician's Determination of Capacity, dated [DATE], which identified the resident demonstrated the capacity to make healthcare decisions. Finally, the medical record did not contain any evidence to suggest Resident #193 ever told facility staff she had a desire to have a DNR order. At 9:45 a.m. on [DATE], a resident interview was conducted with Resident #193. The resident was alert and orientated to time, place, and person. She was able to answer questions appropriately. She was asked if she had told the facility what her wishes were in regards to CPR. She stated, \"I have never really thought about whether or not I would want CPR.\" She further stated, \"I have never told anyone here that I did not want CPR.\" She stated, \"No one has ever asked me that before.\" At 9:52 a.m. on [DATE], Employee #108, Licensed Practical Nurse (LPN) and Employee #90, Registered Nurse (RN) were interviewed. They were asked how they determined whether or not to initiate CPR on a resident. They both confirmed they looked at the resident's Condition Alert sheet in the front of the chart for a \"DNR sticker\". They stated if there was no sticker, they then looked at the resident's POST form. If there was no POST form, they reported they would look at the physician's orders [REDACTED]. At 10:00 a.m. on [DATE], Employee #51, the social worker, was interviewed. She stated the resident was a \"Full Code\". She referred to the care plan conference summary sheet dated [DATE]. She confirmed she had not discussed this with the resident since her return from the hospital. She confirmed the resident had a physician's orders [REDACTED]. Employee #51 confirmed the resident had not signed any paperwork at the facility to indicate she would want to be a DNR. Employee #51 also confirmed the resident had a DNR care plan. At 10:22 a.m. on [DATE], Employee #108, an LPN, was asked to review the medical record of Resident #193 and to indicate if he would perform CPR on the resident should she have an absence of pulse, respirations and/or blood pressure. The LPN reviewed the medical record and indicated he would not perform CPR on this resident because she had a physician's orders [REDACTED]. At 10:25 a.m. on [DATE], Employee #46, an RN, was asked to review the medical record of Resident #193 and to indicate if she would perform CPR on this resident should she have an absence of pulse, respirations and/or blood pressure. The RN reviewed the medical record and stated she would not perform CPR on this resident because she had a physician's orders [REDACTED]. Employee #72, RN, Director of Nursing (DON), was interviewed at 10:30 a.m. on [DATE]. She was asked to review the medical record of Resident #193 and to indicate if she would perform CPR on this resident if there was an absence of pulse, respirations, and/or blood pressure. She stated she would perform CPR on this resident because she did not have a \"DNR sticker\" on her condition alert page in the front of her chart. The DON then reviewed the chart with the surveyor and confirmed the resident had a physician's orders [REDACTED]. She also confirmed the absence of a POST form and of a DNR sticker on the condition alert form at the front of the resident's medical record. At 10:35 a.m. on [DATE], Employee #37, the social worker, reported the facility contacted the acute care hospital and now had a form which the resident had signed while in the hospital. Employee #37 also reported, Employee #51 had spoken with Resident #193 and completed a POST form. The resident indicated to Employee #51 she wanted CPR should it be needed. The POST form was completed to reflect the resident's wishes regarding end of life care. Later in the afternoon of [DATE], Employee #37 provided a copy of a \"Do not Resuscitate and Limited Resuscitation orders (DNR)\" form. This form was completed at the acute care hospital on [DATE]. The form was faxed to the facility at 12:31 p.m. on [DATE]. This form was not signed by Resident #193. It was instead signed by her MPOA. The form was also not signed by a physician which meant it was not a valid physician's orders [REDACTED]. The facility's \"Advance Directives\" policy was reviewed at 8:00 a.m. on [DATE]. The policy states, \"The Social Services Director/Designee assists the resident or legal representative with any questions regarding Advanced Directives at the time of admission by providing them the Advance Directive booklet as applicable.\" The policy further stated, \"The Social Services Director/designee periodically provides education related to Advance Directives. At any time the resident who wishes to initiate or change an advance directive, the Social Service Director/designee directs the resident or legal representative to the appropriate resource(s).\" Upon further review of the \"Advance Directives\" policy the following procedure was identified if the resident or legal representative chooses to request a \"DNR\". \"Documented discussion between the resident or legal representative regarding the request for DNR, which may include signed Request for Do Not Initiate CPR or state specific DNR Consent completed by the resident or legal representative\" This information was not contained on Resident #193's medical record. The policy also stated, \"An advanced directive label is placed on the Condition alert tab within the medical record reflecting the resident's choice.\" This information was not contained on the resident's medical record. b) Resident #217 A review of Resident #217's medical record was completed at 8:30 a.m. on [DATE]. This review revealed the resident had a Physician's Determination of Capacity dated [DATE]. This form indicated Resident #217 demonstrated the capacity to make health care decisions. Further review revealed a POST form which indicated the resident desired to be a \"DNR\". This form indicated this was discussed with the resident's medical power of attorney (MPOA). The form was also signed by the resident's MPOA and not the resident. This form was signed by the MPOA on [DATE] and by the physician [DATE]. The form indicated Employee #51 assisted the MPOA in completing this form. An interview with Employee #51, the social worker, was completed at 9:20 a.m. on [DATE]. Employee #51 stated the resident could not see at all and this was why the resident did not sign the POST form. The social worker reported she did talk to the resident about the POST form, but that the MPOA had signed the form. She reported the resident understood what the POST form was and the resident wanted to be a DNR. The social worker wrote a note, on [DATE], which contained the following information in regards to Resident #217: \"Resident is alert and orientated, but she has her niece (nieces name) as her MPOA to make all decisions for her.\" The note further states, \". . . She does not have many hobbies as she can not see and/or hear. Completed post form with MPOA, she is a DNR nurse notified.....\" At 9:36 a.m. on [DATE], Resident #217 was interviewed. Resident #217 confirmed she wanted to be a DNR. She stated she did not want to have CPR. She stated she did not recall anyone ever discussing this with her. The resident confirmed she did not see well, but she stated she could see well enough to sign a paper if someone will show her where to sign. She reported she signed some paperwork when she first came to the facility and they just showed her where to sign and read her the information. An additional medical record review was completed at 10:00 a.m. on [DATE]. This review revealed an \"Admission Agreement\" which was signed by Resident #217 on [DATE]. This form was also signed by Employee #60, an admissions employee. There was also a \"Representative Designation\" form contained on the medical record which indicated, \"Resident/Patient completing admission paperwork. No Representative Designated.\" .", "filedate": "2015-08-01"}
{"rowid": 10745, "facility_name": "PLEASANT VALLEY NSG. & REHAB C", "facility_id": 515064, "address": "1200 SAND HILL ROAD", "city": "POINT PLEASANT", "state": "WV", "zip": 25550, "inspection_date": "2011-08-31", "deficiency_tag": 155, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "H3XI11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure the advance directives of one (1) of six (6) sampled residents were honored by the facility. Resident #94's expressed her wishes with respect to advance directives in writing prior to losing the capacity to make her own informed medical decisions. The facility permitted the resident's medical power of attorney representative (MPOA) to change these written instructions for end-of-life care after the resident was no longer able to express her wishes. Facility census: 93. Findings include: a) Resident #94 A review of Resident #94's closed medical record revealed she was admitted to the facility on [DATE]. On 05/08/11, the physician determined she possessed the capacity to make her own informed health care decisions. Further record review disclosed a combined WV Advance Directive / Living Will / Medical Power of Attorney document, which had been completed and signed by Resident #94 on 03/13/07. This form contained the following: \"If I should reach a point when I lack capacity to make medical decisions, am in a terminal state, or become permanently unconscious or remain in a permanent vegetative state I have indicated my wishes by my initials on the lines below.\" In the section of the document labeled Living Will, the resident indicated she did not want life prolonging treatment and wished to be permitted to die naturally with only the administration of any medication or the performance of any medical treatment deemed necessary to alleviate pain. Regarding the administration of artificial nourishment, the resident stated, \"I do not want artificially provided water or other artificially provided nourishment or fluids (tube feedings intravenous fluids etc).\" The form had an area labeled \"Special Directions or Limitations\", in which the resident indicated she wanted to be kept comfortable and was to be a DNR (do not resuscitate). In the section designating a medical power of attorney representative, the resident identified her daughter as the person to \"make health care decisions for me, in accordance with this directive, when I no longer have decisional capacity and cannot communicate my healthcare wishes.\" The resident was discharged to home on 06/02/11. She was then readmitted to this facility on 06/30/11, after she had a fall at home resulting in a hospitalization . When the resident was readmitted , her previous advance directives remained unchanged. On 06/30/11, the physician subsequently determined she no longer possessed the capacity to understand and make her own health care decisions capacity to make her own decisions. On 07/01/11, the resident's MPOA came to the facility and changed her code status to a \"Resuscitate\", which was contrary to the wishes the resident specifically stated in her advance directives. The administrator and director of nursing were made aware of this finding at 10:30 a.m. on 08/31/11. The administrator contacted by telephone the nurse who changed this resident's code status to a \"Resuscitate\". The administrator then related that the resident's MPOA requested the change, so the nurse completed a new form.", "filedate": "2014-12-01"}
{"rowid": 11022, "facility_name": "HEARTLAND OF KEYSER", "facility_id": 515122, "address": "135 SOUTHERN DRIVE", "city": "KEYSER", "state": "WV", "zip": 26726, "inspection_date": "2009-02-05", "deficiency_tag": 155, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "53ZE11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure that residents with capacity were involved in making decisions with respect to the advance directives documented on the Physician order [REDACTED]. Resident identifiers: #92 and #104. Facility census: 121. Findings include: a) Resident #92 A review of the medical record revealed a POST form indicating Resident #92 was to receive cardiopulmonary resuscitation (CPR) and \"Limited additional interventions\". This form was signed by the resident's medical power of attorney representative (MPOA) on [DATE]. The resident's attending physician determined Resident #92 lacked the capacity to understand and make healthcare decisions on [DATE]. This determination was validated by a second determination made by a psychologist on [DATE]. On [DATE], the resident's attending physician reversed this and determined the resident now had the capacity to formulate healthcare own decisions. However, there was no evidence in the record to indicate the advance directives recorded on the [DATE] POST form had been reviewed with the resident. During an interview at 11:45 a.m. on [DATE], the social worker (Employee #119) was asked if the advance directives noted on the POST form had been reviewed with the resident. The social worker could not remember and, at the time of exit, she had not produced any evidence to indicate the resident had been informed of the decisions made by the MPOA. b) Resident #104 A review of Resident #104's medical record revealed the resident was admitted on [DATE]. On [DATE], the social worker recorded in social services notes that the resident had the capacity to make his own healthcare decisions and he had \"Full Code\" status. His attending physician also determined, on [DATE], that Resident #104 had the capacity to make healthcare decisions. However, an attached form stated: \"It is my desire that (Name) , my (wife) , sign all forms on my behalf to admit me to Heartland of Keyser, as I am presently in a weakened condition and do not wish to sign all of the forms necessary for admission.\" The resident had several acute hospitalization s, and a social service note on [DATE] indicated his daughter was his health care surrogate and that he was still \"full-code status\". A new POST form, indicating the resident was not to be resuscitated and was to receive limited additional interventions, was signed by his wife on [DATE], while he was in the hospital. There was no evidence to show the wife had any legal authority to make healthcare decisions for him at that time. The resident was readmitted to the facility on [DATE], and all documentation indicated the resident had the capacity to form his own healthcare decisions. However, there was no evidence he had been involved in his healthcare decisions, including formulating the advance directives recorded on the POST form. In an interview with both social workers (Employees #79 and #119) at 2:40 p.m. on [DATE], they were asked if the resident was aware of his code status. Neither answered, nor was any documentation offered. They both verified the resident was alert, oriented, and able to make his needs known with sign language. .", "filedate": "2014-09-01"}
{"rowid": 11105, "facility_name": "GRAFTON CITY HOSPITAL", "facility_id": 515057, "address": "1 HOSPITAL PLAZA", "city": "GRAFTON", "state": "WV", "zip": 26354, "inspection_date": "2011-04-27", "deficiency_tag": 155, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "MWLC11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, record review, and policy review, the facility failed to ensure that a resident's right to refuse treatment. This was evident for one (1) of six (6) sampled residents, who possessed the capacity to understand and make informed health care decisions. The resident refused an injection when he was attempting to leave the facility, and the nurse gave the injection contrary to his wishes. The syringe contained a psychoactive medication ([MEDICATION NAME]). Resident identifier: #23. Facility census: 61. Findings include: a) Resident #23 1. Interview with a social worker (Employee #312), on 04/26/11 at 3:30 p.m., revealed that, on 03/03/11, she observed staff physically trying to pull Resident #23, who was attempting to leave the facility. Employee #312 said she went outside and informed staff they could not do that, as the resident has capacity. She stated that, at one point during this incident, a licensed practical nurse (Employee #35) allegedly told the resident, \"I have the insulin the doctor wants you to take,\" but it was [MEDICATION NAME], instead. At that point, the nurse left him alone and did not administer the injection. Employee #312 said, at another point, she looked out her window and saw two (2) maintenance men and the administrator talking to the resident, and the workers had their hands on the resident. She said those staff members somehow got him back inside the fence, and Employee #35 allegedly gave the injection of [MEDICATION NAME] through his clothing. - 2. Interview with another social worker (Employee #119), on 04/27/11 at 8:30 a.m., revealed Resident #23 was determined by his attending physician on 12/10/10 to have health care decision-making capacity, but at the time of the incident on 03/03/11, Resident #23 was extremely out of control. She said this resident walks with a crutch or a cane, and that was his weapon that day, although he did not hit anyone. Both she and the director of nursing (DON) agreed that Employee #35 gave Resident #23 an injection of [MEDICATION NAME] during the incident. - 3. Review of the facility's policy titled \"Against Medical Advice Discharge\" (revised 09/2008), produced by Employee #119 on 04/27/11 at 12:40 p.m., revealed the following statement: \"No capacitated resident will be held in the nursing facility against their wishes, unless with a court order. Any incapacitated resident cannot be responsible for their medical decisions. These residents will not be allowed to leave the facility as they wish.\" - 4. Interview with Employee #35, on 04/27/11 at 4:30 p.m., revealed when she came to work at 3:00 p.m. on 03/03/11, Resident #23 was already upset and agitated because his wife had come to the facility and brought him some clothing, but he thought he was going home. The family, however, did not want to take him home. Employee #35 asked Resident #23 if she could give him something to calm his nerves, but he refused, so she backed away with the [MEDICATION NAME]. The resident was on the grounds but outside the fence and was in and out of the facility numerous times during this hour-long episode, and police were on the scene at one point. She called the physician, who allegedly told her he had capacity, so let him leave if he wants to, but she spoke her fear that the resident could enter the highway and get killed, and she would be held liable for manslaughter. She said the physician, then, gave her the order to give the resident [MEDICATION NAME] 0.5 mg. According to Employee #35, while staff distracted the resident and tried to take his cane, she gave the injection of [MEDICATION NAME]. Resident #23 was not held down and was not restrained while the injection was given. - 5. Review of the medical record revealed that, on 03/14/11, the facility's medical director (Employee #81) evaluated the resident and determined that he lacked capacity related to dementia with cognitive loss, disorientation to person / place / time, and the inability to understand or make medical decisions, with expected long-term incapacity. - 6. Review of the attending physician's progress notes, dated 03/18/11, found the attending physician \"did not have him declared as lacking mental capacity and with some coercion he got [MEDICATION NAME] intramuscularly and apparently he settled down. I have seen him in the clinic since then to see if I need to change his mental status evaluation ... and I did not change it.\" - 7. During an interview with Resident #23 on 04/27/11 at 4:45 p.m., he said he recalled being mad once when they (facility staff) would not let him leave when he wanted to go home. He did not have clear recall about any injections other than insulin, and he said he had never been hurt by anyone at the facility. .", "filedate": "2014-08-01"}
{"rowid": 11342, "facility_name": "DUNBAR CENTER", "facility_id": 515066, "address": "501 CALDWELL LANE", "city": "DUNBAR", "state": "WV", "zip": 25064, "inspection_date": "2010-12-09", "deficiency_tag": 155, "scope_severity": "D", "complaint": null, "standard": null, "eventid": "OEY611", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to ensure one (1) of seven (7) sampled residents (who had the capacity to understand and make a health care decision) was fully informed in advance of the nature of a surgical procedure (incision and drainage of a large hematoma); understood the possible consequences of the procedure; and was asked for a written consent prior to the undertaking of the procedure. This invasive procedure resulted in harm to the resident, who experienced increased pain, anxiety, and bleeding, which necessitated a transfer to the hospital emergency room for additional procedures. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being alert / oriented and able to make her needs known. In an interview with the social worker (Employee #3) at 3:15 p.m. on 12/08/10, she verified Resident #118 had capacity, although she stated Resident #118's son / MPOA was involved in the resident's care, usually assisted her in decision making, received notices of the care plan conferences, and was notified of changes in her care and health status. This was reflected in her medical record by his signature on various consent forms (e.g., flu vaccine, etc.), her readmission papers after hospitalization , bedhold notices, and notations in nursing notes showing him being notified about changes in her status and/or treatment. -- 2. A review of the medical record found that, at 3:00 p.m. on 12/03/10, the CNP performed an incision and drainage (I&D) on Resident #118's hematoma while at the facility, with two (2) incisions being made. There was no evidence in the medical record that the attending physician had been notified of either the initial assessment of a large hematoma on the resident's lower leg on 12/02/10, or of the decision to proceed with the I&D on 12/03/10, even though the resident had been on long-term [MEDICATION NAME] therapy, had a [DIAGNOSES REDACTED]. - A progress note, dated 12/02/10 and electronically signed by the CNP at 5:34 p.m. on 12/03/10, stated under the heading \"Physical Exam\", \"... general appearance, obese and alert oriented x 3 female in mild amount of distress due to pain left leg-inner aspect. ...\" Under the heading \"Plan\", the CNP recorded, \"A return visit is indicated in 1 day. Resident is stable - hematoma not enlarging at present. ? (unknown) etiology but appears no significant trauma. Most likely due to capillary fragility and [MEDICATION NAME] (sic) tx (treatment). No severe pain. Will elevate and Ice (sic) area and fu (follow-up) (sic) 24 hours and will treat conservatively.\" - A subsequent progress note, dated 12/03/10 and electronically signed by the CNP at 5:40 p.m. on 12/03/10, stated under the heading \"Chief Complaint\", \"FU (follow-up) hematoma left leg. Resident evaluated yesterday for hematoma (etiology unknown) - reevaluated today. Resident was complaining of increased pain, hematoma had doubled in size, and skin was cold to touch. INR 2.1. Stated had increased pain if moved leg or pressure applied.\" Under the heading \"ROS\" (review of systems) was recorded, \"I reviewed the medical, surgical, family, social, medication, food allergy and patient code status histories. ...\" Under the heading \"Physical Exam\" was recorded, \"... general appearance, obese and alert oriented x 3-very pleasant female in distress due to pain left lower leg. ... Large hematoma which has at least doubled in size since initial evaluation yesterday. Skin is extremely taunt (sic) and area is exquisitely tender to palpation. Area measures 5 cmx4cm (sic) and is circumfrential (sic). ...\" Under the heading \"Services Performed\", the CNP recorded, \"Resident is stable but (sic) am concerned about swelling, pain and coolness of skin over hematoma. (15:00) (3:00 p.m.) Residents (sic) vs (vital signs) stable - INR 2.0 (done this am). Due to fact resident may be developing [DIAGNOSES REDACTED], I attempt (sic) to aspirate hematoma. I clean (sic) hematoma with [MEDICATION NAME] (sic) and attempt to make small incision to drain collected blood. I am (sic) successful in draining about 30 cc's but area is still very large and painful. A small incision is made (sic) posterior aspect of hematoma and (sic) am able to evaluate large amount of formed clots from hematoma. ... area is packed ... Sterile dressing was applied with mild amount of pressure. Hemostasis is obtained and resident states (sic) has complete pain relief. ... 16:45 (4:45 p.m.) call (sic) son (name) and discuss (sic) treatment - he agrees to evacuation of hematoma and packing area. Also agrees with dose of antibiotic. Resident is reevaluated at 17:00 (5:00 p.m.) - No bleeding from area. ... Due to fact resident has multiple comorbidities and is on [MEDICATION NAME] (sic), it is determined by Dr. (name) and myself, (sic) that resident would be better evaluated if was at hospital. Son was notified and I discussed this with resident, who agrees to go ... Will be transferred by EMS (emergency medical services).\" -- 3. A nursing note entered by a licensed practical nurse (LPN - Employee #6) at 3:00 p.m. on 12/03/10 stated, \"... NP requested the pain med during I&D of hematoma to L (left) extremity. I administered pain (med) and left room while procedure was taking place. (After) procedure pt's (patient's) leg kept elevated with dressing in place. Pedal pulse checks (+).\" Subsequent nursing notes on 12/03/10 stated: - At 6:15 p.m., Employee #6 wrote, \"Verbal consent to evacuate hematoma to LLE (left lower extremity) by (name) MPOA ...\" - At 6:30 p.m., Employee #8 (another LPN) wrote, \"VSS (vital signs stable) - 131/55, HR 74, R - 18, Temp 97.2. Resident exhibited an episode of vomiting - reports (symbol for 'no') nausea at this time. Pedal pulses present and easy palpable. (Symbol for 'no') c/o (complaint of) pain, (symbol for 'no') numbness or tingling in L lower extremity. Exhibits ability to move all toes on L foot. L leg remains elevated with application of ice as ordered, (symbol for 'no') [MEDICAL CONDITION] noted, (symbol for 'no') redness, (symbol for 'no') bleeding. Small amount of serosanguiness (sic) (serosanguineous drainage) noted on external bandage / ice pack. Nurse Practitionor (sic) was aware of PT/INR lab drawn 12/2/10 - (Symbol for 'no') N/O (new orders) at this time - MPOA aware of information - Call light in reach of resident, in bed resting.\" Employee #6 also wrote the following late entry for 12/03/10, \"7P (7:00 p.m.) late entry for 12/3/10 Pt (patient) was aware of procedure I and D and consented for procedure.\" - During a telephone interview with Employee #6 at 1:25 p.m. on 12/09/10, he stated he had no knowledge of the procedure prior to being instructed to administer pain medication at 3:00 p.m. on 12/03/10, which he did, documenting that the resident complained of pain at a level \"8\" on a scale of \"1 to 10\" and that she was crying. He stated he then left the room and was not present during the procedure, as the CNP was being assisted by a NP student who was with her. He stated he did not hear the procedure discussed with the resident nor did he have any knowledge of the resident giving consent for the procedure, and he reported the resident's MPOA was notified by him after the procedure was completed. He stated that, in his entries into the record, he had written the resident and her MPOA gave consent to the procedure (as noted in the nursing notes by Employee #6 referenced above). However, Employee #6 stated to this surveyor that he wrote these entries because the CNP told him that she had received permission although, after talking to the MPOA, he realized the consent of the MPOA had not been received prior to the procedure. Employee #6 did not witness Resident #118 giving informed consent for the CNP to perform the procedure. Employee #6 stated that, when he assessed the resident after the procedure at 6:30 p.m. on 12/03/10, she had a dressing to her left lower leg which was elevated, and she told him the pain medication had helped. He stated that, shortly after he returned to the nurse's station, a nursing assistant (Employee #9) notified him that the resident's dressing was saturated with blood. He told the CNP, and the CNP and the NP student went in and redressed the wound. (Note there was no mention anywhere in the resident's record, by either the LPNs or the CNP, that the resident's dressing was saturated with blood or that her surgical wounds needed to be redressed.) Employee #6 reported having been told by the CNP that she had contacted the resident's attending physician and had received orders to transfer the resident to the hospital emergency room (ER) for evaluation. An ambulance was called, and the resident was transported at 7:00 p.m. on 12/03/10. -- 4. The ER record dated 12/03/10 stated, \"... palm sized hematoma left medial calf area, not circumferential ... (two incision sites ... packing removed, no active bleeding, both cavities probed, 4 cm deep and no apparent tunneling between the two. Both cavities irrigated with normal saline until clear return noted on multiple irrigations, repacked with [MEDICATION NAME] gauze to help maintain tamponade effect, dressing applied).\" At 8:35 p.m. on 12/03/10, the resident's white blood count was high (19.7, with normal range of 3.0 - 11.0) and her PT was 23.3. The resident returned to the facility at 1:00 a.m. on 12/04/10 with instructions for a revisit in two (2) days. -- 5. A physician's progress note, dated 12/05/10, stated, \"Came in to inspect hematoma and incisions. I was informed of incision /p (symbol for 'after') it was done.\" After the physician was notified of the I&D at approximately 6:30 p.m. on 12/03/10, all further treatment was done by him. -- 6. During an interview with the director of nurses at 12:40 p.m. on 12/09/10, she reported the CNP's services were terminated immediately after the facility learned of this incident and that the CNP had not notified either the resident's family (MPOA) or the physician prior to performing the procedure. She acknowledged Resident #118's record contained no evidence that informed consent was obtained prior to the procedure being done. .", "filedate": "2014-04-01"}
{"rowid": 11529, "facility_name": "HEARTLAND OF KEYSER", "facility_id": 515122, "address": "135 SOUTHERN DRIVE", "city": "KEYSER", "state": "WV", "zip": 26726, "inspection_date": "2010-09-03", "deficiency_tag": 155, "scope_severity": "D", "complaint": null, "standard": null, "eventid": "GVP311", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, family interview, and interview with a hospital social worker, the facility failed, for one (1) of ten (10) sampled residents, to honor the advance directives formulated by this incapacitated resident's medical power of attorney representative (MPOA). Record review revealed nursing staff and the attending physician believed Resident #115 was to receive only \"comfort measures\", which was contrary to the advance directives executed by the resident's MPOA. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10, following a hospital stay during which she was treated for [REDACTED]. - 2. Review of Resident #115's medical record found a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated. The resident's MPOA did not select \"comfort measures\", which was an option available in this section. In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. - 3. At the insistence of the resident's legal representative, the resident was transferred to the hospital on [DATE], where she was readmitted for urosepsis, an infected pressure sore, and severe dehydration. During her 24-day stay at the nursing facility, there was no evidence to reflect the nursing staff was routinely assessing / monitoring the resident for changes in hydration status / fluid balance, nor was there evidence to reflect the facility identified the need for administration of intravenous (IV) fluids to restore fluid balance. - 4. According to the hospital history and physical examination ... (Resident #115) was brought to the emergency room with (sic) chief complaint of progressively worsening mental changes with generalized weakness and lethargy. Also patient has stopped eating and drinking for the last four days or more. ... Patient was advised (sic) hospitalization [MEDICAL CONDITION]; possible source is urinary tract infection and necrotic decubitus ulcer with severe dehydration. ... Patient was recently in (name of hospital) in July 2010 for similar urinary tract infection and dehydration, patient was treated, improved and was admitted to the nursing home following her last hospitalization . ...\" Under \"Clinical Assessment\" was noted: \"1.[MEDICAL CONDITION] secondary to urinary tract infection. 2. Necrotic sacral decubitus ulcer. 3. Severe dehydration. ...\" Under \"Plan\" was noted: \"Is to admit the patient, we will give her IV antibiotics and IV fluids. ...\" The final hospital [DIAGNOSES REDACTED]. E-coli urosepsis. (Escherichia coli are bacteria found in feces.) 2. Infected necrotic sacral decubitus ulcer with staph infection. 3. Septic ulcer disease with GI (gastrointestinal) bleed and [MEDICAL CONDITION]. 4. Acute or [MEDICAL CONDITION]. ...\" - 5. Review of the nursing notes revealed an entry, dated 07/18/10 at 3:50 p.m., stating, \"... (Resident) Resting in bed until lunch. POA (power of attorney) in. Upset that her instructions (sic) not followed. Wants resident up prior to BRK (breakfast). ... This nurse was under the impression that this resident was to stay in bed & that she was comfort measures. Many CNA's (certified nursing assistants) also were of similar belief. ...\" In a progress note dated 08/01/10, the physician stated, \"Pt's (patient's) PO (oral) intake poor but pt's POST form does not allow any tube feeding. ... Plan - continue comfort measures. ...\" - 6. In a telephone interview on 08/30/10 at 8:45 p.m., Resident #115's MPOA revealed that, although she did not a feeding tube inserted, she did want to resident to receive antibiotics and IV fluids if necessary. - 7. An interview with the social worker at the hospital, on 09/03/10 at 9:00 a.m. revealed that, when the resident was brought to the hospital on [DATE], the hospital social worker stated, \"I did the POST form on her last admission to the hospital in July 2010, and the MPOA did not want a feeding tube inserted but wanted antibiotics and IV fluids if needed. There was never any mention by the MPOA of not wanting IV fluids.\" - 8. The facility failed to ensure all staff was aware of and honored this resident's advance directives. .", "filedate": "2014-01-01"}
{"rowid": 395, "facility_name": "CLARY GROVE", "facility_id": 515039, "address": "209 CLOVER STREET", "city": "MARTINSBURG", "state": "WV", "zip": 25404, "inspection_date": "2017-08-11", "deficiency_tag": 156, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "C6IS11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon family interview, staff interview, record review, and facility policy review, the facility failed to ensure that one (1) of eleven (11) (Resident #115) sampled residents family representative was informed of the resident's rights and Medicare charges, and failed to obtain a consent for treatment upon admission. Facility census: 114. Findings include: a) Resident #115 Review of the resident's clinical record revealed he was admitted to the facility on [DATE] and discharge to home on 07/03/17. The resident's admissions [DIAGNOSES REDACTED]. On 06/15/17, the physician determined the resident lacked the capacity to make health care decisions. The admission agreement was signed by the resident's representative and Social Worker (SW) #38 on 07/03/17, but there was no signed consent for treatment in the resident's clinical record. During an interview on 08/08/17 at 4:01 p.m., SW #38 stated one of her responsibilities included obtaining the resident's signature, or the signature of the resident's representative on admission paperwork, which included consent for treatment, resident rights, and Medicare charges. SW #38 stated this information was obtained on admission to the facility within one (1) to two (2) days. SW #38 confirmed she had obtained Resident #115's representative signature on 07/03/17, but was unable to provide why the consent for treatment, resident rights and Medicare charges were not obtained on admission to the facility. During an interview on 08/08/17 at 4:20 p.m., Business Office Manager (BOM) #121 stated the social worker did all the admission paperwork with residents and their families. The BOM #121 stated the corporate expectation was for all admission paperwork to be completed within 72 hours of admission. During a telephone interview on 8/9/17 at 1:21 p.m., Resident #115's representative stated she was in the facility daily from 06/27/17 until the resident's discharge to home on 07/03/17. The representative stated she was in the facility for 20 out of 24 hours each day and confirmed she had signed the admission paperwork on 07/03/17. The family representative was not provided any explanation of facility services, she was just asked to sign the papers. On 08/08/17 at 5:00 p.m., review of the facility's policy entitled Admission Policy, revised 04/19/17, found it included, Center will explain to residents on admission the special characteristics or service limitations of the center, which are also identified in the admission packet.", "filedate": "2020-09-01"}
{"rowid": 620, "facility_name": "HERITAGE CENTER", "facility_id": 515060, "address": "101-13TH STREET", "city": "HUNTINGTON", "state": "WV", "zip": 25701, "inspection_date": "2017-03-17", "deficiency_tag": 156, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "4QX611", "inspection_text": "Based on observation and staff interview the facility failed to ensure residents had access to information regarding Resident Rights and the Regional Ombudsman contact information. The facility had not displayed the written information regarding Resident Rights and Ombudsman information in an easily accessible manner, as required by this regulation. This had the potential to affect any resident wishing to review resident rights or contact the Ombudsman. Facility census: 158. Findings include: a) On 03/13/17 at 1:05 p.m., it was discovered the Resident Rights poster with the Ombudsman contact information was located on the wall between two (2) sets of sliding doors at the entrance to the facility. This posting is required to fulfill the facility's obligation to adequately display Resident Rights and Ombudsman's contact information. b) During an interview with the Nursing Home Administrator (NHA) on 03/17/17 at 8:32 a.m., it was verified the Resident Rights poster with the Ombudsman contact information was not easily accessible for residents viewing. No additional information was provided prior to exit.", "filedate": "2020-09-01"}
{"rowid": 789, "facility_name": "ELDERCARE HEALTH AND REHABILITATION", "facility_id": 515065, "address": "107 MILLER DRIVE", "city": "RIPLEY", "state": "WV", "zip": 25271, "inspection_date": "2017-07-19", "deficiency_tag": 156, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "HITB11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to notify the beneficiary/responsible party of the facility's decision to terminate Medicare services for two (2) of three (3) residents reviewed for the care area of liability notices and beneficiary appeal. This failed practice had the potential to affect an isolated number of residents. Resident identifiers: #8 and #13. Facility census: 100. Findings include: a) Staff Interview At 2:15 p.m. on 07/17/17, the facility social worker, (SW) #102, was asked to provide copies of the information given to the three (3) residents selected by the Quality Indicator Survey (QIS) for review of the care area: Liability Notices and Beneficiary Appeal. The QIS automatically selects three (3) residents discharged from Medicare services within the last six (6) months to determine if the appropriate denial notice was provided. The SW #102 said he was unable to find any information for two (2) Residents: #8 and #13. The facility's resident financial coordinator, (RFC) #30 said she did not have copies of any notices given to Residents #8 and #13 at 2:20 p.m. on 07/17/17. b) Resident #8 At 2:20 p.m. on 07/17/17, RFC #30 verified Resident #8 was re-admitted to the facility on [DATE] and was covered by Medicare, Part A services. The resident was discharged from Medicare services on 06/13/17 and remained at the facility. c) Resident #13 At 2:20 p.m. on 07/17/17, RFC #30 verified Resident #13 was re-admitted to the facility on [DATE]. The resident was covered by Medicare, Part A services. Resident #13 was discharged from Medicare services on 03/09/17. The resident left the faciity on [DATE]. At 2:31 p.m. on 07/17/17, the administrator said he checked with the therapy department and he was unable to find the notices given to Resident's #8 and #13 for denial of Medicare covered services.", "filedate": "2020-09-01"}
{"rowid": 946, "facility_name": "PUTNAM CENTER", "facility_id": 515070, "address": "300 SEVILLE ROAD", "city": "HURRICANE", "state": "WV", "zip": 25526, "inspection_date": "2017-03-22", "deficiency_tag": 156, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "SWUR11", "inspection_text": "Based on resident interview, staff interview and facility record review, the facility failed to ensure residents received and/or were knowledgeable of how to contact State agencies for two (2) of four (4) residents interviewed. Residents were unable to articulate the name of the ombudsman, did not know the purpose of an ombudsman, and did not know how to contact State agencies, or where to find the information in the facility. Resident identifiers: Resident #13 and #126. Facility census: 117 Findings include: a) Resident #13 and #126 During an interview with Resident #126, on 03/22/17 at 10:31 a.m., the resident voiced concerns were reported to the facility staff. Upon inquiry, she said she did not know how to report to State agencies, and did not know the name of the ombudsman or how to contact her. Resident #13, interviewed at 10:38 a.m. on 03/22/17 at 10:38 a.m., said she would refer concerns to the facility. Upon inquiry, the resident said she did not know how to report to State agencies, and did not know how to contact the ombudsman, or the purpose of an ombudsman. Both residents, during the interviews, denied knowledge of where to find contact information for State agencies in the facility. An interview with Social Service Coordinator (SSC) #60, on 03/22/17 at 12:28 p.m., the SSC said signs were posted and residents and/or families were notified of reporting requirements during the 72 hour meeting on admission. When asked how the information was disseminated to all residents and/or families the coordinator said a copy of resident rights was given to residents yearly. Upon inquiry, the coordinator looked at the form and said it did not contain State agency contact information. The SSC confirmed residents were only provided contact information during resident council meetings.", "filedate": "2020-09-01"}
{"rowid": 2536, "facility_name": "PIERPONT CENTER AT FAIRMONT CAMPUS", "facility_id": 515155, "address": "1543 COUNTRY CLUB ROAD", "city": "FAIRMONT", "state": "WV", "zip": 26554, "inspection_date": "2017-08-08", "deficiency_tag": 156, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "0QX311", "inspection_text": "Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility census: 88 Findings include: a) On 07/31/17 at 10:45 a.m., during an observation of the facility, it was discovered there was no written information posted in the facility to inform a resident on how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. During an interview with the Nursing Home Administrator on 07/31/17 at 11:50 a.m., agreed the information was not posted prominently to inform residents on how to apply for and use Medicare and Medicaid benefits.", "filedate": "2020-09-01"}