cms_WV: 10449
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10449 | NELLA'S NURSING HOME, INC. | 5.1e+35 | 200 WHITMAN AVENUE, CRYSTAL SPRINGS | ELKINS | WV | 26241 | 2011-03-16 | 514 | E | 0 | 1 | JSOV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, record review, staff interview, observation, and resident interview, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. This was found for four (4) of forty-four (44) Stage II sample residents. Resident identifiers: #12, #26, #78, and #66. Facility census: 66. Findings include: a) Resident #12 1. During an interview with Resident #12's husband on 03/07/11 at 4:06 p.m., he expressed concern with her decline in skin condition. He stated staff told him it was due to poor circulation. He had asked staff about resumption of physical therapy but had been told she was not a candidate for physical therapy, because she could not follow commands. He stated then asked them to at least move her arms and legs, because he felt that would help poor circulation, but they were not doing it. He expressed she had now lost a leg due to this and had a staph infection. He was afraid that, if they did not move her arms and leg, she would get worse. He pointed out she now had a sore on her hip, about which he was greatly concerned. He said he asked facility staff to resume moving her arms and leg since she returned from the hospital (01/07/11), but he could not recall who he talked to. 2. Resident #12's care plan, when reviewed on 03/09/11 at 9:00 a.m., contained the following problem statement dated 01/20/11: "Risk for skin breakdown due to bowel / bladder incontinence and immobility. Contractures of both hips and right knee. History of stage I area on coccyx. Infusaport left chest wall. Stage IV area right foot. Stage I area left buttock. Left above knee amputation. Red areas behind knees / abdominal folds / groin / buttocks / back." The goal associated with this problem statement was: "Skin will not demonstrate further breakdown." Eighteen (18) approaches were identified to achieve this goal, including: "... 5. Conduct active and passive ROM (range of motion) exercises with resident. ... 14. CNA to perform ROM with AM (morning) care. ..." 3. To follow-up the spouse's concern that Resident #12 was not receiving range of motion (ROM) exercises, which were used to promote circulation and forestall the worsening of contractures, an interview was conducted with a licensed practical nurse (LPN - Employee #46) at 10:00 a.m. on 03/09/11. When asked about the provision of ROM exercises and whether the facility had designated restorative aides to provide these services, Employee #46 stated the facility had restorative nurses but no restorative aides. She was not sure of all the duties they performed, but they did oversee the program. According to Employee #46, the nurse aides on the floor did the ROM exercises and documented this on each resident's activities of daily living (ADL) flow sheet. Immediately after this interview (at 10:05 a.m. on 03/09/11), a photocopy was made of Resident #12's March 2011 ADL flow sheet, which had been obtained from the clean utility room. For the current period of 03/01/11 through 03/08/11, there were two (2) dates with nurse aides' initials in the 7:00 a.m. - 3:00 p.m. (day shift) row (03/05/11 and 03/06/11) to indicate ROM exercises were provided during day shift on those dates only. There were no initials on any date for 3:00 p.m. - 11:00 p.m. (evening shift) or 11:00 p.m. - 7:00 a.m. (night shift). 4. An interview was conducted with one (1) of the directors of nursing (DON - Employee #16) at 10:15 a.m. on 03/09/11. She confirmed that all nurse aides provided restorative nursing services and their documentation was on the ADL flow sheets in the clean utility room. She stated the restorative nurses oversee the program and keep the documentation, summaries, and reports. She offered to have the restorative nurse present for an interview later this morning. 5. An interview was subsequently conducted with a restorative nurse (Employee #42, an LPN) at 10:18 a.m. on 03/09/11. Employee #42 was asked to provide monthly ADL flow sheets back to December 2010, notes regarding active and passive ROM to Resident #12, and any other summaries or reports regarding restorative services provided for the period. Employee #42 reported no restorative services were being provided for the resident at this time, but ROM may be provided by nurse aides during routine provision of ADL care. Employee #42 was shown the resident's active care plan, which contained two (2) approaches indicating that ROM was to be done, and she asked for anything to show that ROM was ever provided and why and when it may have been stopped. At the North side nurses' station, Employee #42 was joined by the DON, who was asked for any more specific directions for nurse aides than what was on the resident's care plan. Employee #42 then (at 10:20 a.m.) presented Resident #12's March 2011 ADL flow sheet from the clean utility room, to demonstrate where the documentation was maintained. Upon examination of the ROM section of the flow sheet, additional initials were present for days that had not been filled out when a photocopy of this form had been made by the surveyor fifteen (15) minutes earlier. The first copy had initials under day shift for 03/05/11 and 03/06/11 only, with the remainder of the blocks blank. The copy of the flow sheet provided by Employee #42, when presented to the surveyor, now had initials for day shift on 03/01/11, 03/02/11, 03/03/11, 03/04/11, 03/05/11, 03/06/11, 03/07/11, and 03/08/11. These additional initials had been added sometime between 10:05 a.m. and 10:20 a.m. on 03/09/11. The initials in the spaces for 03/05/11 and 03/06/11 were the same as those found on the first copy. There were still no initials documenting ROM exercises having been provided on evening or night shift. Information in the ROM section stated: "(blank) ROM to (blank) extremities (blank) x day for (blank) repetitions." (The order for provision of ROM exercises was incomplete.) Another instruction stated: "Initial indicates minimum 5 minutes ROM." Employee #42 also presented the requested monthly ADL flow sheets for the period of December 2010 through February 2011. 6. When asked, on 03/09/11 at 11:55 a.m., how the direct care staff knew what care to provide for each resident, a nurse aide (Employee #57) stated the information was on the paper in the flow sheet packets in the clean utility room (referring to the kardex). The DON (Employee #16), when interviewed on 03/09/11 at 12:00 noon, also identified the kardex in the flow sheet packets as the nurse aides' primary source of information as to the individualized care to be provided each resident. A review of the kardex for Resident #12, on 03/09/11 at 12:05 p.m., revealed no reference to or instruction for the provision of any ROM exercises. 7. During a second interview conducted at 11:38 a.m. on 03/09/11, Employee #42 presented physician's orders regarding restorative nursing services for Resident #12. She stated that, since June 2006, Resident #12 had received only ROM with activities of daily living ADLs. The most recent physician order related to restorative nursing services was dated 06/07/06 and stated: "DC'd (discharged ) from restorative ROM exercises. CNA's to perform ROM with daily care." Employee #42 stated the nurse aides now do ROM with Resident #12 when they do her ADLs. When asked if they should, therefore, have documentation of ROM on all three (3) shifts for every day, Employee #42 replied that they should. When the DON (Employee #16) was asked (on 03/09/11 at 12:00 p.m.) about Resident #12's physician order dated 06/07/06, she stated it had never been discontinued, although it was not being carried over to the current physician's order sheets. She stated the nurse aides did ROM with morning care. 8. Resident #12's ADL flow sheets for January and February 2011 were reviewed at 8:00 a.m. on 03/10/11. The total period reviewed was from 01/08/11 (the date Resident #12 returned from the hospital) through 03/08/11 (the last date completed prior to the ADL flow sheet being copied by the surveyor). Review of the January 2011 flow sheet (from 01/08/11 through 01/31/11 flow sheet) found initials documenting ROM was given for every day on the day shift; there were no initials documenting ROM was provided on any other shift. Information in the ROM section stated: "A&P (active and passive) ROM to all extremities (blank) x day for (blank) repetitions." Added in a blank portion of the heading was "/c (with) AM (morning) care." Another instruction stated: "Initial indicates minimum 5 minutes ROM." For the period of 02/01/11 through 02/28/11, the February 2011 flow sheet contained initials documenting that ROM was given for every day on all three (3) shifts. Information in the ROM section stated: "A&P ROM to All extremities /c AM Care x day for (blank) repetitions." Another instruction stated: "Initial indicates minimum 5 minutes ROM." For the period of 03/01/11 through 03/08/11, the March 2011 flow sheet (which was noted as having documentation added after the initial copy had been made by the surveyor) contained initials purporting to document that ROM was given every day of the period on the day shift only. A request was made to the DON (Employee #16), on 03/10/11 at 10:00 a.m., that the employees whose initials were on the flow sheets for the period of 01/08/11 through 03/08/11 be identified by name, date, and shift. An employee schedule was also requested for the same time period. When the identified employees' initials were cross-checked with the employee schedule, there were fourteen (14) instances in which the employee (whose initials were said to be affixed to the flow sheet) was either not on the schedule or was scheduled to work a different shift than the one which was documented. 9. Two (2) random interviews were conducted with staff working on 03/14/11 who had initials on the flow sheets, one (1) on day shift, and one (1) on afternoon shift. - Employee #72 (an LPN) had been identified as providing documentation of care she had given on day shift on 03/04/11 and 03/05/11. When asked if the initials on the flow sheet were hers, she stated she did not initial the sheet, that those were not her initials. She further stated she had worked in the capacity of a nurse aide on 03/03/11, was off on 03/04/11, and had worked as a nurse on the other wing of the facility on 03/05/11 and 03/06/11. - Employee #20 (a nurse aide) had been identified as providing documentation of ROM exercises she had given on afternoon shift of 02/01/11, 02/02/11, 02/03/11, 02/06/11, 02/08/11, 02/09/11, 02/11/11, 02/12/11, 02/13/11, 02/21/11, 02/22/11, and 02/23/11. When interviewed on 03/14/11 at 3:40 p.m., Employee #20 was asked if the initials on the February 2011, documenting care attributed to her, were accurate. She replied they were accurate, and that the nurse aides do ROM with Resident #12 on afternoon shift. When asked about a day for which she was identified as having initialed the flow sheet but for which her name did not appear on the schedule (02/08/11), and a day for which she was identified as having initialed the flow sheet for the afternoon shift but for which she was on the schedule as having worked day shift (02/11/11), she stated she could have been called in to work but it had not been corrected on the schedule. When asked about the flow sheets for 01/08/11 through 01/31/11 and for 03/01/11 through 03/08/11 (which had no initials at all on any day for any shift except day shift), she replied that she must have forgotten to initial the forms. When it was pointed out that no staff had initialed the sheets for afternoon or night shift at all except for every day in February 2011, she replied the form was confusing and it was easy to make mistakes. 10. An interview was conducted with the administrator (Employee #35) on 03/15/11 at 10:35 a.m., to discuss these discrepancies in Resident #12's medical record. Also present were Employee #16 and the infection control nurse (Employee #54). All issues regarding the apparent completion of the omissions found on the March 2011 ADL flow sheets within fifteen (15) minutes of the first copy being made, the inclusion of two (2) differing ROM approaches in the same care plan, the lack of specificity regarding how and on what shifts the ROM was to be done, and the fact that ROM was not mentioned on the resident's kardex (which all staff interviewed indicated was the primary instruction for the nurse aides in what care to provide and how it was to be done) were presented. The administrator was informed of the fact that the ADL flow sheets provided by facility staff were reviewed and it was found that only the day shift blocks were initialed for 01/08/11 through 01/31/11 and 03/01/11 through 03/08/11, while all three (3) shifts were initialed for 02/01/11 through 02/28/11. There was no explanation offered for this difference. The administrator was informed of the finding that there were fourteen (14) sets of initials during the period of 01/08/11 through 03/08/11 that attributed to staff either not listed on the schedule as having worked on the day(s) the initials were affixed or listed as having worked a different shift. She was informed that two (2) of these staff members were selected at random for interviews on 03/14/11, for day shift and for afternoon shift, and she told of their responses. She voiced understanding and stated that this would be taken care of. 11. During a subsequent conversation with the husband of Resident #12 in the social worker's (Employee #83) office on 03/09/11 at 1:15 p.m., he stated he had nothing bad to say about the facility. He stated he could have taken her to a facility closer to his home, but he chose to drive the extra twenty-one (21) miles to visit her so she could remain in the facility. 12. A care plan review form was submitted by the Employee #83 at 10:00 a.m. on 03/16/11. It was signed by the husband of Resident #12 and stated he had no care concerns or complaints, that Resident #12's care was good, and that he was satisfied. b) Resident #26 Review of Resident #26's medical record revealed the consulting pharmacist conducted a medication regimen review on 03/15/10. There was date to indicate when the consulting pharmacist signed the form. The attending physician's comments on the review were dated 03/19/10; however, the form was dated as having been printed on 03/31/10. In an interview on the morning of 03/15/11, the consulting pharmacist confirmed the form was printed on 03/31/10. He stated the print date was set by the computer system and cannot be changed. The physician's review was said to have occurred on a date prior to the date the form was printed and received at the facility. -- c) Resident #78 and #66 1. Record review revealed Resident #78, an [AGE] year old female, was admitted to the facility on [DATE]. Although she had been determined by her physician to lack the capacity to form her own health care decisions, she was also noted to be alert and oriented to person and place, have no communication difficulties, and make her own day-to-day care decisions. The original Room Roster, presented to the surveyors shortly after entry at 11:45 a.m. on 03/07/11, indicated the resident was one room, but when that room was visited during the general tour at 12:10 p.m. on 03/07/11, the bed was unmade except for a filled bag sitting on it and a stack of books and other items on the bedside table. There was no name signage by the door indicating that Resident #78 resided there. However, the room was currently occupied by Resident #51 During an interview of Resident #51 in her room at 1:00 p.m. on 03/07/11, she was asked if she had a roommate; Resident #51 replied that she did not have a roommate but was going to get one. She stated that a nurse aide had brought in someone's things, and she pointed out a full plastic bag on the unmade bed in her room and a stack of books and things on the bedside table. When asked if she knew who her new roommate was to be, she stated that no one had told her. When questioned about the location of Resident #78 at 12:15 p.m. on 03/07/11, Employee #72 (an LPN) took the surveyor back to Resident #51's room and pointed to Resident #78, who was sitting in a chair beside the other bed. Employee #72 did not know why the survey team had been told Resident #78 was on the South side and stated the resident had only been in the present room a few days, because the facility had vacated the "North Back" Hall due to low census. During an interview with Resident #78 at this time she stated she had been at the facility for about 1-1/2 years. She stated she was in one (1) room on the North side, then she was moved to another room on the North side, and then was moved to the present room (on the South side) two (2) days ago. She did not know why she was moved, but she stated she had no objections. A review of Resident #78's medical record failed to show any evidence of room changes, the reason for the move, or that the resident's guardian (WV Department of Health and Human Resources - DHHR) or her family had been notified. Because of the lack of documentation, the lack of room numbers on chart forms, and the inconsistency of the staff's answers, it was not possible to determine the actual dates of these transfers. During an interview with the SW and one (1) of the DON (Employee #21) at 4:08 p.m. on 03/07/11, they were asked who was being moved into the room with Resident #51. The SW denied that anyone was being transferred to that bed and was surprised when told there were someone's belongings already there, because they had kept Resident #51 alone due to the resident's complaints about roommates in the past. The DON offered no explanation either, when told that there was no evidence in the record of any room changes or that the resident knew of a new roommate. The SW and the DON denied any knowledge that Resident #78 was being transferred. The SW said that Resident #78 had been transferred from one room to another on the North side due to problems between her and her roommate (Resident #66). The SW was asked at this time to furnish the surveyors with a corrected listing of room numbers for each resident. A census dated 03/08/11 was received the following day, showing Resident #78 as residing in the same room with Resident #51 on the South side. At 9:00 a.m. on 03/08/11, Resident #78 was observed in the room she shared with Resident #51. Her chart was located in the rack at the South nurses' station, but it contained no nurses' note since 03/03/11, no SW note since 02/04/11, and no physician's order (either on chart or in "pending order file") for the room change or evidence of the physician or the resident's responsible party was notified of the room change. In an interview at 10:30 a.m. on 03/08/11 in room where they were now both residing, Residents #51 and #78 told the surveyor that Resident #78 had been transferred into this room the prior evening after supper. -- 2. Resident #66 was observed sitting in a wheelchair in her room with a fan pointed toward her at 12:15 p.m. on 03/07/11. She stated she had asthma and the room was too hot (it was very warm), but that maintenance had been in and disconnected the heat a short time ago and it was getting cooler. She stated she had been moved last week on Wednesday (03/02/11) because: "There weren't enough people to fill the other end of the hall." She stated she did not like this room, because the people across the hall were always bothering her with their wandering and yelling. When asked if she had agreed to the move, she said she wasn't asked. A review of the medical record failed to show any evidence of Resident #66's room change, the reason for the move, or that the resident's surrogate decision-maker had been notified. -- 3. During an interview with the administrator, one (1) of the two (2) DONs (Employee #21), and a registered nurse (Employee #7) at 3:15 p.m. on 03/09/11, the administrator stated that residents residing on the facility's North Back Hall were transferred off the unit last week due to low census and the need to isolated residents with [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA). The administrator acknowledged that Residents #78 and #66 were among those transferred. When asked for any documentation that would reflect the residents, their responsible parties, or the physician had been notified in advance of the room changes, the administrator stated they did not require a physician's order for room changes but that he had been told. No documentation was presented. At 8:00 a.m. on 03/10/11, the administrator brought the activities director (Employee #24) to present copies of an activity progress note containing a standardized typed statement (regarding notification of room change) with the resident's name added at the bottom, for the residents who had been moved off of North Back Hall. All of the forms were dated 03/01/11, except for the form for Resident #78, which was dated 03/07/11. All were signed by either Employee #24 or Employee #77 (another member of the activities department). The administrator stated these forms had been located in the activities office and they were the ones who explained the moves to the residents. Employee #24 stated the notes were for their use only and had not been added to the residents' medical records. The medical records for Residents #78 and #66 were incomplete, as there was no evidence to reflect these alert residents were consulted prior to room changes, either about the actual transfer or about the change of roommate. There was no documentation in their nurses' notes about the actual transfers or of each resident's reaction to the transfer. Because of the lack of documentation, the lack of room numbers on chart forms, and the inconsistencies between the staff's responses during interviews, it was not possible to determine the actual dates on which these room changes had occurred. -- 4. During an interview with the administrator and the two (2) DONs at 10:30 a.m. on 03/15/11, the above stated concerns regarding Residents #78 and #66's room changes were relayed to them. At the time of the survey exit conference on 03/16/11, no additional information had been presented. | 2015-04-01 |