cms_WV: 10680
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10680 | SUMMERS NURSING AND REHABILITATION CENTER LLC | 515170 | JOHN COOK ROAD, PO BOX 1240 | HINTON | WV | 25951 | 2011-09-13 | 152 | D | 1 | 0 | 8CVP11 | **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. . | 2015-01-01 |