cms_WV: 10961
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 10961 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2011-07-13 | 493 | F | 1 | 0 | V0KG11 | . Based on policy review and staff interview, the governing body failed to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practical well-being of each resident. A commercially-published nursing service policy manual was not reviewed, revised to reflect facility-specific activities, and formally adopted for use by the facility's administrative staff (including the administrator). The drug formulary found in the pharmacy manual was not the formulary currently in use. The dietary department policy manual was kept in the director of nursing (DON) office. Policy / procedure manuals from the facility's corporation were available on-line but were not revised to reflect facility-specific requirements or printed and/or otherwise available / accessible to staff for day-to-day use. In general, the policies and procedures intended to guide staff in the rendering of resident care / services and the day-to-day operations of this facility were not approved / adopted and readily available for use by staff. This practice has the potential to affect all residents. Facility census: 47. Findings include: a) A review of the facility's Nursing Service Policy Manual, provided by the director of nursing (DON) at 3:30 p.m. on 07/12/11, revealed all of the policies were from "Med Path", which is a commercially available manual. Each printed page had a blank area with directions for the purchaser to insert information distinctive to the facility, as well as revision dates and signatures. These areas were blank on all pages. In addition, there was no evidence to reflect the policies had been initially reviewed and adopted for use by anyone in the facility - including the administrator, the DON, and the medical director (as this manual contained resident care policies and procedures). The DON verified this was the only copy of this manual in the facility, and it was kept in the DON's office. - The Nursing Service Policy Manual contained a pharmacy policy and the facility's drug formulary, which had been adopted in 2009 by a DON and an administrator who were no longer present in this facility. There was no evidence that either the pharmacy policy or the drug formulary were ever reviewed or revised after the initial signature date of 09/28/09. The formulary in this manual was not the drug formulary in use by the facility. This was verified by the DON at 2:00 p.m. on 07/13/11, when she produced the drug formulary currently in use. - The DON also produced a Long Term Care Facility's Pharmacy Services and Procedure Manual from Omnicare, Inc. (the facility's contracted pharmacy vendor) dated May 2010. She stated that Omnicare provided an updated manual every year. This manual had a cover page with allowed for the recording of the signatures of the administrator, DON, medical director, and consultant on an annual basis. There were no signatures on the sheet to indicate when this manual's contents had been reviewed, adopted, or revised. There were two (2) pharmacy manuals from previous years located in the DON's office, but neither of these contained any evidence of them having been reviewed / adopted for use. - During an interview with the certified dietary manager at 8:45 a.m. on 07/13/11, she produced an up-to-date dietary resource manual published by the Iowa Dietetic Association, but when asked about facility-specific dietary department policies, she stated they were in the "Facility Policy Manual" which was maintained by the DON. The facility's policies regarding dietary service was requested from the DON at 9:40 a.m. on 07/13/11. She stated, "There is no hard copy." She then brought up on the computer a generic policy / procedure manual from a website titled "Emeritus Senior Living". There was no identification of The Heritage, Inc. as an included entity, and none of the policies were identified as long term care (nursing home) policies. - In an interview with the DON at 8:00 a.m. on 07/13/11, she deferred to the administrator for any governing body questions or administrative facility policies. - During an interview with the administrator at 9:15 a.m. on 07/13/11, he confirmed there was no hard copy of the facility's policies, that most of the policies were available "on-line on the computer". He further stated, "Emeritus, that owns the facility, had previously only governed assisted living facilities and is slowly getting caught up to LTC requirements." The administrator was asked to provide any policies that addressed the distinct population or environment of this facility and/or evidence that anyone (e.g., the facility's board of directors, himself, the medical director, or any committee) had initially reviewed, approved and/or revised any of the policies addressing resident care or the day-to-day operation for this facility. He acknowledged the request, but prior to exit, he offered none of these things except the following: - A copy of his job description, which included the following under the heading "Essential Functions": "Ensure safety of residents, their visitors and staff regarding Infection Control, Fire, and Safety policies and procedures" "Maintain current knowledge of State Regulations and ensure compliance in all surveys conducted by licensing authority" - A mission statement from Emeritus Senior Living, which stated: "It is our goal to continually exceed the expectations of our residents, families, and employees by immediately addressing issues in a professional manner and constantly striving to deliver the highest level of customer value through exceptional quality service." - In a second interview with the DON and the administrator at 3:00 p.m. on 07/13/11, in the presence of the entire survey team, they were again asked for any evidence that the facility's policies had been reviewed / approved and by whom. The administrator had no comment. . | 2014-11-01 |