cms_WV: 11
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 280 | D | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to review and/or revise care plans timely related to an arteriovenous (AV) graft (#159), restorative ambulation (#141), and an actual falls (#115). This practice affected three (3) of thirty-two (32) Stage 2 residents. Facility census: 116. Resident identifiers: #159, #141, and #115. Findings include: a) Resident #159 Medical record review revealed a physician's orders [REDACTED]. Upon inquiry, Health Information Management Coordinator (HIMC) #50, interviewed on 05/30/17 at 4:03 p.m., provided information noting the AV graft had been placed when the resident went to the hospital on [DATE] and returned to the facility on [DATE]. Further review of the medical record revealed the resident had discharge on 03/11/17 and re-entered the facility on 03/13/17. The care plan was not revised until after completion of the resident's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 04/11/17. The care plan noted a revision date of 04/17/17 to reflect Resident #159 had an arteriovenous graft. MDS Coordinator #108, interviewed on 05/24/17, verbalized it was the nursing staff's responsibility to update and/or revise the care plan with a change in condition. b) Resident #141 During a Stage 1 interview on 05/16/17 at 2:57 p.m., Resident #141 verbalized he was supposed to receive restorative therapy for ambulation, but had not received it for three (3) weeks. The resident voiced a concern that he lost strength and endurance when he did not walk with restorative. Medical record review revealed a current care plan with a goal to walk 150 feet two (2) times a day, six (6) days a week, initiated on 04/28/17. The intervention, dated 09/22/16, indicated Resident #141 would ambulate 200 feet twice a day, six (6) days a week. During an interview on 05/24/17 at 2:36 p.m., Nurse Aide (NA) #23 reviewed the restorative records and said Resident #141 walked 150 feet two (2) times a day. Additionally, the physician's orders [REDACTED]. An interview with the director of nursing, immediately following the interview with NA #23, confirmed the care plan intervention had not been revised to reflect the physician's orders [REDACTED].> c) Resident #115 Medical record review on 05/30/17 found this resident, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. According to the medical record, she experienced actual falls on 04/30/17, 05/03/17, and 05/12/17. On the first and second occurrence she was found lying on the floor by the bed. On the latter occurrence, she slipped out of the wheelchair and onto the floor. Review of the current care plan found this resident was care planned as at risk for falls. The care plan was silent for any revisions showing the resident was not only at risk for falls, but that she had sustained actual falls since coming to the facility. In an interview with minimum data set (MDS) Registered Nurse #68 on 05/31/17 at 10:39 a.m., she reviewed the care plan and said they did not revise care plans to include the actual falls a resident experiences. When interviewed on 05/31/17 at 10:50 a.m., the administrator acknowledged that the care plan was not revised to include that she had sustained actual falls since admission to the facility. She said they typically update new interventions they may have added after a fall, but they do not revise the care plan to include either that the resident had sustained actual falls, or the dates of the falls. | 2020-09-01 |