cms_WV: 11016
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
11016 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2009-02-05 | 514 | B | 0 | 1 | 53ZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain complete and accurate clinical records for two (2) of twenty one (21) sampled residents. Resident identifiers: #53 and #92. Facility census: 121. Findings include: a) Resident #53 Record review, on 02/04/09, revealed a doctor's progress note indicating the resident lacked the capacity to make healthcare decisions. This progress note contained no date and time. A social worker (Employee #79) provided a copy of the doctor's progress note at 2:50 p.m. on 02/04/09. The social worker was interviewed at this time, reviewed the record, and verified the note contained no date and time. b) Resident #92 A review of the medical record revealed a social services progress note, dated 10/22/08, which contained the following: "Resident is a full-code status per POST." Review of the Physician order [REDACTED]. These additional limitations would be contrary to a "Full Code". During an interview with the two (2) social workers (Employees #79 and #119) at 11:45 a.m. on 02/04/09, they reviewed the record and agreed that "Full Code" was an error in their notes. . | 2014-09-01 |