cms_WV: 11017
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11017 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2009-02-05 | 165 | D | 0 | 1 | 53ZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to address grievances in a timely manner. Resident #109 had resided in the facility for over seven (7) years, and the facility failed to adequately address his repeated requests to have a cool sleeping environment at night. This was evident for one (1) of twenty-one (21) sampled residents. Resident identifier: #109. Facility census: 121. Findings include: a) Resident #109 Record review revealed Resident #109 was an alert, oriented [AGE] year old male who resided in the facility for nearly eight (8) years. His physician had determined he had the capacity to understand and make his own informed healthcare decisions. Due to [DIAGNOSES REDACTED], he required total assistance from staff with the performance of activities of daily living. He was unable to leave his bed unless lifted out with a mechanical or other total lift, was unable to walk, and used a motorized wheelchair. During an interview on 02/04/09 at approximately 10:00 a.m., he stated his desire to keep his room warm by day and cool at night. Per the resident, he gets up in his scooter by day and feels cold. At night, he likes to cover up in bed with his warm blanket to keep his trunk and extremities warm, but he needs to have cooler air during sleep to facilitate breathing, feeling like he smothers if the air is too hot. He stated staff has known of these needs for years. He stated the heat last night was so unbearable he could not breathe, but staff refused to turn down the heat as he requested. He said he awoke drenched in sweat and had to get up at 2:30 a.m. to sit in his scooter for the remainder of the night, so he could breathe. He said he would like to have his room at 66 degrees Fahrenheit (F) while sleeping at night, although this was an estimated number as there was no thermometer in the room to measure the exact temperature. He was considering moving to another facility, but he stated his preference would be to stay where he was, since this was his home, if only the heat could be turned down at night. Interview with a social worker (Employee #119), on 02/04/09 at 2:15 p.m., revealed she was aware of his desire for coolness at night during sleep, and she admitted this had been an ongoing problem resulting in numerous roommate changes over the years. She said his current roommate, who had dementia, was placed there in the past week or so, and he was unable to speak for himself and say if he felt warm or cold. Interview with Resident #109's former roommate (Resident #9), on 02/04/09 at 2:45 p.m., revealed Resident #9 (aged 95) recently moved out of that room because it was too cold at night. He transferred to another room down the hall but, due to the television being too loud, he transferred again to the private room where he currently resides. At this time, Resident #9 was fully dressed and wore a heavy jacket over his street clothes and his room felt very warm, yet he stated he just felt comfortable at the moment. This resident had resided in the facility since 01/23/09. An attempt was made to interview Resident #109's current roommate on 02/04/09 a 3:15 p.m., but he was not interviewable due to his [DIAGNOSES REDACTED]. Interview with the assistant director of nursing (Employee #65), on 02/04/09 at approximately 3:00 p.m., revealed she, too, was aware of his desire for a cool room at night. She stated the water pipes in that room froze once about a year ago. She agreed the resident's stated desire for a 66 degree F temperature at night was not too cold for her, but there was no thermometer to objectively gauge the actual room temperature. She reported that, once, a nurse arrived to work at 7:00 a.m. and said she could see her breath in that room. Resident #109's unresolved desire for a cool sleeping environment was relayed to the administrator, the director of nursing, and other staff present on 02/04/09 at approximately 4:00 p.m., and they acknowledged this has been a recurring problem throughout the years trying to suit him with compatible roommates. On 02/05/09 at 8:45 a.m., the social worker (Employee #119) reported the facility obtained a thermometer for the resident's room and planned to keep the room between 72 degrees F and 81 degrees F, and she asked if the State regulation stipulated a room temperature between these two (2) parameters, as there was a roommate to consider who could not speak for himself. She stated that to her knowledge there had never been a thermometer in his room before. When asked if the facility was abiding by Resident #109's wishes for his comfort zone (citing his comfort as the right temperature for him), and about the facility's inability to find a suitable roommate in the seven (7) years Resident #109 had resided there, Employee #119 offered no further information at this time. On 02/05/09 at 9:45 a.m., observation found Resident #109 lying in his bed. When interviewed, he reported feeling "completely beat" due to two (2) nights in a row without good sleep due to the heat. He stated, "I woke up and couldn't get my breath and was wringing wet." He stated the nurse told him, at 3:00 a.m., that it was 78 degrees F and informed him the room temperature had to be at least 72 degrees F and she would not lower the heat for him. Review of nursing notes, dated 02/05/09 at 3:00 a.m., found, "Heat on set @ (at) 78 degrees per thermometer in room." A subsequent note, at 5:00 a.m., recorded the room temperature at 74 degrees, documented his complaint of sweating and not breathing well due to the heat, and documented verbal exchanges for the preceding twenty (20) minutes that acknowledged "he is miserable" but contained no documentation of comfort measures nor reassurances being offered. Clinical record review revealed a social services progress note, dated 01/29/09, documenting Resident #109 being upset about the food and reporting he could move to another facility, followed by staff advisement "that we only wanted to keep both he and his roommate comfortable". Another social services progress note, dated 02/03/09, documented a meeting with Resident #109, during which the author "completed an assessment for possible transfer. . . . (Resident) has been unhappy with HOK (Heartland of Keyser) regarding room temperatures". The note further indicated a plan to contact another facility when a bed becomes available. . | 2014-09-01 |