cms_WV: 11113
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11113 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2011-04-01 | 221 | D | 1 | 0 | 0DKH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, medical record review, staff interviews, and review of the State Operations Manual (Appendix PP - Guidance to Surveyors), the facility failed to assure one (1) of three (3) sampled residents was free from physical restraints imposed for the purpose of convenience and not required to treat the resident's medical symptoms. Resident identifier: #65. Facility census: 84. Findings include: a) Resident #65 Review of facility documents found a former quality aide (QA - Employee #0) reported Resident #65 had been restrained in her bed by the use a of tightly tucked blanket / sheet at approximately 9:00 p.m. on 03/10/11. Review of Resident #65's medical record found no evidence the treating physician ordered the resident to be restrained while in the bed. Further review of the medical record found a minimum data set (MDS) with an assessment reference date (ARD) of 01/17/11. Review of this MDS revealed this [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was assessed as having long and short term memory problems and difficulty focusing attention with disorganized thinking, and she displayed moderately impaired cognitive skills for daily decision making with noted delusions. She is always incontinent of bowel and bladder. She required one person physical assistance with bed mobility, transfers, dressing, eating, personal hygiene and total assistance with bathing. -- The following interviews were conducted with former and current staff: 1. Employee #0 (a QA) Employee #0 was interviewed at 9:59 a.m. on 04/01/11. She stated she was working the evening shift on 03/10/11 at approximately 9:00 p.m., when she walked past Resident #65's room and heard her call out "Baby Doll". Employee #0 stated she entered the resident's room to determine if the resident was trying to get up or had fallen. She noticed Resident #65 was lying on her back and was trying to raise her upper body but could only lift up about a foot. When she looked closer, she saw the resident's sheet and blanket was "really tight" across her abdomen. She reported this to Employee #65, a medical records clerk. 2. Employee #65 (medical records clerk) Employee #65 was interviewed at 3:19 p.m. on 03/30/11. She stated she worked late on the evening of 03/10/11 when, at about 9:30 p.m., Employee #0 approached her and told her she needed to check Resident #65, as the QA believed the resident was being restrained. Employee #65 went into Resident #65's room and noticed the resident was lying on her back on the bed. Employee #65 described walking over to the resident's bed and pulling on the blanket beneath her breast area, which appeared to be tight. She stated she was only able to move the blanket about an inch from the resident's body. She stated she reported the resident's condition to the charge nurse, a licensed practical nurse (LPN - Employee #93). 3. Employee #93 (an LPN) Employee #93 was interviewed at 8:45 a.m. on 03/31/11. She stated that, at approximately 9:15 p.m., Employee #65 requested her to come and look at Resident #65, that she was tied to her bed. Employee #93 described that, when she entered the resident's room, she noted a thin white blanket was tucked tightly under the resident's mattress. She left the room to get assistance from Employee #22, a certified nursing assistant (CNA). She stated both she and Employee #22 had to rip the blanket to get it off the resident. 4. Employee #4 (a QA) Employee #4 was interviewed at 4:43 p.m. on 03/30/11. She stated that, two or three days before 03/10/11, she and another QA were in Resident #65's room with a CNA (Employee #25). She stated Employee #25 showed them that the resident's sheet was tucked between the mattress and the bed frame. She relayed that Employee #25 stated, "This is why (Resident #65) isn't getting up." Employee #4 stated the QAs were required to watch Resident #65, because she would try to stand up / get up when she is in her bed and would fall. She stated it was really hard to pass ice and snacks and also have to watch this resident. 5. Employee #47 (the social worker) Employee #47, the social worker for the facility, was interviewed on the afternoon of 03/31/11. She stated she saw the blanket that had been removed from Resident #65's bed. She described two (2) jagged tears on two (2) of the corners of the resident's blanket. 6. Employee #25 (a CNA) Employee #25 was the CNA assigned to care for Resident #65 on the evening shift on 03/30/11. He was the only aide assigned to the resident's hallway. He was interviewed at 5:04 p.m. on 03/31/11. He denied restraining the resident by tightly tucking the blanket or sheet under the resident's mattress. 7. Employee #68 (a CNA) An interview with Employee #68 was conducted at 6:54 p.m. on 03/30/11. She stated that, on the evening shift on 03/30/11 after the 9:00 p.m. bedcheck, Employee #22 told them they were not to "tie nobody up, restrain nobody, tie the covers or tuck them in until they can't move". When Employee #68 asked Employee #22 why they were being told this, she stated Employee #22 informed her they had to rip the two (2) corners of the sheets to get Resident #65's covers loose. -- The facility obtained a statement from Employee #22, a CNA who worked night shift aide on 03/11/11. Her statement concurred that Resident #65's sheet was tucked tightly under the mattress. (This individual was not available to be interviewed by the surveyor.) -- Review of the State Operations Manual, Guidance to Surveyors, F221, found examples of restraints included, "... Tucking in or using Velcro to hold a sheet, fabric, or clothing tightly so that a resident's movement is restricted...". . | 2014-08-01 |