cms_WV: 11115
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11115 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2009-04-30 | 279 | E | 0 | 1 | 6TSD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, observation, and staff interview, the facility failed to initiate a care plan and/or adequately address problems identified in the comprehensive resident assessment for five (5) of thirteen (13) sampled residents. Resident identifiers: #83, #78, #24, #43, and #158. Facility census: 101. Findings include: a) Resident #83 A review of Resident #83's medical revealed an [AGE] year old female with [DIAGNOSES REDACTED]. She was identified, on her quarterly minimum data set assessment (MDS) completed on 04/08/09, as exhibiting the behavior of wandering, and there were two (2) recorded incidents of resident-to-resident conflicts (08/01/08 and 03/06/09) involving her wandering behavior. A resident assessment protocol indicated this behavior would be care planned, but a review of the resident's entire current care plan failed to find wandering identified as a care plan problem with measurable goals and/or nursing interventions to be implemented. During an interview with the administrator and the director of nursing (DON) at 5:15 p.m. on 04/28/09, the DON acknowledged that, except for general interventions for cognitive deficiency, the resident's wandering behaviors were not addressed in her current care plan. On 04/30/09, the DON presented copies of an addendum to the resident's care plan addressing, "Resident @ risk for injury R/T (related to) wandering with-in facility." b) Resident #78 A review of Resident #78's medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. At the confidential resident group meeting held at 3:00 p.m. on 04/28/09, five (5) residents in attendance complained about Resident #78 wandering in and out of their rooms many times during the night. Resident #78 was also observed walking in a random manner several times throughout the survey. Review of her significant change in status MDS (02/07/08) and the most recent quarterly MDS (03/04/09) revealed the assessor indicated the resident exhibiting wandering during the assessment reference periods, and a resident assessment protocol (RAP) completed in conjunction with the significant change in status MDS indicated this behavior would be addressed in the resident's care plan. A review of the resident's entire current care plan failed to find wandering identified as a care plan problem with measurable goals and/or nursing interventions to be implemented. During an interview with the administrator and the DON at 5:15 p.m. on 04/28/09, the DON acknowledged that, except for general interventions for cognitive deficiency, the resident's wandering behaviors were not addressed in her current care plan. On 04/30/09, the DON presented copies of an addendum to the resident's care plan addressing, "Resident @ risk for injury R/T wandering with-in facility." c) Resident #24 A review of Resident #24's medical record revealed an [AGE] year old male with [DIAGNOSES REDACTED]. At the confidential resident group meeting held at 3:00 p.m. on 04/28/09, five (5) residents in attendance complained about Resident #24 wandering in and out of their rooms many times during the night. Nurses notes documented the following: - On 02/19/09, "... up all night. Physically combative when redirected." - On 03/06/09, "... up ambulating all hours day and night. Only sleeps short periods." - On 04/27/09, "Wandered throughout night." The quarterly MDS (03/25/09) identified the resident as exhibiting wandering behaviors which are not easily redirected, and there was an incident report regarding elopement, when he exited the building on 04/27/09. A review of the resident's entire current care plan failed to find wandering identified as a care plan problem with measurable goals and/or nursing interventions to be implemented. During an interview with the administrator and the DON at 5:15 p.m. on 04/28/09, the DON acknowledged that, except for general interventions for cognitive deficiency, the resident's wandering behaviors were not addressed in her current care plan. On 04/30/09, the DON presented copies of an addendum to the resident's care plan addressing, "Resident @ risk for injury R/T wandering with-infacility." d) Resident #43 Review of Resident #43's current care plan, on 04/27/09, revealed the facility had not addressed wandering as a care problem for this resident. Observations of Resident #43, on 04/28/09 and 04/29/09, revealed the resident would wander into the rooms of other residents. Observation, on 04/29/09 at 2:20 p.m., found Resident #43 in the hallway her scooter chair removing the soft Velcro bars from the door frame of another's resident room and entering hallway into the room. Interview with the resident occupying the room into which Resident #43 entered revealed this occurred frequently. In an interview on the late afternoon of 04/29/09, Employee #80 acknowledged Resident #43 did wander into other residents' room. e) Resident #158 A review of nursing notes found an entry, dated 01/22/09, recording the resident was found in a male resident's room, sitting on the male resident's bed. The male resident had his hand on Resident #158's thigh, and staff believed the male resident through Resident #158 was his wife. A subsequent nursing note, later on 01/22/09, indicated Resident #158 was still wandering into other residents' rooms. A review of the nurse's notes found the resident was put on one-on-one monitoring, and a care plan was developed on 01/27/09, which was later discontinued on 01/30/09. On 01/30/09, the resident's care plan was updated to indicate staff was to monitor the resident every fifteen (15) minutes; this intervention was discontinued on 02/03/09. Further record review revealed a nursing note, dated 02/11/09 at 11:35 a.m., recording this resident drank approximately 1 teaspoon of green apple hand sanitizer. A review of the incident report and accompanying investigation found the resident accessed the hand sanitizer in the housekeeping supervisor's office. A review of the 02/11/09 interim care plan found the resident was to be in areas of supervision. On 02/22/09, the resident continued to wander in and out of other residents' rooms and was hard to redirect. The resident described was "combative and unwilling to leave other's rooms." Nursing notes, dated 03/06/09, 03/08/09, 03/22/09, and 03/26/09, contained descriptions of wandering, difficulty redirecting, rummaging in other residents' closets, drinking other residents' drinks, and waking up other residents. On 04/11/09, the resident's care plan was revised in response to Resident #158 striking out at another resident. Interventions included: "redirect, remind of inappropriate behavior and not to strike, and monitor activity..." On 04/12/09, the resident was found outside. The care plan included interventions, such as: "Maintain Watchmate sensor per orders, monitor whereabouts through shifts, and answer alarms promptly." The care plan did not include interventions developed specifically for the resident. A review of the resident's entire current care plan found a care plan had not been developed to address the identification what might be precipitating the resident's behaviors. Interventions in the care plans only addressed interim and temporary solutions but did not address ongoing and specific interventions for the resident. . d) Resident #43 Review of Resident #43's current care plan, on 04/27/09, revealed the facility had not addressed wandering as a care problem for this resident. Observations of Resident #43, on 04/28/09 and 04/29/09, revealed the resident would wander into the rooms of other residents. Observation, on 04/29/09 at 2:20 p.m., found Resident #43 in the hallway her scooter chair removing the soft Velcro bars from the door frame of another's resident room and entering hallway into the room. Interview with the resident occupying the room into which Resident #43 entered revealed this occurred frequently. In an interview on the late afternoon of 04/29/09, Employee #80 acknowledged Resident #43 did wander into other residents' room. e) Resident #158 A review of nursing notes found an entry, dated 01/22/09, recording the resident was found in a male resident's room, sitting on the male resident's bed. The male resident had his hand on Resident #158's thigh, and staff believed the male resident through Resident #158 was his wife. A subsequent nursing note, later on 01/22/09, indicated Resident #158 was still wandering into other residents' rooms. A review of the nurse's notes found the resident was put on one-on-one monitoring, and a care plan was developed on 01/27/09, which was later discontinued on 01/30/09. On 01/30/09, the resident's care plan was updated to indicate staff was to monitor the resident every fifteen (15) minutes; this intervention was discontinued on 02/03/09. Further record review revealed a nursing note, dated 02/11/09 at 11:35 a.m., recording the this resident drank approximately 1 teaspoon of green apple hand sanitizer. A review of the incident report and accompanying investigation found the resident accessed the hand sanitizer in the housekeeping supervisor's office. A review of the 02/11/09 interim care plan found the resident was to be in areas of supervision. On 02/22/09, the resident continued to wander in and out of other residents' rooms and was hard to redirect. The resident described was "combative and unwilling to leave other's rooms." Nursing notes, dated 03/06/09, 03/08/09, 03/22/09, and 03/26/09, contained descriptions of wandering, difficulty redirecting, rummaging in other residents' closets, drinking other residents' drinks, and waking up other residents. On 04/11/09, the resident's care plan was revised in response to Resident #158 striking out at another resident. Interventions included: "redirect, remind of inappropriate behavior and not to strike, and monitor activity..." On 04/12/09, the resident was found outside. The care plan included interventions, such as: "Maintain Watchmate sensor per orders, monitor whereabouts through shifts, and answer alarms promptly." The care plan did not include interventions developed specifically for the resident. A review of the resident's entire current care plan found a care plan had not been developed to address the identification what might be precipitating the resident's behaviors. Interventions in the care plans only addressed interim and temporary solutions but did not address ongoing and specific interventions for the resident. . | 2014-08-01 |