cms_WV: 11225
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11225 | ANSTED CENTER | 515133 | 106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400 | ANSTED | WV | 25812 | 2009-09-24 | 250 | E | 1 | 0 | 0T3Z11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, a review of the facility's policy and procedure titled "4.1 Social Service Progress Notes" and staff interview, the facility failed to assure the residents were assessed for unmet social service needs. The facility did not complete assessments to identify the need for social services and to promote actions by staff to enhance each resident's individuality. There was no evidence the facility assessed the current mental / psychological status, education level, prior living arrangements, and pertinent events affecting each resident's condition to assure his/her social service needs were met. This was found for four (4) of nine (9) sampled residents. Resident identifiers: #58, #38, #23, and #19. Facility census: 57. Findings include: a) Resident #58 Record review revealed Resident #58, a [AGE] year old female, was admitted to the facility from the hospital with chronic health problems. Prior to admission, her husband had been caring for her at home. The physician determined this resident had the capacity to understand and make her own health care decisions. It was also noted that her diabetes was very unstable and required close monitoring and frequent changes to her insulin. She experienced blood pressure elevations, and her medications were frequently changed. She received dialysis three (3) times a week. She had severe peripheral vascular disease (PVD), and her skin condition was very poor. She was admitted to the facility with extensive skin treatments. Further documentation in her record revealed she verbalized frequently that she wanted to go home. There was evidence in the progress notes that the Medicaid aged and disabled waiver program had told the facility the resident was a danger to herself due to her unsafe medical decisions. There was also evidence that the adult protective service worker (APS) had stated the husband could not care for her at home. Review of the resident's social history found no assessment to determine the social service needs of this resident either upon admission or throughout the entire time the resident was in the facility. b) Resident #38 Record review revealed this resident was admitted on [DATE]. As of 09/24/09, there was no evidence this resident was assessed to identify any unmet social service needs. In fact, there was nothing entered in the social service section of his medical record. Documentation noted the physician had determined he possessed the capacity to understand and make informed health care decision, and his care plan stated the facility's social service staff would assess the resident's response to the new situation. There was no evidence in the record to reflect this had occurred. During an interview on 09/24/09 at 10:45 a.m., the social worker confirmed she had not completed an assessment for this resident as required by facility policy to assess his needs. c) Resident #23 Record review revealed this [AGE] year old resident with multiple medical complications [REDACTED]. The social worker completed a mini-mental examination of the resident on 09/10/09. This was the only social service-related assessment completed for this resident. There was nothing to address his illness and his lifestyle prior to his hospitalization . During an interview on 09/24/09 at 10:45 a.m., the social worker confirmed she had not completed an assessment for this resident as required by facility policy to assess his needs. d) Resident #19 Record review revealed this resident was admitted to the facility on [DATE]. There was no evidence of a social service assessment completed since her admission. Her social service note simply stated, "Resident was admitted on [DATE] from the hospital for rehab to home care." This resident received dialysis three (3) times a week and had multiple chronic medical issues. Her care plan, established on 08/19/09, stated that social services would assess the resident's response to the new situation. There was no evidence to reflect this had occurred or that an assessment was completed to identify any unmet social service needs. During an interview on 09/24/09 at 10:45 a.m., the social worker confirmed she had not completed an assessment for this resident as required by facility policy to assess his needs. e) The corporate nurse, when asked for a copy of the facility's social service policy and procedures, produced a policy titled "4.1 Social Services Progress Notes" with an effective date of 06/01/01. Review of this policy revealed the facility's social service staff was to complete a progress note / check-off form which correlated with the interdisciplinary care plan (ICP) upon admission and at least quarterly. The social service staff was also to document the significant events occurring between quarterly reviews (i.e. change in health, discharge, transfer, hospitalization ) with interim notes. The policy stated the customer's progress and status was be assessed by an interview with the customer, observation, and medical record review. The concurrent note should include the following information: - 3.1 Review of the customers rights (first note, annually and as needed) - 3.2 Events leading to the admission (first note only) - 3.3 Adjustment issues (first note and ongoing) - 3.4 Functional ability and rehabilitation potential (first note and ongoing) - 3.5 Medical / cognitive / emotional status (first note and ongoing) - 3.6 Family / responsible party involvement (first note and ongoing) - 3.7 Psychotropic drug use (first note and ongoing) - 3.8 Advance directives (first note and as needed) - 3.9 Center therapeutic recreation involvement (first note and ongoing) - 3.10 Social Service intervention / involvement (first note and ongoing) - 3.11 Goals and approaches implemented by Social Service staff (first note and ongoing) - 3.12 Input from customer / responsible party (first note and ongoing) - 3.13 Discharge potential (first note and ongoing) - 3.14 Progress toward goals and effectiveness of approaches (ongoing) - 3.15 Level of peer interaction (first note and ongoing) - 3.16 Addressing of concerns / issues / interventions (first note and ongoing) - 3.17 Restraint assessment and use (first note and ongoing) - 3.18 Sensory concerns (first note and ongoing) - 3.19 Mood state and behavior problems / psychosocial adjustment (first note and ongoing) - 3.20 Personal needs / pay status (first note and ongoing) - 3.21 Referrals and use of outside resources (first note and ongoing) - 3.22 Functional abilities (first note and ongoing) - 3.23 Federal / state specific requirements - 3.24 Others as appropriate. According to the policy, whether writing in narrative format or using the check-off form, social service staff was to complete a progress note upon admission, quarterly, as needed, and at the time of the annual ICP meeting. The check-off note covered most of the above mentioned areas; however, in the comment section (on the reverse side of the form), one was able to add additional narrative information. This documentation was observed in some of the residents' records, but it was not found for these four (4) residents. . | 2014-07-01 |