cms_WV: 11278
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11278 | LINCOLN NURSING AND REHABILITATION CENTER, LLC | 515171 | 200 MONDAY DRIVE | HAMLIN | WV | 25523 | 2010-09-22 | 490 | K | 1 | 0 | LVTE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, policy review, staff interviews, and review of 64CSR13 (the Nursing Home Licensure Rule), the governing body failed to ensure the facility was administered in an efficient and effective manner as evidenced by the presence of system failures in the areas of quality of care, infection control, and dietary services, and failed to develop and implement appropriate plans of action to correct these quality deficiencies. This failure placed more than an isolated number of residents in immediate jeopardy related to the failure to ensure all staff was knowledgeable of the location of an assembled suction machine ready-for-use in the event of a medical emergency; placed all residents at risk for more than minimal harm related to an ineffective infection control program that was not based on current standards of professional practice; and presented the potential for more than minimal harm to all residents related to the facility's failure to procure the services of a qualified dietary manager during the extended absence of the dietary department supervisor. These actions resulted in findings of immediate jeopardy and substandard quality of care. The administrator of this facility was ultimately responsible for the operation of this facility, as this individual alone possessed the authority to manage the facility and make needed changed to facility systems. Facility census: 58. Findings include: a) Findings of immediate jeopardy During random observation of the resident environment on 09/15/10 at 2:20 p.m., a call for help was heard from Resident #28's room. Employee #56 was observed to retrieve the crash cart located by the nursing station and race to the resident's room. It was noted that no suction machine was present on the crash cart. Observation in Resident #28's room found Resident #28 slumped forward in his wheelchair and unresponsive to attempts by nursing staff to arouse him. Staff lifted the resident onto his bed and called for oxygen. Employee #56 was observed to search through the drawers of the crash cart and open two (2) bags of oxygen tubing without locating a nasal cannula. A staff member was heard to state, "Where's my oxygen?", when Employee #56 ran to the clean utility room to obtain a nasal cannula. Following transportation of the resident to the hospital, Employee #56 was asked, at 2:55 p.m., to locate a suction machine. Employee #56 immediately went to the crash cart and searched through the drawers without locating a suction machine. She then entered the clean utility room and searched the shelves without locating a suction machine. She then walked up the A-wing hallway, past the dining room, to the service hallway and opened the door to a room labeled nursing storage. She was searching this room for a suction machine when a records information systems clerk (Employee #47) entered the room and asked Employee #56 if she was looking for a suction machine. Employee #56 stated that she was looking for a suction machine for the crash cart. Employee #47 stated that suction machines were on the crash carts in the dining room and in the activities room. Employee #56 stated she did not know about suction machines in the dining room or the activities room but needed one (1) for the crash cart. Employee #47 asked Employee #56 if she checked the bottom drawer of the crash cart. Employee #56 stated that she had looked and there was no suction machine. A members of the environmental services staff (Employee #46) approached and stated that a suction machine was in the dining room and the activities room. He located an unassembled suction machine in a drawer in the dining room at 3:02 p.m., a total of seven and one-half (7.5) minutes after the first request was made for the location of a suction machine. Employee #46 was then asked to locate the suction machine in the activities room. He entered the activities room, pointed to an empty section of counter and stated, "It should be right there." There was no suction machine located in the activity room at that time. -- At 3:05 p.m., nursing staff members present at the nursing station were asked for the list of items to be kept on the crash cart. The staff members stated the list was kept in the top drawer of the crash cart. All the drawers of the crash cart were searched with no list being located. At 3:15 p.m., the director of nursing (DON) was asked to provide the list of items to be kept on the crash cart. She was unable to provide one and stated that she would look for it. This surveyor located the list in a stack of folders on top of a shelf in the nursing station at 3:40 p.m. The nursing staff members confirmed this was the list used for the crash cart. Review of the document entitled "Crash Cart Contents" found the following information: "Top Of Cart - Extra Back Board (1) Suction Machine (1) Nebulizer (1) Adult Manual Resuscitator with Mask (1)...". At 3:45 p.m. on 09/15/10, the administrator was informed that the facility placed residents in immediate jeopardy of injury or death by the failure to ensure that a suction machine was kept assembled and readily available for use during a choking emergency. The immediate jeopardy was abated at 4:08 p.m. on 09/15/10, when staff assembled a suction machine, placed it on top of the crash cart, and inserviced all personnel present on its use and location. (See citation at F309 for additional details.) -- b) Infection control 1. Residents #55, #50, #40, #53, #35, #58, #48, and #29 Review of facility's infection control logs, on the afternoon of 09/20/10, revealed Residents #55, #50, #40, #53, #35, #58, #48, and #29 contracted a nosocomial UTI during the month of July 2010. Observation of incontinence care for an uncircumcised male (Resident #4), on 09/20/10 at 2:20 p.m., found the nursing assistant (NA - Employee #16) utilizing a soapy washcloth to cleanse the resident's pubis. She then made one (1) downward stroke with the washcloth toward the resident's urethra. Employee #16 did not retract the resident's foreskin to cleanse this area. This practice placed Resident #4 at risk of contracting a UTI from the contaminated washcloth utilized to first cleanse his pubis. Failing to first cleanse the resident's meatus and area under the foreskin, prior to cleansing the pubis, introduced organisms to the resident's urethra and placed him at risk of infection. The director of nursing (DON - Employee #66) was advised of the above observation and provided a policy on perineal care at 3:00 p.m. on 09/20/10. Review of the perineal care policy (revised 05/01/06), under the section entitled "Steps in the Procedure", found the following: "10. For a male resident:... b. Wash perineal area starting with the urethra and working outward... (1) Retract foreskin of the uncircumcised male." Employee #66 was asked for evidence that staff members had been inserviced on proper perineal care, as this is a common source of UTIs. She provided evidence of an inservice for perineal care dated 07/23/09, as being the last inservice given on this topic. When asked, on 09/21/10 at 11:05 a.m., for evidence that the facility conducted an investigation into the causal factors related to the nosocomial UTIs for July 2010, the DON could provide no evidence of any investigation conducted by the facility. - 2. Residents #5, #17, #30, #39, #52, and #59 Further review of the facility's infection control logs found that the six (6) residents identified above contracted nosocomial UTIs requiring the use of antibiotics in the month of August 2010. - 3. As of 09/21/10, the facility could provide no evidence to reflect an investigation had been conducted into the causal factors related to fourteen (14) facility residents requiring medical treatment for [REDACTED]. Additionally, the facility failed to assure that nursing staff was provided appropriate training and monitoring related to the provision of perineal care. (See citation at 441 for additional details.) -- c) Dietary department On 09/16/10 at 10:30 a.m., a request was made to speak with the dietary manager, to obtain a list of residents who regularly eat in their room. Employee #33 provided the list and was identified as being the acting dietary supervisor. Review of the numbered list of employees provided by the facility found that Employee #33 held the title of dietary services assistant and Employee #37 was identified as the dietary services supervisor. The administrator was asked, on the morning of 09/16/10, if Employee #33 was a certified dietary manager. He stated Employee #33 was not certified and was taking the place of Employee #37 while she was on maternity leave. He stated Employee #37 had been absent since the last of August 2010 and was unable to determine how long she would remain absent. Review of Employee #37's payroll records found her to be absent as of 08/20/10. Review of 64CSR13-8.15.a.3. found the following: "The dietary manager, under the direction of the dietitian, is responsible for the daily operation of the dietetic service." Review of 64CSR13-8.15.a.2.A. through C. of the nursing home licensure rule found the following: "A dietary manager shall be employed if a dietitian is not employed full-time and shall be one of the following: "- A dietetic technician, registered by the American Dietetic Association; "- A certified dietary manager, as certified by the Dietary Manager's Association; or "- A graduate of an associate or baccalaureate degree program in foods and nutrition or food service management." The facility provided no evidence that a qualified dietary manager was present to oversee the daily operations of the dietetic department. (See citation at F492 for additional details.) . | 2014-07-01 |