cms_WV: 11286
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11286 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2009-05-21 | 323 | G | 1 | 0 | JD6Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to assure the safety of one (1) of eight (8) sampled residents, by not providing adequate supervision to prevent an accident with injury requiring emergency medical intervention. Resident identifier: #57. Facility census: 56. Findings include: a) Resident #57 Review of Resident #57's closed medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. The resident fell in her room on 06/04/08, striking her head and requiring an emergency transport to the hospital for closure of the laceration. The resident's daughter, when interviewed, reported the resident was standing at the sink while a nursing assistant was making her bed when she fell , although her mother was supposed to have the assistance of two (2) staff members when up. The resident's daughter stated she questioned the facility about the lack of assistance at the time of the fall. Documentation on the incident report of the fall stated, "Pt. (patient) was ambulating in walker and CNA (certified nursing assistant), lost balance and fell backwards." While the description of the circumstances surrounding the fall varied between these two (2) sources, both the incident report and the resident's daughter indicated only one (1) staff member was present at the time of Resident #57's fall. A review of Resident #57's care plan revealed a nursing intervention indicating the resident required the assistance of two (2) staff members when getting out of bed. An activities of daily living (ADL) assistance form communicated to the nursing assistants, on 09/26/07 and again on 04/24/08, that the number of staff Resident #57 required for bed mobility, transfers, and toileting as "2+" (two (2) or more). Documentation by the nursing assistants on the ADL flow sheet, for 06/04/08, recorded Resident #57 required maximum physical help or total dependence of staff for bed mobility, transfers, and toileting. The daughter's concern about the lack of adequate staff assistance when the fall occurred (an allegation of neglect) was not reported to the appropriate State agencies, and there was no documentation to indicate the facility conducted a thorough investigation into the daughter's concerns even though the nurses' notes indicated the resident's daughter returned to the facility with the resident and spoke to the director of nursing (DON) about the fall. During an interview with the administrator at 11:05 a.m. on 05/21/09, she acknowledged the daughter had been upset at the fact that there were not two (2) persons assisting Resident #57 at the time of the fall, but the administrator stated there was a nursing assistant in the room and the resident had a walker. She also stated the resident had gotten herself out of bed, although there was no evidence of this, and it was not mentioned in either the nurses' notes or the incident report. The administrator did acknowledge, after reviewing the record, there should have been two (2) nursing assistants present to assist the resident whenever she was out of bed. . | 2014-07-01 |