cms_WV: 11327
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11327 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2009-02-12 | 279 | E | 0 | 1 | IH3P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, observations, and staff interviews, the facility did not develop a care plan for each resident which was based on the comprehensive assessment and included measurable goals. For example, residents were assessed as being on scheduled toileting plans, yet their care plans did not include a plan for incontinence management. Goals were not stated in measurable terms, so that progress toward the goal or a need to alter the approaches to the problem could be determined. Additionally, in some instances, the interventions did not lend to achievement of the stated goal. Resident identifiers: #82, #30, #80, and #15. Facility census: 106. Findings include: a) Resident #82 1. Review of the resident's most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/01/08, revealed she had both short-term and long-term memory problems. She had been assessed as having severe impairment in the area of decision-making; as being understood sometimes; and as rarely being able to understand what was said to her. Her [DIAGNOSES REDACTED]. She was able to move about in her wheelchair independently. Observations of the resident, on 02/11/09, found she had wandered into a room near her own room at 3:30 p.m., and at 3:45 p.m., she had maneuvered her wheelchair into another room nearby. A nursing assistant (Employee #77) was asked whether the resident often wandered into other residents' rooms and replied that she did. Review of the resident's care plan found no care plan to address the issue of this resident wandering into other residents' rooms. 2. Review of the medical record found a nursing entry on 10/03/08 regarding the resident licking her bedside table. Subsequent nurses' notes also described the resident licking things such as the desk at the nurses' station. On 02/11/09, in mid morning, Employee #112 was asked whether the resident still licked things. She said the resident continued to lick things and that the doctor was aware. She also said the resident would usually stop when instructed to do so. Review of the resident's care plan found no plan had been developed to address this behavior. 3. The following goal had been established: "Will maintain existing ADL (activities of daily living) self performance thru next care plan review." This goal was not measurable. 4. Another goal was: "'Res(ident) will remain oriented to self thru next care plan review." The interventions were to attempt to have her imitate the activity staff wanted her to perform, to attempt to provide consistent routines and caregivers, provide access to a clock and calendar, etc. None of the interventions offered guidance to care givers regarding how the resident was to be "oriented to self." 5. Another goal was: "Ensure needs will be met AEB (as evidenced by) res will be kept clean, dry and well groomed daily thru next care plan review." The interventions were: "When talking to resident, use gestures and simple sentences while maintaining eye contact. Monitor for and report any changes in communication abilities / efforts. Provide reassurance and patience when communicating with resident. Gain individual's attention before beginning to converse." These interventions were related to communication, which did not address the stated goal regarding grooming and hygiene. Additionally, the goal was staff-oriented (what staff would do for the resident), not resident-oriented (what the resident would do for herself). b) Resident #30 1. The goal was: "Resident will show less frequent experiences of sundown type of anxiouness (sic) by next care plan review." This goal included no parameters by which a determination of "less frequent" could be made. 2. Another goal was: "Will maintain existing ADL self performance. Resident will be clean well groomed and dressed daily thru next care plan review." There were no parameters included in this part of the care plan to render it measurable. 3. Another goal was: "Will be oriented to self thru next care plan review." The interventions associated with this goal did not provide insight as to how the resident would be oriented to self. 4. Another goal was: "Ensure needs will be met by staff AEB (as evidenced by) resident will be clean, well groomed and dressed daily thru next care plan review." The interventions were: "When talking to resident, use gestures and simple sentences while maintaining eye contact. Monitor for and report any changes in communication abilities/efforts. Provide reassurance and patience when communicating with resident." The interventions were related to communication, which did not address the stated goal regarding grooming and hygiene. Additionally, the goal was not resident-oriented. 5. Another goal was: "To show minimal/no side effects of medications thru next care plan review." The problem statement include the resident was on an antipsychotic medication, but the medications was not identified anywhere in this plan. The interventions were: "Monitor for and report to physician signs of adverse reaction such as .... Review medication regimen. Evaluate effectiveness and side effects of medications for possible decrease/elimination of [MEDICAL CONDITION] drugs. Monitor mood state/ behavior. AIMS (abnormal involuntary movement scale) testing q (every) 6 months & prn (as needed). [MEDICAL CONDITION] drug gradual dose reduction if not clinically contraindicated." None of the interventions would prevent side effects of medications. 6. According to the resident's most recent quarterly MDS, with an ARD of 01/09/09, the resident was able to feed herself with supervision. She was also noted to have chewing and swallowing problems. These factors had not been incorporated in the resident's care plan. 7. The resident's quarterly assessment also indicated she had been assessed as continent of bowel and frequently incontinent of bladder. She was coded as being on a scheduled toileting plan, however, the care plan did not include anything regarding incontinence management. c) Resident #80 1. A goal was: "Will improve ADL self performance as evidenced by (sic) thru next care plan review." There was nothing included in the goal to identify how improvement would be evidenced. The goal was not measurable. According to the quarterly MDS, with an ARD of 01/02/09, the resident required limited to extensive assistance with most ADLs. 2. Another goal was: "Demonstrate understanding by completing task when requested thru next care plan review." No frequency of the expectation of occurrence was included. The problem statement associated with this goal was: "Difficulty communicating as evidenced by expressive / communication impairment related to multi-infarct dementia." According to her quarterly MDS, she usually understood what was said to her and she could usually be understood. Therefore, there was an inconsistency between the assessment and this care plan. 3. Another problem was: "Dental or oral cavity health problem as evidenced by res with carious, broken, missing teeth." The goal was: "will (sic) be able to chew food sufficiently to swallow safely / without pain thru next care plan review." The interventions were: "Assist with oral hygiene as needed. Monitor for and report any changes in oral cavity, chewing ability, S&S (signs and symptoms) oral pain, etc." The plan did not address how the resident was to be enabled to chew food sufficiently in order to swallow safely / without pain. 4. The resident's assessment of 01/02/09, identified the resident as requiring the extensive assistance of one (1) for toileting. She was noted to be occasionally incontinent of bladder and usually continent of bowel and to be on a scheduled toileting plan. Incontinence management was not addressed in the resident's care plan. d) Resident #15 1. A goal was: "Res. will not have any complications r/t (related to)[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease) by next care plan review." The interventions were: "Monitor effectiveness of medication taken. Administer med per MD order. Notify MD prn." Although the goal was stated in preventative terms, the interventions, other than administration of medications, were not preventative in nature. Additionally, no nursing interventions were described in the plan. 2. A goal was established for the resident to show improvement in his balance, range of motion, mobility, ability to transfer, sitting tolerance, and shaping of his stump. The goal did not include any parameters so that progress, or lack of progress, toward the goal could be determined. 3. A problem statement was: "Decreased safety and I (independence) with self-care ADL's (sic)" with a goal of "Maximize safety and I with self-care ADL's". The only intervention was: "there ex, there act, ADL (therapeutic exercise, therapeutic activity, activities of daily living)." This plan offered little insight into the resident's needs. Additionally, it was not stated in measurable terms. . | 2014-06-01 |