cms_WV: 11333
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11333 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-12-28 | 225 | D | OYFI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and family interview, the facility failed to report allegations involving mistreatment and/or neglect to the appropriate agencies in accordance with State law for three (3) of six (6) sampled residents. Resident identifiers: #37, #38, and #67. Facility census: 89. Findings include: a) Resident #37 A review of the medical record revealed Resident #37 was an [AGE] year old male who has been determined to lack the capacity to form healthcare decisions, and his minimum data set and care plan indicated he was totally dependent upon staff for hygiene. A review of a grievance form revealed that, on 11/16/10, the resident's wife / healthcare surrogate (HCS) reported to a nurse (Employee #7) that the resident's nails were dirty at times and that she always had to cut his nails herself. The nurses' notes indicated this allegation of neglect was investigated and being followed up by Employee #7 and a nursing assistant and, when checked on 11/17/10, his nails were clean. Daily monitoring of the resident's nails was ordered by the physician and added to the care plan. But this allegation of neglect was not reported to the Ombudsman, Adult Protective Services, or to State survey and certification agency as required by state law and the facility's policy. -- b) Resident #38 A review of the clinical record for Resident #38 revealed an [AGE] year old male with [DIAGNOSES REDACTED]. He had been determined by the attending physician to lack the capacity to form healthcare decisions, and his niece was his medical power of attorney representative (MPOA). A grievance form was filed on 11/08/10, after the facility received a letter from the MPOA stating she had spoken to a staff member two (2) weeks prior and complained that the resident had become unable to physically lift his arm enough to feed himself, but nothing had been done and he was still having his tray set up and being left to feed himself. During an interview with the MPOA at 12:50 p.m. on 12/28/10, she verified she had told three (3) different employees about the fact that the resident could no longer feed himself or get a drink of water on his own. The MPOA stated the resident's mouth was very dry and the nurse had told her that he was losing weight. Her only answer from nursing was, "We'll write it in the notes." She stated she had asked an aide to feed him but was told they needed to get an "okay" from the nurse. She stated that, after she wrote the letter, the facility took action, had tests done, and instructed the staff to feed him. The original assessment by the registered dietitian (RD), on 06/20/10, noted his weight as 204.2 pounds and his intake at 92%. A dietary entry on 12/16/10 noted, "MPOA aware of Monthly weight trigger; Resident has had a 9.54% wt. loss x 1 month, 10.15% wt. loss x 3 months and 14.68% wt. loss x 6 months." An investigation took place as evidenced by an immediate speech therapy evaluation; a referral to the Veteran's Hospital for an evaluation of his decline; and, on 11/10/10, he was changed to having meals in the restorative dining room. But this allegation of neglect was not reported to the Ombudsman, Adult Protective Services, or to State survey and certification agency as required by state law and the facility's policy. -- c) Resident #67 A review of the grievance reports revealed that, on 11/15/10, Resident #67 (who had been determined by the attending physician to have the capacity to form her own healthcare decisions on 10/10/10) reported allegations that she was not getting the care she needed. She stated to Employee #8 (the admissions person) that: (1) she could not reach her call bell; (2) she hadn't been gotten out of bed for two (2) days, and (3) one (1) of the aides (Employee #9) had been rude to her when she asked to get up and told her she would have to wait and that he didn't have to do what she said. Employee #8 recorded the allegations and began an investigation, and counseling was done with the staff, but these allegations of neglect were not reported to the Ombudsman, Adult Protective Services, or to State survey and certification agency as required by state law and the facility's policy. During the investigation, Employee #10 gave a signed statement the resident had also reported to her on 11/12/10, that her light was not being answered. -- d) During an interview with the administrator, the acting director of nursing, and the social worker at 1:45 p.m. on 12/28/10, this surveyor stated to them that the above grievances contained allegations of mistreatment and/or neglect and, as such, should have been immediately reported to the appropriate State officials prior to the initiating of investigations. The outcome of the investigations should also have been reported. The three (3) of them reviewed the grievances and did not offer any alternative explanations but stated that they would file reports as soon as possible. . | 2014-04-01 |