cms_WV: 11339
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11339 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2010-12-09 | 157 | D | U1IJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to notify a resident's legal representative when they commenced a new form of treatment. One (1) of six (6) sampled residents was initiated into the fine dining program and the walk-to-dine program (during which residents are transferred from their wheelchairs into regular chairs without the use of mobility alarms or seat belts), with no evidence of family notification of this change in treatment or what it involved. The resident, who was seated in a regular chair at a table in the dining room without safety devices, got up from the chair by herself and fell to the floor, sustaining significant injury. The family of the resident was not informed that the use of these safety devices would not be permitted during fine dining and/or the walk-to-dine program. Resident identifier: #111. Facility census: 110. Findings include: a) Resident #111 1. Closed record review revealed Resident #111 was walked to the dining room by a staff member on [DATE] and assisted to sit in a chair at the dining room table with no alarms or seat belts in place; she then arose from the chair without assistance and sustained a fall with significant injuries. Subsequently, she was sent to the hospital per ambulance, was diagnosed with [REDACTED]. She expired on [DATE]. -- 2. Record review revealed physician's orders [REDACTED]. Review of the November physician's orders [REDACTED]. The was also revealed no evidence of orders for gradual reduction of restraint alternative or for permission for the resident to sit up in the chair without either a self-release Velcro seat belt or chair alarm. -- 3. Review of the resident's care plan effective in [DATE] revealed a problem of having a history of falls, decreased mobility and cognitive impairment. Interventions included: "Monitor Tab alarm is secured to back of bed when resident is in bed and secured to back of chair when resident is oob (out of bed) to chair. ... "Monitor resident to have self-release seat belt with alarm on when oob to w/c (wheel chair)." Review of the care plan revealed no evidence of plans to walk the resident to the dining room for the fine dining or walk-to-dine program, for gradual reduction of restraint alternatives, or for the resident to be up in a dining room chair without a chair alarm or seat belt. -- 4. During an interview on [DATE] at 9:30 a.m., a restorative nursing assistant (Employee #69) said that she and other staff were told that residents who are walked to the dining room were to be seated and pushed up close to the table, that the big dining room chairs with armrests were too heavy for residents to scoot, and residents wouldn't need alarms and seat belts while in those heavy chairs, as there was always staff in the dining room. She said the facility's plan was for residents to be ambulated to the dining room if they are able, and those who could not ambulate were to be brought to the dining room in wheelchairs. She said Resident #111 had no alarms, wheelchair, or safety belt in place in the dining room on [DATE], and she was sitting in a regular dining room chair prior to the fall. -- 5. Interviews with two (2) nursing assistants (Employees #4 and #56), a restorative nursing assistant (Employee #49), and a registered nurse (Employee #27), on [DATE] and [DATE], revealed they were told that residents in the restorative program are to be walked and assisted to sit in the dining room chair without alarms. However, residents who were wheeled to the dining room were allowed to have tab alarms or safety belts if they used them. -- 6. Interview, on [DATE] at 1:30 p.m., with the director of nursing (DON - Employee #104) revealed Resident #111 had an order for [REDACTED]. The DON explained that, sometime in September or [DATE], the corporate office encouraged the facility to have a fine dining program and a walk-to-dine program, and they were moving slowly into those programs. When asked if there were a policy or procedure regarding safety needs of residents who attended fine dining (such as not allowing alarms or seat belts if they walk to the dining room), she said they were in the process of writing procedures and she would try to look and see if there were any policies regarding safety issues in fine dining. When asked, she said she could not speak to whether Resident #111's legal representative was made aware of her transition to fine dining and that alarms or seat belts would not be used while dining. -- 7. Record review of nursing notes, from [DATE] until her death on [DATE], found no evidence of communication to the family related to Resident #111 participating in the fine dining or walk-to-dine program. In an interview on [DATE] at 1:45, the social workers (Employees #96 and #108) revealed they did not know whether Resident #111's power of attorney knew, before the resident's fall in the dining room on [DATE], that the resident's tab alarm and safety belt were not being used because of the change to fine dining. Employee #108 stated that, if a letter were sent out to everyone about a resident's transition to fine dining, then everyone would be assured of having been notified, but no letter was sent to families to her knowledge. They said they believed that seat belts were not allowed while residents were seated in regular chairs during fine dining as that would not be dignified. . | 2014-04-01 |