cms_WV: 11340
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 |
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11340 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2010-12-09 | 280 | D | U1IJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to revise a care plan for one (1) of six (6) sampled residents when she was initiated into the facility's newly established walk-to-dine and fine dining programs, during which residents are transferred from their wheelchairs into regular chairs without the use of mobility alarms or seat belts. Resident #111, who had an order for [REDACTED]. needs while in the walk-to-dine / fine dining program. Resident identifier: #111. Facility census: 110. Findingd 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]. There was also 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. 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. -- 4. 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. -- 5. 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. . | 2014-04-01 |