cms_WV: 11440
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11440 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2010-11-18 | 323 | G | 65CW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide adequate supervision and/or assistive devices for one (1) of five (5) residents reviewed to prevent avoidable accidents. Resident #89, who had experienced a decline in physical condition and was diagnosed with [REDACTED]. There was no evidence the facility evaluated the resident's ability to be unsupervised in the wheelchair due to her condition at 9:00 a.m., her weakened condition due to pneumonia, and her potential weakness as the result of refusing both meals prior to the fall. The resident was not assessed to determine whether supervision to avoid an accident was necessary. The facility had not evaluated the risk of this resident having an avoidable accident or implemented any interventions to reduce the risk of a fall. Later that day, the resident was gotten out of bed and placed in a wheelchair so an air mattress could be placed on the bed. She was unsupervised in the wheelchair and was found on the floor at 4:23 p.m. on 10/13/10. She sustained injuries and required hospitalization . There was no evidence that staff, who placed her in the wheelchair, had been made aware the resident was put to bed earlier in the day because she was leaning forward in her wheelchair. Subsequently, the resident experienced a fall from the wheelchair with injuries. Resident identifier: #89. Facility census: 88. Findings include: a) Resident #89 When reviewed on 11/17/10 and 11/18/10, the medical record of Resident #89 disclosed this [AGE] year old female had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. - On 10/13/10 at 9:00 a.m., a nursing note stated, "Resident up in w/c (wheelchair) with 1 person assist leaning (sic) forward in w/c assisted resident back to bed." A nursing note, dated 10/13/10 at 9:31 a.m., stated, "Resident's daughter was upset over finding her mother slumped in her bed ...Resident has shown a steady decline over last several months. Oral intake is poor. Resident refuses to be fed." A nursing note entry dated 10/13/2010 at 15:57 (3:57 p.m.) described that the resident was propelling herself in the wheelchair, and was found in the floor. Further review of the medical record revealed no interventions relative to safety and/or to prevent further falls. An additional nursing note, on 10/13/10 at 16:23 (4:23 p.m.), stated, "Notified by staff that resident was found in the floor. Resident had been gotten out of bed to place air mattress on bed. Resident had been wheeling self about facility and then was found in the floor on A hall. Resident was found face down with a laceration to the R (right) eyebrow and cheek. Complained of pain to R hip." The resident was transported to an area hospital. The medical record described the residents weakened Physical condition and continued decline. Documentation in the resident's medical record described a slow decline in her physical condition from the time of admission. The resident had acquired Clostridium difficile (C. diff - a condition that results in frequent diarrhea) after admission to the facility on [DATE] and, following treatment, had a negative stool culture on 10/05/10. The resident was diagnosed with [REDACTED]. The resident's oral intake was minimal from the time of admission. The resident's weight record stated an admission weight of 139.5# on 07/28/10 and a weight of 131# on 10/06/10. On 08/06/10, the resident was placed on the medication Megace to increase her appetite, and it was discontinued on 10/01/10. Meal intake reviews showed that, shortly before her hospitalization on [DATE], the resident's meal intake ranged from 0% (refusal) to 50%. The resident refused both meals prior to her fall and hospitalization on [DATE]. - A facility's occupational therapist (OT - Employee #3), who had worked with Resident #89 until shortly before her fall with injury, was interviewed at 10:30 a.m. on 10/18/10. When asked about her experiences with the resident and the resident's condition, the OT stated the resident had had a slow decline in her condition almost from the time of admission and, in the last few days prior to discontinuation of services, the resident had been less responsive and unable to follow direction. A nursing note, dated 10/06/10, stated, "Resident to be discharged from therapy services today." - The facility's director of nurses (DON), when interviewed on 11/18/10 concerning the resident's fall, stated she was fully aware of the resident's decline in several areas, to include her bout of [DIAGNOSES REDACTED], poor appetite and meal refusals, weight loss, and pneumonia, but that the resident had remained able to sit upright in her wheelchair. The DON did not know if facility staff who placed her in the wheelchair were aware the resident had been unable to sit up earlier in the day. The DON further confirmed the resident had not been re-evaluated for her ability to be independent in her wheelchair as her condition declined. | 2014-03-01 |