cms_WV: 11500
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11500 | MAPLESHIRE NURSING AND REHABILITATION CENTER | 515058 | 30 MON GENERAL DRIVE | MORGANTOWN | WV | 26505 | 2011-04-26 | 279 | D | NEGO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed, for one (1) of forty (40) Stage II sample residents, to develop a care plan to include measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs. Resident #21 was admitted for a planned short rehabilitation stay and remained in the facility after rehabilitation goals had been met. No care plan was implemented to address the resident's discharge needs. The resident also was known to be at risk for falls at the time of admission, and no care plan goals and interventions were developed to address the risk. The resident did incur additional falls. Resident identifier: #21. Facility census: 77. Findings include: a) Resident #21 1. When reviewed on 04/25/11, the medical record for Resident #21 revealed an admission date of [DATE]. According to a discharge summary report (dated 10/26/10) from the hospital where she was last admitted , this [AGE] year old female had fallen from bed in her home and sustained "multiple bilateral lower extremity fractures". Review of the physician's determination of capacity for this resident divulged that, at the time of admission (10/26/10), the resident's attending physician determined she did not have the capacity to understand and make health care decisions. This determination was changed on 01/03/11, when it was determined at that time that she did possess the capacity to make those decisions. An entry in social service (SS) notes, dated 11/09/10, stated: "D/C (discharge) plans are to return home." Again on 11/24/10, a SS note stated: "D/c plans remain to return home. No d/c date at this time." On 01/17/11, a SS note stated: "She plans to rehab & return home. MPOA (medical power of attorney) states resident will be LTC (long term care)." One (1) of two (2) minimum data set assessment (MDS) coordinators (Employee #65), when questioned on 04/25/11 at approximately 11:00 a.m. about the resident's plan to return to her home, stated the resident was occasionally confused, and Employee #65 did not feel the resident could care for herself at home, manage her diabetes, etc. She further stated she did not think the resident's family was willing to help her at home. The resident's care plan, when reviewed on 04/25/11, contained no mention of discharge and/or discharge planning for this resident on this document, which was most recently updated on 04/11/11. When reviewed again on 04/26/11, the resident's care plan had been updated to reflect the uncertainty of the resident's plan to discharge home. The facility's social worker (Employee #27), when interviewed on 04/26/11, confirmed she had not initiated any care plan related to discharge for this resident until 04/26/11. This employee further confirmed the resident's ability to make medical decisions was questionable and that a review of her capacity status had been requested. Recent calls to the resident's family / MPOA had gone unreturned, according to this employee. -- 2. The resident's individual interim plan of care, dated as completed on 10/27/10, was reviewed with respect to falls. The document stated the resident had the problem of falls due to a past history of falls. There were, however, no goals or approaches listed on the document to address this problem in an effort to prevent further falls. A physician's orders [REDACTED]. A falls investigation / root cause analysis form for this resident was noted to have been completed on 02/20/11. This document, and the information attached to it, stated the resident complained of hip pain when being re-positioned in the restorative room on the morning of 02/20/11, stating she fell out of bed the previous night and "yelled for help" and was assisted back to bed. Although the facility's investigation could provide no staff with knowledge of this incident, the resident received an x-ray to her right hip, which was negative for "acute fractures". An additional falls investigation / root cause analysis form for this resident was noted to have been completed on 03/31/11. This document, and the information attached to it, stated, "I found resident sitting on floor between beds, she was yelling out, her alarm was on & working". The document made no mention of the resident having been in a low bed at the time of the fall. An update to the resident's care plan was instituted on 03/31/11, stating the resident had an actual fall. Interventions at that time included: mat on floor; extensive assist with transfers; low bed; and start "falling star" program. The director of nursing (DON - Employee #63) was interviewed at 2:45 p.m. on 04/25/11. Following review of the resident's medical record and the above mentioned documents, the DON confirmed that no interventions to address falls were implemented at the time of admission (even though she had been hospitalized prior to her admission to the nursing home because of injuries she sustained as a result of a fall at home). Interventions were not implemented until after the resident had possibly fallen from the bed on 02/20/11 and after she had definitely fallen from the bed on 03/31/11. . | 2014-01-01 |