cms_WV: 12
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 12 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 282 | E | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, visitor/family interview, staff interview, observation, and policy review, the facility failed to ensure services were provided according to the resident's written plan of care for five (5) of thirty-two (32) Stage 2 residents. Residents #27 and #141 did not receive planned restorative services. Resident #143 did not participate in activities as identied on her care plan. Resident #163 did not receive treatments in accordance with the plan of care, and Resident #124 did not receive foods in accordance with her plan of care. Facility census: 116. Resident identifiers: Resident #27, #143, #141, #163 and #124. Findings include: a) Resident #27 A medical record review related to accidents revealed a physician's orders [REDACTED].#27 required limited assistance of one (1) person for ambulation, and utilized a walker and/or wheelchair. The assessment noted the resident was not steady, but able to stabilize without staff assistance. [DIAGNOSES REDACTED]. Further review of the medical record revealed a physician's orders [REDACTED]. - nursing to assist resident to ambulate 80 feet two (2) times a day with roll walker and gait belt using CGA (contact guard assist) six (6) days a week. Re-evaluate in 90 days and as needed. -Restorative nursing to assist with bilateral lower extremity (BLE) exercises using two pound (2 lb) weight-hip flexion, knee extension three (3) sets times ten (10) repetitions daily six (6) days a week. Re-evaluate in 90 days and as needed. The care plan indicated Resident #27 was at risk for falls and risk for bleeding related to anticoagulant therapy. It noted the resident demonstrated a deficit in ambulation related to (r/t) functional deterioration resolved on 04/01/17 and revised on 04/20/17. During an observation and interview with Resident #27 on 05/31/17 at 4:32 p.m., the resident voiced she stayed in her room most of the time, but walked to the bathroom. Upon inquiry, the visitor said she was at the facility about three (3) times a week, and was adamant that Resident #27 had not been walking in the hallway with restorative nursing. Restorative Nursing records, reviewed from 05/01/17 through 05/24/17 indicated Resident #27 only walked one (1) time a day on the days she received restorative ambulation. Additionally, no evidence was present to indicate the resident received restorative as ordered 05/10/17 through 05/24/17. No data was entered for the dates of 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, or 05/23/17. The restorative nursing for bilateral lower extremity exercises yielded no data for 05/10/17, 05/11/17, 05/12/17, 05/14/17, 05/18/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, and 05/23/17. Nurse Aide (NA) #37, interviewed on 05/23/17 at 12:48 p.m., verbalized only the restorative nurse aides walked with Resident#27 in the hallway for restorative care. NA #23, interviewed on 05/24/17 at 2:36 p.m., verified the residents did not receive restorative therapy if no data was present. The restorative/rehabilitative nursing program plan indicated the skilled functional area deficit was required because a potential for decline existed and to maintain the current level of function. Program instructions indicated therapy be completed six (6) days a week. The interim center nurse executive (CNE), interviewed on 05/24/17 at about 3:30 p.m., confirmed restorative care had not been provided as directed by the plan of care. b) Resident #143 A Stage 1 family interview, on 05/16/17 at 1:58 a.m., revealed Resident #143 preferred church activities. The family member said the resident liked to attend church services and went every Sunday morning. The minimum data set (MDS) with an assessment reference date (ARD) of 05/05/17 noted a brief interview for mental status (BIMS) score of ten (10) which indicated moderate cognitive impairment. The preferences for customary and activity section noted it was important for the resident to receive a snack between meals, music, reading, doing things with groups of people, participating in favorite activities, and participating in religious activities or practices. The recreation assessment noted the resident enjoyed small groups. The resident's care plan indicated Resident #143 enjoyed being in the dining room for lunch and socializing with staff. A nursing assessment dated [DATE] noted the resident watched television (TV) and attended church on occasion. The recreation assessment noted the resident seemed to enjoy games and religious activities. Observations on 05/15/17 at 1:46 p.m., 05/16/17 at 8:28 a.m., 05/31/17 at 10:04 a.m., revealed no evidence of participation in activities. Nurse Aide (NA) #73, interviewed on 05/31/17 at 10:23 a.m., said she was not sure what Resident #143 liked as she usually always worked on the south hallway. NA #100, interviewed at 10:24 a.m., said she had not really worked the hallway too long, and was not sure what the resident liked to do. The NA verbalized the resident did not come out of the room much and wanted staff to leave her alone. The (MONTH) (YEAR) recreation log indicated Resident #143 participated with socialization daily, attended a special event on one occasion (05/24/17), hydration cart two (2) of 28 opportunities,and participated with reminiscence daily. It noted she attended church on four (4) of seven (7) opportunities, Bible study two (2) of four (4) opportunities, and gospel music two (2) of five (5) opportunities. Recreation Assistant (RA) #34, interviewed on 05/31/17 at 1:33 p.m., said church services were usually in the morning and Bible study in the evenings. The RA reviewed the calendar and said the facility did have church services every Sunday morning and of four (4) opportunities, no evidence was present to indicate Resident #143 had been invited to two (2) of them. Upon inquiry, the RA said the floor staff were not provided information as to whom should attend each event. During an interview and observation on 05/31/17 at 1:56 p.m., Resident #143 was eating lunch in her room. She said she had lasagna for lunch (one small piece of pasta remained on her plate) and they put too much mayo (mayonnaise) on the salad. She exhibited confusion as to person and place, and talked about her mother. When asked what time she would like to get up she said around eight o'clock (8:00 a.m.). Upon inquiry as to what activities she liked, Resident #143 said she went to church every Sunday. The resident said she did not care what denomination it was, just Christian. On 05/31/17 from 4:37 p.m., until 4:59 p.m., during a dining observation, Resident #143 sat at a table with two (2) other residents. She was seated at the corner of the table, attempting to eat a sandwich with a spoon. The residents did not interact. RA #34, NA #116, RA #22, NA #79, Bookkeeper #20, and Activity Director/Guest Services #36 assisted in the dining room. No one conversed with the resident. RA #34 verbalized the social activity in which Resident #143 participated daily at 4:30 p.m., was the pre-meal activity. Upon inquiry, the recreation assistant verbalized Resident #143 would be included as having participated in the activity, even though no one socially interacted with the resident. The activity log and observations were reviewed with administrator on 05/31/17 at 6:12 p.m. She acknowledged the noted lack of participation related to the number of opportunities for things which were important to Resident #143. Additionally, she verbalized acknowledgement related to lack of socialization for the dining event and concurred the resident did not receive activities in accordance with the plan of care. c) Resident #141 During a Stage 1 interview, on 05/16/17 at 2:57 p.m., Resident #141 verbalized he was supposed to receive restorative therapy for ambulation, but had not received it for three (3) weeks. The resident voiced a concern that he lost strength and endurance when he did not walk with restorative. The medical record revealed a current care plan with a goal to walk 150 feet two (2) times a day, six (6) days a week, initiated on 04/28/17. Additionally, the physician's orders [REDACTED]. During an observation and interview with Resident #141, on 05/23/17 at 9:15 a.m. the resident said he had his bath and was waiting for the nurse to provide his pain relief therapy. He verbalized restorative would walk him after that. At 12:28 p.m., the resident said, No one has walked me yet. and at 2:30 p.m., the resident said he had not yet walked. The resident said he had walked three (3) times the previous week, but had not walked at all the three (3) weeks prior to that. Resident #141 expressed he felt like he was losing his strength. Another observation at 5:53 p.m. revealed the resident sleeping bed. Nurse Aide (NA) #34, interviewed at 12:48 p.m. on 05/23/17, said Resident #141 walked with restorative aides, but they get pulled to the floor a lot so it doesn't (does not) get done. The NA said the resident had no routine, just slept most of the day. The NA voiced the resident did not usually refuse to walk, but it took him a while because his legs shake. The NA reported it took about forty-five (45) minutes to an hour to walk him from his room to the doorway of the conference room and back, and that he usually took a break. The NA verbalized the resident walked on a good week four (4) times. An interview with Nurse Aide (NA) #23 on 05/24/17 at 2:36 p.m., reviewed the restorative records and said Resident #141 was supposed to walk 150 feet two (2) times a day. The NA verbalized restorative noted the shift and time of resident participation and/or refusal. The NA said if no entry was present then restorative did not ask the resident to ambulate. Upon request, the NA reviewed the (MONTH) (YEAR) and (MONTH) (YEAR) activity participation log and confirmed no evidence was present to indicate services had been offered on the dates of 05/01/17, 05/02/17, 05/05/17, 05/06/17, 05/07/17, 05/09/17, 05/10/17, 05/11/17, 05/12/17, 05/13/17, 05/14/17, 05/15/17, 05/16/17, 05/19/17, 05/21/17, 05/22/17, and 05/23/17. Additionally, no evidence was present to indicate it was offered twice on the dates of 05/17/17, 05/18/17, 05/20/17 and 05/24/17. The log noted Resident #141 had refused on the 3-11 shift on 05/03/17, 05/04/17 and 05/08/17, with no evidence it was offered during the 7-3 shift. The (MONTH) (YEAR) log indicated Resident #141 did not receive restorative ambulation services for the dates of 04/07/17, 04/09/17, 04/10/17, 04/13/17, 04/14/17, 04/15/17, 04/16/17, 04/18/17, 04/19/17, 04/21/17, 04/22/17, 04/25/17, 04/27/17 04/29/17 or 04/30/17. Additionally, NA #23 confirmed no evidence was present to indicate ambulation services had been offered twice daily on 04/08/17, 4/17/17, 04/23/17 and 04/28/17. Resident was out of facility for one (1) date and refused (R) for four (4) of twenty-three (23) opportunities. The interim Center Nurse Executive (CNE) interviewed on 05/24/17 at about 3:00 p.m., confirmed Resident #141 had not received restorative services as per the plan of care. d) Resident #163 A medical record review revealed a physician's orders [REDACTED]. Another order noted to cleanse an unstageable wound to the right second toe with wound cleanser and apply sure prep daily. Observation of wound care on 05/18/17 at 10:21 a.m., with Licensed Practical Nurse (LPN) # --- revealed the Stage 2 pressure ulcer present on the Resident #163's coccyx. Upon inquiry as to whether the unit charge nurses completed treatments, the LPN said she completed the treatments for the entire facility. The medical record and treatment administration records, reviewed for (MONTH) and (MONTH) (YEAR), revealed no evidence the treatment for [REDACTED]. No evidence was present to indicate the Stage 2 coccyx wound treatment was completed for seven (7) of forty (40)opportunities, on seven o'clock in the morning until three o'clock in the afternoon (7:00 a.m. - 3:00 p.m.) shift on the dates 05/14/17, 05/13/17, 05/12/17, 05/11/17, 04/15/17, 04/16/17 and 04/17/17. The CNE reviewed the medical record on 05/31/17 and confirmed omission of data. No evidence was present to indicate the facility had provided the wound care treatments as directed by the plan of care. e) Resident #124 The medical record was reviewed on 06/01/17. [DIAGNOSES REDACTED]. She weighed only 82 pounds on 05/26/17, as recorded on the computer weight records. Medications ordered included [MEDICATION NAME] fifteen (15) milligrams daily to help increase her appetite. Review of the current comprehensive care plan included interventions for weight maintenance or gain for this edentulous resident on pages twenty-one (21) and twenty-two (22) of the care plan. Interventions included eight (8) ounces of buttermilk with meals three (3) times per day at her request, and ice cream with lunch and dinner. She was observed eating her evening meal on 06/01/17 at 5:25 p.m. She had no buttermilk. Rather, dietary sent her a carton of skim milk. Dietary sent her a small bowl covered with cellophane wrap that looked like pudding. When asked if that was ice cream, the resident replied in the negative. When asked if she liked buttermilk with her meals, she replied in the affirmative. Nursing Assistant (NA) #11 was in the room at the time, assisting the resident's room-mate with her tray. NA #11 asked the resident if she would like some buttermilk, and the resident replied I sure would! NA #11 said she would also get her some ice cream from the dietary kitchen. An interview was conducted with the dietary director #89 on 06/01/17 at 5:50 p.m. Upon inquiry as to whether he received dietary orders for this resident to have eight (8) ounces of buttermilk with each meal, and ice cream with lunch and dinner, he slightly thumbed through some half sheets of dietary orders and diet changes he kept in a folder. He said he would have to check his file to see if he received an order for [REDACTED]. On 06/01/17 at 7:05 an interview was conducted with the director of nursing and the administrator. The administrator said the dietary director sent the buttermilk tonight after surveyor intervention. The administrator said the dietary director found he had ice cream, and sent ice cream to the resident this evening after we had discussed it. She agreed that the care plan directed this resident to receive eight (8) ounces of buttermilk with each meal, and ice cream daily with each lunch and dinner meal. | 2020-09-01 |