cms_WV: 23
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 23 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2017-06-02 | 514 | E | 0 | 1 | ELSQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to maintain complete and accurate medical records. For Resident #190, neurological assessments were incomplete. For Resident #163, documentation regarding treatments, response to pain medication, and a voiding diary were incomplete. For Resident #159, [MEDICAL TREATMENT] communication sheets and activities of daily living (ADLs) date were incomplete. ADL sheets were incomplete for Resident #76 and meal/snack percentages were not documented for Resident #143. This was true for five (5) of thirty-two (32) records reviewed. Resident identifiers: #190, #163, #159, #76, and #143. Facility census: 116. Findings include: a) Resident #190 Review of the resident's medical record on 05/30/17 found he sustained an unwitnessed fall in his room on 04/10/17 at 5:05 p.m. As a result of the fall, he incurred an abrasion and a skin tear to the back of his left arm between his elbow and shoulder. The facility initiated a neurological assessment flow sheet right away. On 04/11/17 at 4:30 p.m. and at 8:30 p.m., the flow sheet was silent for neurological assessments, vital signs, observations, or staff signatures. The assessment resumed on 04/12/17 at 12:30 a.m. On 05/30/2017 at 4:04 p.m., after reviewing the neurological assessment flow sheet, the director of nursing (DON) agreed there was incomplete documentation on 04/11/17 at 4:30 p.m. and at 8:30 p.m. with no documented refusals, and noted the night shift picked it back up as did the day shift, with no abnormalities noted. b) Resident #163 1. Review of the resident's medical record and treatment administration records for (MONTH) and (MONTH) (YEAR), found 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. 2. Further review of the medical record revealed a new order for [MEDICATION NAME] sulfate 20 mg/ml (milligrams per milliliter) administer 0.75 ml sublingually (sl) every hour as needed and was clarified to administer 0.5 ml sl every hour as needed. Pain assessment records revealed no evidence the facility reassessed pain after administration of [MEDICATION NAME] sulfate on 05/18/17, 05/15/17 and 05/08/17, 04/23/17, 04/21/17, 04/18/17, 04/15/17, and 04/12/17. A pain presence monitoring tool was not present for (MONTH) (YEAR). 3. The three (3) day incontinence management diary, dated 04/12/17 through 04/15/17, revealed no data for 9 of 36 opportunities including 7:00 a.m. to 9:00 a.m., 9:00 a.m. to 11:00 a.m., 11:00 a.m. to 1:00 p.m., and 1:00 p.m. to 3:00 p.m. on 04/14/17 and 04/15/17, and 11:00 p.m. to 1:00 a.m. on 04/12/17. c) Resident #159 1. [MEDICAL TREATMENT] communication records, reviewed for the period from 12/15/16 to present, revealed incomplete records for fourteen (14) of fifteen (15) records reviewed. The communication record included a pre-[MEDICAL TREATMENT] assessment for the facility nurse to complete, a middle section for the [MEDICAL TREATMENT] center to complete, and a post-[MEDICAL TREATMENT] assessment for the facility to complete. Incomplete records were found for 05/23/17, 05/20/17, 05/18/17, 05/15/17, 05/12/17, 05/09/17, 05/06/17, 05/04/17, 05/02/17, 12/24/16, 12/22/17, 12/20/16,12/17/16, and 12/15/16. Records between 12/24/16 and 05/02/17 were absent from the [MEDICAL TREATMENT] records. On 06/12/17 at 6:17 p.m., when asked what the facility's responsibility related to the permacath and graft site were, Registered Nurse (RN) #120 verbalized none, and said the [MEDICAL TREATMENT] site managed the line. Further inquiry related to the facility's responsibility for assessing and monitoring the site, RN #120 said the facility did not have a responsibility. Licensed Practical Nurse (LPN) #132 verbalized the facility was required to monitor the bruit and thrill of the graft site. RN #120 reviewed the [MEDICAL TREATMENT] communication records and confirmed they were incomplete. On 05/30/17 at 12:34 p.m., the communication records were reviewed with the interim Center Nurse Executive (CNE), who also confirmed the records were incomplete. The CNE said she did not know how laboratory results were communicated between [MEDICAL TREATMENT] and the facility. The nurse said she thought the [MEDICAL TREATMENT] center did send a report at times and would ask Health Information Management Coordinator (HIMC). The HIMC verbalized at 4:03 p.m., that no additional information was present in the medical record or thinned files. Additionally, HIMC said the graft had been placed on 02/08/17, but the facility did not have an order to monitor for thrill and bruit until 05/24/17. No evidence was present to indicate the bruit and thrill were monitored for the months of February, March, and (MONTH) (YEAR). 2. Activity of daily living records reviewed for (MONTH) (YEAR) revealed omissions of data for meal percentages for 05/30/17, 05/29/17, 05/27/17, 05/26/16, 05/08/17, and 05/06/17. Omissions related to snacks included 05/31/17, 05/30/17, 05/29/17, 05/27/17, 05/26/17, 05/24/17, 05/16/17, 05/09/16, 05/08/16, 05/06/17, and 05/04/17. The interim CNE reviewed the medical record on 06/01/17 and confirmed the record was not complete. d) Resident #76 05/30/17 at 10:24:05 p.m., review of the resident's activities of daily living (ADL) records found incomplete data for bed mobility, transfers, eating, toilet, walking, locomotion, dressing, personal hygiene, bathing, meals, bladder, and bowel for dates 05/07/17, 05/08/17, 05/11/17, 05/12/17, 05/17/17, 05/19/17, 05/20/17, 05/21/17, 05/22/17, and 05/24/17. e) Resident #143 Review of the resident's medical record related to nutrition revealed omissions of data for meal percentages and bedtime snacks. The (MONTH) (YEAR) activity of daily living records noted omissions of data for 18 of 93 opportunities for meals on 05/31/17, 05/30/17, 05/26/17, 05/22/17, 05/21/17, 05/20/17, 05/13/17, 05/02/17, and 05/01/17. Snack data omissions included 6 of 31 opportunities for snacks on 05/30/17, 05/29/17, 05/26/17, 05/25/17, 05/05/17, and 05/02/17. | 2020-09-01 |