cms_WV: 2826
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2826 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2018-11-09 | 867 | J | 0 | 1 | KBQP11 | Based on staff interview and facility policy review, the facility failed to ensure an effective quality assurance (QA) program was implemented after determining Licensed Practical Nursing (LPN) staff were performing Intravenous (IV) therapy without having IV training and verification which resulted in an Immediate Jeopardy. On 11/08/18 at 4:27 PM, the Administrator and the Director of Nursing (DON) were notified verbally that Immediate Jeopardy existed and began on 10/26/18, when Resident #58 was readmitted with a peripheral inserted central catheter (PICC). According to an audit provided by the Administrator and the DON on 11/09/18 at 8:30 AM, LPN #3, #27, #133, #156 and #177 performed IV therapy for Resident #58 and #76 without having an IV certification. This information was not addressed in QAPI (Quality Assurance and Performance Improvement). committee. Immediate Jeopardy was abated on 11/08/18 at 6:47 PM when the facility completed a full audit of all residents who had IV access that would require IV therapy. The facility revised the staffing schedule to ensure an RN or an IV certified LPN would be performing IV therapy for the four residents with IV access and any newly admitted residents with IV access. Although the Immediate Jeopardy was removed, the facility remained out of compliance at severity level two (no actual harm, with potential for more than minimal harm that is not immediate jeopardy until systemic issues related to IV training and verification of LPNs. See F883 (Facility Assessment), F726 (Staff Competency) and F684 (Quality of Care) for additional information. The facility census was 128. Findings include: An interview was conducted on 11/08/18 at 11:20 AM, the staff development Registered Nurse (RN) #15 who was responsible for staff development. She stated she completed an audit on 10/03/18 regarding which LPN staff had IV training and verification. She stated she identified a number of LPN staff who were not IV trained and notified the Director of Nursing (DON) and the Administrator of the results of her audit. An interview was conducted on 11/08/18 at 12:30 PM with the Administrator and the DON. The Administrator and the DON stated they were notified of RN #15's audit regarding LPN IV training and verification. They stated they were not aware any LPNs were performing IV therapy without being IV certified. The Administrator stated the audit information had not been discussed in Q[NAME] An interview with the Regional Medical Director for the facility on 11/09/18 at 10:35 AM was conducted. She stated she does attend QA (Quality Assurance) meetings regularly. She stated she was not aware LPNs were performing IV therapy without training and verification of such. She stated this had not been discussed in Q[NAME] She stated her expectation was for nurses to be trained on the care they were providing. Although the facility identified the need for LPN IV training and competency for a number of LPN staff, the facility failed to follow through with an improvement plan to ensure LPNs were performing IV therapy with properly training. See F684, F838 and F726 for failure to ensure residents received appropriate IV therapy by a qualified staff member. | 2020-09-01 |