cms_WV: 3717
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3717 | LAKIN HOSPITAL | 5.1e+125 | 1 BATEMAN CIRCLE | WEST COLUMBIA | WV | 25287 | 2019-09-12 | 609 | D | 0 | 1 | K00K11 | Based on review of the facility suggestion/complaint forms, facility policy and procedure, and staff interview, the facility failed to ensure allegations of neglect were reported in accordance with State law to the State Survey Agency, Ombudsman, and adult protective services. In addition, the administrator was unaware of the allegations. This was a random opportunity for discovery with the potential to affect a limited number of residents. Resident identifiers: #54, #4, and #64. Facility census: 75. Findings included: a) Review of facility suggestion/complaint forms Review of a facility document entitled, Suggestion/Complaint Form (To be used by all concerned persons) at 1:00 PM on 09/10/19, found a Health Service Assistant (HSA) #171 filed a hand written complaint on behalf of C- North Hall Residents #54, #4 and #64 on 08/23/19. The name of resident's was listed as C North Residents, evening shift. Description of the incident: Residents not being given showers. Attached to the complaint form was a hand written statement from HSA #171: (Typed as written), This is a formal complaint on behalf of several residents that I myself have observed when on the units. I was on C-North today with (Name of Resident # 54) he smelled so bad it was a sour smell. This was not the first time I have smelled that with (Name of Resident #54). He states he has not been in the shower this week they wipe him off and shower him in bed. He also states that when the day shift leaves he gets offered Nothing to drink. Then I observed (Name of Resident #4 ) had crud I'm thinking poop thick under his finger nails and smeared between some of his toes. I know it had to been there a while because it was hard. Also I was told by one/two of day shift CNA's (certified nursing assistants) that (name of resident #64) has not been cleaned properly due to when they change him the cleaning rag would be black. I'm sure there's more but this is what I witnessed myself . I feel I need to speak up for these residents. I will state the ones I mentioned are evening showers that aren't being done. Attached to the complaint form was also a hand written statement from Health Services Worker (HSW) #145, dated 8/23/19. There has been multiple occasions that I have worked with (name of Resident #54) and he has made the statement that he did not get a shower, yet his face had been shaved. When I ask him where did they shave you at he has stated in my bed. (Name of Resident #54) has also had an odor coming from him. When wiping and doing care on (Name of Resident #64 a brown residue is left on the wash rag Also attached to the complaint form was a handwritten statement, dated 08/23/19, from HSW #134. There have been multiple times that myself and other HSW have went in to do care on (Resident name) and have noticed a very strong odor coming from him. Resident also stated to HSW that they only shave him and wipe him off while laying in bed. Also, while doing care on (Name of Resident) I noticed as you wipe him a brown residue will come off of him. The suggestion/complaint form required the following to be completed: Steps taken to investigate: Check the shower schedule, et (typed as written) monitor the bathing of the patients. Summary of findings/conclusion: Rsdt's (Residents) were bathed as scheduled. Witnessed rsdt's shower via shower gurney. Statement Complaint valid/not valid: Not valid. Corrective action? (if any) Monitor rsdt's et their bathing schedule et ensure completion. The form was signed only by the Assistant Director Of Nursing (ADON). The form also required the signature of the administrator. The form was not signed. On 09/10/19 at 03:58 PM, a facility social work supervisor (SWS) #56 said she was aware of the allegations but she did not investigate them. She said the allegations were not reported to the proper state agencies because she didn't think the allegations were true. An interview with the ADON on 09/10/19 at 4:09 PM, revealed the allegations were not reported to State authorities. The ADON said she had placed a sticky note on the complaint form noting each resident was showered. The ADON pointed to the note which indicated each resident was showered on 08/23/19; #54 received a shower at 3:30 PM, #4 received at shower at 3:50 PM, and #64 received a shower at 4:10 PM. When asked if she had any other information to provide regarding the situation, she said, no. The ADON retrieved the shower schedule for the 3 residents in question. All 3 residents are to receive showers on the afternoon shift. Review of the schedule with the ADON revealed the following information from 08/01/19 through 08/23/19: Resident #54 receives showers on Monday, Wednesday, and Friday. Resident #54 was not showered on the following Mondays in August, 2019 8/5/19, 8/19/19. Resident #54 was not showered on the following Fridays in August, 2019: 08/02/19, 08/09/19, 08/16/19. Resident #4 receives showers on Saturday, Tuesday and Thursday. Resident #4 missed the following showers on Saturdays: 08/10/19, 08/17/19. Resident #64 is showered on Monday, Wednesday, and Friday. Resident #64 did not receive a shower on 08/02/19, 08/05/19, 08/09/19, and 08/16/19. b) Interviews with staff The ADON agreed the residents were not bathed as scheduled prior to the allegation. The ADON said she did not obtain any statements from other staff. She obtained no statements from the afternoon staff responsible for bathing the 3 residents. She did not have any information to determine why these 3 residents were not provided showers as scheduled. There was also no investigation into the allegation regarding Resident #54, Doesn't get anything to drink. An interview with HSA #171 on 09/11/19 at 10:13 AM, found she works on the special needs unit. HSA verified she made a complaint because, These Residents need to be taken care of. She said she witnessed what she believed to be human feces on Resident #4. She also witnessed a odor coming from Resident #54. She said another worker told her about Resident #64. An interview with the administrator on 09/11/19 at 10:56 AM revealed the administrator was unaware of the suggestion/complaint form completed on 08/23/19. The administrator was unaware of any investigations that may or may not have occurred. The administrator verified she should have been made aware of the concern form. c) Facility Policy and procedure for Abuse and Neglect Reporting/Investigation Review of the facility's policy, entitled Abuse and Neglect Reporting/reporting/response: A covered individual (mandatory reported) will immediately report to Adult Protective Services, State Agency, (OHFLAC), the administrator and to all other required agencies (e.g., law enforcement when applicable) within specified timeframe's. The mandatory reported may contact the Resident Advocate/Grievance Official for assistance if needed. The Charge Nurse will assist with reporting of allegations on nights, weekends and holidays Allegations that DO NOT involve abuse or result in serious bodily injury must be reported to appropriate State agencies no later than 24 hours after allegation is made. Additionally, as a result of the investigation the facility will take all necessary actions which may include, but are not limited to, the following: Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; Defining how care provision will be changed and /or improved to protect residents receiving services; Training of staff on changes made and demonstration of staff competency after training is implemented; Identification of staff responsible for implementation of corrective actions; The expected date for implementation; and Identification of staff responsible for monitoring the implementation of the plan. | 2020-09-01 |