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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2018-02-09 | 677 | D | 1 | 0 | 3JZJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review, facility staff interview and local Veterans Administration Medical Center (VAMC) staff interview, the facility failed to ensure Resident #92 received the care and services regarding an aspect of his life in the facility which was significant to the resident regarding bathing and shaving, and did not receive proper grooming when going to appointments outside the facility. This was true for one (1) of eleven (11) sample residents. This practice had the potential to affect more than a limited number of residents. Resident identifier: #92. Facility census: 107. Findings include: a) Baths and shaving On 02/06/18 at 9:05 AM, review of grievance and concerns revealed a grievance dated 09/12/17 revealing one of the issues was not being shaven adequately to allow for the use of the diathermy machine to be placed on his face. Resolution to the concerns were completed by 09/ 27/17 with staff being educated, Kardex being updated with the resident's preferences. The KARDEX provides specific instructions for the nursing assistants concerning individualized care to be provided for a resident. Review of Resident #92's Kardex showed it was important for resident to choose between a tub bath, shower, bed bath, or sponge bath, and under skin care it was noted as written ****Shave Resident daily****. Review of care plan, on 02/08/18 at 4:40 PM, revealed under the care area of self-care deficit an intervention to ****Shave Resident daily**** initiated 10/26/17. Resident #92 a legally blind paraplegic, totally dependent for all care, was to receive a shave and bed bath daily. The resident was incontinent of bowel and had a Foley catheter. Review of the ADL (activities of daily living) Record, on 02/07/18 at 4:00 PM, revealed during the month of (MONTH) (YEAR), Resident#92 had a minimum of twenty-five (25) opportunities to receive a bed bath and he only received fifteen (15) according to the ADL Record. There are thirty-one (31) days in December, and the resident was at the hospital on [DATE] until 12/04/17, on 12/11/17 until 12/13/17, and on 12/26/17 until 12/28/17, a total of six (6) days out of the facility (Note - It is possible the resident could have had or needed a bed bath on the days he went to the hospital and/or returned from the hospital. It is also possible an incontinent resident might need more than one bed bath per day). The resident received bed baths on fourteen days in December, on one day (12/05/17) he received two (2) baths. There was no evidence the resident refused any bed baths or refused being shaven. On 02/08/18 at 3:27 PM, interview with Nurse Aid (NA#40) revealed Resident #92 loved bed baths. NA#40 said, Resident #92 loved bed baths, they relaxed him and helped him sleep, he would take a two (2) hour nap after he got one. NA#40 denied ever knowing Resident #92 refusing a bed bath. Interview with NA#39, on 02/08/18 at 3:38 PM, revealed NA#39 stated, Resident #92 loved bed baths. I never knew of him refusing a bed bath. On 02/08/18 at 4:47 PM, an interview with two (2) Licensed Practical Nurse (LPN) LPN#44 and LPN#70 revealed the following information. When asked, as nurses, what their expectations of how often a totally dependent resident, incontinent of bowel should receive bed baths from nurse aides, both LPNs said at least daily, if not more depending on the resident's incontinence episodes. Both LPN#44 and LPN#70 said the nurse aides should have instruction on the resident's care plan and the Kardex for bathing and hygiene care. b) Grooming for appointments outside the facility On 02/06/18 at 11:25 AM, review of reportable events revealed a report concerning Resident #92, dated 12/26/17, where the Veterans Administration Medical Center (VAMC) notified the facility of an incident occurring that morning that was reported to all appropriate agencies. The incident reported to the facility, alleged upon EMS (emergency management service) ambulance arriving to take the resident to scheduled appointments, the resident was not cleaned up, had no breakfast, catheter needed emptied, and call light was not in reach. Review of the facility's investigation findings, revealed EMS arrived at approximately 7:00 AM on 12/26/17, and the NA (Nurse Aid) had not cleaned the resident up yet. The facility did not ensure Resident #92 was; cleaned up and shaven; catheter drainage bag was emptied; and resident was ready to be transported for medical appointments via ambulance, as was scheduled on the facility's appointment calendar book for 12/26/17 at 7:00 AM. The catheter drainage bag was emptied by a nurse aid (NA) after the ambulance crew arrived and only after a nurse had to instruct the NA to clean up the resident. Social worker SW#68's written investigation statement in response to the allegations, dated 12/27/17, stated the ambulance arrived closed to 7:00 AM for a 9:00 AM appointment ., however the facility's appointment calendar book for the month of (MONTH) (YEAR) showed Resident #92 had labs at 7:30 AM and an appointment at 9:00 AM at the VAMC Spinal Injury Clinic. Also, noted on the calendar was the time the ambulance was to pick up Resident #92, which was 7:00 AM on 12/26/17. On 02/06/18 at 1:15 PM, an interview with Staff#5, responsible for logging resident's appointments, revealed when a resident has an appointment Staff#5 writes the resident's name, date and time of the appointment, and the time the ambulance is to pick up the resident on the appointment calendar book. Staff#5 said, then the charge nurse has the appointment calendar book and lets the nurse aides know when they need to have the residents cleaned up and ready to go. Review of the appointment calendar book for the month of (MONTH) (YEAR), with Staff#5, revealed Resident #92 had labs at 7:30 AM and an appointment at 9:00 AM at the VAMC Spinal Injury Clinic. Staff#5 confirmed EMS ambulance was scheduled to arrive to pick Resident#92 up at 7:00 AM on 12/26/17. The facility's investigation Witness statements verified the ambulance arrived as scheduled and the resident was not cleaned up and ready to be transported. Resident #92 was cleaned and his catheter emptied, only after the NA was told by the nurse to clean him up for his appointment, after the ambulance crew arrived and waited. Review of VAMC SW#302 progress note, dated 12/26/17, revealed the ambulance crew reported, (Name of facility) knew we were picking him up for a doctor appointment today. When we arrived, he was not cleaned up . We had to ask someone to empty his catheter bag. When staff emptied the bag, they did not look under the covers to check to see if anything else needed taken care of. On 02/08/18 at 11:03 AM, an interview with VAMC Social Worker, VAMC SW#302 revealed she first saw the resident (Resident#92), on 12/26/17, after first being asked to see him by the VAMC Nurse Practitioner (Family Nurse Practitioner Certification - FNPC), VAMC FNPC#304. VAMC SW#302 said, When I saw him (Resident #92) he was laying on a stretcher, unshaven, with a neck brace on. VAMC SW#302 said, The ambulance crew reported the facility knew he was being picked up for a doctor's appointment, but he was not cleaned up . The ambulance crew said he was upset because he wanted to be shaven and cleaned up before leaving for his appointment. | 2020-09-01 |