cms_WV: 4011
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4011 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 241 | D | 1 | 0 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to promote care for residents in a manner that maintained or enhanced dignity and respect by dating and initialing a wound dressing adhered to a resident's body, and by not clothing a resident from the waist down while in bed. This practice was found for two (2) of twenty-six (26) Stage 2 residents. Resident identifiers: #74 and #49. Facility census: 61. Findings include: a) Resident #74 On 02/21/17 at 9:10 a.m., at the conclusion of wound care/treatment the Assistant Director of Nursing (ADON)/Wound Care nurse secured the wound dressing to Resident #74's coccyx. The ADON then proceeded to write the date and her initials on the wound dressing adhered to Resident #74's bottom. During an interview with the ADON immediately following this observation, she confirmed she had written on the dressing after adhering it to Resident #74's body and should have labeled the dressing prior to applying it to the resident. Wound care observations were reviewed with the Director of Nursing (DON) on 02/21/17 at 10:50 a.m. The DON confirmed the dressing should have been dated and initialed prior to adhering it to Resident #74's bottom. During a review of the wound care observation with the Director of Nursing (DON) on 02/21/17 at 10:50 a.m., she confirmed dating and initialing of the dressing should have been done prior to it being placed on the resident's bottom. b) Resident #49 On 02/22/17 medical record review found the resident's most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 11/24/16, found her Brief Interview for Mental Status (BIMS) score was three (03), indicating severe cognitive impairment. This resident, who lacked capacity for medical decision-making, had pertinent [DIAGNOSES REDACTED]. On 02/21/17 at 9:50 a.m., an observation of the resident's incontinence care was completed. Nurse Aides (NA) #157 and #145 provided perineal care to the resident, while in the attendance of Licensed Nurse #119. The NAs removed the resident's wet, but far from saturated, disposable brief. After the NAs used cleansing wipes to clean the resident's perineal area and buttocks, the nurse applied Remedy skin protectant. Following this incontinence care, the staff did not apply another brief, underwear, or trousers to the resident. Rather, they covered her with a top sheet and a blanket. The nurse explained that she picks at paper incontinence products and eats it. She said this resident was care planned to wear disposable incontinence products only while up in her chair. For naps and hour of sleep, they placed cloth pads beneath her. When asked if staff put any clothing on the resident's bottom when she went to bed, the nurse replied in the negative. The nurse said the resident did not have enough clothing to put sweat pants on her for times of sleep as she would soil them and go through them quickly. This resident was noted to be the object of nonconsensual sexual contact by a male resident on more than one occasion. During one confidential interview (CI), CI #11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs. She said she told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. Upon inquiry as to whether they put panties on the resident when she was bed for dignity, the nurse agreed that would provide her with more dignity. She said she would contact the resident's responsible party about getting her some underpants and bringing them in. Review of a nurse progress note dated 02/21/17 at 10:08 a.m., found the nurse spoke with the resident's sister and asked her to bring this resident underwear when she came in. The nurse noted she said she would bring them in on 02/22/17. The nurse added that the resident needed to wear them when in bed, as she tore/ate pieces of regular disposable briefs. This information was shared with the director of nursing on 02/28/17 at 1:00 p.m. with no further information provided by the exit conference. | 2020-03-01 |