cms_WV: 4040
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4040 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 279 | D | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop comprehensive and/or initial care plans based on the residents' current health condition/status that included measurable objectives and timetables to meet the resident's medical, nursing and psychosocial needs. Care plans lacked individualized goals and interventions for residents with, or at risk for pressure ulcers (Residents #74 and #75), and for a resident (#49) receiving antipsychotic medications. This practice was identified for three (3) of twenty-six (26) Stage 2 sample residents whose care plans were reviewed during the Quality Indicator Survey (QIS). Resident identifiers: #74, #75, and #49. Facility census: 61. Findings include: a) Resident #74 On 02/16/17 at 8:12 a.m., medical record review revealed this eighty-two (82) year old man was admitted to the facility after a thirteen (13) day stay in an acute care facility. The acute care hospital's discharge summary dated 12/18/16 listed [DIAGNOSES REDACTED]. The plan of care written in the discharge summary identified Resident #74's sacral decubitus ulcer. The plan stated, Protect skin from further breakdown and compromise. The interventions were, Frequent repositioning, keep patient active, and enforce aggressive wound care. The facility's admission physical assessment, written on 12/19/16 at 5:13 p.m. by Registered Nurse (RN) #153, stated, [AGE] year old male discharged from (Name) hospital and admitted to (Name) Nursing Care Facility II .with HX (history): Increased weakness. Pressure ulcers of sacral region .Incontinent to bowel and bladder .wears brief .Buttocks with old scar right proximal. Will continue to monitor. The Nurse Aide resident care record dated 12/19/16 at 9:57 p.m. noted Resident #74 required the assistance of one (1) with turning and repositioning, was a two (2) person transfer with a lift device, required assistance with all other activities of daily living (ADLS) including eating, and was incontinent of bowel and bladder. The initial interim care plan dated 12/19/16, and the current care plan dated 12/29/16, did not identify Resident #74's sacral pressure ulcer and the potential risk of recurrent skin breakdown in this area until he developed two (2) new Stage II pressure ulcers on his buttocks. The facility did not establish individualized measurable goals and interventions to meet the immediate needs of this resident at the time of admission for the identified recent sacral pressure ulcer. The facility did not implement any preventative measures until after staff identified the pressure ulcers on his buttocks on 01/25/17. During an interview on 02/20/17 at 2:45 p.m., the Minimum Data Set (MDS) nurse reported she completed the Braden skin assessment during her MDS review and placed the interventions in the care plan. The MDS nurse reviewed the medical records and reported Resident #74's Braden score was thirteen (13) on 12/28/16, and acknowledged Resident #74 was at moderate risk for skin breakdown. She agreed the interim care plan initiated on 12/19/16 and updated 12/21/16, and the typed care plan dated 12/29/16, did not address Resident #74's history of a sacral pressure ulcer and risks of developing additional pressure ulcers. b) Resident #75 Review of the resident's medical record on 02/20/17 at 1:43 p.m. revealed this resident, admitted on [DATE] and discharged to home on 01/18/17, had [DIAGNOSES REDACTED]. The wound/pressure ulcer forms for the resident contained the following wound descriptions: -- 12/27/17 the wound size was documented as 1 cm (centimeter) x (by) 1 cm -- 01/02/17 the wound size was documented as 0.25 cm round -- 01/9/17 the wound was documented as not open -- 01/16/17 the wound was documented as not open The resident's care plan contained no individualized goals and interventions regarding pressure ulcer assessment, monitoring, prevention, or treatment. After reviewing the care plan for Resident #75, the Assistant Director of Nursing (ADON), who was also the Wound Nurse stated, No the care plan does not say anything about assessment and treatment, I didn't know it was supposed to say anything about how often it is to be looked at. I guess I have a lot to learn with this wound care thing. c) Resident #49 Medical record review on 02/15/17 found [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Review of the care plan revealed goals that were not individualized related to the [MEDICAL CONDITION] medications. The facility care planned [MEDICATION NAME] usage and the potential for complications/side effects related to its use. The facility did not develop an individualized goal for what it hoped to achieve with the use of [MEDICATION NAME], rather, the goal was for the side effects to be minimal related to the use of the medication. The facility care planned as a problem that she received antidepressant medication related to depression. The facility did not develop a care plan with an individualized goal of what it hoped to achieve with the use of that medication, rather, the goal was that the resident will not exhibit signs of drug related sedation, [MEDICAL CONDITION], or [MEDICATION NAME] symptoms. The facility care planned antipsychotic medications related to anxiety/depression, and at risk for side effects of medication use. She had a [DIAGNOSES REDACTED]. During a brief interview on 02/20/17 at 2:30 p.m., when informed of the lack of individualized care plan goals, the director of nurse was asked to provide any additional information she might have. No further information was provided prior to exit. In an interview on 02/28/17 at 3:00 p.m., the administrator acknowledged the issue of not having individualized goals on the care plan related to [MEDICAL CONDITION] medications. | 2020-02-01 |