cms_WV: 4054
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4054 | TAYLOR HEALTH CARE CENTER | 515057 | 2 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2017-03-01 | 514 | E | 0 | 1 | WA6611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, confidential interviews, and policy review, the facility failed to maintain complete, accurately documented clinical records of each resident. Staff failed to accurately monitor and document Resident #75's, Resident #74's, and Resident #33's pressure ulcers, to include depth, any exudate (wound drainage) and a description of the pressure ulcer including surrounding tissue. Resident #74's medical record also contained an incorrect discharge date documented on the form used to document pressure ulcers. In addition, residents' medical records lacked documentation of incidents of sexual abuse. This practice had the potential to affect all residents residing in the facility. Resident identifiers: #75, #74, #33, #26, #39, #51, #49, #24, #37, and #1. Facility census: 61. Findings include: a) Resident #75 Review of the medical record on 02/15/17 at 9:07 a.m. found Resident #75, admitted on [DATE], had [DIAGNOSES REDACTED]. He was discharged from the facility to home on 01/18/17. The wound/pressure ulcer forms lacked documentation of any measurement of wound depth if present, exudate, description of the wound bed and surrounding tissue. -- On 12/27/17, the wound/pressure ulcer size was documented as 1 cm (centimeter) x (by) 1 cm -- On 01/02/17, the wound/pressure ulcer size was documented as 0.25 cm round -- On 01/9/17, the wound/pressure ulcer size was documented as not open -- On 01/16/17 the wound/pressure ulcer size was documented as not open The column titled Eschar/Necrotic was blank. The column titled site was documented on each of the previous dates as L (left) buttock. Also, a handwritten discharge date of [DATE] was documented on the form, when the resident was discharged from the facility on 01/18/17. After reviewing the wound/pressure ulcer forms for Resident #75 on 02/15/17 at 9:00 a.m., the Assistant Director of Nursing (ADON)/Wound Nurse #112 stated, No the form does not show an accurate measurement of the wound which should include depth or a zero for no depth. No it does not describe what the wound looks like. I just used these forms and did not make any adjustments, not sure if these are hospital forms or not. On 02/15/17 at 10:12 a.m., after reviewing the wound sheets for Resident #75, the Director of Nursing (DON) stated, No it definitely is not a complete and accurate wound sheet, it does not even describe the wound and depth is always part of the wound measurement. The discharge date should always be correct on the wound sheet and this discharge date is not even close to being correct. c) Resident #74 Review of the medical record on 02/16/17 at 8:12 a.m., revealed Resident #74 was admitted to the facility with Stage II pressure ulcers on both elbows and a Stage I pressure ulcer on his coccyx. The resident developed pressure ulcers on his buttocks, heel and toes after admission on 12/19/16. The nursing physical assessment admission note dated 12/19/16 stated Left elbow Stage II wound 3 centimeter (CM) circle with hole in middle open purple with serious serioussangus (sic) drainage noted. Right elbow 3 cm round hole 1.25 depth with brownish/tan drainage noted. Buttocks with old red scar right proximal. The records were silent in regards to any further wound assessments until 12/30/16. --On 12/30/16 the Assistant Director of Nursing (ADON)/wound care nurse documented a wound assessment in the computerized progress notes. bilateral elbows were a stage 2 on admission - now are resolving and only has some redness around perimeter . The handwritten wound form provided by the ADON on 02/16/16, identifies the Stage II pressure ulcers on the elbows present on admission but lacks information related to tunneling, odor, wound edges, and pain. --On 01/09/17 the ADON/wound nurse documented an assessment in the computerized notes stating: Bilateral elbows were noted to have stage 2 pressure ulcers on admission - areas are now dry and slightly red area - continue to use skin prep bilaterally BID (twice a day) [MEDICATION NAME]. No assessment was found on the hand written wound form to correlate with this assessment. --On 01/16/17 the ADON/wound nurse wrote in the computerized progress notes, right elbow - slightly pink - open area 0.50 cm round and 0.25 deep - using skin prep - added elbow protectors resident has tendency to lean to right and puts pressure on elbow - very bony all over . The handwritten wound form stated, right elbow 0.5 open hole area. Left elbow ___0.5 scab area Both are checked as Stage II pressure ulcers. There is no information related to odor, tunneling, wound edges, surrounding tissue or discomfort. --On 01/25/17 at 2:02 p.m. the ADON/wound nurse documented in the computerized progress notes: a (left elbow per pressure ulcer/location unisex body form) - resolving stage 2 - 4 cm round dk (dark) purple - not open - skin prep and elbow protectors. b (right elbow per pressure ulcer/location unisex body form) resolving stage 2 - 4 cm round dk (dark) purple with open area - 0.10 deep - skin prep - elbow protectors. There was no information related to odor, tunneling, wound edges, surrounding tissue or discomfort. --On 01/26/17, the Director of Nursing (DON) documented the wound assessment in the section titled Pressure Ulcer Condition: Rt (right) buttocks with 2 open areas red periwound with yellow center. Lt (left) buttocks with 1 open area red periwound with pink center. Rt heel with DTI (deep tissue injury) skin intact. Rt great toe posterior (top) pinpoint open area. All areas no odor noted. Under the section titled Pressure Ulcer Stage, the DON documented: --A - RT buttocks 0.5 x 0.25 cm Stage 2. --B - RT buttocks 0.25 cm x --C - LT buttocks 0.25 cm x --RT heel - DTI 1 cm x 1 cm unstagable. --RT Great toe pinpoint area Stage 2. --On 02/06/17, the DON documented a wound assessment evaluation in the computerized records: she wrote: --A - RT (right) buttock with open area pink center no drainage, 0.25 cm x 0.25 cm x 0,25 cm Stage 2 --B - RT buttock no open area pink in color, 0.25 circular area superficial D/I (dry and intact) pink in color Stage 2 --C - LT buttock no open area pink in color, superficial D/I (dry and intact) pink in color Stage 2 areas with healthy tissue --D - RT heel DTI intact area drying 1 cm x 1 cm edges intact --E - RT great toe pinpoint scabbed area posterior UTD (unable to determine) edges intact unable to determine --F- RT elbow --G - LT elbow superficial area pink in color skin intact resolved Stage 2 The wound care notes were reviewed with the ADON/wound nurse during an interview on 02/16/17 at 9:30 a.m. She reported she had no education or training in wound care, nor did she have a mentor she could contact with questions. She acknowledged her wound form tracking sheets were confusing and incomplete. The section titled Date facility acquired is blank or is marked for the day she completed the assessments. The wound sheets lacked complete measurements, exudates, and a description of the wound and surrounding tissues. The Director of Nursing (DON) reviewed the medical record during and interview at 9:45 a.m. on 02/16/17. She agreed the wound records were incomplete. Weekly wound assessments were not documented and assessments lacked complete descriptions of the wounds, including full measurements, tunneling, drainage, odor, wound edges, surrounding tissue, and pain. The facility policy titled Preventing Pressure Ulcers with a revision date of 12/23/2010, states under #4 of the procedure section: For any resident that is determined to have a Stage I pressure ulcer or higher, a Registered Nurse will document a weekly assessment . Resident #74 was admitted with pressure ulcers to his elbows and a Stage I sacral pressure ulcer. Weekly skin and wound assessments were not conducted and the inexperienced wound nurse's assessments lacked descriptive information of the wound and surrounding areas. Also, a handwritten discharge date of [DATE] was documented on the form, when the resident was discharged from the facility on 01/18/17. c) Resident #33 On 2/15/17 at 9:03 a.m., during a review of Resident #33, a wound assessment form competed on 01/20/17 by Registered Nurse #105 indicated a pressure ulcer for Resident #33 had worsened, but the pressure ulcer records were incomplete. They lacked a full description of the wound including size, tunneling, odor, wound edges, exudate type, amount and consistency, wound edges, wound pain, and description of surrounding tissue. d) Resident #39 The following incidents of sexual abuse were found in the alleged perpetrator's (Resident #10) medical record, but nothing was found in Resident #39's medical record: - 09/28/16 at 14:06 (12:06 p.m.) Behavior Monitoring nurses notes stated Alert and orientated . Resident later removed from 29-2 bed (Resident #39). He (Resident #10) states 'I was trying to get a piece of ass.' Resident was redirected and room monitored. - 10/09/16 at 6:46 a.m., the Behavior Monitoring nurses notes for stated Alert and oriented . Resident was up adlib (as desires) early this morning via wheelchair. Resident observed to approach resident 29B (Resident #39) as she was resting quietly on couch near nurses station with eyes closed. Resident put his hand on 29s crotch and began rubbing it. She opened her eyes and kicked his wheelchair away from her, pushing him backwards. Resident was redirected by this nurse. He laughed. Resident was relocated by this LPN (licensed practical nurse) away from resident 29B. - A review of the nurses' notes found on 10/26/16 at 16:09 (4:09 p.m.) Resident #10 was found in bed with Resident #39. Resident #10 was relocated out of the room. - On 02/01/17 at 6:42 p.m. - a nurse's note stated Resident #10 was found by staff on top of female (Resident #39) with his [MEDICAL CONDITION] bag off and bowel movement all over Resident #39. Resident #10 and #39 were kissing on the lips. Both residents were separated then showered. No evidence was found of documentation of any of these incident's in Resident #39's medical record. In an interview with the Director of Nursing (DON), on 02/22/17 at 2:06 p.m., the DON agreed the incidents of sexual abuse should have been documented in Resident #39's medical record. e) Resident #26 The following incidents of sexual abuse were recorded in the alleged perpetrator's (Resident #62) medical record, but were not reflected in Resident #26's medical record: On 10/06/17 at 10:06 a.m., in nursing notes Resident #62 found reaching for the crotch of Resident #26. Again at 18:47 (6:47 p.m.) found Resident #62 reaching for the crotch of Resident #26 and residents were separated and continued to follow. No evidence was found in Resident #26's medical record of this event. In an interview with the Director of Nursing (DON), on 02/22/17 at 2:06 p.m., the DON agreed the incidents of sexual abuse should have been documented in Resident #39's medical record. f) Resident #51 Confidential interviewees (CI) #3 and CI #4, in separate interviews, both said they had witnessed Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to whomever was the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she has seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informs the nurse whenever this occurs. An incident report was reviewed dated 12/08/16. According to the incident report, Resident #51 sat in a recliner chair by the nurses' station, when male Resident #62 pulled up her shirt and fondled her breasts and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. Review of the nurse progress reports found no documentation about this 12/08/16 incident between the two (2) residents, nor of notification of the responsible party, nor of notification of the physician. Review of the medical record on 02/28/17 found the medical record was silent for reports that she was inappropriately touched by male residents. g) Resident #49 Confidential interviews were obtained with CI#1, CI#2, CI#6, CI#10, and CI#11 in separate interviews. All five (5) said they had witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to whomever was the nurse in charge at the time of those events. CI #1 said that male Resident #11 and male Resident #62 were both removed from Resident #49 on 02/20/17. She said other staff separated the residents, and she did not witness it herself. She said the 02/20/17 incidents were the first time she had ever heard anything about Resident #49 being touched inappropriately. CI #2 said Resident #62 wheels his wheelchair through the hallway, and goes real slow when he sees a female resident. She said she has heard handicapped Resident #49 holler, then found Resident #62 with his hands between her legs. She said she was aware that Resident #11 has touched Resident #49 inappropriately over her clothing. She said she reports inappropriate touching to the nurse in charge whenever it occurs. CI#10 said she had seen male Resident #11 put his hands on Resident #49's inner thighs and her crotch area many times. She said Resident #49 generally sat at the nurses' station in her wheelchair, but no one paid any attention to her. 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. Review of the medical record on 02/28/17 found it was silent for reports of inappropriate touching of this resident by male residents. h) Resident #24 CI #11 said that once over a month ago she saw male Resident #62 sitting in his wheelchair next to Resident #24's bed. She said the resident's covers were off of her, and she acted scared to death. She said Resident #24 clenched her hands into fists and held them beneath her chin, with her elbows bent and her arms covering her chest area. She said Resident #24 shook because he scared the crap out of her. She said she heard Resident #24 tell him to leave. CI #11 said she reported this to the nurse in charge at the time. Review of the medical record on 02/28/17 found it was silent for reports of inappropriate touching of this resident by certain male residents. i) Resident #37 CI #4 said she had seen male Resident #62 inappropriately touch Resident #37. She said she always reported the inappropriate behaviors to the nurse in charge. CI #5 said she had seen Resident #10 snuggle up next to Resident #37 in the solarium, and run his hand up her leg. She said this happened just a short while back. Review of the medical record on 02/28/17 found it was silent for reports of inappropriate touching of this resident by certain male residents. j) Resident #1 CI #11 said she had seen Resident #52 touch Resident #1 inappropriately. She said she had seen him rub Resident #1 on her legs and inner thighs. When she saw him do that, she told him he could not do it and made him leave. She said she reported this to the nurse in charge at the time. Review of the medical record on 02/28/17 found it was silent for reports of inappropriate touching of this resident by a male resident. The DON agreed there was an absence of documentation in the nurse progress notes related to these episodes of inappropriate touching. | 2020-02-01 |