cms_WV: 4788
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 4788 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2016-01-20 | 226 | F | 0 | 1 | V5RK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, medical record review, policy review and review of the Affordable Care Act (ACA) guidelines, the facility failed to operationalize abuse/neglect policies and procedures for screening, training, identification, prevention, and investigating allegations of abuse and neglect for three (3) of nine (9) residents reviewed. The facility failed to thoroughly investigate allegations of neglect for Resident #77. The facility failed to identify an allegation of neglect and protect a resident after an allegation of neglect was made by Resident #48. The facility failed to ensure Resident #14 was free from abuse. Resident #14 was involuntarily secluded from other residents and activities. The facility failed to report an allegation of neglect to State agencies for Resident #106. In addition, they failed to operationalize screening policies and procedures to ensure completion of a fingerprint based criminal background check for one (1) of ten (10) employee personnel files reviewed. These practices had the potential to affect all residents in the facility. Resident identifiers: Resident #14, #48, #77, and #106. Facility census: 81. Findings include: a) Resident #48 During a Stage 1 interview, on 01/19/16 at 11:53 a.m., Resident #48 related he felt like staff did not want to come to his room at times. He related he believed he had been verbally abused. The resident said the incidents occurred more than once over the past couple of months. Resident #48 also related he felt like some of the staff got rough with him, because they had to provide care for him. Additionally, the resident related he had been left in urine and poop and not enough staff was available. He related the licensed practical nurses or registered nurses would answer the call bell, but would not provide care, and he had to wait for thirty (30) minutes. He further added, It gets old. The resident related he told the supervisor. Upon inquiry, Resident #48 related he told Social Worker (SW) #76. The minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/20/15, reviewed of 01/14/15 at 8:08 a.m., revealed a brief interview for mental status (BIMS) score of 14, indicating Resident #48 was cognitively intact. The highest attainable score was 15. Further review revealed he was totally dependent upon staff for bed mobility, transfer, toileting, personal hygiene and bathing. Concern/complaint/grievance forms, and reportable allegations, reviewed on 01/13/15, revealed no evidence the facility had filed a concern or allegation on Resident #48's behalf. During an interview with SW #76 on 01/19/16 at 11:53 a.m., she related Resident #48 often called her into his room as she was walking down the hall. The SW said the resident complained that his alarm would go off and he would have to wait for a long time. She related the resident told her he felt like staff did not want to come in there at times. SW #76 related the resident told her he had been left in urine and feces, but denied neglect, and did not want it reported. She related, I told him, now you know I have to report this, are you sure? The social worker related she would review tapes and interview staff. On 01/19/2016 2:45 p.m., another interview with SW#76, revealed the SW tried to determine what actually happened with an incident prior to reporting the incidents. SW #76 related if a concern/complaint/allegation was made, she would say to the staff, This is what I was told and then she would try to determine what actually occurred, and if she deemed it reportable, she would report it. During an interview with Resident #48, on 01/20/16 at 8:35 a.m., the resident related the social worker had not visited him this week (Monday, Tuesday or Wednesday.) He related he was not notified of the outcome of the concerns/allegations he had reported. A follow-up interview with SW #76 on 01/20/16 at 3:30 p.m., confirmed no reports had been filed related to Resident #48's concerns, and was unable to provide evidence the concerns had been investigated. A review of a reportable allegation, on 01/13/16 at 3:20 p.m., revealed a note dated 11/21/15 at 7:14 p.m., and signed by Licensed Practical Nurse (LPN) #93. The report indicated a family member had reported to LPN #101 that Resident #77 was out of the facility. Staff immediately contacted (local) Police Dept. and began searching in and out of the facility. LPN #95 and minimum data set (MDS) Nurse #78 reviewed the cameras, which indicated the resident was last seen walking toward the water tower and up the hill behind the nursing home at 11:24 a.m. Inspection of the courtyard revealed knee prints, and wires that were holding the fencing together to the pole were untwisted. The physical area was fixed to prevent further elopement. The report did not indicate what time the resident was reported as missing, nor staffs lack of awareness the resident was missing. The immediate fax reporting of allegation form indicated the time of the incident as 11:24 a.m. on the 400-hall west side courtyard. The reports indicated a search was initiated in side and out-side of the facility, and was found about one (1) mile away, heading back towards the facility. The form did not indicate the time the search was initiated, not the time the resident was found. An interview with Licensed Practical Nurse #93 (LPN), on 01/13/16 at 3:59 p.m., revealed Resident #77 had eloped under the fence in the courtyard near the administrator's office. The LPN related another nurse had called and related someone had seen the resident, and the facility transported him back. When asked how the facility identified how the resident eloped, the LPN related staff had watched the cameras. LPN #77 related she could not remember whether staff completed witness statements related to the event. LPN #93 related the 911 emergency line, and the police were called to make sure the resident was safely found. LPN #93 reviewed the medical record and confirmed the record did not indicate at what time the resident was reported missing, nor the time of his return. She related she could not remember. Further inquiry, revealed she was the unit charge nurse at the time of the incident. The LPN related staff had not reported an inability to locate the resident prior to the family notifying the facility. LPN #93 related she was unaware of any follow-up intervention related to staff oversight of residents. The nurse indicated staff had not reported the resident as unavailable during smoke breaks or for lunch. An interview with the 911 center, on 01/19/16 at 1:29 p.m., revealed the facility called in the elopement at 15:06 (3:06) p.m. on 11/21/15. Upon inquiry as to who completed the investigation, LPN #93 related she believed the social worker was responsible. Additionally, interviews, with the Activity Director (AD) on 01/12/16 at 2:42 p.m. and Registered nurse #18 (RN), on 01/13/16 at 9:50 a.m., also revealed the social worker completed investigation of abuse and neglect when she returned to work. On 01/13/16 at 8:40 a.m., review of the abuse and neglect policy, located in a binder at the nurses ' station, revealed the chain of command was to report to the immediate supervisor, and the facility would take whatever measures were necessary to protect the victim. It indicated the facility would review the work schedule and identify staff who had worked up to 72 hours prior to the event and each employee would be questioned individually. A form indicating the date, time reported, response and description of abuse was to be placed under the door of the social worker or administrator. An interview with Social Worker #76 (SW), indicated the incident occurred on a weekend. She related the director of nursing would have been notified first, and a registered nurse supervisor (RN #18) was present and informed her. She further related the facility fixed the areas right then and there. The SW related the fence was relatively new and was built as a non-smoking area. During another interview with SW #76, on 01//14/16 at 9:29 a.m., the SW related the facility was not aware Resident #77 had been a flight risk. She did relate, however, the resident had blamed her and said she was keeping him hostage at the facility. SW#76 reviewed the reportable allegation and related she believed the resident returned to the facility earlier than the note, which was dated and times as 11/21/15 at 7:14 p.m. When asked how long the resident had been missing prior to staff's awareness, the social worker related she did not know. Further review of the medical record, on 01/14/16 at 9:51 a.m., revealed [DIAGNOSES REDACTED]. The brief interview for mental status (BIMS) score was eleven (11) which indicated cognitive impairment. The immediate five (5) day follow-up completed by SW #76 noted, Resident was/did elope from facility while staff not watching. Resident was found by staff and brought back to the facility safe with only minor redness and scrapes . The social worker confirmed no evidence was present to indicate staff were interviewed, or the incident had been thoroughly investigated to ensure the resident had been adequately supervised at the time of the elopement. c) Resident #14 During a stage one interview, on 01/11/16 at 12:55 p.m., Resident #14 related he only participated in his rooms. The resident related he was told he had an infection and could not go outside of his room for activities. The carbapenem resistant [MEDICATION NAME] (CRE) policy, reviewed on 01/12/16 at 2:59 p.m., revealed the purpose was to prevent transmission ., and to ensure compliance with federal and state regulations .according to centers for disease control (CDC) guidelines. The policy also indicated isolation would be discontinued after completion of antibiotic therapy, then in thirty (30) days, three (3) consecutive cultures obtained from the source of infection and results were negative, unless otherwise advised. A physician's orders summary, dated 12/29/15, reviewed on 01/12/16 at 3:30 p.m., revealed an order for [REDACTED]. Review of the care plan, on 01/12/16, at 4:00 p.m. revealed a focus, initiated on 06/19/14 related to isolation precautions due to Resident #14 had a history of [REDACTED]. Interventions indicated gloves would be worn upon entry of the room, and other PPE would only be required if substantial contact with resident expected. An interview with the infection control preventionist, Licensed Practical Nurse (LPN #106), on 01/13/16 at 10:02 a.m., revealed she utilized the CRE toolkit and the CDC had been contacted when Resident #14 was admitted to the facility. The nurse related one infectious disease specialist indicated the resident should be kept in isolation indefinitely; and the other specialist indicated the resident could be removed from isolation in (MONTH) of (YEAR). LPN #106 related Resident #14 would sometimes have a home pass, had a catheter, and knew how to wash his hands. She related the medical director did not feel comfortable allowing the resident out of his room, and had continued contact precautions, including segregation from other residents. LPN #106 related Resident #14 had acquired CRE prior to admission, and contact precautions were implemented immediately, and had never been out of isolation, since admission on 06/17/2014. The nurse related the infectious disease specialist was contacted and had told the facility, There was no reason for the resident to return to his office. Progress notes, reviewed from admission to current, revealed notes dated: --06/19/14, which indicated .Contact isolation precautions continue d/t (due to) CRE in urine .New orders to schedule appointment with infectious disease specialist for further treatment instructions of CRE. Resident to remain in isolation until cleared by the infectious disease doctor per the medical director. --07/14/14 progress note indicated the resident was out of facility with EMS (emergency medical service) to an appointment with Infectious Disease Specialist #1 (IDS#1). The resident returned to the facility with an order for [REDACTED].#1. --07/16/14 progress note indicated the physician had spoken with IDS#1 and the specialist had recommended the resident remain in isolation while in the facility due to his history of CRE, VRE and [MEDICAL CONDITION]. --07/30/14 progress note indicated Resident #14 attended an appointment scheduled with IDS#2 for a second opinion, and indicated IDS#2 recommended the resident continue contact isolation for six (6) more months. --08/05/14 note indicated the LPN #106 contacted the CDC for recommendations, to no fruition, and a note dated 08/06/14 indicated the facility received an email from the CDC noting, No recommendation can be made regarding when to discontinue contact precautions. --11/14/14 physician's order note indicated a urine culture and sensitivity (C&S) result indicated, No VRE,[MEDICAL CONDITION] or CRE identified. --01/23/15 health status note indicated Resident #14 had an appointment with IDS#2, who recommended the resident remain in isolation until (MONTH) (YEAR) and follow up as needed. --03/25/15 - a plan of care note indicated the social worker was to monitor Resident #14's adjustment to being placed in isolation and not having enough social contact. Resident will remain in isolation until 06/01/15. --06/17/15 nursing note indicated the facility physician was notified of the IDS#2 recommendation for the resident to be removed from isolation, but the facility physician related he decided to go with IDS#1 .and leave the resident in isolation indefinitely. Urinalysis with culture and sensitivity, obtained on 08/31/15, 11/25/15, and 12/18/15 failed to isolate CRE and/or noted No CRE or VRE isolated. Review of the Facility Guidance for Control of Carbapenem-resistant [MEDICATION NAME] (CRE) (MONTH) (YEAR) Update - CRE Toolkit, indicated, residents with CRE at lower risk for transmission .do not need to be restricted from common gatherings in the facility (e.g. meals, group activities .) An observation and interview, on 01/20/2016 at 8:46:55 AM, with Resident #14 revealed the resident lying in bed, supine position, watching television. A cart was placed outside the door of the room and contained, gowns, gloves, booties, hairnets, upon inquiry as to how the resident felt about staying in his room, he related he sometime left his room in the evenings when no one else was in the hallway - not very often. Related he could not go out anytime he wanted, but did get showers. Resident #14 said it made him, feel bad that he could no go out of his room during times of activities. Further inquiry revealed the resident did not touch his catheter and knew how to wash his hands. An interview with Nurse Aide #27(NA) on 01/201/6 at 8:49 a.m., revealed the resident left his room, once in a while, late at night. The NA indicated the resident used to go outside when no one else was out there, but did not believe he had been out since summer, and said activities were done in his room. The NA related the catheter seldom leaked and the resident knew how to wash his hands. She further added, He is very good at that. An interview with the centers for disease control, on 01/20/16 at 10:42 a.m., indicated residents who were colonized with CRE, and were low risk for transmission, required standard precautions. Upon inquiry, the CDC consultant related it was not necessary for the resident to be confined to his room and referred to CDC guidelines for multi-drug resistant organisms. The consultant also suggested guidance from the state health department for more stringent guidelines imposed by state regulations. An interview with the epidemiologist, on 01/20/16 at 11:16 a.m., also revealed the resident did not require segregation from other residents. He related as long as the resident was negative for CRE, and the secretions were contained, he should not be isolated from other residents. Upon inquiry as to incontinence, the epidemiologist related, if the stool was contained in the brief, the resident should be able to leave his room. Further inquiry revealed a stool culture was not necessary. Another interview with the infection control preventionist, and the administrator, on 01/20/16 at 11:52 a.m., again revealed LPN #106 had referred the Resident #14 to the physician/medical director in (MONTH) (YEAR), requesting the resident be allowed to leave his room, but the doctor did not feel comfortable. She again related IDS#1 had indicated the resident remain in isolation indefinitely and IDS#2 had related the isolation could be stopped in six to twelve (6-12) months, which ended (MONTH) (YEAR). LPN #106 related the doctor had been notified of ongoing negative urine cultures, which the physician had reviewed and signed. Upon inquiry, the LPN related the resident had no un-contained fluids. She related the resident utilized a catheter for urine and a brief for stool. An interview with the physician/medical director, on 01/20/16 at 11:58 a.m., confirmed he had not contacted IDS#1 after the urine cultures returned negative. The physician related the specialist had previously related, Not enough was known about the disease, and related the resident should remain isolated indefinitely. Upon inquiry, the physician related he had not reviewed the (MONTH) (YEAR) CRE update provided by the CDC, and would confer with specialists again. The abuse and neglect policy reviewed on 01/14/16, indicated prevention of abuse was accomplished through education of residents and families as to what constituted abuse and monitor to assure those policies and procedures were implemented. Lastly, the policy noted, One major item to keep in mind during the investigation is to keep the resident protected from any further harm until the problem has been resolved. d) Resident #106 Review of concerns and grievances, on 01/18/15 revealed an allegation dated 11/23/15 by Licensed Practical Nurse #107 (LPN) which indicated a responsible party had called the facility on 11/22/15 alleging abuse of Resident #106. The allegation indicated Resident #106 had not received her medication ([MEDICATION NAME]) and was treated for [REDACTED]. The hospital told me she was overdosed, and you shouldn't (should not) be asking me if she's (she is) confused you should do your job and read through her chart A note, dated 11/23/15 indicated Assistant Director of Nursing #34 (ADON) had called the daughter to request a meeting. No evidence was present to indicate the allegation of abuse had been reported to the appropriate State agencies. An interview with Social Worker #76 (SW) confirmed the event had not been reported to State agencies. She related the director of nursing (DON) had handled it, and that she had not reviewed it. e) Criminal background checks The Affordable Care Act and West Virginia Code Chapter 16, Article 49 required nursing facilities, at a minimum, complete State and Federal fingerprint-based criminal investigation background checks prior to hire. Personnel records, reviewed on 01/13/16 at 1:52 p.m. with Medical Records (MR) #70 revealed no evidence the facility completed a State and Federal criminal background check for Physical Therapist (PT) #108, prior to hire on 10/15/15. A review of the time sheet, on 01//13/16 at 2:55 p.m., confirmed PT #108 had worked on 11/27/15, 12/19/15, 12/24/15, and 01/01/16. An interview with the administrator on 01/13/16 at 3:20 p.m. revealed the contracted company was responsible for completing criminal background checks, and confirmed a fingerprint background check was not completed. f) Policy Review On 01/13/16 at 8:40 a.m., review of the abuse and neglect policy, located in a binder at the nurses ' station, revealed the chain of command was to report to the immediate supervisor, and the facility would take whatever measures were necessary to protect the victim. It indicated the facility would review the work schedule and identify staff who had worked up to 72 hours prior to the event and each employee would be questioned individually. A form indicating the date, time reported, response and description of abuse was to be placed under the door of the social worker or administrator. The facility failed to protect Resident #48 by not identifying his allegations of neglect and not investigating those allegations. The policy further stated, Training .Each employee must understand that it is a requirement by law to report any allegation of abuse, neglect, or misappropriation of a residents property .Each employee is considered a mandated reporter. Prevention: In order to eliminate the possibility of abuse or neglect actually happening, the key item must deal with prevention. Prevention is accomplished by the education of staff, the residents and their families s to what constitutes abuse, neglect, and misappropriation of residents property. In addition to education, we must constantly monitor to assure those policies and procedures are being followed and each of us plays an important role in its implementation. The facility will require all newly hired employees to read and review the patients ' bill of rights and the abuse and neglect policy to ensure that each individual hired is aware of their responsibilities and will follow established policy and procedures . A review of the facility policy revealed the following in regards to screening employees, In order to protect all residents, during the hiring process a newly hired employee will be screened. This will be accomplished through the local law enforcement, state police and other agencies. Once the checks have been completed and show no evidence of abuse or neglect the employee will then be fingerprinted and a background check is then initiated. The employee will be allowed to work until the background check comes back to facility. If the report is unfavorable, the individual will be terminated immediately. | 2019-07-01 |