cms_WV: 5099
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5099 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2015-04-10 | 152 | D | 0 | 1 | CRGX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, the West Virginia Health Care Decisions Act, and staff interview, the facility failed to ensure residents' health care surrogate appointments were completed and implemented in accordance with State law. For Resident #66, the physician's determination of capacity failed to include the reason for the incapacity, the expected duration of incapacity, and evidence the resident was informed of who would be making her decisions. For Resident #21, the facility allowed a person who was not appointed as the health care surrogate to complete advance directives for the resident. This was found for two (2) of two (2) residents while reviewing for participation in planning care. Resident identifiers: #66 and #21. Facility census: 66. Findings include: a) Resident #66 At 11:10 a.m. on 04/06/15, during stage 1 of the Quality Indicator Survey (QIS), Resident #66 stated she did not have any input into her care at the facility. She did not understand why the facility was allowing her daughter to make medical decisions for her. The resident stated she did not want her daughter involved, because she could speak for herself. She gave the following example: I had a feeding tube. I had been eating for months by mouth, eating food that looks like baby food. I wanted my feeding tube removed and they didn't listen so I took it out myself a few weeks ago. Review of the medical record, on 04/07/14, found the resident's daughter was appointed the resident's health care surrogate decision maker on 12/09/12 during a hospitalization . This form indicated the appointment was temporary and was the result of a [MEDICATION NAME] hemorrhage. Record review, on 04/07/15, found the facility's physician completed a determination of capacity on 02/05/13, after the resident was admitted to the nursing home. The capacity statement noted the resident lacked capacity to make medical decisions. The nature of the incapacity and the [DIAGNOSES REDACTED]. The form indicated the resident was to be informed of the person who would be making health care decisions for her during her incapacity. This information was not documented on the incapacity form. The resident's last full minimum date set (MDS), with an assessment reference date (ARD) of 02/05/15, found the resident's score on the brief interview for mental status (BIMS) was a fifteen (15), the highest possible score, indicating she was cognitively intact. The resident's initial admission MDS, with an ARD of 02/02/13, found the resident's score on the BIMS was a six (6), indicating severe impairment. The medical record contained no further evaluations of the resident's capacity, since the 02/05/13 evaluation. A progress note entered in the medical record by the activity director on 02/25/15 found, . She is becoming more independent in communicating her needs and decisions daily. At 2:30 p.m. on 04/07/15, the social worker, Employee #59, verified the 02/05/13 physician's determination of capacity was the only one completed since the resident was admitted . When asked if the facility had completed the determination of capacity as directed on the form, Employee #59 replied, No. The West Virginia Health Care Decisions Act, 16-30-7, of the West Virginia Legislative Code requires: . (b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. (c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decision-maker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED].> b) Resident #21 On 04/06/15 at 11:04 a.m., during an interview with the resident's husband, who was appointed as her medical power of attorney (MPOA), the MPOA said staff did not inform him of his wife's condition. The MPOA became visibly upset when discussing the matter. The MPOA stated, The facility staff thinks I have no sense, they always call our daughter instead of telling me Review of Resident #21's medical record, on 04/07/15 at 2:30 p.m., revealed Resident #21 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On 06/13/13, the attending physician determined Resident #21 lacked the capacity to make informed medical decisions. Further record review found a State of West Virginia Medical Power of Attorney (MPOA) completed on 05/09/11. According to that document, Resident #21 appointed her husband as her representative to act on her behalf to give, withhold, or withdraw informed consent regarding health care decisions. On admission to the facility, the facility allowed the resident's daughter to sign all admission documents, including the Physician order [REDACTED]. An interview with Employee #42, Director of Admissions (DOA) and Employee #59, Social Services (SS), on 04/08/15 at 1:15 p.m., confirmed Resident #52's husband was her MPOA and should have completed her admission papers. They further confirmed the husband should be informed of the resident's condition. | 2019-03-01 |