cms_WV: 5644
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5644 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 154 | D | 0 | 1 | DSPZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, family interview, and staff interview, the facility failed to ensure the responsible party of a resident with a severe decline in health status was given information about the resident's reasonable available alternatives; including the option of palliative care. Resident identifier: 98. Facility census: 99. Findings include: a) Resident #98 A review of the clinical record revealed Resident #98 was a [AGE] year-old male initially admitted to the facility on [DATE]. He was determined by his physician to lack the capacity to make health care decisions and his brother was his medical power of attorney (MPOA). Resident #98 was designated to be a Full Code, meaning he was to be resuscitated should he stop breathing or his heart stop. His present [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED].#217 at 10:15 a.m. on 07/22/15. The resident had multiple hospitalization s in (YEAR). When discharged to the hospital on [DATE], his skin was clear with no pressure ulcers. On readmission on 04/02/15, his admission physical indicated [MEDICAL CONDITION] of his lower extremities, but no evidence of pressure ulcers. A Significant Change comprehensive assessment was completed on 04/09/15. An entry in the clinical record by NP #217 on 05/21/15, indicated the resident had multiple unstageable pressure wounds. His last readmission was 07/08/15 and although there was no terminal [DIAGNOSES REDACTED]. The record on readmission indicated Resident #98 was a Full Code. The record indicated Resident #98 now had 1 unstageable and 11 deep tissue injuries (DTIs) and the treatment goal stated by the NP/Physician was, Expectation is for non-healing with goal to prevent worsening of wounds. The care plan meeting notes from 07/19/15, indicated he was a full code; had recent cognitive changes and scored 0/15 on his brief interview for mental status (BIMS); and was refusing oral intake. There was no evidence of any discussion of the resident's status with the MPOA. During an interview with the resident's brother/MPOA at 9:35 a.m. on 07/21/15, he said he knew the resident had been getting worse for the past few months. When asked what the plan of care was at present, he stated they wanted him to eat more and be able to get out of bed more. The resident, observed during the conversation was very frail and thin, with pale skin. He was lying on one side with his knees drawn up. He was awake but did not respond when spoken to. During an interview with Social Worker (SW) #145 at 2:00 p.m. on 07/23/15, she was asked if there had been a discussion with the MPOA about changing the code status, or about the use of palliative care or Hospice when the resident's health status deteriorated. She stated she had no knowledge of this and referred to SW #154, who was unavailable at that time. At 10:50 a.m. on 07/27/15, SW #154 was interviewed and also asked the same questions. She stated she had spoken to the MPOA and he had refused hospice, but would have to review her notes. At 11:45 a.m. SW #154 returned after reviewing the record and stated she had been unable to find written evidence of the MPOA being informed of available palliative or hospice care. At 4:30 p.m., on the same day, SW #154 stated she had informed the resident's brother/MPOA of the option of hospice/palliative care and had entered it into the record. | 2018-09-01 |