cms_WV: 5701
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 5701 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2015-01-29 | 282 | E | 0 | 1 | WCKU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, and staff interview, the facility failed to implement the interventions established in care plans for four (4) of nineteen (19) residents whose care plans were reviewed in Stage 2 of the survey. Resident #75 and Resident #132 did not receive showers as directed by the care plan. Resident #54 did not have her vital signs taken before and after her [MEDICAL TREATMENT] treatments as directed by the care plan. Resident #137 did not have interventions implemented in accordance with his care plan when the resident refused care. Resident identifiers: #75, #54, #137, and #132. Facility census: 108. Findings include: a) Resident #75 During Stage 1 of the Quality Indicator Survey, at 1:47 p.m. on 01/19/15, the resident was asked, Do you choose how many times a week you take a bath or shower? The resident replied, They don't tell me when I am getting a shower. I am supposed to get two (2) a week, but I don't know when they are scheduled. Medical record review revealed Resident # 75 was scheduled to receive showers twice a week on Tuesdays and Friday on the 7-3 shift. Review of the care plan identified the resident had a self-care deficit related to cognitive impairment, muscle weakness, visual impairment, and shortness of breath at times. The goal regarding this was for the resident to continue to participate in activities of daily living (ADLs), continue to be independent to supervision only with ADL functions and to have a neat, clean well groomed appearance, be appropriately dressed, be odor free, and needs met daily. An intervention was, Baths and showers per schedule and when necessary (PRN). Skin checks, shower, shampoo hair, nail care and lotion PRN. Review of the medical record for (MONTH) 2014, found the resident did not receive showers on six (6) of nine (9) scheduled days as directed by the care plan. Review of the (MONTH) (YEAR) documentation found the resident did not receive a shower on four (4) of seven (7) scheduled days as directed by the care plan. An interview on 01/26/15 at 1:45 p.m., with the DON, confirmed Resident #75 had not received her showers as directed by the care plan. She verified there were six (6) days in (MONTH) 2014 and four (4) days in (MONTH) (YEAR) this resident was not showered as directed in her care plan. b) Resident #54 Medical record review on 01/27/15 revealed Resident #54 had a [DIAGNOSES REDACTED]. Review of the care plan identified the resident currently receiving [MEDICAL TREATMENT] related to end stage [MEDICAL CONDITION]. The goal was resident will attend [MEDICAL TREATMENT] per schedule. An intervention was, Vital signs prior to and after [MEDICAL TREATMENT]. Review of thirty-two (32) [MEDICAL TREATMENT] communication forms dated 11/01/14 to 01/20/15 found the resident's pre and post [MEDICAL TREATMENT] vital signs and other information were not recorded by the facility on twenty-six (26) of the thirty-two (32) days: 11/01/14, 11/04/14, 11/06/14, 11/08/14, 11/11/14, 11/13/14, 11/15/14, 11/18/14, 11/20/14, 11/25/14, 11/26/14, 11/29/14, 12/02/14, 12/06/14, 12/09/14, 12/13/14 12/16/14, 12/18/14, 12/20/14, 12/27/14, 12/29/14, 01/08/15, 01/10/15, 01/13/15, 01/15/15, and 01/17/15. An interview on 01/26/15 at 1:45 p.m. with the DON, confirmed Resident #54 had not had her vital signs taken before and after [MEDICAL TREATMENT] as directed by the care plan. She verified there were 26 of 32 [MEDICAL TREATMENT] days that the resident's vital signs were not obtained as directed in her care plan. c) Resident #137 Observation of the resident during Stage 1 of the Quality Indicator Survey (QIS) at 9:27 a.m. on 01/20/15, found the resident's fingernails were long and dirty, his hair was uncombed, and his face was unshaven. Pieces of egg, served at breakfast, littered the resident's facial hairs, shirt, and bed sheets. At 4:45 p.m. on 01/20/15, the resident remained in the same condition as the 9:27 a.m. observation. At 8:20 a.m. on 01/21/15, the resident was still wearing the same egg stained shirt as the day before and his hygiene had not changed. Employee #32, the resident's nursing assistant was asked why the resident was still wearing the same clothes as the day before, and why he had not been cleaned up. She stated she had tried, but the resident refused care. She said, He wants to do it himself. Review of the nursing assistant activities of daily living (ADL) record found the resident had refused assistance with personal hygiene daily from 01/05/15 to 01/21/15. He had refused to accept assistance with dressing and bathing. At 9:15 a.m. on 01/21/15, the director of nursing (DON) stated the resident refused personal care and he would not let the staff put clean clothes on him. She stated the resident had capacity and could refuse care, which the facility had documented on the care plan. Review of the resident's current care plan, revised on 09/17/14, found the problem: Resident exhibits behavior: resists care or treatment as noted by cursing, yelling at staff, refusal of medications, labs and to be cleaned up, have clothes changed, keeps personal belongings on the floor etc. Combative and has struck CNA (certified nursing assistant) staff in the past as well as swung at lab tech. (technician). The goal associated with this problem was, Resident will have no behaviors as noted by no episodes of cursing/threatening staff or attempting to hit staff during care or refusing care including ADLs medications and meals 4 out of 7 days per week thru next review. Interventions associated with the problem and goal included: -- Divert resident by giving alternative objects or activity, -- Document interventions and resident's response, -- If resident refuses care, leave resident and return in 5-10 minutes and re-attempt. Do not argue with resident, advise residents staff nurse of refusals, -- Listen to resident's needs and adjust plan as appropriate, Notify social services with behaviors. At 11:30 a.m. on 01/22/15, the social services director, Employee #128, the author of the care plan indicated she would look for supporting documentation to show the implementation of the care plan interventions. She said she would return later with the information. At 2:00 p.m. on 01/22/15, Employee #128 said she had read the nurses' notes and could not find anything to support the interventions taken when the resident had refused care. d) Resident #132 1. At 2:00 p.m. on 01/19/15, Resident #132 was asked if she was able to choose how many times a week she took a bath or shower. She replied, No I have only had one (1) shower the entire time I have been here. She further indicated her daughter had called and talked to the staff about it the previous week, but it did not do any good because she still had not received a shower. Observations of Resident #132 made at this time revealed her hair appeared to be unclean and oily. 2. A review Resident #132's medical record at 1:48 p.m. on 01/22/15 revealed Resident #132 was initially admitted to the facility on [DATE]. She remained in the facility until 10/08/14 when she was discharged to the hospital. Between 09/23/14 and 10/08/14, Resident #132 was scheduled to receive a shower on 09/25/14, 09/29/14, 10/02/14 and 10/06/14. A review of Resident #132's Activities of Daily Living (ADL) record for 09/23/14 through 10/08/14 revealed Resident #132 received a shower on 10/02/14 and did not receive her other three (3) scheduled showers. There were no documented shower refusals for Resident #132 during this period. 3. Resident #132 was readmitted from the hospital to the facility on [DATE]. She remained at the facility until 12/09/14 when she was discharged back to the hospital. Between 10/17/14 and 12/09/14 Resident #132 was scheduled to receive a shower on 10/20/14, 10/23/14, 10/27/14, 10/30/14, 11/03/14, 11/06/14, 11/10/14, 11/13/14, 11/17/14, 11/20/14, 11/24/14, 11/27/14, 12/01/14, 12/04/14, and 12/08/14. A review of Resident #132's ADL record for 10/17/14 through 12/08/14 found Resident #132 only received a shower on 11/10/14. The ADL record indicated Resident #132 had refused a shower on 11/6/14, 11/13/14, 11/20/14, 12/01/14, 12/04/14, and 12/08/14. Therefore, Resident #132 only received one (1) shower, on 11/10/14, during this period. The facility did offer showers on six (6) other occasions, which the resident refused. Resident #132 was not showered, nor offered a shower on the remaining seven (7) scheduled shower days. The documented refusals on 11/13/14 and 12/01/14 indicated the resident had requested to have a shower in the morning (11/14/14 and 12/02/14) there was no evidence the staff offered to shower Resident #132 on the morning of 11/14/14 and 12/02/14. 4. Resident #132 came back from the hospital to the facility on [DATE]. She remained at the facility until 12/22/14 when she went back to the hospital. Between 12/11/14 and 12/22/14, the facility scheduled Resident #132 to receive a shower on 12/15/14 and 12/18/14. A review of Resident #132's ADL record for 12/11/14 through 12/22/14 revealed Resident #132 refused both scheduled showers during this period. Documentation indicated Resident #132 refused her shower on 12/18/14 because she had been out of the facility to a doctor appointment and did not feel like taking a shower. There was no evidence to support facility staff offered to shower Resident #132 on any other days during this period. 5. Resident #132 returned to the facility from the hospital on [DATE] and had no other discharges at the time of this review. Between 12/30/14 and 01/22/14, the time this review was conducted Resident #132 was scheduled to receive a shower on 12/31/14, 01/03/14, 01/07/14, 01/10/14, 01/13/14, and 01/17/14. A review of Resident #132's ADL record for 12/30/14 through 01/22/14 found Resident #132 received a shower on 01/13/14. There were no documented refusals of showers during this period. Therefore, Resident #132 received and/or was offered one (1) of her six (6) scheduled showers. 6. A review of Resident #132's care plan revealed the following focus (typed as written): Self-care deficit r/t (related to) recent hospital stay . The goal for this focus was (typed as written): Resident will be clean, dry and well groomed through next quarterly review. One (1) of multiple interventions listed to help achieve this goal was (typed as written): Bed baths daily with showers 2 x's (times) a week and PRN (as needed). Shave and nail care PRN. This intervention had a creation date of 10/02/14. With Resident #132's most recent admitted , being the date this goal was last initiated. 7. The Director of Nursing (DON), in an interview at 1:43 p.m. on 01/26/15, confirmed all resident showers should be documented on the ADL record. The DON reviewed the ADL record for Resident #132 since the resident's admission date of [DATE]. The DON confirmed Resident #132 did not receive her showers as scheduled. She indicated she would have the staff give her a shower today. The DON stated if a resident refused a shower and requested one the next day, the nurse aides should honor that request. She stated the schedule was something the staff went by, but if a resident requested a shower on a different day, the nurse aides were to honor the residents' request. The DON was asked to review Resident #132's care plan related to her self-care deficit. After she had completed reviewing the care plan, the DON confirmed the intervention pertaining to showers was not implemented because Resident #132 was not showered or offered a shower twice weekly during her stay at the facility. | 2018-08-01 |