cms_WV: 647
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 647 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2018-04-26 | 600 | J | 0 | 1 | FJW311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review the facility failed to ensure each resident was free from verbal abuse and neglect. The facility failed to provide timely incontinence care to Resident #119. The resident also tearfully reported being verbally abused by a nurse aide because he had called the nurses' station for help after no one responded to his call bell for thirty (30) minutes. The lack of incontinence care and the verbal abuse caused the resident to experience pain, skin breakdown, and psychological harm. Until the surveyor identified the resident's problems and intervened, staff were not aware of the seriousness of his condition. These findings were determined to constitute immediate jeopardy to Resident #119. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) at 1:25 PM on 04/25/18, and preparation of a written statement, the Administrator and Director of Nursing were notified of the Immediate Jeopardy. The facility provided an acceptable at 4:17 PM on 04/25/18. After verifying implementation of the plan of correction, the immediate jeopardy was abated at 5:26 PM on 04/25/18. No deficient practice remained for this requirement after removal of the immediate jeopardy. This affected one (1) of seven (7) residents reviewed for activities of daily living. Resident identifier: #119. Facility census: 156. Findings included: a) Resident #119 During the initial screening for the Long Term Care Survey Process, an interview on 04/23/18 at 11:37 AM, Resident #119 stated he had a pressure ulcer on his buttock from sitting in urine for 30 minutes or longer. He went on to explain he could not walk, that he tried to use a urinal, but sometimes did not get all of the urine in the urinal. Medical record review found his [DIAGNOSES REDACTED].>- muscle weakness - heart failure - Retention of urine - Type 2 Diabetes underlying condition with hyperosmolarity - Chronic [MEDICAL CONDITIONS] - Obesity - History of pressure ulcers on the right heel and penis According to his minimum data set assessment (MDS) with an assessment reference date (ARD) of ____, his Brief Interview for Mental Status Score (BIMS) was 15, indicating he was cognitively intact. Review of his medical records found no mention of current pressure ulcers. Skin Check Performed Sheets dated from 01/27/18 to 04/23/18 documented the following: - 01/27/18- No Skin Injury/Wounds by Licensed Practical Nurse (LPN) #172 - 02/04/18 -No Skin Injury/Wounds by LPN #92 - 02/10/18- No Skin Injury/Wounds by LPN #172 - 02/17/18- No Skin Injury/Wounds by LPN #92 - 02/24/18- No Skin Injury/Wounds by LPN #172 - 03/03/18- No Skin Injury/Wounds by LPN #92 - 03/10/18- No Skin Injury/Wounds by LPN #172 - 03/17/18 -Yes Skin Injury/Wounds identified No New Skin Injury/Wounds Type of Skin Injury/Wounds Moisture Associated Skin Damage by Registered Nurse (RN) #4 - 03/24/18- No Skin Injury/Wounds by LPN #172 - 04/02/18- No Skin Injury/Wounds by RN #4 - 04/07/18- No Skin Injury/Wounds by LPN #33 - 04/23/18 -No Skin Injury/Wounds by LPN #92 On 04/25/18 at 9:15 AM, Wound Care Nurse #120 agreed to do a complete skin assessment with the surveyor present. On entering the room, Resident #119 was emotional and tearful saying that he was, chewed out, by Nurse Aide #96 for calling the nurses' station with his cell phone. He stated that she told him to only use his call light that was what it was for and not to call the nurses' station again. He said NA #96 told him that he was not the only one on this floor and he just needed to wait his turn. He said he responded by telling her he used the call light and had been waiting for more than 30 minutes before he called the nurses' station with his cell phone because his skin was on fire from sitting in urine. Resident #119 told this to the surveyor, Wound Care Nurse #120, and Nurse Aide #84. With the resident's permission, Wound Care Nurse #120 pulled the sheets back revealing a very large red excoriation on his upper outer thighs. Further investigation found areas of broken skin under his scrotum and coccyx. The resident's tee shirt was saturated with urine up his back and had small amount of stool on the bottom. The resident said NA #96 had changed him, therefore the nurse aide left him with a soiled shirt. Wound Care Nurse #120 removed the resident's tee shirt. When the nurse asked how long his skin had been in this condition, the resident replied it had been a year - that it started after being on this floor for a week. The complete skin audit by Wound Care Nurse #120 found: - 1. Pressure Ulcer Stage II on Coccyx - 2. Pressure Ulcer Stage II on right ear - 3. Excoriated areas bilateral groin, under both breast, bilateral abdominal folds, bilateral upper outer thighs and bilateral calf's. - 4. Reddened area to the right great toe, second and third toes, right heel. During an interview on 04/25/18 at 9:35 AM, Wound Care Nurse #120 stated that he was, Just mortified by what was just discovered, referring to the condition of Resident #119's skin. He went on to say he had no excuse and they had failed this resident. On 04/25/18 at 9:45 AM, the DoN was informed of the findings for Resident #119. She said she was already aware and was working on a plan of correction. On 04/25/18 at 1:10 PM, Resident #119 said that he was still upset over the NA #96 fussing at him that morning and it was not the first time he had had to wait for over 30 minutes for assistance. He went on to say he had called his wife many times to have her call the facility to ask them to help him. The resident's care plan, dated 04/03/17 included a plan for impaired skin integrity due to his psoriasis, Moisture Associated Skin Damage (MASD), and history of pressure ulcers. The interventions were: - Monitor skin for signs/symptoms of skin breakdown i.e. - Observe skin condition with ADL care daily and report abnormalities - Skin check per policy - Weekly skin assessment by license nurse - Weekly wound assessment The facility's policy, NSG236 Skin Integrity Management Effective date 07/01/01, Revision date 11/28/16, directed the staff to continually observe and monitor for skin changes and implement revisions to the plan of care. The purpose, to provide safe and effective care to prevent the occurrence of pressure ulcers and promote healing of all wounds The facility's policy,OPS300 Abuse Prohibition, effective date 06/01/96 Revision date 04/07/17, stated all employees would be trained ongoing to prevent abuse. The facility reported the resident's allegations concerning NA #96 to the Nurse Aide Program at OHFLAC on 04/26/18. These findings were determined to constitute immediate jeopardy to Resident #119. After consultation with the Office of Health Facility Licensure and Certification (OHFLAC) at 1:25 PM on 04/25/18, and preparation of a written statement, the Administrator and Director of Nursing were notified of the Immediate Jeopardy. The facility provided an acceptable at 4:17 PM on 04/25/18. After verifying implementation of the plan of correction, the immediate jeopardy was abated at 5:26 PM on 04/25/18. No deficient practice remained for this requirement after removal of the immediate jeopardy. The Facility's Plan of Correction: On 04/25/18 The RN wound nurse evaluated Resident #119's skin at 3:50 PM, a pain assessment was conducted by RN wound nurse at 3:50 and a Social Worker (SW)/designee will interview the resident on 04/25/18 by 5 PM, to address alleged psychological harm with corrective action upon discovery. The physician was notified of changes at 3:50 PM, by RN wound nurse. On 04/25/18 the center SW reported the allegation of neglect to the appropriate state agencies at 10:44 AM. All residents of the facility have the potential to be affected. The DON/designees will begin to conduct observation of all residents' skin on 04/25/18 with corrective action upon discovery. SW/designees will begin to interview all interview able residents on 04/25/18 to ensure that incontinence care and pain are addressed timely and that residents have not experienced any psychologic harm as evidenced by lack of verbalized fear and be completed by 04/25/18 with corrective action upon discovery. The DON/designees will begin observations of non-interview able residents' skin sweeps on 04/04/25/18 and completed by 04/26/18, including completion of the non-interview able pain evaluation with corrective action upon discovery. The Nurse Practice Educator (NPE)/designee will re-educate all licensed staff on accurate completion and documentation of the weekly skin checks to monitor the patients and his/her wound's response to treatments and interventions beginning on 04/25/18 and all center staff will be re-educated to ensure all center residents are free from neglect, including pain and psychological harm, respond to residents in a timely manner with a post-test to validate understanding beginning 04/25/18. Staff not available during this timeframe will be provided re-education including post-test by the NPE/designee, upon return to work. New hires will be provided education and post-tests during orientation by the NPE/designee. The Unit Managers (UMS)/designee will conduct observation of weekly skin checks, timely response of continence care, pain monitor flow sheets daily for two weeks across all shifts including weekends, then three times a week for two weeks then randomly thereafter to ensure that weekly skin checks are accurate, incontinence care is provided in a timely manner to avoid skin breakdown, and residents pain is addressed based on daily MAR pain evaluation. The SW/designee will conduct sixteen (16) random interviews daily for two weeks across all shifts including weekends, then three times a week for two weeks then randomly thereafter to ensure that residents do not experience any neglect or psychological harm. Trends identified will be reported by the DON monthly to the Quality Improvement Committee (QIC) for any additional follow up and/or in-servicing until the issue is resolved and randomly thereafter as determined by the QIC. | 2020-09-01 |