cms_WV: 7171
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7171 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-07-16 | 152 | D | 1 | 0 | 1X1U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to establish a resident who had been determined to lack the capacity to make health care decisions had a legally appointed individual, appointed under State law, to act on her behalf to help exercise her rights on admission to the long term care facility. This decision applied to one (1) of nine (9) residents reviewed during the investigation of a complaint. Resident identifier: #61. Facility census: 104. Findings include: a) Resident #61 A review of the medical record revealed Resident #61 was a [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital. Her [DIAGNOSES REDACTED]. She also had deep tissue injuries to both feet, right hip, coccyx, both ears, and left hip. The 5 foot 4 inch tall resident weighed 90.2 pounds on admission. Both the physician who discharged the resident from acute care, and the attending physician at the nursing home, who was the resident's prior family physician, determined the resident lacked the capacity to process the information needed to form her health care decisions. A review of the hospital records forwarded to the facility revealed the resident had been referred to Adult Protective Services (APS) on admission to the hospital (07/01/14) because of suspected elder abuse neglect. A Forensic Nurse Examiner Consult completed on 07/02/14, revealed, . patient is confused, does know her name and that she lives in (name of town/city). The Nurse affirmed an APS referral had been made. She also indicated the hospital Social Worker had informed them the resident's Son #1, who was indicated to be the responsible party, had agreed to nursing home placement. Resident #61 was admitted to the facility on [DATE]. The nurses' notes indicated she arrived by ambulance and indicated Son #2 and his wife were notified. There was no evidence of an attempt to contact Son #1, the resident's medical power of attorney (MPOA). The nurses' notes revealed Son #1 was in to visit the resident on the evening of her admission (07/06/14). The nurses' notes revealed the APS worker visited the resident on 07/08/14. During a review of the clinical record for Resident #61, at 9:00 a.m. on 07/10/14, a full-sized red paper was found on the opening of the chart. This document indicate the resident's code status, should her heart or breathing stop, was Do Not Resuscitate (DNR). Further review failed to find documented evidence of a Physician's Orders for Scope of Treatment (POST) form or any document indicating who the legally responsible person was for Resident #61. The resident had been deemed to lack the capacity to form her own health care decisions by the attending physician, who had also written an order for [REDACTED]. During an interview with Employees #119 and #131 (both Licensed Social Workers) at 10:00 a.m. on 07/10/14, they were asked to provide evidence that Resident #61 had a legally appointed health care surrogate. Employee #131 stated the daughter-in-law was making decisions, but she acknowledged the absence of a HCS document. She stated Son #2 and his wife had gone on vacation and said they would take care of that on their return. When asked about the status of Son #1, they stated they had been unable to reach him and he had not contacted them. They were asked about the status of the APS investigation and both acknowledged they had not contacted APS since the resident's admission. They stated the contact had been made at the hospital and they had not heard anything. They were not aware the APS worker had been to the facility to interview the resident. A review of the entire record revealed only one entry of an attempt to reach Son #1 since admission, and it was by the director of nurses (DON) on 07/10/14. At 11:35 a.m. on 07/14/14, Resident #61 was observed meeting her son (Son #1) in the hall next to the South Nurses' Station. Both were happy to see the other and greeted each other warmly. Both were being pushed in wheelchairs. They continued to the dining room and were observed sitting next to each other during the meal, where he stayed to visit her while she ate. During an interview with Employee #131 at 2:00 p.m. on 07/14/14, she stated she had contacted APS and confirmed an investigation was pending. She had also contacted the attending physician who informed her he was the family doctor for both the resident and Son #1, who was also sick. When asked why there was still no evidence of a legally designated responsible party, no Physician's Order for Scope of Treatment (POST) form, or no signed admission forms/consents of any kind on the chart, she stated she had been waiting for Son #2 to return from vacation and had been unable to reach Son #1. She also pointed out the front sheet on the record had been changed and Son #2 and his wife were no longer entered as HCS designees. Review of the medical record on 07/14/14, revealed Employee #131 had contacted APS at 12:06 p.m. on 07/10/14 as stated. A note written by Employee #131 at 1:34 p.m. on 07/10/14, stated, SS (social services) spoke with resident's physician who stated that he has MPOA (Medical Power of Attorney) paperwork on resident. At 2:20 p.m. on 07/14/14, Employee #131, accompanied by the DON, produced a HCS form dated 07/07/14 and signed by Son #2 on 07/14/14 (today) appointing him HCS. She also had a copy of the MPOA form dated 07/03/2012 naming Son #1, which, per the time stamp, had been received via fax at 12:29, on 07/10/14. Employee #131 stated she had called a local attorney and he said if they could not reach the MPOA, the physician could revoke the MPOA due to the neglect allegation made to APS and re-assign the HCS to Son #2 because he was the successor representative on the MPOA document. The DON had no comment when informed Son #1, accompanied by his son, was in earlier and visited with the resident throughout lunch. Employee #131 did agree there had been no information from APS confirming the allegation investigation had been completed and/or substantiated; and there was no evidence of documentation by the physician of revocation of the MPOA, although he had signed the HCS form on 07/07/14. During an interview with Employee #131, the Administrator, and the DON at 2:15 p.m. on 07/15/14, the Administrator reported they had contacted Son #1 and he had immediately come into the facility and informed them he intended to remain the MPOA. He also authorized a DNR status for the resident. They acknowledged the resident had been in the facility since 07/06/14 (9 days) without a legally appointed responsible party. | 2017-07-01 |