cms_WV: 7390
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
7390 | ROSEWOOD CENTER | 515105 | 8 ROSE STREET | GRAFTON | WV | 26354 | 2013-08-15 | 152 | D | 0 | 1 | PDFH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to ensure a legally appointed healthcare decision-maker was in place for a resident the facility decided was unable to make her own health care decisions. This was found for one (1) of thirty-two (32) Stage 2 sample residents. Resident identifier: #2. Facility census: 62. Findings include: a) Resident #2 This resident's medical record was reviewed on 08/13/13 at 1:07 p.m. While reviewing the record, it was noted there were inconsistencies related to who was making healthcare decisions for this resident. This [AGE] year old resident was admitted to the facility on [DATE], transferred to another facility on 11/29/11, and was subsequently readmitted on [DATE]. Her [DIAGNOSES REDACTED]. She was determined by a physician to lack the capacity to make informed medical decisions on 06/28/13. Her Brief Interview for Mental Status (BIMS) score, as assessed on 07/02/13, was 14, indicating she was cognitively intact. (The highest possible BIMS score is 15.) An interview was conducted with the social worker (SW), Employee #18, on 08/14/13 at 9:29 a.m. She confirmed Resident #2 was determined to have capacity at the facility where she resided prior to her admission. The resident was determined to possess the capacity to make informed healthcare decisions by a physician. The SW said the resident had acted as her own decision-maker there. According the SW, since the resident was determined to lack capacity to make healthcare decisions upon her admission, a person needed to be selected to make health care decisions on the resident's behalf. An appointment of a Health Care Surrogate was necessary, but had not been completed. The resident's cousin was willing to assume this responsibility according to the social worker. In the meantime, Resident #2's choices related to refusal of care and other treatment were documented as being followed without question or counseling regarding the impact of those decisions, even though the facility had determined she was unable to make healthcare decisions for herself. Her cousin had already signed all consents and admission documents authorizing the facility to admit and treat Resident #2, although she had no legal basis for doing so. The administrator, Employee #33, was interviewed on 08/14/13 at 4:12 p.m. The situation regarding the lack of any legal authority to make medical decisions for Resident #2 was discussed. She confirmed Resident #2 was determined by her physician to lack the capacity to make medical decisions upon admission, but there was still no documented legal designation of any other person to make decisions on her behalf. The resident's cousin was permitted to sign all the admission documents and consents without the authority to do so. This had been the situation from admission on 06/27/13, until it was identified during the survey on 08/14/13. | 2017-05-01 |