cms_WV: 7472
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7472 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2013-06-13 | 490 | E | 0 | 1 | TA7B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** ' Based on record review and staff interview, the administration failed to ensure the facility was administered in an efficient and effective manner to maintain the highest practicable physical, mental, and psychosocial well-being of more than a limited number of residents. In the area of resident behavior and facility practices, the facility failed to investigate and report allegations of abuse, neglect, and misappropriation of resident property. In the areas of resident quality of life practices, the facility failed to ensure resident dignity was maintained during the dining experience; failed to maintain a resident's privacy during a physician's visit; failed to ensure resident choices in regard to bathing was upheld; and, failed to ensure the physical environment of the facility was in good repair. In the area of quality of care practices, the facility failed to ensure care and services were provided for the highest well being of a resident; care and treatment was provided to prevent pressure ulcers and the drug regimen of a resident was free from unnecessary medications. In addition, there were system issues in the areas of resident funds, timely physician visits, revision of resident care plans for change of condition, and assistance in scheduling dental appointments in a timely manner. As well, pharmacy recommendations were not addressed by the physician in a timely manner, medications were not available in an emergency, staff were unaware of infection control practices, physicians were not notified of laboratory results, and medical records were not complete and accurate. These isues were identified during the survey from [DATE] through [DATE]. Facility census: 113. Findings include: a) The facility failed to ensure personal funds were available at all times. Resident funds were not accessible to the residents in the evenings or on the weekends. b) The facility failed to ensure the personal privacy of a resident during a physician's visit. The physician examined a resident in the hallway and a progress note was dictated at the nurses' station in front of staff and other residents. c) The facility failed to ensure allegations of mistreatment, neglect, misappropriation of property, and/or abuse were reported and investigated for six (6) of eight (8) residents reviewed. The family of Resident #43 alleged neglect and verbal abuse. Resident #212 and her family alleged neglect. Resident #61 reported a missing wedding band. Resident #145 alleged verbal abuse. The family of Resident #69 alleged physical abuse. The family of resident #116 alleged neglect. There was no evidence any of these allegations were investigated. In addition, five (5) of six (6) of these allegations were not reported. d) The facility failed to provide care in a manner that maintained residents' dignity, self esteem, and /or self worth. Resident #33 was not groomed as she desired. In addition, grooming was not provided the resident in a dignified manner. Resident #10 was not provided dignity during dining. The resident waited a long time for a meal, after the resident seated at the same table received her meal. e) The facility failed to allow two (2) of three (3) residents, who triggered the care area of choices, the right to exercise autonomy regarding what these residents considered important aspects of their lives. Residents #33 and #116 were not allowed the opportunity to make a choice regarding their preferences for showers or tub bathing. In addition, Resident #33 was not allowed an opportunity to choose the days and times preferred for bathing. f) The physical environment was not in good repair. Doors and walls had black marks and scratches on them, ceilings and floors were stained, and door frames were scratched and were missing paint. This practice affected six (6) of thirty-seven (37) rooms observed. Room numbers of affected rooms: #122, #126, #132, #146, #147, #148. g) The facility failed to revise the care plans, for four (4) of twenty-five (25) Stage 2 sample residents, to reflect changes in the residents' conditions. The care plans/interventions for maintenance of weight for Residents #204 and #116 were not revised after they experienced weight losses. Resident #122's care plan was not revised when deep tissue injury developed into a pressure ulcer. The nutritional care plan goals and interventions for Resident #157 were not revised when the resident began receiving hospice services. In addition, the facility failed to develop a care plan, based on the comprehensive assessment, for one (1) of twenty-five (25) residents reviewed in Stage 2 of the survey. Resident #42 had contractures for which therapy was discontinued. The facility did not develop a care plan to assist the resident to maintain her level of functioning after the therapy was discontinued. h) The facility failed to provide necessary care and services for one (1) resident, of a sample of one (1), who triggered the care area of death in Stage 2 of the survey. The facility failed to maintain the emergency supply of [MEDICATION NAME] sulfate in the facility. This medication was ordered for this resident, who was in the active dying process, but was unavailable at the time it was ordered by the physician. i) The facility failed to ensure one (1) of three (3) residents reviewed for pressure ulcers in Stage 2 was provided services to prevent pressure ulcer development. Resident #18 entered the facility without a pressure ulcer and seven (7) days after admission developed unstageable pressure ulcers on both heels. j) The facility failed to ensure residents were free from unnecessary medications for two (2) of ten (10) residents reviewed for unnecessary medications. For Resident #116, the facility administered a PRN (as needed) anti-anxiety medication ([MEDICATION NAME]) without consistently documenting the indications for use, the non-pharmacological interventions provided before administration, and the effects of the medication. This resident was also receiving an excessive dose of [MEDICATION NAME]. The facility failed to ensure the resident's physician addressed the consulting pharmacist's recommendations for a gradual dose reduction and/or the excessive dose of [MEDICATION NAME]. Resident #225 was administered duplicate medications without conformation of the benefits of multiple medications from the same class with similar therapeutic effects. In addition, the consultant pharmacist did not identify this as an irregularity during the monthly medication regimen review. k) The facility failed to ensure the physician was taking an active role in supervising the care of four (4) of ten (10) residents reviewed for unnecessary medications during Stage 2 of the Quality Indicator Survey. physician's orders [REDACTED]. In addition, the facility failed to ensure a newly admitted resident was seen by the physician within the required thirty (30) day time frame after admission to the facility. l) The facility failed to ensure two (2) of four (4) residents, who triggered dental services during Stage II of the Quality Indicator Survey, received dental services for broken and/or damaged teeth. The facility did not follow through with a request from the resident's family for a dental consult for Resident #116 and failed to promptly address Resident #2's need for the extraction of all of her teeth. m) The facility failed to ensure the physician addressed and acted upon irregularities reported by the consultant pharmacist in a timely manner for two (2) of ten (10) residents (Residents #110 and #116) whose medical records were reviewed for unnecessary medications during Stage II of the Quality Indicator Survey. In addition, the consultant pharmacist failed to identify and report a medication irregularity for (1) of ten (10) residents (Resident #225) whose medical records were reviewed for unnecessary medications. n) The facility failed to ensure safe medication storage and availability of a medication. The emergency supply of liquid [MEDICATION NAME] sulfate was not available when needed for Resident #89. An expired multi-dose vial of purified protein derivative (PPD) was found in the south hall medication refrigerator. Multiple bottles of over the counter medications and vials of insulin were not dated when opened on medication carts on the south hall. o) The facility failed to maintain a system of communication to ensure the prevention of the onset and spread of disease and infection when residents had room changes. The facility failed to update their Patient Information Worksheet (PIW), the communication form used to inform line staff of necessary infection control practices, when a resident was moved from one room to another. In addition, the facility failed to ensure all staff members were aware of, and adhered to, the visual methods of determining what type of precautions were necessary prior to entering a resident's room. p) The facility failed to ensure the physician was notified of laboratory results for one (1) of twenty-five (25) sampled residents who was receiving a medication which required monitoring for therapeutic levels of the medication. Resident #86 The resident had been receiving [MEDICATION NAME] ([MEDICATION NAME] sodium) 500 mg by mouth twice daily for behaviors since [DATE]. A Vallproic Acid ([MEDICATION NAME]) level was done on [DATE], and reported as:28 with a reference range of (50 - 100). It was to be re-checked every 6 months. There was no evidence the physician received and/or reviewed the laboratory results. q) The facility failed to ensure three (3) of five (5) employee personnel records reviewed contained the information as required. Two (2) employees, who were hired between [DATE] and [DATE], Employees #2 and #52, did not have evidence of a pre-employment physical in their personnel file. In addition, one (1) employee, Employee #148, had no job description for the position which the employee held. r) The facility failed to ensure the completeness and/or accuracy of the medical records within acceptable professional standards for nine (9) of twenty-five (25) sample residents. Resident identifiers: #225, #122, #204, #175,#75 #42, #4, #86, and #174. | 2017-04-01 |