cms_WV: 7617
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 7617 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2013-03-13 | 280 | E | 0 | 1 | 0BYS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of medical records, the facility's interdisciplinary team failed to periodically review and revise residents' care plans to address changes in their conditions and needs. Two (2) residents care plans were not updated to reflect their discharge plans, one (1) was not updated after an infection ([MEDICAL CONDITION]) had resolved, one (1) was not revised after the resident no longer needed a divided plate and special utensils, one (1) was not revised after a deep tissue injury had resolved, one (1) was not updated after the resident no longer used hyperglycemic and [MEDICAL CONDITION] medications, and one (1) was not revised after a deep tissue injury had resolved and therapy had recommended devices to prevent further skin issues. Six (6) of twenty-nine (29) residents on the Stage II sample were affected. Resident identifiers: #21, #67, #65, #104, #40, and #39. Facility census: 65. Findings include: a) Resident #21 Review of medical records, on 03/07/13 at 9:30 a.m., revealed this resident was admitted on [DATE]. The discharge plan on admission was for the resident to return to an assisted living facility in which the resident had resided prior to hospitalization . The plan was for this to occur within ninety (90) days. The quarterly care plan, dated 02/28/13, found a goal and interventions in which resident would be discharged within ninety (90) days after admission to the facility to an assisted living facility. An interview, on 03/07/13 at 10:00 a.m., with Employee #86, the social worker, confirmed the discharge plan had not been revised to indicate the resident's current discharge plan. She further stated, The resident had not progressed as expected in therapy and the resident's family had decided her stay at the center would be long term. b) Resident #67 1) Review of the care plan, on 03/07/13 at 2:05 p.m., revealed a care plan had been created on 12/27/12 related to a [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#67 received antibiotic treatment for [REDACTED]. Review of the care plan, on 03/07/13 at 2:20 p.m., revealed the care plan had not been revised when the resident no longer needed a care plan for [MEDICAL CONDITION]. An interview, on 03/11/13 at 2:30 p.m., with Employee #65, the director of nursing (DON), confirmed the care plan for Resident #67 related to [MEDICAL CONDITION] had not been revised to discontinue the care plan since treatment was completed. Resident #67 did not show any signs or symptoms requiring further treatment. 2) During review of the medical record for Resident #67, on 03/11/13 at 10:00 a.m., it was discovered she had a deep tissue injury to her right buttocks. Further review of the medical record identified the deep tissue injury had healed on 12/27/12. Review of the care plan found it had not been revised to reflect the wound had healed. On 03/06/14, at 10:14 a.m., Employee #65 (director of nursing) confirmed the wound had healed on 12/27/12 and the care plan had not been revised. c) Resident #65 During observations of the lunch meal, on 03/11/13, this resident was observed being fed by a staff member. Review of the care plan, on 03/11/13, at 2:00 p.m., identified the resident had interventions in place including a divided plate and special utensils to assist her with eating. Further review of the medical record discovered the resident was totally dependent upon staff for eating. An interview, conducted with an unidentified dietary employee, on 03/11/13 at approximately 2:15 p.m., found the resident was no longer using the divided plate and the special utensils because she was totally dependent upon staff for feeding. On 03/11/13 at 2:00 p.m., Employee #58 (Coordinator of Clinical Records) verified the care plan was not revised when Resident #67 no longer needed a divided plate and special utensils. She further stated, The resident is totally dependent upon staff for feeding. d) Resident #104 During review of the medical record, on 03/12/13 at 1:36 p.m., it was discovered a care plan for diabetic medications and [MEDICAL CONDITION] medications had been developed. Review of the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 03/02/13, identified the resident was not on [MEDICAL CONDITION] medications or diabetic medications. During an interview with Employee #58 (Coordinator of Clinical Records), on 03/12/13 at 1:45 p.m., it was confirmed the resident's care plan was not revised when the resident no longer needed [MEDICAL CONDITION] medications and diabetic medications. e) Resident #40 Review of the medical record found the resident had a deep tissue injury to the right heel which healed on 01/01/13. Further review of the medical record found a physician's orders [REDACTED]. A new order for pressure relieving boots to bilateral heels was added on 01/01/13. Review of the current care plan, on 03/12/13, revealed a care plan, initiated on 06/06/12, addressing the deep tissue injury to the right heel. The care plan identified the deep tissue injury as a current problem. Employee #58, the registered nurse care plan coordinator, was interviewed at 1:33 p.m. on 03/12/13. She verified the care plan was not updated when the deep tissue injury healed on 01/01/13 and the order for pressure relieving boots to bilateral heels was not included in the current plan of care. f) Resident #39 Review, on 03/11/13 at 12:55 p.m., of Resident #39's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 02/25/13, revealed plans to discharge the resident to the community. On 03/11/13 at 1:00 p.m., review of Resident #39's current care plan, with a revision date of 03/07/13, revealed The admission of the resident is anticipated to be long term due to resident needing twenty-four hour care. In an interview, on 03/11/13 at 1:10 p.m., rehabilitation staff, Employee #96, stated that Resident #39 was improving and plans were for the resident to return home. On 03/11/13 at 1:20 p.m., the social worker, Employee #86, stated that upon admission the family was thinking about Resident #39 being admitted long term. Employee #86 stated she had not revised the care plan to reflect Resident #39's plan to return home. | 2017-03-01 |