cms_WV: 83
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 |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
83 | GUARDIAN ELDER CARE AT WHEELING | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2019-08-06 | 867 | E | 0 | 1 | WJ7O11 | Based on facility record review, staff interview, and review of deficient practices identified during the survey, the facility failed to maintain an effective Quality Assurance Committee to develop and implement appropriate plans to correct identified quality deficiencies and coordinate the facility's required implementation of all regulatory changes. No attempts were made to correct nurses' failure to sign off narcotic counts at shift change after the pharmacist identified the concern. This has the potential to affect all residents residing in the facility. Facility census: 140. Findings include: a) On 07/31/19 at 4:31 PM, a review of the Controlled Substance Forms on the 200 hall with Licensed Practical Nurse (LPN) #143 revealed nurses failed to initial the sheets at the change of shift after controlled medications were counted. LPN #143, confirmed medication counts are to be completed between two (2) nurses at the change of shift and both nurses are to initial the forms. Further review at this time found incomplete Controlled Substance Forms on both medication carts on the 200 and 300 hall and the single cart located on the 100 hall. The Assistant Director of Nursing (ADON) acknowledged the Controlled Substance Forms were incomplete during an interview on 07/31/19 at 4:32 PM. On 08/05/19 at 9:52 AM, a review of the pharmacist's Controlled Substance Audit dated 02/08/19 with the ADON revealed the pharmacist identified missing signatures during a random audit of the change of shift count forms. On 08/05/19 at 3:17 PM, a review of the Quality Assurance & Performance Improvement Plan 2019 presented with the Quality Assurance & Performance Improvement (QAPI) policy revealed the facility did not address the incomplete controlled substance forms. An interview was conducted with the Administrator, the person in charge of Quality Assurance #136 and Corporate Consultant (CC) #154 on 08/05/19 at 3:30 PM. The Administrator and CC #154 confirmed they were unaware of results of the pharmacist's 02/08/19 findings of missing signatures during a random audit of the change of shift count forms. CC #154, acknowledged a plan was initiated on 08/01/19, after the survey team identified the concern. | 2020-09-01 |