cms_WV: 835
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 835 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2018-05-17 | 689 | L | 0 | 1 | H2ZY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, resident interview, medical record review, staff interview, and observation of Resident #35, the facility failed to ensure one (1) of three (3) cigarette smokers was capable of safely smoking independently. The resident was observed smoking outside on the sidewalk alone on 05/15/18 at 9:05 a.m. He could not be readily observed by staff inside the building. It was also noted the resident was smoking in an area where a sign was posted prohibiting smoking. The wind was blowing and ashes would blow back on the resident and his clothing. When the ashes would land on his clothing, he appeared unaware of the ashes and made no attempt to brush them off. He was not wearing a smoking apron and there were noticeable holes in the sweatpants he wore. Further investigation found this severely cognitively impaired resident kept his cigarettes and his lighter on his person at all times. These findings were determined to pose a potential for serious harm to the safety and well-being of Resident #35 and to other residents residing in the facility. The Chief Executive Officer (CEO) was informed these findings constituted an immediate jeopardy to the safety and well-being of Resident #35 and to the facility's other residents on 05/15/18 at 9:24 a.m. Written notification of the findings leading to the determination of immediate jeopardy and request for a plan of correction were provided to the CEO. The facility provided an acceptable plan of correction and after verifying implementation of its plan, the immediate jeopardy was abated at 4:30 p.m. on 05/15/18. After removal of the immediate jeopardy, no deficient practice remained for this requirement. Resident identifiers: #35 and the other facility residents. Facility census: 111. Findings included: a) Resident #35 Observations on 05/15/18 at 9:05 a.m., found the resident seated in a wheelchair outside on the front sidewalk smoking a cigarette. No staff were monitoring the resident. Closer observation noted holes in his sweatpants that looked like burn holes from cigarette ashes. Accompanied by another surveyor, the resident was observed again. The wind was blowing and ashes were falling from the cigarette onto his sweat pants. The resident appeared unaware of the ashes falling onto his clothing as he made no attempt to brush the ashes from his clothing. There was no ashtray or receptacle for ashes and cigarette butts near the resident. The area where the resident was smoking had a No smoking allowed within 15 feet of an exit door and near operable windows sign posted. At 9:30 a.m., accompanied by the Chief Executive Officer (CEO), a third observation of Resident #35 found he had moved to another area of the sidewalk. He was not smoking, but the CEO could see the holes in the resident's sweatpants. During the afternoon of 05/15/18, review of the facility's smoking policy, with a revision date of 06/17/17, found the policy directed smoking supplies were to be stored by staff with the resident's name and room number in a suitable cabinet in the nursing station. Additionally, the policy stated in individual special circumstances, the resident might need to wear a smoking apron during smoking. If the resident was cognitively able, the resident could secure all smoking materials in a locked compartment. According to the policy, residents were not allowed to keep lighters or matches. Review of the resident's minimum data set (MDS) assessments, an annual with an assessment reference date (ARD) of 09/09/17 and two (2) subsequent quarterly assessments with ARDs of 12/08/17 and 03/08/17, found his Brief Interview for Mental Status (BIMS) identified he score 6 on all 3 assessments. A score of 6 indicated he had severe cognitive impairment. The quarterly assessments also identified he resisted care 1 to 3 days during the assessment look back periods. The resident's behaviors were addressed in his care plan. Observation on 05/15/18, and by resident and staff interviews, found the resident always kept his lighter and cigarettes on his person in the waistband of his clothing. He did have a compartment in his room to store his smoking materials, but refused to use the compartment A smoking evaluation dated 01/04/18, identified the resident as safe to hold a cigarette, put out ashes, and he did not need a smoking apron. The care plan identified him as being able to smoke according to his smoking assessment which stated he demonstrated safe independent smoking. This care plan, implemented 06/13/16, had the most recent revision on 01/14/18. An interview with the CEO and director of nursing on 05/15/18 at 1:15 p.m. revealed he had a change of condition recently. On 05/04/18, he began pushing and kicking, rejecting care and making disruptive sounds. The CEO and Director of Nursing (DON) reported the resident was known to have paranoid [MEDICAL CONDITION] and behavior changes with increased agitation. Additional interview with the CEO on 05/15/18 at 3:30 p.m., revealed the staff felt the resident had been determined to be safe to smoke independently and had not been seen to be unsafe during his smoking assessment. The resident was known to wear the pants with holes frequently, but the CEO was unaware of the holes in the clothing until the immediate jeopardy was brought to her attention. findings were determined to pose a potential for serious harm to the safety and well-being of Resident #35 and to other residents residing in the facility. The Chief Executive Officer (CEO) was informed these findings constituted an immediate jeopardy to the safety and well-being of Resident #35 and to the facility's other residents on 05/15/18 at 9:24 a.m. Written notification of the findings leading to the determination of immediate jeopardy and request for a plan of correction were provided to the CEO. The facility provided an acceptable plan of correction and after verifying implementation of its plan, the immediate jeopardy was abated at 4:30 p.m. on 05/15/18. After removal of the immediate jeopardy, no deficient practice remained for this requirement. b ) The facility's plan of correction May 15, (YEAR) 12:15pm 1) The Administrator immediately assigned 1:1 supervision to resident #35, on (MONTH) 15, (YEAR) at approximately 9:15am to observe resident for safe use of lighter and smoking materials and to offer/encourage use of safety garment to ensure resident sustains no injury or causes no harm to other residents. He will remain on 1:1 supervision until he is compliant with Smoking Policy. Resident will be encouraged to move 15 foot away from building. Resident #35 will be offered a smoking blanket on his next smoking activity. He and responsible party will be reeducated on smoking policy and desigated area. Administrator identified holes in pants, but nature of cause could not be determined. Resident has very limited clothing and could not determine age of holes. Skin Assessment was attempted, but refused by resident #35. A Skin Assessment had previously been completed on (MONTH) 15, (YEAR), with no skin integrity issues identified. Resident continued to smoke safely, with 1:1 supervision, due to noncompliance with smoking materials and smoking area at 2:30 Social Worker and Administrator explained need for all smoking material and retrieved smoking material at 3:30pm. Staff will continue to provide 1:1 supervision for 24 hours and re-assess at that time. Resident #35, assessment will reflect supervised smoking required, including wearing apron/blanket. 2) At 9:30am the Administrator had all resident rooms checked for smoking materials. No additional smoking material was found at this time. All residents of the facility who smoke have the potential to be effected. No residents of the facility have experienced any negative outcome. The Administrator/designee will re-educate smoking residents/responsible party regarding facilities Smoking Policy on (MONTH) 15, (YEAR), and upon admission and readmission. 3) The Administrator/designee will re-educate all center staff to ensure residents smoking supplies are secured at all times, including lighters, with a post-test to validate understanding, on (MONTH) 15, (YEAR). Staff not available during this time frame will be provided re-education including post-test by Practice Development Specialist/Designee upon return to work. New staff during orientation will be provided education including post-test by PDS/designee. 4) Independent resident smoking materials will be maintained in the medication room, on each unit and signed out by resident/staff and signed back in with the nurse/designee at the completion of the smoke break across all shifts, 7 days per week. Audits will be conducted by Director of Nurses/designee daily across all shifts x 2 weeks then 3 x per week x 2 weeks then randomly thereafter to ensure that smoking materials are secured. 5) Trends identified will be reported by the Director of Nurses/designee monthly at the Quality Improvement Committee (QIC) for any additional follow up and/or in servicing until the issue is resolved and randomly thereafter as determined by the QIC committee. | 2020-09-01 |