cms_WV: 9890

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

Data source: Big Local News · About: big-local-datasette

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
9890 EASTBROOK CENTER LLC 515089 3819 CHESTERFIELD AVENUE CHARLESTON WV 25304 2011-08-25 278 D 0 1 MZQB12 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure minimum data set assessments (MDSs) accurately reflected the health and functional status of two (2) of fourteen (14) sampled records. Resident identifiers: #141 and #21. Facility census: 140. Findings include: a) Resident #141 Record review revealed Resident #141 was admitted to the facility on [DATE]. Review of Resident #141's discharge MDS, with assessment reference date (ARD) of 08/04/11, found the assessor noted the number of falls since the prior assessment (which was a quarterly MDS with an ARD of 07/13/11) as follows: - Fall with no injury - none - Fall with injury (except major) - none - Fall with major injury - 1 - A review of the incident reports, nursing notes, and the significant event reporting in the computer revealed that Resident #141 had sustained falls as follows: - On 07/20/11 at 5:00 p.m., he was found on the floor and had sustained a scratch to his right hand measuring approximately 5 cm long. - On 07/22/11 at 7:30 p.m., he slid down the side of a chair after missing the seat, and an assessment found no apparent injuries. - On 07/24/11 at 10:45 a.m., he fell , hitting his left arm and the left side of his head against a door frame; he subsequently was found to have sustained a fractured humerus and a subdural hematoma. - The above assessment was inaccurate with respect to the numbers and types of falls that had occurred since his prior MDS with an ARD of 07/13/11. -- b) Resident #21 A review of a significant change in status MDS with an ARD of 05/02/11 found the assessor indicated, in Item M0300F, that Resident #21 had one (1) unstageable pressure ulcer. In a quarterly MDS with ARD of 07/27/11, the assessor again indicated the presence of one (1) unstageable pressure ulcer (measuring 0.4 cm x 0.5 cm) in Item M0300F. - Review of the resident's nursing notes revealed an entry, at 9:50 a.m. on 06/21/11, stating: "Note necrotic tissue to L (left) heel wound came off. Wound bed with slough and sm (small) area of necrotic tissue present. ..." Another entry, at 7:41 a.m. on 07/06/11, stated: "Wound to L heel 0.6 x 1 cm slough to center of wound /c (with) scant drainage ... Stage III." - The instructions for Item M0300F direct the assessor to encode the "number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar". - During an interview with the MDS nurse (Employee #164) and a corporate nurse consultant (Employee #192) at 2:00 p.m. on 08/23/11, the MDS nurse stated she was aware of the Stage 3 determination by the wound care nurse, but she never changes the staging on the MDS as the ulcer is healing, as that was her understanding of the RAI (resident assessment instrument) user manual. - Review of the RAI user manual for the MDS 3.0 found the following instructions: "Coding Instructions for M0300F "- Enter the number of pressure ulcers that are unstageable due related to slough and/or eschar. "... Enter the number of unstageable pressure ulcers due related to slough and/or eschar that were first noted at the time of admission AND - for residents who are reentering the facility being readmitted after a hospital stay - that were acquired during the hospitalization ." "Coding Tips " - Pressure ulcers that are covered with slough and/or eschar should be coded as unstageable because the true depth (and therefore stage) cannot be determined. Only until enough slough and/or eschar is removed to expose the depth of the tissue layers involved, can the stage of the wound be determined. "- Stable eschar (i.e., dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heels serves as 'the body's natural (biological) cover' and should only be not be removed after careful clinical consideration including ruling out ischemia and consultation with the resident's physician, or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. "- Once the pressure ulcer is debrided of slough and/or eschar such that the tissues involved can be determined, then code the ulcer for the reclassified stage. The pressure ulcer does not have to be completely debrided or free of all slough and/or eschar tissue in order for reclassification of stage to occur." After reviewing the RAI, both nurses agreed the MDS should be corrected to indicate pressure the ulcer was a Stage 3. . 2015-08-01