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| Link | rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag ▼ | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11117 | 11117 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2009-04-30 | 150 | D | 0 | 1 | 6TSD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to act upon a resident's wish to change her advance directives. Resident #54, who was determined to possess the capacity to understand and make her own medical decisions, upon admission indicated she wished to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or [MEDICAL CONDITION] arrest. Shortly after admission, she decided she did not want to receive CPR, and the facility failed to act upon her request for do not resuscitate (DNR). Resident identifier: #54. Facility census: 101. Findings include: a) Resident #54 Record review, on [DATE], revealed Resident #54 was admitted to the facility on [DATE]. Review of her interdisciplinary progress notes (by nursing) revealed an entry, dated [DATE], stating the resident was a "full code at this time", meaning the resident was to receive CPR in the event of cardiac or [MEDICAL CONDITION] arrest. A physician's orders [REDACTED]. Review of a subsequent entry in the interdisciplinary progress notes (by social services), dated [DATE], revealed, "POST (physician's orders [REDACTED]. Code status DNR." This form was completed by the resident and Employee #133, but there was no physician's signature on it. Interview with Employee #80 on [DATE], and with other staff reviewing the resident's medical record on [DATE], confirmed the facility had not followed through to ensure the resident's request for DNR was confirmed by an order signed by the attending physician. . | 2014-08-01 |
| 5787 | 5787 | WEIRTON GERIATRIC CENTER | 515037 | 2525 PENNSYLVANIA AVENUE | WEIRTON | WV | 26062 | 2014-10-07 | 151 | D | 0 | 1 | U60O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, family interview, and staff interview, the facility failed to allow one (1) of thirty-one (31) residents reviewed to exercise his rights. The facility restricted access to his power wheelchair without evaluating the resident's physical and cognitive ability to use the power wheelchair. Resident Identifier: #111. Facility census: 132. Findings Include: a) Resident #111 On 09/24/14 at 3:30 p.m., during an interview with Resident #124, during Stage 1 of the Quality Indicator Survey (QIS) process, she voiced a concern. She said her husband, Resident #111, had left the facility in his power wheelchair at 2:00 a.m. a few weeks earlier. She reported the facility would no longer allow him to use his power wheelchair. She said staff told her that her husband could have his power wheelchair back when they could trust that he would not leave the facility. At 3:00 p.m. on 10/06/14, during a review of the facility's unusual occurrences, the elopement of Resident #111 was identified. The report stated on 08/04/14 the resident left the facility around 2:00 a.m. in his power wheelchair. When found by the police, no injuries were identified. The report further stated the power wheelchair was removed from the resident's possession for his safety. On 10/06/14 at 3:45 p.m., during an interview with Resident #111, the resident was observed self propelling in a manual wheelchair in his room. Upon inquiry as to the wheelchair in which he was seated, he said he had a power wheelchair, but the facility took it away from him. When asked why, he said because he had been a bad boy. He explained that during the summer he left the facility late one night, and had taken a road trip. He said he knew what he had done, and he knew it had been the wrong thing to do. The resident said he had just wanted to have some control over his life, and at that time, that was how he took control. He said because he had left the facility in the m… | 2018-07-01 |
| 6351 | 6351 | BRAXTON HEALTH CARE CENTER | 515180 | 859 DAYS DRIVE | SUTTON | WV | 26601 | 2014-06-02 | 151 | D | 0 | 1 | OMIN11 | Based on resident interview, record review, review of complaints and grievances, and staff interview, the facility failed to ensure one (1) of two (2) residents, reviewed for the right to exercise rights, was afforded the opportunity to exercise her rights about how she lived in the facility. The resident was not able to exercise her right to privacy in her room. Resident Identifier: #24. Facility Census: 61. Findings Include: a) Resident #24 During an interview with Resident #24, at 10:30 a.m. on 05/28/14, she was asked, Are residents able to exercise their rights? Resident #24 responded with, That's a hard one, I would say no. The resident said she paid the facility $6,000 a month for her private room and she did not have any privacy in her room. She stated there were two (2) occasions the previous week when she came into her room and found other residents of the facility in her bathroom. She stated the interventions the facility attempted did not work. For example, she stated they were supposed to keep her door closed, but it was often left open by the staff. The resident said she also might not get it closed at times, because it was sometimes difficult to shut. The resident stated she felt she was not able to exercise her right to privacy because others went in and out of her room when she was not in there. The facility grievances and complaints were reviewed. This review revealed a Grievance/Complaint Report, dated 02/24/14, for Resident #24. The resident told Employee #61, the social service supervisor (SSS), that housekeeping said her dentures were found on the floor of her room when they went in to mop the floor. Resident #24 also told Employee #61 her bed had been getting messed up. Under the section for documentation of the facility's follow-up was, SW (social worker) suggested putting safest knob back on door, make sure door is closed. Resident #24 said they have tried those things as well as a stop sign on the door. Under the section titled, resolution of grievance/complaint was documented, Staff will… | 2018-04-01 |
| 8036 | 8036 | BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER | 515055 | 600 MEDICAL PARK | WHEELING | WV | 26003 | 2012-08-22 | 151 | D | 0 | 1 | 8KXK11 | Based on resident interview, staff interview, observations, and a review of Resident Council minutes for the months of April, May, June, and July 2012, it was determined the facility failed to notify the Resident Council of the implementation of a new non-smoking policy. This practice affected three (3) of three (3) residents who smoke in this facility. Interviews conducted with Residents #217, #68, and #150, revealed the facility had decided to implement a non-smoking policy both in the facility and on the grounds. It was also discovered during a review of Resident Council minutes this new rule had not been taken to the Resident Council prior to imposing the new policy and presenting the three (3) smoking residents with the notification. Resident identifiers: #217, #68, and #150. Facility census was 127. Findings include: a) Resident #127 During an interview with Resident #217, on 08/16/12 at 10:15 a.m., the resident stated the facility had informed the residents who smoked this facility was to become a non-smoking campus - meaning there would be no smoking allowed on the facility property. The resident further indicated the facility nursing home administrator (NHA) (Employee #116) had provided the residents who smoke a written announcement of the new policy with the effective date of 09/10/12. This notified them they would have to stop smoking on that date. Resident # 217 stated she did not want to stop smoking. The resident stated smoking was the last and only pleasure she had left in life and she could not give it up. During the interview, it was discovered there were three (3) smokers in this facility. b) Residents #68 and #150 Interviews conducted with Resident #68 and Resident #150, on 08/21/12 at 2:30 p.m., found they had also been given the non-smoking notice and informed they could receive assistance with giving up smoking. Both Residents #68 and #150 stated they did not want to quit smoking. It was observed the announcement of the new smoking policy had been distributed in the public and resident areas… | 2016-10-01 |
| 8446 | 8446 | FAIRMONT HEALTH AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2012-06-22 | 151 | E | 0 | 1 | NISF11 | Based on resident/staff interview and record review, the facility failed to ensure residents were provided the opportunity to exercise their rights as a citizen. Voting rights were not maintained/promoted by the facility for 9 of 9 residents attending the group meeting (R10, R18, R27, R41, R56, R63, R64, R72, and R74) and 1 additional sampled resident (R43.) Findings include: 1. A group interview was conducted on 06/19/12 at 2:00pm with 9 residents whom the facility identified as alert, oriented, and credible historians. Interview with the group revealed 9 of the 9 residents wanted to vote; however, the facility had not assisted them with voter registration, making arrangements for transportation to the polls, or obtaining absentee ballots. 2. An individual interview was conducted with R43 on 06/19/12 at 12:35pm. The resident stated, I'm looking forward, to the coming presidential election. He indicated he was registered to vote and revealed he voted in every presidential election since he was old enough to vote. Review of the Recreation History and Assessment Long Stay form dated 06/24/11 for R43 revealed the Activities Director (AD) identified R43 as a Registered Voter. An interview with the Social Services Director (SSD) on 06/21/12 at 4:30pm revealed the facility had no system in place to get the voter information from the AD to the SSD. Interview on 06/21/12 at 3:30pm with the Social Services Director (SSD) revealed she obtained absentee ballots for any residents who asked for them, but did not have a system to assure that all residents who were capable and interested were informed of their right to vote and provided with assistance as needed. Further interview with the SSD on 06/21/12 at 4:30pm revealed she had discussed voting in resident council meetings, and information about voting should be included in the minutes of the meetings. Review of all Resident Council meeting minutes for 2012 revealed the topic of assistance with voting had not been discussed. | 2016-06-01 |
| 8467 | 8467 | NELLA'S INC. | 51A010 | 399 FERGUSON ROAD | ELKINS | WV | 26241 | 2012-05-11 | 151 | E | 0 | 1 | HIO211 | Based on interview, the facility failed to ensure that residents were provided the opportunity to exercise their rights as a citizen. Voting rights were not maintained for 2 of 19 sampled residents (R54, R58) and 9 additional residents (R8, 16, 19, 36, 57, 61, 71, 81, and 84.) Findings include: During a group interview with residents identified by the facility as alert and oriented on 05/08/12 at 3:00pm, only 2 of the 13 residents stated they were registered to vote and had voted since their admission to the facility. Upon further conversation, it was determined that neither of the 2 residents who voted had been assisted to do so by the facility. R64 had a Personal Computer (PC) and independently utilized the PC to register to vote, and R26 stated his sister assisted him to register. All of the other 11 residents (R8, 16, 19, 36, 54, 57, 58, 61, 71, 81, and 84) interviewed in group said they would like to vote. All present agreed the facility Social Worker (SW) had never approached any of the attendees concerning voter's registration or educated them on their right to vote either by absentee ballot or at the nearest polling place. On 05/11/12 at 10:21am, the SW stated she personally assisted several residents to register and to vote. The only residents she could identify as having voted in the last 8 years were R64 and R26. She was unable to provide the names of other alert and oriented residents she had assisted with the voting process. She stated she was unable to provide any evidence to prove she had educated the residents on how to continue to exercise their voting rights once they were admitted to the facility. | 2016-06-01 |
| 8873 | 8873 | TRINITY HEALTH CARE OF LOGAN | 515140 | 1000 WEST PARK AVENUE | LOGAN | WV | 25601 | 2012-05-25 | 151 | E | 0 | 1 | ZX7V11 | Based on interview and Resident Council Meeting Minutes review, the facility failed to ensure residents were provided the opportunity to exercise their rights as a citizen related to voting. Voting rights were not maintained nor promoted for 6 of 12 residents identified by the facility as alert and oriented. (R26, 32, 34, 45, 77, and 79.) Findings include: A group interview was conducted on 05/22/12 with 12 residents whom the facility had identified as alert, oriented, and credible historians. Interview with the group revealed that 6 of the 12 residents wanted to vote; however, the facility had not assisted them, either help with voter registration, making arrangements for transportation to the polls, or obtaining absentee ballots. Interview with R32 revealed, They used to help you, in making arrangements to vote, and R34 added, No one approached me. Interview on 05/23/12 at 2:40pm with the Social Services (SS) Director revealed that Activities staff was currently responsible for assisting with voting. She related that she used to attend the Resident Council meetings, and would provide information about voting to the residents. The SS Director related that if the need for assistance with voting was still being discussed in Resident Council, information about it should be included in the minutes of the meetings. Review of all Resident Council meeting minutes for 2012 revealed the topic of need for assistance with voting had not been discussed. On 05/22/12 at 3:10pm, interview with the Activities Director (AD) revealed that some residents in the facility were registered to vote, and several had sent in absentee ballots in the last election, two weeks prior to the survey date. She added that residents are asked upon admission if they are interested in voting. Further interview with the AD on 05/22/12 at 3:35pm revealed that she had checked the records of each of the residents present in group who had related they were interested in voting. She confirmed both R34 and R45 were registered to vote, and stated staff had … | 2016-03-01 |
| 9140 | 9140 | CAREHAVEN OF PLEASANTS | 515191 | PO BOX 625 | BELMONT | WV | 26134 | 2012-04-26 | 151 | D | 0 | 1 | JRXZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, and record review, the facility failed to allow one (1) of thirty-three (33) residents the opportunity to exercise his resident rights, and gave the resident a thirty (30) day notice for refusing care and treatment. Resident identifier: #78. Facility census: 61. Findings include: a) Resident #78. Review of the medical record found several occasions when Resident #78 had refused care and treatment. No evidence could be found the facility investigated why the resident refused care and treatment. Resident #78 was admitted to the facility on [DATE]. The admission [DIAGNOSES REDACTED]. During an interview with the resident, on 04/23/12 at 3:00 p.m., it was learned the resident did not like the type of solution used to treat his wounds. The resident stated, It's a bleach solution and [MEDICAL CONDITION] nose. The treatment was ordered twice a day. The resident stated he was not going to let the facility use Dakins solution twice a day. According to Employee #97, the treatment nurse, in an interview on 04/25/12 at 9:14 a.m., Resident #78 had voiced his opinion of the Dakins solution to her. She stated, He is non-compliant with a twice a day treatment. She further added she contacted the wound care center, but they would not change the treatment. Employee #97 was asked whether she had contacted the attending physician to get the treatment changed. She stated, He will not go against the wound care center. She stated at one time they had used a patch which only had to be changed every three (3) days, and the resident was more compliant with this treatment. No evidence could be found the physician was aware of Resident #78 having difficulty with the current treatment. No evidence could be found the facility alerted the physician to why Resident #78 was refusing treatments. The resident further stated, he had friends who worked at the facility, and he did not want them to provide his care. The resident stated… | 2016-02-01 |
| 10608 | 10608 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2011-09-30 | 151 | D | 1 | 0 | 0VZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to allow one (1) of eight (8) sampled residents the right to exercise her rights as a resident of the facility. This resident was not permitted to choose how she wished to live her everyday life and receive care. The facility cleaned the resident's room without permission and did not allow the resident to refuse a medication when she clearly stated she did not want the medication. Resident identifier: #41. Facility census: 38. Findings include: a) Resident #41 Closed medical record review, on 09/28/11, revealed this resident was admitted to the facility on [DATE]. The resident was determined to possess the capacity to understand and make informed health care decisions in May 2011. According to the medical record, the resident was very upset on 06/06/11, because a nurse cleaned her dresser drawers, threw away some newspapers, and sent some soiled clothing to the laundry. There was no evidence that staff had obtained her permission to go through the resident's personal belongings when cleaning her room. Instead, all evidence suggested the resident was told, after the fact, why it was done. This was an infringement on the resident's rights which led to the following infringement on the resident's rights: - On 06/07/11, nurse's notes described the resident continued to be upset about her room being cleaned and her possessions being thrown away. Additionally, nurse's notes indicated the resident continued to be angry and agitated up to and including 06/10/11. - On 06/10/11, nurse's notes described the resident was agitated about the change in her medications and refused to take them. At 20:00 (8:00 p.m.), a telephone order was obtained for "[MEDICATION NAME] 1 mg IM now". At 20:10 (8:10 p.m.), when staff attempted to give the injection to this resident, the resident screamed, "You're not giving me no shot." The resident was walked to her room, all the while screaming "No, no… | 2015-01-01 |
| 107 | 107 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2017-09-07 | 152 | D | 0 | 1 | QLZ111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility staff failed to identify the appointed Health Care Surrogate (HCS) for Resident #84, as designated by the attending physician on 06/05/17. Thus, the designated HCS was unable to exercise the resident rights to the extent provided by state law. Resident identifier: #84. Facility census: 180. Findings include: a) Resident #84 Review of Resident #84's medical records, on 08/30/17 at 11:15 a.m., found the resident was admitted to the facility on [DATE] following a hospitalization . Admission paperwork was completed by the resident's daughter. Further review found a HCS selection form completed 06/05/17, by the attending physician, designating the son as the HCS. No further HCS designation forms could be located in the medical records. Interview with Employee #122, social worker (SW), on 09/06/17 at 9:15 a.m., revealed she thought the daughter was the HCS on admission and had asked to appoint her brother the HCS due to personal issues. When asked, Is there another HCS designation form. She replied, I don't see any in the medical records. On 09/06/17 at 11:00 a.m., Employee #122, SW, provided a HCS designation form dated 05/30/17. She further confirmed this form had been faxed to her on 09/06/17 at 10:35 a.m. This HCS form indicated the Daughter was in fact appointed as the HCS while the resident was in the hospital. However, this HCS became void when the attending physician at the facility appointed Resident #84's son as the HCS on 06/05/17. The facility continued to notify Resident #84's daughter of changes in her condition and had the daughter listed as the health care decision maker on the resident face sheet even after Resident #84's son was appointed HCS on 06/05/17. On 09/07/17 at 10:25 a.m., the Director of Nursing (DON) and the Nursing Home Administrator (NHA) was both notified. No further information was provided. | 2020-09-01 |
| 2959 | 2959 | LOGAN CENTER | 515175 | 55 LOGAN MINGO MENTAL HEALTH CENTER ROAD | LOGAN | WV | 25601 | 2017-09-28 | 152 | D | 0 | 1 | BKPR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of death had a health care decision maker. Resident Identifier: #4. Facility census: 61. Findings include: a) Resident #4 Resident #4 was admitted to the facility on [DATE] for palliative care. The Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/02/17, Section C, Cognitive Patterns, gave a Brief Interview for Mental Status (BIMS) score of 00. Medical records review for Resident #4 revealed a Personal Care Pre-Admission Screening Form dated 07/21/17 which stated (Individual #1) and (Individual #2) were the Medical Power of Attorneys. A Designated Surrogate form dated 04/06/16 stated (Individual #2) was designated as surrogate. The Designated Surrogate form was not signed by a physician. According to facility records, (Individual #1) was designated by the facility as first emergency contact and Medical Power of Attorney. (Individual #2) was designated as second emergency contact and alternate Medical Power of Attorney. During an interview on 09/27/17 at 3:55 p.m., the Center Executive Director was shown the Personal Care Pre-Admission Screening Form dated 07/21/17 and the Designated Surrogate form dated 04/06/16. The Center Executive Director was unable to produce a document appointing a health care decision maker. She stated the Pre-Admission Screening Form dated 07/21/17 might have been the document the facility believed appointed the Medical Power of Attorney. | 2020-09-01 |
| 4550 | 4550 | ST. BARBARA'S MEMORIAL NURSING HOME | 515012 | PO BOX 9066 | FAIRMONT | WV | 26555 | 2016-11-22 | 152 | D | 0 | 1 | EZR311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, resident interview, staff interview, and review of West Virginia State Nursing Home Licensure Rule 64-13, the facility failed to ensure the legal surrogate designated in accordance with State law only exercised the resident's rights to the extent provided by State law. This was found for one (1) random resident reviewed for capacity to make informed medical decisions. Resident identifier: #10. Facility census: 55. Findings include: a) Review of the medical record for Resident #10, began on 11/15/16 at 2:45 p.m., revealed she was [AGE] years of age, and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was determined by a physician to possess the capacity to make informed medical decisions. b) Record review found Resident #10 was determined by the attending physician to lack the capacity to make informed medical decisions upon her admission. The determination was reversed on 08/02/16 at which time the attending physician determined she possessed the capacity to make informed medical decisions. c) Pertinent social services notes were found as follows (typed as written): --05/11/16 at 1:02 p.m. a Social Service Note stated: Quarterly MDS (minimum data set assessment) Review: The resident is alert with confusion at times secondary to Dementia. She has been deemed to lack capacity. Her daughter is acting as her MPOA (Medical Power of Attorney). BIMS (Brief Interview for Mental Status) score of 14 this review. A dx. (diagnosis) of Depression is present with orders in place for [MEDICATION NAME], anti-depressant medication. The resident denies any s/s (signs and symptoms) of an altered mood this review. A care plan remains in place to address her impaired decision making and risk for increased s/s of an altered mood. No behavioral issues noted. Code status reviewed as DNR (do not resusitate.) --08/08/16 at 10:36 a.m. a Social Service Note stated: Annual residents rights review mailed out in June, but the sig… | 2019-09-01 |
| 5099 | 5099 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2015-04-10 | 152 | D | 0 | 1 | CRGX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, the West Virginia Health Care Decisions Act, and staff interview, the facility failed to ensure residents' health care surrogate appointments were completed and implemented in accordance with State law. For Resident #66, the physician's determination of capacity failed to include the reason for the incapacity, the expected duration of incapacity, and evidence the resident was informed of who would be making her decisions. For Resident #21, the facility allowed a person who was not appointed as the health care surrogate to complete advance directives for the resident. This was found for two (2) of two (2) residents while reviewing for participation in planning care. Resident identifiers: #66 and #21. Facility census: 66. Findings include: a) Resident #66 At 11:10 a.m. on 04/06/15, during stage 1 of the Quality Indicator Survey (QIS), Resident #66 stated she did not have any input into her care at the facility. She did not understand why the facility was allowing her daughter to make medical decisions for her. The resident stated she did not want her daughter involved, because she could speak for herself. She gave the following example: I had a feeding tube. I had been eating for months by mouth, eating food that looks like baby food. I wanted my feeding tube removed and they didn't listen so I took it out myself a few weeks ago. Review of the medical record, on 04/07/14, found the resident's daughter was appointed the resident's health care surrogate decision maker on 12/09/12 during a hospitalization . This form indicated the appointment was temporary and was the result of a [MEDICATION NAME] hemorrhage. Record review, on 04/07/15, found the facility's physician completed a determination of capacity on 02/05/13, after the resident was admitted to the nursing home. The capacity statement noted the resident lacked capacity to make medical decisions. The nature of the incapacity and the [DIAGNOSES REDA… | 2019-03-01 |
| 6377 | 6377 | GREENBRIER HEALTH CARE CENTER | 515185 | 1115 MAPLEWOOD AVENUE | LEWISBURG | WV | 24901 | 2014-06-27 | 152 | E | 0 | 1 | 35BV11 | Based on staff interview, observation, review of facility policy, family interview, and resident interview, the facility failed to ensure four (4) of four (4) residents reviewed for rights were afforded the opportunity to exercise their rights. Residents were not free to exercise their rights regarding the use of side rails. Resident identifiers: # 98, #71, #29, and #2. Facility census: 77. Findings include: a) During the survey, residents and family members expressed serious concerns regarding the facility's decision to discontinue the use of side rails. The residents who expressed concern were those who used the side rails for turning and repositioning. An interview with Employee #1 (director of nursing), on 06/24/14 at 9:30 a.m., revealed the side rails were discontinued on 06/11/14 at the request of the medical director. Review of a new policy regarding side rails, which the facility implemented on 06/11/14, revealed the statement, No Resident will have side rails, unless the resident has capacity. Capacity to make health care decisions and the right to use side rails are not one and the same. The decision to discontinue the side rails was not discussed with the resident to judge how well the resident understood the facility's concerns with the use of side rails and/or how the resident used the side rails. Each of the residents for whom concerns were raised were deemed to not have capacity to make health care decisions. The facility also did not allow the person appointed under State law to act on the resident's behalf regarding the use of the side rails. 1) Resident #98 On 06/23/14 at 1:47 p.m., during an interview with Resident #98 and his wife, who acts as the resident's medical power of attorney (MPOA), the MPOA said a couple of weeks ago a facility staff member informed them the resident could no longer use his side rails. The MPOA became visibly upset when discussing the matter. The MPOA stated the facility staff member said, State says we can't use side rails because someone may get their head caught i… | 2018-04-01 |
| 6526 | 6526 | EASTBROOK CENTER | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2015-02-17 | 152 | D | 1 | 0 | O5Z211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the person appointed by the court to act on the resident's behalf exercised the rights of a resident, who was adjudicated incompetent by a court of law. The facility allowed Resident #126 to leave the facility for several hours with family members on three (3) separate occasions. There was no evidence to support the court appointed guardian gave consent for the visits with family members. This was true for one (1) of seven (7) residents whose closed records were reviewed for the care area of admission, transfer, and discharge. Resident identifier: #126. Facility census: 125. Findings include: a) Resident #126 Medical record review, on 02/16/15 at 1:00 p.m., found this fifty-eight (58) year old resident was admitted to the facility on [DATE]. The circuit court appointed the Department of Health and Human Services (DHHR), Adult Protective Services (APS) to act as guardian for the resident on 10/17/13. A representative of the DHHR completed the admission paper work at the time of the resident's admission. Review of the admission social services assessment contained no information of any family members. The only contacts listed for the resident on the admission record was the DHHR. On the afternoon of 02/16/15 at 3:30 p.m., Assistant Director of Nursing #106, provided a copy of the occasions the resident had been out with family members. She explained each resident did not have their own individual sheet and she had to review all daily sheets for every resident to compile a list of occasions when this resident went out with family members. Review of the information, provided by Employee #106 found the resident had been out of the facility on 11/27/14, 12/24/14, and 01/14/15 with family members. Review of the medical record, on 02/16/15 at 4:00 p.m., found no documentation the resident was signed out by family on 11/27/14. There was no evidence the resident was assessed upon… | 2018-02-01 |
| 7013 | 7013 | SHENANDOAH CENTER | 515167 | 50 MULBERRY TREE STREET | CHARLES TOWN | WV | 25414 | 2013-08-29 | 152 | D | 0 | 1 | 30TC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident was evaluated for capacity to make medical decisions, according to the law. The medical record contained two (2) conflicting statements regarding the resident's capacity to make health care decisions. Both statements were completed by the same physician. This was true for one (1) of twenty (20) residents reviewed during Stage 2 of the quality indicator survey. Resident identifier: #177. Facility census: 73. Findings include: a) Resident #177 Medical record review found the resident was admitted to the facility on [DATE]. Further review of the medical record, on 08/26/13, found two (2) conflicting statements of determination of capacity for health care decision-making in the resident's medical record. The first determination of capacity was completed by the facility physician on 07/07/13. It indicated the resident did not have capacity to make medical decisions based on cognitive loss and an inability to understand or make medical decisions. The expected duration of incapacity (long term or short term) was not completed by the physician. A second determination of capacity, dated only July 2013, indicated the resident had capacity to make medical decisions. This was completed by the same physician. The physician did not document the exact day this capacity determination was completed. The director of nursing (DON), Employee #23, was interviewed on 08/26/13 at 2:00 p.m. After she reviewed the conflicting statements for determination of capacity she verified she did not know if the resident had capacity or did not have capacity to make medical decisions. The DON reviewed the physician's progress notes in an attempt to determine when the undated determination of capacity form was completed. She presented a copy of the physician's progress note, dated 07/04/13, which contained the following information: His daughter was in today . She would also like to have him de… | 2017-09-01 |
| 7171 | 7171 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-07-16 | 152 | D | 1 | 0 | 1X1U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to establish a resident who had been determined to lack the capacity to make health care decisions had a legally appointed individual, appointed under State law, to act on her behalf to help exercise her rights on admission to the long term care facility. This decision applied to one (1) of nine (9) residents reviewed during the investigation of a complaint. Resident identifier: #61. Facility census: 104. Findings include: a) Resident #61 A review of the medical record revealed Resident #61 was a [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital. Her [DIAGNOSES REDACTED]. She also had deep tissue injuries to both feet, right hip, coccyx, both ears, and left hip. The 5 foot 4 inch tall resident weighed 90.2 pounds on admission. Both the physician who discharged the resident from acute care, and the attending physician at the nursing home, who was the resident's prior family physician, determined the resident lacked the capacity to process the information needed to form her health care decisions. A review of the hospital records forwarded to the facility revealed the resident had been referred to Adult Protective Services (APS) on admission to the hospital (07/01/14) because of suspected elder abuse neglect. A Forensic Nurse Examiner Consult completed on 07/02/14, revealed, . patient is confused, does know her name and that she lives in (name of town/city). The Nurse affirmed an APS referral had been made. She also indicated the hospital Social Worker had informed them the resident's Son #1, who was indicated to be the responsible party, had agreed to nursing home placement. Resident #61 was admitted to the facility on [DATE]. The nurses' notes indicated she arrived by ambulance and indicated Son #2 and his wife were notified. There was no evidence of an attempt to contact Son #1, the resident's medical power of attorney (MPOA). The nurses' notes … | 2017-07-01 |
| 7390 | 7390 | ROSEWOOD CENTER | 515105 | 8 ROSE STREET | GRAFTON | WV | 26354 | 2013-08-15 | 152 | D | 0 | 1 | PDFH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to ensure a legally appointed healthcare decision-maker was in place for a resident the facility decided was unable to make her own health care decisions. This was found for one (1) of thirty-two (32) Stage 2 sample residents. Resident identifier: #2. Facility census: 62. Findings include: a) Resident #2 This resident's medical record was reviewed on 08/13/13 at 1:07 p.m. While reviewing the record, it was noted there were inconsistencies related to who was making healthcare decisions for this resident. This [AGE] year old resident was admitted to the facility on [DATE], transferred to another facility on 11/29/11, and was subsequently readmitted on [DATE]. Her [DIAGNOSES REDACTED]. She was determined by a physician to lack the capacity to make informed medical decisions on 06/28/13. Her Brief Interview for Mental Status (BIMS) score, as assessed on 07/02/13, was 14, indicating she was cognitively intact. (The highest possible BIMS score is 15.) An interview was conducted with the social worker (SW), Employee #18, on 08/14/13 at 9:29 a.m. She confirmed Resident #2 was determined to have capacity at the facility where she resided prior to her admission. The resident was determined to possess the capacity to make informed healthcare decisions by a physician. The SW said the resident had acted as her own decision-maker there. According the SW, since the resident was determined to lack capacity to make healthcare decisions upon her admission, a person needed to be selected to make health care decisions on the resident's behalf. An appointment of a Health Care Surrogate was necessary, but had not been completed. The resident's cousin was willing to assume this responsibility according to the social worker. In the meantime, Resident #2's choices related to refusal of care and other treatment were documented as being followed without question or counseling regarding the impact of thos… | 2017-05-01 |
| 8079 | 8079 | EASTBROOK CENTER LLC | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2013-10-22 | 152 | D | 1 | 0 | KE9711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the resident's legal representative was permitted to make medical decisions on behalf of one (1) of five (5) residents reviewed. The health care surrogate (HCS) for Resident #66 was unaware of the facility's decision to transport the resident to an out of state facility for treatment of [REDACTED]. Resident identifier: #66. Facility census: 121. Findings include: a) Resident #66 Medical record review found the resident was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Upon admission to the facility, the resident had HCS which was appointed during her stay at the referring hospital. Further review of the medical record revealed the resident was transferred and admitted to an out of state hospital's psychiatric unit for treatment of [REDACTED]. On the day of discharge (09/30/13), only three (3) entries were recorded in the resident's computerized medical record. -- The first entry was written at 2:15 p.m., (Name of health care surrogate) aware of new order to send resident to (name of hospital) for evaluation. -- The second entry was made at 3:59 p.m. by a facility social worker, Employee #80 which stated, A referral was made to (name of facility), there are no openings at the current time, requested documents will be faxed for review. A referral was made to (another name of a facility) documents will be faxed for review. A referral was made to (name of a third facility) documents will be faxed for review. Two (2) of these three (3) referrals were made to out of state facilities. -- The third entry, on 09/30/13 was made at 4:12 p.m., (Name of ambulance service) here to transport resident to (name of the state). Resident and family aware. (Note: The resident's legal representative was not a family member.) On 10/21/13 at 12:05 p.m., the director of nursing (DON) was asked how the HCS was notified regarding the transfer of Resident #66. The DON… | 2016-10-01 |
| 8112 | 8112 | OHIO VALLEY HEALTH CARE | 515181 | 222 NICOLETTE ROAD | PARKERSBURG | WV | 26104 | 2013-10-25 | 152 | D | 1 | 0 | CYPC11 | Based on record review and staff interview, the facility failed to follow the directives of a person acting on behalf of an incapacitated resident. The family and Medical Power of Attorney (MPOA) informed staff they did not want a resident to receive an influenza vaccination. The facility administered the influenza vaccine without having consent to do so. This was evident for one (1) of six (6) residents reviewed for the facility's annual influenza vaccination program. Resident identifier: #29. Facility census: 61. Findings include: a) Resident #29 Review of the medical record revealed that family members did not want Resident #29 to receive an influenza vaccine. On 07/22/13, the resident's Medical Power of Attorney (MPOA) signed an influenza immunization form. By signing, this form, they acknowledged having received educational materials on the risks and benefits that may result from accepting or declining the influenza vaccine. The MPOA did not sign consent giving permission for the resident to receive the vaccine. A nursing progress note, dated 08/16/13, was reviewed. The resident's family/MPOA called and spoke with the nurse. The MPOA requested that the orders for flu vaccine and pneumonia vaccine be discontinued. On 10/23/13 at 2:30 p.m., the Director of Nursing (DON) produced a copy of the Medications Administration History for October 2013. She verified that a nurse administered the influenza vaccine to the resident's left deltoid muscle on 10/08/13 at 11:00 a.m. A nursing progress note, dated 10/09/13, conveyed that a nurse called the spouse of the MPOA and told her that the resident had received the flu vaccine with no adverse reaction. During an interview with the DON, on 10/23/13 at 2:30 p.m., she acknowledged that the resident was given the flu vaccine without consent of the MPOA. | 2016-10-01 |
| 8435 | 8435 | OAK RIDGE CENTER | 515174 | 1000 ASSOCIATION DRIVE | CHARLESTON | WV | 25311 | 2013-06-18 | 152 | D | 1 | 0 | RXW311 | Based on record review and staff interview, the facility failed to follow the instructions that were given for allowing a resident to be taken out of the facility without permission from the legal guardian. Resident #50 was identified as a protected person and had a court appointed guardian/conservator. Written instructions were provided to the facility to indicate who was allowed to take the resident out of the facility. The facility did not follow the instructions and allowed the resident to leave the facility with a person who was not authorized to take the resident out of the facility. The court appointed guardian was not made aware the resident had left the facility. This was true for one (1) of five (5) sampled residents. Resident identifier: #50. Facility Census: 70. Findings include: a) Resident #50 It was recorded in this resident's medical record this resident had been determined by the Court to be a protected person. The Court had appointed a legal guardian to make decisions on the resident's behalf on 09/24/07. A review of the medical record, on 06/18/13, revealed a note that Resident #50 was not to leave the facility with anyone in his family. According to the note, he was only to leave with his court appointed guardian or her husband, whose name was specified. During an interview with the Administrator (Employee #83), it was verified that Resident #50 went out of the facility on 06/06/13 with an unauthorized person and went to his legal guardian's house without permission from the legal guardian. The facility had no knowledge of him leaving the facility until he returned. It was confirmed the facility did not follow the instructions of the legal guardian and failed to notify the responsible party that the resident wanted to go out of the facility with someone other than the individuals she had specified. The facility also failed to follow practices for signing out residents when they leave the facility. | 2016-06-01 |
| 8640 | 8640 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2011-08-17 | 152 | D | 0 | 1 | 5VE911 | Based on record review and staff interview, the facility failed to ensure the individuals making financial decisions for two (2) of three (3) sampled residents had the legal authority to do so. Review of Resident #11's financial file found a family member was being permitted to act as the resident's financial power of attorney in the absence of documentation to demonstrate this individual had the legal authority to do so. The physician appointed a health care surrogate (HCS) to make health care decisions on behalf of Resident #2, and the facility permitted this individual to also make financial decisions on behalf of the resident; such authority is not conferred by State law to a HCS. Facility census: 89. Findings include: a) Resident #11 Review of the financial file for Resident #11 revealed there was no documentation to indicate the individual making financial decisions on behalf of this resident who had the legal authority to do so. There was notice in the file by the facility, asking a family member to provide the necessary paperwork to prove they were the resident's financial power of attorney, but no such documentation had been supplied as yet. -- b) Resident #2 Review of the financial file for Resident #2 revealed he had been making his own financial decisions at the time of admission, but his status had changed such that he was no longer able to do so. The physician appointed a HCS to make health care decisions on behalf of the resident, but State law does not confer the authority to a HCS to also make financial decisions. -- c) The above concerns were discussed with Employee #29 (the business office manager) at 1:05 p.m. on 8/10/11. | 2016-04-01 |
| 8752 | 8752 | PINE LODGE | 515001 | 405 STANAFORD ROAD | BECKLEY | WV | 25801 | 2013-03-13 | 152 | D | 1 | 0 | MS9D11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that for residents who had been determined to lack the capacity to make informed medical decisions, a legal surrogate was designated in accordance with State law to exercise the resident's rights to the extent provided by the law. This was found for two (2) of four (4) residents whose records were reviewed. Resident identifiers: #116 and #117. Facility census: 115. Findings include: a) Resident #116 The medical record of Resident #116 was reviewed on 3/11/13 at 3:40 p.m. Resident #116 was admitted to the facility on [DATE], and discharged on [DATE]. He was seventy (70) years old. His [DIAGNOSES REDACTED]. He was determined by a physician to lack the capacity to make informed healthcare decisions on 02/27/13. He was admitted to the facility for skilled therapy services designed to strengthen him, and improve his ability to assist with activities of daily living (ADLs) to allow him to return home with his son and daughter-in-law. There was an indication in the admission paperwork that a health care surrogate (HCS) had been appointed. Further review found a form entitled West Virginia Health Care Surrogate Designation, which had been faxed to the facility on [DATE] from the admitting hospital. The form indicated the resident's sister had consented over the telephone to act as the resident's HCS on 02/18/13. The cause of Resident #116's incapacity to make his own decisions was not completed. The expected duration of his incapacity to make his own decisions was not completed. The person that the physician intended to appoint as HCS was not named. There was a signature in the space marked attending physician, but the signature was not dated. During an interview, on 03/13/13 at 8:45 a.m., the administrator, Employee #38, stated that a new health care surrogate appointment form containing all the information required by the West Virginia Health Care Decisions Act ?16-30-1 shoul… | 2016-03-01 |
| 9081 | 9081 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2013-02-21 | 152 | D | 1 | 0 | RESW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a person making health care decisions had the legal authority to do so under state law, ?16-30-1, the West Virginia Health Care Decisions Act. The facility allowed a person to make health care decisions prior to having documentation to support the person had the legal authority to do so for one (1) of four (4) sampled residents. Resident Identifier: # 94. Facility Census: 107. Findings include: a) Resident #94 Medical record review, conducted at 1:45 p.m. on 01/25/13, revealed a Durable Power of Attorney (DPOA) for Resident #94. The DPOA did not provide legal authority for the person named as the DPOA to make health care decisions for Resident #94, because it was not signed by Resident #94. Therefore it was not a legally binding document. If the DPOA had been signed by the resident and was legally binding it still did not contain a health care decision clause giving permission for the person to make health care decisions for Resident # 94. This document was placed on the medical record by the facility staff, therefore the facility felt it was a legally binding document. The facility staff was not aware the document was not signed by Resident #94, until it was pointed out during the by the survey. There were no other documents within the medical record which gave anyone the legal authority to make health care decisions for the resident. The medical record revealed a Physician order [REDACTED]. This form was signed by a person other than Resident #94 on 10/21/09. The person signing the form signed in the signature box labeled, Signature of Patient/Resident, Parent of Minor, or Guardian/MPOA Representative/Surrogate(Mandatory). Also contained in the medical record of Resident # 94 was a form titled, Resident admission agreement/consent to treatment. This form was also signed by the same person who signed the POST form. This form was also dated 10/21/09, on the line… | 2016-02-01 |
| 9429 | 9429 | CLAY HEALTH CARE CENTER | 515142 | HC 75, BOX 153 | IVYDALE | WV | 25113 | 2011-07-28 | 152 | D | 0 | 1 | TF5T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview it was found that the Physician order [REDACTED]. This was evident for 1 (one) of 37 stage II sampled residents. Census: 57 residents currently in facility. Findings include: A) Resident #51 Review of the medical record for this resident revealed that there had been a previous POST form completed with a physician signature and date of 12/29/09. It stated the resident would want: Do Not Resuscitate (DNR), comfort measure only, antibiotics, IV (intravenous fluids)for a trial period and no tube feedings. Another POST form was noted which was dated by staff on 1/26/11. This document had listed that the resident would want DNR, no antibiotics, no IV, no tube feedings. It was not signed nor dated as to when the physician would have reviewed this information with the resident or responsible party and informed them of this change in treatment that would be provided. Spoke with director of nursing on 7/26/11 at mid afternoon regarding the lack of the signature and date by the physician. There was no further details submitted to the surveyor as of exit on 7/28/11 | 2015-11-01 |
| 9596 | 9596 | HILLCREST HEALTH CARE CENTER | 515117 | P.O. BOX 605 | DANVILLE | WV | 25053 | 2012-10-05 | 152 | D | 1 | 0 | D8F011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the West Virginia Code, the facility failed to ensure a third evaluation of the resident's ability to make health care decisions was completed after the facility obtained two conflicting statements regarding the resident's ability to make health care decisions. The unresolved conflict resulted in various individuals making health care decisions for the resident. This was true for one (1) of six (6) medical records reviewed for resident rights exercised by a representative. Resident identifier: #81. Facility census: 89. Findings include: a) Resident #81 Review of the medical record found the resident's physician had determined the resident demonstrated capacity to make medical decisions on 07/17/12. Further review of the medical record found the local Department of Health and Human Services (DHHR) had completed the admission paper work on 07/19/12, two (2) days after the resident's physician determined the resident had the capacity to make his own medical decisions. The DHHR had also completed a, West Virginia Physician order [REDACTED]. The admissions director, Employee #56, was interviewed at 10:00 a.m. on 10/2/12. He stated the resident had lacked capacity upon admission. On 10/02/12 at 10:25 a.m., the facility social worker, Employee #62, presented a physician's determination of capacity from a local hospital, dated 06/27/12, which determined the resident lacked capacity to make medical decisions and appointed the DHHR as the resident's health care surrogate. According to the West Virginia Code (16-30-22), .shall have two physicians, one of whom may be the attending physician, or one physician and a qualified psychologist, or one physician and an advanced nurse practitioner, certify that the principal has regained capacity. Further review of the physician's orders [REDACTED]. The director of nursing (DON), Employee #88, and the corporate nurse, Employee #89, were made aware of … | 2015-10-01 |
| 9692 | 9692 | OAK RIDGE CENTER | 515174 | 1000 ASSOCIATION DRIVE | CHARLESTON | WV | 25311 | 2010-01-07 | 152 | D | 0 | 1 | 9PJH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to ensure each resident's health care decisions were made by the individual appointed by the resident. Additionally, determination of the resident's incapacity did not clearly indicate the nature of the incapacity. This was true for one (1) of thirteen (13) sampled residents. Resident identifier: #17. Facility census: 72. Findings include: a) Resident #17 1. Review of the resident's medical record found the resident had appointed Individual #1 as her first choice to be her medical power of attorney representative (MPOA). She had appointed Individual #2 as the successor MPOA should Individual #1 be unable, unwilling, or disqualified to serve. Further record review found Individual #2 had signed the physician's orders [REDACTED]. However, no evidence was found in the medical record indicating Individual #1 was unwilling or unable to serve, or that he had been disqualified. On the morning of 01/07/10, Employee #95 was asked whether something had happened to Individual #1, as Individual #2 had been making the resident's health care decisions. She said she did not know but would find the answer. At 9:20 a.m. on 01/07/10, Employee #95 said she had contacted Individual #2, who said she had been making the resident's health care decisions because Individual #1 had been working a lot of overtime. 2. This resident was admitted on [DATE]. A Physician Determination of Capacity had been completed on 12/10/09, by a physician other than the resident's primary physician. The form contained the following sentence: In my opinion this patient HAS ___ or LACKS ___ sufficient mental or physical capacity to appreciate the nature and implication of health care decisions. The physician placed a checkmark in the blank beside Lacks. In a section directing Please check the nature of the incapacitation as evidenced by:, the evaluator recorded: Disorientation to person, place, and time. The word… | 2015-10-01 |
| 9834 | 9834 | GOLDEN LIVINGCENTER - RIVERSIDE | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2012-08-02 | 152 | D | 1 | 0 | K6SZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to aenure a resident who was alert and oriented was provided the opportunity to make her own health care decisions. Resident #85 had expressed that she did not want cardiopulmonary resuscitation (CPR) and two days later, her medical power of attorney (MPOA) changed this decision without the legal authority to do so and without evidence the resident was involved in this decision. The resident's family was also permitted to sign her admission paperwork without evidence the resident was involved in her admission or in decisions regarding her care at this facility. This practice was evident for one (1) of nine (9) sampled residents. Resident identifier: #85. Facility Census: 84. Findings include: a) Resident #85 Resident #85 was admitted to the facility on [DATE]. Her advance directives were reviewed and it was determined she had appointed a medical power of attorney on [DATE], just two (2) days prior to her admission to this facility. At the time of this resident's admission, on [DATE], the resident completed a cardiopulmonary resuscitation (CPR) form to express her wishes if she were to suffer a [MEDICAL CONDITION], respiratory arrest, or if death was imminent. She directed the facility withhold CPR and all life saving measures. The resident signed this form along with her representative who she had appointed her MPOA. Review of the medical record found that this resident was examined by the physician on [DATE]. It was recorded in the history and physical that she was alert and oriented times four (x 4). There was no incapacity statement found in the medical record to establish this residtn was not able to make her own medical decision and to activate her medical power of attorney. Further review of the medical record found that on [DATE], the appointed MPOA completed and signed a new CPR form stating "I want CPR". This form did not have the resident's signature on it and was com… | 2015-08-01 |
| 10023 | 10023 | BARBOUR COUNTY GOOD SAMARITAN SOCIETY | 515116 | 216 SAMARITAN CIRCLE | BELINGTON | WV | 26250 | 2010-02-11 | 152 | D | 0 | 1 | 4T1611 | . Based on medical record review and staff interview, the facility failed to ensure the rights of one (1) of twelve (12) sampled residents, who had been determined to lack capacity to make informed health care decisions, were exercised by an individual appointed in accordance with State law. The physician appointed two (2) individuals to serve jointly as Resident #49's health care surrogate (HCS); however, WV State Code 16-30-8 allows a physician to appoint only one (1) HCS. Additionally, the facility allowed a family member who had not been appointed to the role of HCS to make health care decisions on Resident #49's behalf. Facility census: 50. Findings include: a) Resident #49 Medical record review revealed the physician appointed two (2) persons to serve jointly as Resident #49's HCS, to make health care decisions for this resident. In addition, record review also revealed health care decisions were being made by the resident's mother, who was had not been appointed to serve as HCS. In an interview with the administrator and the person in charge of resident funds (Employee #5) at 2:15 p.m. on 02/10/10, they acknowledged understanding the State law only allows for the appointment of one (1) person to serve as HCS for an incapacitated individual, and they acknowledged the resident's mother was not the resident's legal representative. They state they would see that all staff was made aware of this. According to WV Code 16-30-8. Selection of a surrogate.: "(a) If no representative or court-appointed guardian is authorized or capable and willing to serve, the attending physician or advanced nurse practitioner is authorized to select a health care surrogate." "(b)(1) Where there are multiple possible surrogate decisionmakers at the same priority level, the attending physician or the advanced nurse practitioner shall, after reasonable inquiry, select as the surrogate the person who reasonably appears to be best qualified." This State law does not allow for the simultaneous appointment of more than one (1) person to s… | 2015-07-01 |
| 10115 | 10115 | ELKINS REGIONAL CONVALESCENT CENTER | 515025 | 1175 BEVERLY PIKE | ELKINS | WV | 26241 | 2009-10-23 | 152 | D | 0 | 1 | 9ELI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility failed to ensure the individual acting on behalf of an incapacitated resident had the legal authority to make health care decisions. The facility had not obtained documentation to validate the appointment of a health care surrogate for the resident. One (1) of eighteen (18) residents on the sample was affected. Resident identifier: #40. Facility census: 99. Findings include: a) Resident #40 The resident was admitted to the facility on [DATE]. According to documentation in the resident's medical record, a health care surrogate had been appointed for the resident. An individual, other than the resident, had signed documents regarding health care decisions. However, there was no evidence the health care surrogate appointment had been validated. On 10/21/09 at 4:00 p.m., the social worker (Employee #23), when asked whether a copy of the health care surrogate appointment had been obtained, said she had asked the appointed individual to bring in a copy, but he had yet to do so. It was suggested a copy might have been received with the documents provided by the hospital at the time of transfer. Employee #23 checked, but was unable to locate a copy of the surrogate appointment. On 10/22/09 at 8:10 a.m., Employee #23 provided a copy of the health care surrogate appointment that had been faxed to the facility at 8:09 a.m. that morning. The facility had not obtained verification of the health care surrogate appointment for nearly a month after the resident was admitted . . | 2015-06-01 |
| 10182 | 10182 | MEADOWVIEW MANOR HEALTH CARE | 515141 | 41 CRESTVIEW TERRACE | BRIDGEPORT | WV | 26330 | 2009-10-08 | 152 | D | 0 | 1 | XHIH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure determinations of incapacity were documented in accordance with State law for two (2) of thirteen (13) sampled residents. One (1) resident's determination of incapacity did not indicate the expected duration of incapacity, nor was there evidence the physician informed this alert resident that a surrogate decision-maker would be acting on her behalf. Another resident's determination of incapacity also did not note the expected duration of incapacity. Resident identifiers: Resident identifiers: #18 and #36. Facility census: 59. Findings include: a) Resident #18 The medical record of Resident #18, when reviewed on 10/05/09, disclosed the resident's physician had, on 02/05/09, determined she lacked the capacity to understand and make her own informed medical decisions. The resident had been admitted to the facility on [DATE] and had posessed capacity until this time. The physician's documentation did not indicate this alert resident had been informed that her medical power of attorney representative (MPOA) would be making medical decisions of her behalf, as required by State law. The documentation also did not include the length of time the physician expected the resident to lack this capacity. b) Resident #36 The medical record of Resident #36, when reviewed on 10/05/09, disclosed the resident's physician had determined she lacked the capacity to understand and make her own informed medical decisions. The physician's documentation did not indicate this alert resident had been informed that her MPOA would be making medical decisions of her behalf, as required by State law. In an interview on 10/07/09 at 3:30 p.m., the director of nursing (Employee #69) agreed the was no evidence to reflect physician had informed the resident that her MPOA would be making her medical decisions, as required by State law. c) According to W.V.C. 16-30-7. Determination of incapacity.: "(a) For t… | 2015-06-01 |
| 10580 | 10580 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2009-07-30 | 152 | D | 0 | 1 | OPXH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the legal surrogate, of one (1) of thirteen (13) residents reviewed, exercised the resident's rights in accordance with State law. Resident #24 had designated a medical power of attorney representative (MPOA) to make health care decisions for her in the event she should lack the capacity to do so. The MPOA was making health care decisions on the resident's behalf, although there was no determination of incapacity in her record to reflect she was incapable of making these decisions for herself. Resident identifier: #24. Facility census: 60. Findings include: a) Resident #24 The medical record of Resident #24, when reviewed on 07/27/09, disclosed this [AGE] year old female had been admitted to the facility on [DATE], following hospitalization after a fall resulting in a subdural hematoma and cervical fracture. Review of the resident's admission documents, as well as the physician's orders [REDACTED]. The resident's medical record contained no document stating she herself did not have the capacity to make her own health care decisions. The facility's director of nursing (DON), when interviewed related to these findings on 07/29/09, confirmed that, although the resident was indeed unable physically and mentally to make her own decisions, there was no determination of incapacity completed by the attending physician for this resident. . | 2015-01-01 |
| 10605 | 10605 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2011-09-30 | 152 | E | 1 | 0 | 0VZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and review of State law, the facility failed to determine a resident's capacity according to State law (WVC 16-30 - West Virginia Health Care Decisions Act) for six (6) of eight (8) sampled residents. Resident identifiers: #38, #40, #17, #35, #9, and #5. Facility census: 38. Findings include: a) Residents #38, #40, #17, and #35 1. Resident #38 A review of Resident #38's medical record revealed the resident was determined to be incapacitated due to bilateral hearing impairment and dementia. - 2. Resident #40 A review of Resident #40's medical record revealed the resident was determined to be incapacitated due to dementia. - 3. Resident #17 A review of Resident #17's medical record revealed the resident was determined to be incapacitated due to dementia. The form was not dated as to when the determination of capacity had been made. - 4. Resident #35 A review of Resident #35's medical record revealed the resident was determined to be incapacitated due to dementia. - 5. According to WVC 16-30-7. "Determination of incapacity. "(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. "(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ..." - 6. On 09/28/11 at 12:12 p.m., an interview with the director of nursing (DON - Employee #169) and the … | 2015-01-01 |
| 10680 | 10680 | SUMMERS NURSING AND REHABILITATION CENTER LLC | 515170 | JOHN COOK ROAD, PO BOX 1240 | HINTON | WV | 25951 | 2011-09-13 | 152 | D | 1 | 0 | 8CVP11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the medical record and staff interview, the facility failed to assure documentation was obtained to verify who had authority to make health care decisions on behalf of the resident. On numerous occasions throughout the medical record of Resident #56, the facility referred to the resident's daughter as the resident's medical power of attorney representative (MPOA) and allowed her to make medical decisions for the resident; however, the medical record failed to contain any documentation showing the resident had designated the daughter as his MPOA. Furthermore, the facility also failed to obtain an evaluation of the resident's capacity to understand and make informed health care decisions when it was determined the resident had severe cognitive impairment. This was true for one (1) of ten (10) sampled residents. Resident identifier: #56. Facility census: 110. Findings include: a) Resident #56 Medical record review revealed this [AGE] year old male was admitted to the facility on [DATE]. Active [DIAGNOSES REDACTED]. Further review of the medical record found an admission minimum data set assessment (MDS) with an assessment reference date (ARD) of 02/13/11. The results of the brief interview for mental status (BIMS) contained in this MDS revealed a score of "5", indicating the resident's cognitive performance was severely impaired. A quarterly MDS, with an ARD of 07/28/11, revealed a BIMS score of "9", indicating the resident's cognitive performance was moderately impaired. (A BIMS score of "0" to "7" indicates severely impaired cognitive performance; a score of "8" to "12" indicates moderately impaired cognitive performance; and a score of "13" to "15" indicates a resident is cognitively intact.) The medical record contained no further documentation to reflect the facility had assessed the resident's cognitive status. The medical record also contained no documentation to reflect the physician had completed an assessment of th… | 2015-01-01 |
| 10711 | 10711 | GUARDIAN ELDER CARE AT WHEELING, LLC | 515002 | 20 HOMESTEAD AVENUE | WHEELING | WV | 26003 | 2009-08-20 | 152 | D | 0 | 1 | S2JZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the determination of incapacity, for one (1) of twenty-one (21) sampled residents, was documented in accordance with State law. Resident #106's record lacked any information regarding the cause or nature of the incapacity as required by W.Va. Code 16-30-7(b). Additionally, there was no evidence the resident was notified of the determination of incapacity as required by W.Va. Code 16-30-7(c). Resident identifier: #106. Facility census: 138. Findings include: a) Resident #106 According to the medical record, the resident was admitted to the facility on [DATE]. A "Physician's Determination of Capacity" form, completed by the attending physician on 04/23/08, indicated the resident "Demonstrates INCAPACITY to make medical decisions" for a "Short term" duration. The form listed "sequelae of [MEDICATION NAME] toxicity" without additional explanation as to the nature or cause of the resident's incapacity. Additionally, no evidence could be found the physician informed this conscious resident of the determination of incapacity or of the fact that a surrogate decision-maker would be acting on the resident's behalf. During an interview with the administrator and the three (3) social workers at 2:40 p.m. on 08/19/09, they acknowledged, after reviewing the resident's determination of incapacity, the documentation was incomplete. b) Per W.Va. Code 16-30-7. Determination of incapacity. "(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. "(b) The determination of incapacity shall be recorded contemporaneously in the person's medical… | 2014-12-01 |
| 10755 | 10755 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2009-06-25 | 152 | E | 0 | 1 | 667111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, a review of the West Virginia Health Care Decisions Act, and staff interview, the facility failed to ensure, for three (3) of thirteen (13) sampled residents, a legal surrogate was appointed in accordance with State law for residents lacking the capacity to understand and make their own informed health care decisions. Determinations of incapacity were made solely based on a [DIAGNOSES REDACTED]. Resident identifiers: #50, #33, and #47. Facility census: 75. Findings include: a) Resident #50 On 06/24/09 at approximately 2:00 p.m., review of Resident #50's medical record revealed a physician's determination of capacity form indicating Resident #50 lacked the capacity to understand and make informed health care decisions. However, the cause of the incapacity had not been recorded on the form. b) Resident #47 On 06/23/09, review of Resident #47's medical record revealed a physician's determination of capacity form indicating Resident #47 lacked the capacity to understand and make informed health care decisions due to having a [DIAGNOSES REDACTED]. c) Resident #33 Review of Resident #33's medical record, on 06/23/09, revealed the physician determined she lacked the capacity to understand and make her own health care decisions; however, the cause of her incapacity was not recorded. d) According to '16-30-7. Determination of incapacity., "(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. "(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a … | 2014-12-01 |
| 10804 | 10804 | MARMET CENTER | 515146 | ONE SUTPHIN DRIVE | MARMET | WV | 25315 | 2009-09-25 | 152 | D | 0 | 1 | 7F5X11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility failed to ensure the rights of residents were exercised by an individual appointed in accordance with State law. One (1) resident, who been determined to lack capacity prior to admission, had a health care surrogate appointed while in the hospital. Documentation indicated some staff was aware of this; however, others were a party to completion of a medical power of attorney document (MPOA), which would not be valid as the resident had not been deemed to have the capacity to make the appointment. Additionally, the MPOA had been witnessed by two (2) facility staff members, which was prohibited by the facility's policy. Two (2) residents, who were found to have capacity, had health care decisions made by others. Three (3) of the fifteen (15) current residents on the sample were affected. Resident identifiers: #6, #81, and #46. Facility census: 86. Findings include: a) Resident #6 This resident was admitted to the facility on [DATE]. 1. Review of the resident's medical record found a document entitled "Health Care Decision Making" that listed the resident's representative as Individual A and noted he was the resident's health care surrogate (HCS). At the bottom of the document, "Surrogate Decision Maker for Health Care" was marked as being the resident's advance directive. A date of 08/17/09, initialed by Employee #58, had been entered as the date the HCS document had been obtained. A "Physician order [REDACTED]. This form had been prepared by Employee #20, a registered nurse. This was further evidence some staff was aware the resident had previously had a health care surrogate appointed due to a determination of incapacity. 2. A copy of a "State of West Virginia Medical Power of Attorney" was also found in the resident's medical record. The form was dated 08/24/09 and signed by the resident. This form named Individual A as the resident's MPOA representative. There was no indica… | 2014-12-01 |
| 10838 | 10838 | MAPLES NURSING HOME | 515186 | 1600 BLAND STREET | BLUEFIELD | WV | 24701 | 2009-08-14 | 152 | D | 0 | 1 | L59911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, the facility failed to ensure the determination of capacity for a resident was made in accordance with Chapter 16, Article 30 of the West Virginia State Code, prior to allowing another individual to make health care decisions on behalf of the resident. The cause, nature, and duration of the incapacity were not identified for one (1) of the twelve (12) residents on the sample. Resident identifier: #28. Facility census: 48. Findings include: a) Resident #28 Review of the medical record for this resident found determinations of capacity dated 02/13/08 and 03/17/09. Both of the assessments identified the resident as lacking capacity to make health care decisions. The "Physician's Determination of Capacity" dated 02/13/08 had an "X" in the box by "[MEDICAL CONDITION]" in the section for "Nature". ("[MEDICAL CONDITION]" means the resident was unable to speak but would not necessarily mean the resident was unable to communicate and/or make medical decisions.) In the section for the cause of the incapacity, "ASCVD" ([MEDICAL CONDITION] cardiovascular disease) had been written. Again, this [DIAGNOSES REDACTED]. Additionally, the box by the section indicating the resident had been informed that someone else would be making her health care decisions was not checked. On the same form, another section for "Periodic Capacity Review" had been completed on 03/17/09. An "X" had been placed in the box by "Demonstrates INCAPACITY to make medical decisions." It had not been marked to indicate the resident was informed of the decision, and nothing had been checked or written for the nature and cause of the incapacity. The West Virginia Health Care Decisions Act, ?16-30-7. Determination of incapacity., states: "(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person… | 2014-12-01 |
| 10864 | 10864 | GLEN WOOD PARK, INC. | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2009-12-11 | 152 | D | 0 | 1 | IPRG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure one (1) of eleven (11) residents received a re-evaluation in their capacity status after a determination of short term incapacity had been made in 02/06/09. Resident identifier: #51. Facility census: 61. Findings include: a.) Resident #51 On 12/08/09 at approximately 9:30 a.m., medical record review for Resident #51 revealed she lacked the capacity to understand and make her own medical decisions. This determination occurred on 02/06/09, at which time the physician selected "short-term" for the duration incapacity and listed [MEDICAL CONDITION] cardiovascular disease as the cause. The physician identified as the nature of incapacity that the resident could not process information. The physician's determination of capacity form allowed for periodic capacity review; however, the facility had not completed the periodic review for this resident. On 12/08/09 at approximately 9:45 a.m., Employee #87 (registered nurse) indicated the resident received treatment from a psychiatrist who comes to the facility. She provided copies of the psychiatrist's progress notes which reflected no change in the resident's mental capacity. On 12/08/09, the physician re-evaluated the resident, at which time he determined the resident now possessed the capacity to understand and make her own medical decisions. . | 2014-11-01 |
| 10943 | 10943 | HAMPSHIRE CENTER | 515176 | 260 SUNRISE BOULEVARD | ROMNEY | WV | 26757 | 2009-06-18 | 152 | D | 0 | 1 | HO2T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ascertain a capacitated resident's wishes with respect to advance directives, allowed a medical power of attorney representative (MPOA) to make a health care decision on behalf of the resident without the legal authority to do so, and failed to identify and resolve conflicts between physician's orders [REDACTED]. Resident identifier: #4. Facility census: 61. Finding include: a) Resident #4 Review of Resident #4's medical record, on 06/17/09, revealed she was admitted to the facility on [DATE], with admitting orders signed by the physician for "Advance Directives: DNR (do not resuscitate)." Review of the "Physician Determination of Capacity", dated 01/11/09, revealed the resident had the capacity to understand and make her own informed health care decisions. The "staff member involved" with the completion of Resident #4's Advanced Directive Acknowledgment Form (Employee #63) marked an "X" at Item 6 indicating, "Do not perform cardiopulmonary resuscitation", and recorded, "Per conservation with POA (power of attorney) 01/09/09 2:50 PM." There was no signature of the form from the person making this health care decision on behalf of Resident #4, and there was no indication that Resident #4, who had the capacity to make this decision herself, was consulted regarding this matter. The "physician acknowledgement" of the form was signed by the physician on 01/09/09. Review of the resident's history and physical, dated and signed by the physician on 01/12/09 at 3:50 p.m., revealed: "CODE STATUS: FULL RESUSCITATION in the event of cardiopulmonary arrest, including intubation with mechanical ventilation and/or cardioversion pending her POST form and official DNR status. Will get further details from the long-term care unit." Review of the Physician order [REDACTED]. The form had been signed by the resident's MPOA - not the resident, and the MPOA's signature was not dated. The phy… | 2014-11-01 |
| 11021 | 11021 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2009-02-05 | 152 | D | 0 | 1 | 53ZE11 | Based on record review and staff interview, the facility failed to assure a resident, who had been determined to lack the capacity to understand and make informed healthcare decisions, had his decisions made by a legal surrogate designated in accordance with State law. The facility had Resident #92 sign an informed consent form authorizing the administration of the influenza vaccine, even though he had been determined to lack the capacity to make such healthcare decisions. Resident identifier: #92. Facility census: 121. Findings include: a) Resident #92 Medical record review revealed the attending physician determined Resident #92 lacked the capacity to understand and make healthcare decisions on 07/28/08. This determination was validated by a second determination made by a psychologist on 08/01/08. Further record review revealed Resident #92 had signed an informed consent form authorizing the administration of the influenza vaccine on 10/22/08. No other signature was on the form. During an interview with the social worker at 11:45 a.m. on 02/04/09, she acknowledged, after reviewing the chart, that Resident #92 should not have been asked to sign this form, as the resident did not have the capacity to understand and make healthcare decisions at that time. (Note: After the fact, on 11/19/08, the resident's attending physician reversed this and determined the resident had the capacity to formulate healthcare decisions. However, at the time the resident signed the vaccination consent form, he did not.) . | 2014-09-01 |
| 11048 | 11048 | VALLEY CENTER | 515169 | 1000 LINCOLN DRIVE | SOUTH CHARLESTON | WV | 25309 | 2009-06-25 | 152 | E | 0 | 1 | OJEL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed, for four (4) of twenty-eight (28) sampled records, to ensure legal surrogates were designated in accordance with State law for residents who have been determined to lack the capacity to understand and make their own health care decisions. Additionally, the facility failed to ensure the correct legal surrogate was identified in the medical record and contacted when health care decisions needed to be made. Resident identifiers: #3, #113, #131, and #19. Facility census: 128. Findings include: a) Resident #3 Medical record review, completed on 06/24/09, revealed the face sheet (demographic sheet) identified the resident's son was his medical power of attorney representative (MPOA). Review of the resident's MPOA document revealed the wife was the primary MPOA and the son was the successor MPOA. Further review revealed, on 11/19/08, the facility sent a notice to the resident's son, informing him of an upcoming care plan meeting. When interviewed on 06/24/09 at 11:20 a.m., the social worker (Employee #22) identified that the correct legal representative was the wife and the medical record face sheet was incorrect. Shortly after this interview, the face sheet was corrected. b) Resident #113 Medical record review, on 06/23/09, revealed Resident #113 was determined by his physician to lack capacity to make an informed choice regarding medical decisions on 03/27/09. Documentation on the form entitled "Physician Determination of Capacity" stated the resident lacked capacity due to a "[MEDICAL CONDITION]" ([MEDICAL CONDITION] - stroke). The determination of incapacity was based solely on a medical condition and did not provide information to describe what components of the disease interfered with his ability to understand and make informed health care decisions. The facility's director of nursing (DON - Employee #82), when provided this information on 06/25/09, was unable to provide … | 2014-09-01 |
| 11116 | 11116 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2009-04-30 | 152 | D | 0 | 1 | 6TSD11 | Based on record review and staff interview, the facility failed to ensure that the persons making healthcare decisions for two (2) of thirteen (13) sampled residents, who had been determined to lack the capacity to make such decisions for themselves, were appointed in accordance with State law. Resident identifiers: #45 and #60. Facility census: 101. Findings include: a) Resident #45 A review of Resident #45's medical record revealed a copy of a document appointing the resident's son as her medical power of attorney representative (MPOA). Review of the resident's advance directives, consents for vaccination, and other legal documents revealed these healthcare decisions had been made by the resident's daughter as evidenced by her signatures on these documents. During an interview with the director of nursing (DON) at 5:15 p.m. on 04/28/09, she stated the son was the MPOA of record, but the facility accepted the daughter's signature because she was the one who came in most often. b) Resident #60 A review of Resident #60's medical recordrevealed the individual who gave consent for a do not resuscitate order and for use of psychoactive medications, and who made other healthcare decisions for Resident #60 was not the person designated by the resident to serve as MPOA. During an interview with the DON at 5:15 p.m. on 04/28/09, she acknowledged that the person making the resident's healthcare decisions was not the resident's legally appointed MPOA. | 2014-08-01 |
| 11154 | 11154 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2009-08-12 | 152 | D | 0 | 1 | OCKG11 | Based on record review and staff interview, the facility allowed a resident to sign legal documents for health care decisions on the same day the resident's physician determined he did not possess the capacity to understand and make informed health care decisions and no one had been designated to serve as health care surrogate for the resident. Additionally, the physician failed to record the cause and duration of Resident #50's incapacity. This was evident for one (1) of thirteen (13) sampled residents. Resident identifier: #50. Facility census: 50. Findings include: a) Resident #50 Record review revealed Resident #50 had a determination of incapacity statement signed by his attending physician at the facility. Record review also revealed that, on the same day the incapacity statement was signed by the physician, Resident #50 had signed the following documents: acknowledgment for bed rail use; acknowledgment of resident rights and privacy notice; immunization acknowledgment for declination of influenza vaccine; advance directives acknowledgment form; and permission to release information form. Interview with the social worker (Employee #8), on 08/12/09 at 2:00 p.m., revealed the resident had recently been admitted to the facility on her day off; he was accompanied by one (1) of his children. Employee #8 said, on the following day, she contacted one (1) of his children, who agreed to come in that day and speak with her, but the daughter did not appear. The next day, the physician assessed Resident #50 and determined he lacked the capacity to understand and make health care decisions. Employee #8 spoke her plans to have a yet-to-be assigned health care surrogate co-sign his legal documents, and she was in the process of making phone calls and going down the long list of family members to identify who was willing and able to serve as his health care surrogate. Interview with the social worker, on 08/12/09 at approximately 6:00 p.m., revealed she was still in the process of calling family members to determine who wa… | 2014-08-01 |
| 11211 | 11211 | TEAYS VALLEY CENTER | 515106 | 590 NORTH POPLAR FORK ROAD | HURRICANE | WV | 25526 | 2009-12-03 | 152 | D | 0 | 1 | TDS111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to identify the nature of incapacity for one (1) of twenty-one (21) sampled residents determined by the physician to lack the ability to understand and make informed health care decisions. Resident identifier: #3. Facility census: 116. Findings include: a) Resident #3 Review of Resident #3's determination of incapacity statement, dated 10/28/09, revealed the physician identified the resident lacked decision-making capacity due to the [DIAGNOSES REDACTED]. During interview with the director of nursing (DON) the morning of 12/02/09, she stated the facility's practice is for the physician to note not only the [DIAGNOSES REDACTED]. When informed of Resident #3's incapacity statement, which noted only the diagnosis, she said she would bring this to the physician's attention for correction. According to W.V.C. 16-30-7. Determination of incapacity.: "(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. "(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ..." . | 2014-07-01 |
| 11332 | 11332 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2010-12-28 | 152 | D | OYFI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to verify that a surrogate decision-maker had the necessary authority to act on behalf of a resident who had been determined to lack the capacity to make healthcare decisions, for one (1) of six (6) sampled residents. Resident identifier: #23. Facility census: 89. Findings include: a) Resident #23 A review of Resident #23's medical record revealed a [AGE] year old female who was originally admitted to the facility on [DATE], and who had been determined to lack the capacity to make healthcare decisions by her attending physician on 08/21/08. The face sheet in the resident's record indicated the resident had designated an individual to serve as her medical power of attorney representative (MPOA), but there was no copy of this document in the record. Social service notes, dated 12/13/10, stated the resident's sister had been appointed to serve as her health care surrogate (HCS), and documentation elsewhere in the record indicated this HCS was making healthcare decisions for the resident. No record of the appointment of a HCS by the resident's attending physician was located in the record. During an interview with the social worker (Employee #5) at 10:40 a.m. on 12/28/10, she verified, after review of the resident's medical record and her office records, that there was no record of a legal representative. She speculated it had been misplaced at some point. . | 2014-04-01 | ||
| 11505 | 11505 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2009-05-29 | 152 | D | E5O711 | Based on medical record review, and staff interview, the facility failed to assure the right to make medical decisions for one (1) of ten (10) sampled residents was exercised in accordance with State law (the West Virginia Health Care Decisions Act). The facility allowed a health care surrogate (HCS) to transfer decision-making authority to a different family member when the HCS was unavailable. Resident identifier: #4. Facility census: 29. Findings include: a) Resident #4 Review of Resident #4's medical record found the treating physician determined the resident lacked capacity to understand and make informed medical decisions on 04/17/09. The physician appointed Family Member #1 to act as the resident's HCS. Further review found a handwritten, notarized document which appeared to be authored by Family Member #1, transferring the health care decision-making authority to Family Member #2 in the event Family Member #1 could not be reached. On 05/28/09 at 1:00 p.m., the document was shown to two (2) facility nurses (Employees #24 and #27). Each was asked what they would do if Family Member #1 could not be reached to make a health care decision. Both stated that, because the document was notarized, they would contact Family Member #2 to make health care decisions. Review of section 16-30-8 (a) of the West Virginia Health Care Decisions Act found the following language, "When a person is or becomes incapacitated, the attending physician or the advanced nurse practitioner with the assistance of other health care providers as necessary, shall select, in writing, a surrogate." The facility allowed a HCS to transfer medical decision-making authority to another individual in violation of the West Virginia Health Care Decisions Act. Only the attending physician or advanced nurse practitioner may select a surrogate decision-maker. . | 2014-01-01 | ||
| 6917 | 6917 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2014-10-08 | 153 | B | 1 | 0 | KVTV11 | Based on review of the facility's policies and procedures, the facility failed to ensure the policies established for accessing medical records was in compliance with this regulation. The current facility policy had the potential to result in residents and/or the legal representative being denied access to medical records within 24 hours (excluding weekends and holidays) as required. This practice had the potential to affect any resident/responsible party who exercised the right to access clinical records. Facility Census: 81. Findings include: a) Review of the facility's policy titled Request for Medical Records, last reviewed 2013, revealed in section 6, . the documents should be produced within five (5) days of receipt of the notification that the request for a medical record is valid. | 2017-10-01 |
| 11423 | 11423 | HEARTLAND OF BECKLEY | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2010-11-02 | 153 | D | U2Q611 | . Based on a review of the State Board of Review hearing notice, staff interview, family interview, and a review of a Release of Medical Record form, the facility failed to ensure a resident or his / her legal representative had the right, upon an oral or written request, to access all records pertaining to his/her stay at the facility, including current clinical records, within twenty-four (24) hours (excluding weekends and holidays) of receipt of the request. This occurred for one (1) of eleven (11) residents included in the sample. Resident identifier: #162. Facility census: 150. Findings include: a) Resident #162 During a telephone interview on 11/01/10 at 7:30 p.m., Resident #162's legal representative reported the facility did not allow access to the resident's medical record for review prior to an appeal for discharge hearing with the State Board of Review at 1:00 p.m. on 09/27/10. The representative reported having called the facility on 09/23/10 or 09/24/10 and leaving a voice message for the assistant administrator, asking to review the information the facility was going to use in the hearing. She said she was not provided the information prior to the hearing. During an interview on 11/02/10 at 11:00 a.m., the assistant administrator reported the request was made on 09/24/10 (a Friday) and, at that time, the information was being gathered by the facility administrator for the hearing. He said the information was not available for review until the hearing at 1:00 p.m. on 09/27/10. Review of the hearing notice, dated 09/20/10, found a second page with a section titled, "You Have the Right To:" The first item under this title stated, "1. Examine all documents and manual sections to be used at the hearing, both before, during, and after the hearing. Please call the nursing home if you wish to look at the evidence before the hearing." The administrator, who was interviewed on 11/02/10 just after the assistant administrator, stated the resident's legal representative did not ask to review the resident's recor… | 2014-03-01 | ||
| 827 | 827 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2017-03-22 | 154 | D | 0 | 1 | ZQ9211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and record review it was determined the facility failed to ensure two (2) of five (5) residents reviewed for unnecessary medications who received psychoactive medications were informed of the risks and benefits of psychoactive medications. Failure to provide residents and/or the legal representative information regarding psychoactive medications placed the residents at risk to not be fully informed about their care and potential alternate treatment options. Resident identifiers: #35 and #113. Facility census: 85. Findings include: a) Resident #35 Review of physician orders, on 03/21/17 at 10:15 a.m., revealed Resident #35 received the anti-psychotic medication, [MEDICATION NAME], and the anti-depressant medication, [MEDICATION NAME], daily since 09/09/16. On 03/21/17 at 10:25 a.m., review of the Minimum Data Set (MDS) with an Assessment Reference Date of 02/04/17 revealed the resident had moderately impaired cognitive skills. In an interview, on 03/21/17 at 11:35 a.m., Resident #35 was unable to state any of the medications she received nor what she took them for. Review of the resident's record, on 03/21/17 at 10:43 a.m., revealed a paper form entitled Psychotherapeutic Medication Administration Disclosure. The form included different classifications of psychoactive medications, their benefits, adverse reactions and special concerns for staff to select based on the resident's assessed care needs. While someone had circled the anti-psychotic medication [MEDICATION NAME], the form failed to identify the anti-depressant [MEDICATION NAME]. There were no signatures from the resident, the resident's representative, or facility staff, nor was there any indication verbal consent was obtained. There was no date on the form. In an interview, on 03/21/17 at 2:25 p.m., the Assistant Director of Nursing (ADON) #79 stated the hard copy of the Medication Administration Disclosure should be in the chart under th… | 2020-09-01 |
| 2612 | 2612 | WILLOW TREE HEALTHCARE CENTER | 515156 | 1263 SOUTH GEORGE STREET | CHARLES TOWN | WV | 25414 | 2017-08-17 | 154 | E | 0 | 1 | OM4311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to inform the responsible parties of the risks and benefits of receiving psychopharmacological medications in advance of administering them to cognitively impaired residents. This affected two (2) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #46, and #118. The facility census was 101. Findings include: a) Resident #46 On 08/17/17 at 9:32 a.m., review of the resident's medical record revealed [REDACTED]. Review of current physician orders [REDACTED]. Review of the medical record on 08/17/17 at 11:15 a.m. revealed Resident #46 lacked capacity to make her own medical decisions and her daughter was indicated as the resident's responsible party and emergency contact. Concurrent review of the resident's plans of care revealed a current plan of care with a revision dated of 03/29/17 for the resident's use of [MEDICAL CONDITION] drug for dementia. The care plan problem stated the use of [MEDICAL CONDITION] drug use placed the resident at risk for drug related [MEDICAL CONDITION], gait disturbance, cognitive impairments, behavior impairment, activities of daily living decline, decline in appetite, and abnormal involuntary movements. The care planned interventions included antipsychotic side effects list #1 not limited to: [DIAGNOSES REDACTED]: [DIAGNOSES REDACTED] (stiffness of neck), [MEDICATION NAME] symptoms: dry mouth, blurred vision, constipation, [MEDICAL CONDITIONS], sedation/drowsiness, increased falls/dizziness, cardiac abnormalities ([MEDICAL CONDITIONS], irregular heart rate), anxiety/agitation, blurred vision, sweating/rashes, headache, [MEDICAL CONDITION]/hesitancy, pseudo-parkinsonism: cogwheel rigidity, bradykinesia, tremors, appetite change/weight change. Educate resident/family/POA about risk versus benefits of medication/side effects/adverse effects. Further review of the medical record found no evidence the resident's responsible par… | 2020-09-01 |
| 3893 | 3893 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 154 | D | 0 | 1 | 0MB311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to ensure Resident #170 was given information in advance sufficient enough for her to make a knowledgeable health care decision in regards to a fluid restriction which her attending physician at the hospital (who was also her attending physician at the facility) had recommended upon her discharge from the hospital on [DATE]. This was true for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT]. Resident Identifier: #170. Facility Census: 178 Findings include: a) Resident #170 A review of Resident #170's medical record at 9:00 a.m. on 09/23/16, found a discharge summary completed by Resident #170's attending physician while she was at the hospital. The discharge summary completed on 08/22/16 included her attending physician recommended a fluid restriction due to her status as a [MEDICAL TREATMENT] patient and her [DIAGNOSES REDACTED]. The same physician was also her attending physician at the facility. During an interview with the corporation's Chief Medical Officer Medical Doctor (CMO-MD) #271 at 10:20 a.m. on 09/23/16, when asked why Resident #170, a [MEDICAL TREATMENT] patient, was not ordered a fluid restriction upon her return from the hospital on [DATE], he replied not every one on [MEDICAL TREATMENT] needed a fluid restriction. He indicated that people in the community very seldom ever restrict their fluid. He proceeded to state the risk and benefits related to not watching her fluid intake was explained to the resident, but she was alert and orientated and able to make her own decisions. Therefore, she had the right refuse the fluid restriction which is why she was not currently ordered a fluid restriction. CFO-MD #271 was then asked if the conversation explaining the risk and benefits related to her refusal of a physician recommended fluid restriction was documented in her medical record. He informed the surveyor that this … | 2020-04-01 |
| 5100 | 5100 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2015-04-10 | 154 | D | 0 | 1 | CRGX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for resident rights was informed of his health status and needs. The resident's daughter, and not the resident, who had capacity to make health care decisions, was informed of the resident's health status. Resident identifier: #76. Facility census: 66. Findings include: a) Resident #76 On 04/06/15 at 11:04 a.m., the resident voiced concerns that staff did not involve him in his plan of care. He stated, I want my daughter involved and notified; however, I want to be notified first. Medical record review, on 04/06/15 at 1:20 p.m., found Resident #76 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. On 11/29/14, Resident #76's attending physician determined he had capacity to make informed health care decisions. Review of nurse's notes since admission found Resident #76's daughter was notified of his condition instead of the resident. An interview with Employee #42, Director of Admissions (DOA) and Employee #59, Social Services (SS), on 04/08/15 at 1:15 p.m., confirmed Resident #76 should be notified and involved in his plan of care. On 04/08/15 at 2:00 p.m., after intervention during the survey, Employee #42 spoke with Resident #76. The resident voiced his concern of not being allowed to be involved in his plan of care. In-service documentation, provided on 04/08/15, confirmed Resident #76 had capacity to make health care decisions and wished to actively participate in his care process. | 2019-03-01 |
| 5644 | 5644 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 154 | D | 0 | 1 | DSPZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, family interview, and staff interview, the facility failed to ensure the responsible party of a resident with a severe decline in health status was given information about the resident's reasonable available alternatives; including the option of palliative care. Resident identifier: 98. Facility census: 99. Findings include: a) Resident #98 A review of the clinical record revealed Resident #98 was a [AGE] year-old male initially admitted to the facility on [DATE]. He was determined by his physician to lack the capacity to make health care decisions and his brother was his medical power of attorney (MPOA). Resident #98 was designated to be a Full Code, meaning he was to be resuscitated should he stop breathing or his heart stop. His present [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED].#217 at 10:15 a.m. on 07/22/15. The resident had multiple hospitalization s in (YEAR). When discharged to the hospital on [DATE], his skin was clear with no pressure ulcers. On readmission on 04/02/15, his admission physical indicated [MEDICAL CONDITION] of his lower extremities, but no evidence of pressure ulcers. A Significant Change comprehensive assessment was completed on 04/09/15. An entry in the clinical record by NP #217 on 05/21/15, indicated the resident had multiple unstageable pressure wounds. His last readmission was 07/08/15 and although there was no terminal [DIAGNOSES REDACTED]. The record on readmission indicated Resident #98 was a Full Code. The record indicated Resident #98 now had 1 unstageable and 11 deep tissue injuries (DTIs) and the treatment goal stated by the NP/Physician was, Expectation is for non-healing with goal to prevent worsening of wounds. The care plan meeting notes from 07/19/15, indicated he was a full code; had recent cognitive changes and scored 0/15 on his brief interview for mental status (BIMS); and was refusing oral intake. There was no evidence of any … | 2018-09-01 |
| 5711 | 5711 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2014-11-19 | 154 | D | 0 | 1 | H5V711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, resident interview, and staff interview, the facility failed to ensure a resident was fully informed in language that she could understand of her total health status, including but not limited to, her medical condition and, in advance, about care and treatment and of any changes in that care or treatment that may affect her well-being. The facility failed to inform a resident they documented as having the capacity to make informed medical decisions that they had honored her medical power of attorney's decision to change her treatment to comfort measures only. This was found for one (1) randomly reviewed resident. Resident identifier: #147. Facility census: 110. Findings include: a) Resident #147 The medical record review for Resident #147, on 11/12/14 at 1:20 p.m., revealed she was most recently admitted to the facility on [DATE] and subsequently re-admitted on [DATE]. She was determined by a physician to possess the capacity to make informed medical decisions on 05/07/14. b) A physician's determination of capacity completed at the acute- care hospital on [DATE] just prior to resident #147's admission to the facility stated she possessed the capacity to make informed medical decisions. The initial determination of capacity made after her admission to the facility was on 05/05/14 and determined she lacked the capacity to make informed medical decisions, and the duration of her incapacity was long term. There was no nature or cause of her incapacity recorded. Another determination of capacity was completed at the facility on 05/07/14 as a periodic capacity review. Besides the reasons provided on the form for capacity review, which were Significant Change, Annual, and Readmission, a fourth reason, Tiebreaker, had been hand-written and was checked. This tiebreaker assessment determined she possessed the capacity to make informed medical decisions. There were no other physician's determinations of capacity found in the me… | 2018-08-01 |
| 6078 | 6078 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 154 | E | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to fully inform residents who had been determined to possess the capacity to act as their own decision-maker, in a language that he or she could understand, of identified concerns regarding his or her total health status, including their cognitive status and psychosocial status as initiated in their individualized care plans. Residents were not informed of care plans established for behaviors. This was found for four (4) of four (4) residents who had voiced multiple documented complaints during 2013. Resident identifiers: #19, #62, #25, and #57. Facility census: 100. Findings include: a) Review of complaints, concerns, and abuse/neglect reporting began on 01/08/13 at 9:00 a.m. This review was continued and expanded on 01/20/14 as part of the extended survey protocol. 1) Resident #19 Review of the complaint/concern files identified this resident had thirty (30) documented concerns in 2013 to date. According to the documentation regarding these issues, the facility had attempted to resolve all of the resident's issues. The facility had not dismissed any of the resident ' s concerns as being unfounded or untrue. The high number of concerns filed by this resident prompted review of her medical record. This review the resident's physician had determined she possessed the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score, as assessed on 12/17/13, was 15, indicating she was cognitively intact. She was acting as her own decision-maker. Review of her care plan, on 01/16/13 at 1:00 p.m., found she had a focus item for being at risk for changes in behavior problems related to making false accusations towards staff. The goal for this problem was (typed as written), Will remain free of behavioral disturbances daily thru next review. Interventions implemented toward meeting this goal were (typed as written): 1. Anticipate needs and provide care a… | 2018-05-01 |
| 6420 | 6420 | PRINCETON CENTER | 515028 | 1924 GLEN WOOD PARK ROAD | PRINCETON | WV | 24740 | 2015-03-06 | 154 | D | 1 | 0 | S2LQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to inform one (1) of five (5) sampled residents of the healthcare status and treatment which necessitated medication changes. Resident #54 was receiving two (2) medications used to treat sexual behaviors. These medications had dosage adjustments of which Resident #54 was not informed. Resident Identifier: #54 Facility Census: 68. Findings Include: a) Resident #54 Review of Resident #54's medical record, at 3:17 p.m. on 03/03/15, found the resident had capacity to make medical decisions. The medical record contained one (1) capacity statement completed by the attending physician. The capacity statement indicated Resident #54 had the ability to appreciate the nature and implications of a health care decision, to make an informed choice regarding the alternatives presented, and to communicate the choice in an unambiguous manner. This form was completed on 05/31/14 and was still in effect at the time of this review. Further review of Resident #54's medical record found a physician's orders [REDACTED]. The nurse progress notes were reviewed. A note, dated 02/16/15, indicated Resident #54's spouse was notified of the medication change. There was no evidence in the medical record to suggest Resident #54 was notified of this medication change or was informed of the reason the medications were ordered and provided. Interview with the Director of Nursing (DON), at 12:23 p.m. on 03/06/15, confirmed there was no evidence to suggest Resident #54 was informed of the medication change on 02/16/15. She said staff called the spouse, but there was no evidence the resident was informed. The DON stated the physician was going to review the resident's capacity; however, at the time of the medication changes the resident was determined capable of making medical decisions. | 2018-03-01 |
| 8217 | 8217 | HILLTOP CENTER | 515061 | PO BOX 125 | HILLTOP | WV | 25855 | 2013-07-25 | 154 | D | 1 | 0 | 1LKT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to accurately inform the family and resident of the total health status related to antibiotic use for one (1) of three (3) residents reviewed for the use of antibiotics. The facility notified the resident and family member the resident was receiving the antibiotic [MEDICATION NAME] for a urinary tract infection. The resident was actually receiving the antibiotic for another diagnosis. He did not have a urinary tract infection at the time this antibiotic was ordered. Resident identifier: #114. Facility census: 112. Findings include: a) Resident #114 Review of the medical record, on 07/24/13, identified a physician's orders [REDACTED].#90 (licensed practical nurse - LPN) dated 06/29/13. The physician's orders [REDACTED]. Further review of the medical record found a general note written by Employee #90 (LPN), on 06/29/13 at 19:12, stating the family was notified this resident was ordered [MEDICATION NAME] for a urinary tract infection. During an interview conducted on 07/24/13 at 3:11 p.m., Employee #137 (family nurse practitioner), revealed she did not order [MEDICATION NAME] for a urinary tract infection. She stated, The [MEDICATION NAME] was ordered for results of a chest-x-ray called to me on 06/29/13, by the facility. Employee #137 also stated, I wouldn't have ordered [MEDICATION NAME] for a urinary tract infection. Review of the medical record identified a chest x-ray, dated 06/29/13, with the following impression: Under ventilated lungs, mild cardiomegaly, ill-defined densities left lung base could represent atelectasis or mild consolidation, recommend follow up. | 2016-07-01 |
| 9546 | 9546 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2009-11-20 | 154 | D | 0 | 1 | 5V2011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to inform one (1) of twenty-one (21) sampled residents of the potential risks and available alternative treatments relating to bladder elimination. An alert and oriented resident, whose indwelling Foley urinary catheter continued to be used at her request (beyond the time-limited physician's orders [REDACTED]. Resident identifier: 25. Facility census: 157. Findings include: a) Resident #25 Resident #25's medical record, when reviewed on 11/19/09 at 1:30 p.m., revealed a [AGE] year old female who was admitted to the facility on [DATE]. The resident was alert and oriented and had been determined by her physician to possess the capacity to understand and make informed healthcare decisions. The resident was on bedrest due to a fall at home resulting in fractures to the lumbar spine. The physician ordered an indwelling Foley urinary catheter for seven (7) days on 11/01/09 due to excoriation. Resident #25, when observed in bed at 1:45 p.m. on 11/19/09, had in place an indwelling urinary catheter. The resident, when interviewed, reported she did not want the catheter removed until she was off of bedrest and able to ambulate. The director of nurses (DON - Employee #165), when interviewed on 11/20/09 at 3:15 p.m., reported it was the resident's choice to keep the catheter. However, the DON did acknowledge the facility failed to inform the resident of potential risks of continuing to use an indwelling catheter over an extended period of time or alternative treatments available. | 2015-10-01 |
| 10569 | 10569 | HEARTLAND OF MARTINSBURG | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2009-10-29 | 154 | D | 0 | 1 | 0YSZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to fully inform one (1) of twenty (20) sampled residents, who had been determined by his physician to have the capacity to make his own healthcare decisions, of his rights as a resident, his healthcare status and the treatment interventions planned, and/or his discharge planning arrangements. Resident identifier: #62. Facility census: 114. Findings include: a) Resident #62 A review of the medical record revealed Resident #62 was a [AGE] year old male with [DIAGNOSES REDACTED]. He was admitted to the facility on [DATE]. His attending physician determined he lacked the capacity to make his own informed healthcare decisions on 04/13/09, and assigned his niece as his health care surrogate (HCS). The social services note, written by the social worker (SW - Employee #80) on 09/29/09, recorded the resident's niece came to the facility on this date and stated that, for health reasons, she could no longer serve as the resident's HCS. She was advised the facility would seek a HCS from WV DHHR. There was also evidence that a 30-day notice of discharge had been mailed to the HCS on or about 09/24/09, although she reported to the SW she had not received it. On 10/06/09, the resident's attending physician determined the resident now demonstrated the capacity to make his own informed healthcare decisions. All social services notes, progress notes, and nurses' notes after that date were reviewed, but there was no evidence that the resident had his care plan (especially his discharge plan) or his rights explained to him. During the general tour at 3:30 p.m. on 10/19/09, this resident approached the surveyor and asked if there was any rule about the sharing of the television in his room; he also asked the surveyor to find out why he had not been discharged yet. At 11:20 a.m. on 10/20/09, the resident was interviewed about his healthcare status. He said he was sick a few months… | 2015-01-01 |
| 10783 | 10783 | HEARTLAND OF CLARKSBURG | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2011-08-02 | 154 | D | 1 | 0 | H4MU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, physician interview, and family interview, the facility failed to ensure the responsible party of one (1) of five (5) sampled residents, who lacked capacity to understand and make informed healthcare decisions, was informed in advance about a change in care that may affect the resident's well-being. The facility did not receive approval from Resident #72's health care surrogate (HCS) before discontinuing the resident's medication, labs and diagnostic tests, and weights. Facility census: 106. Findings include: a) Resident #72 Record review revealed Resident #72 was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident weighed 88 pounds (#) on admission, and his current weight on 08/02/11 was 98#. -- On 06/23/11, a physician's orders [REDACTED]. Resident refusal." -- An interview with the social worker, on 08/02/11 at 11:35 a.m., revealed the social worker had no knowledge of the resident not receiving his medication, labs and diagnostic tests, and weights. She was not aware that the resident was refusing to take his medication and was refusing to be weighed. She also stated, "I was unaware that the HCS was not returning the calls to the nursing staff about his (the resident's) refusal to take his medication and refusing to be weighed." -- An interview with the director of nursing (DON), on 08/02/11 at 10:00 a.m., revealed the resident was refusing to take his medication and refusing to be weighed. She stated, "The HCS was notified multiple times and did not return the calls." She further stated, "When a resident is refusing to take their medication and refusing to be weighed, it is my practice to have the physician discontinue the medication and weights." -- An interview with the physician, on 08/02/11 at 2:00 p.m., revealed the physician was unaware that the resident's HCS was not informed of the medications and the weights discontinued. She s… | 2014-12-01 |
| 10944 | 10944 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2009-05-22 | 154 | D | 0 | 1 | T34S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, review of the facility's policy regarding cardiopulmonary resuscitation (CPR), and staff interview, the facility failed to ensure residents were fully informed in advance of care or treatment that might affect their well-being. Resident #94's medical record included a Physician order [REDACTED]. There was no evidence the resident / responsible party had been made aware of the facility's policy. One (1) of eight (8) residents whose closed record was reviewed was affected. Resident identifier: #94. Facility census: 86. Findings include: a) Resident #94 Review of the resident's medical record found a POST form had been completed by the resident's medical power of attorney representative (MPOA) on [DATE]. The MPOA had checked the POST form, indicating the resident was to be resuscitated. Further review of the medical record found an entry, dated [DATE] at 3:00 a.m., recording, "Called to residents (sic) room by staff at 12:30 AM (sic) No pulse - radial/carotid. No respirations. Skin cold to touch. Pupils fixed / dilated /c (with) pupil indented. Tem (temperature) 87.2 (degree mark) F...." The note continued, and the MPOA was quoted as saying, "I spent a long time with her a couple of days ago and I have been expecting this." No attempts were made to provide CPR. The director of nursing (DON), when interviewed regarding these findings at 7:45 a.m. on [DATE], stated they have night time briefs so staff do not have to disturb residents so often. She said staff does not go in and check to see whether residents are still breathing every two (2) hours, as this would disturb the sleeping residents. The DON said this resident had been stiff when she was found, and the resident's death was "very unexpected". The DON was asked whether there was a policy regarding when CPR would be provided. Shortly after, she provided a copy of the facility's policy entitled "Cardiopulmonary Resuscitation." The policy included, "Cardiopu… | 2014-11-01 |
| 11148 | 11148 | EMERITUS AT THE HERITAGE | 5.1e+153 | RT. 4, BOX 17 | BRIDGEPORT | WV | 26330 | 2009-08-12 | 154 | D | 0 | 1 | OCKG11 | Based on medical record review and staff interview, the facility failed to ensure one (1) of thirteen (13) sampled residents was fully informed in advance of medication changes. Resident #8 was determined to possess the capacity to make her own health care decisions, but a note in the resident's medical record indicated her daughter, who was not a legally designated health care surrogate, was to be informed of medication changes before the resident was. Facility census: 50. Findings include: a) Resident #8 Resident #8 was an alert and oriented resident who had been determined by her physician to possess the capacity to understand and make her own health care decisions. Review of Resident #8's medical record found the following statement dated 02/24/09 and signed by the former director of nursing: "Nurses: Please contact (name) before ordering new medications for (Resident #8). She would like to talk it over with her mother first. The above is not to be discussed with (Resident #8)." A review of the statement with the current director of nursing, on 08/12/09 at 2:00 p.m., found the director of nursing was unaware of the note in the resident's medical record. . | 2014-08-01 |
| 11218 | 11218 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2011-03-16 | 154 | D | 1 | 0 | 81RJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility did not inform the legal representatives of three (3) of five (5) sampled residents when changes were made to their care and/or treatment. Resident identifiers: #73, #85, and #8. Facility census: 116. Findings include: a) Residents #73, #85, and #8 A review of MEDICATION ORDERS FOR [REDACTED]. 1. Resident #73 Record review revealed a physician's orders [REDACTED]." On 12/08/10, another physician's orders [REDACTED]. Each physician's telephone order form contained a place for the nurse to record the name of the family member who was notified of the new order; these areas were blank on the above telephone orders. - 2. Resident #85 Record review revealed a physician's orders [REDACTED]. Each physician's telephone order form contained a place for the nurse to record the name of the family member who was notified of the new order; this area was blank on the above telephone order. - 3. Resident #8 Record review revealed a physician's orders [REDACTED]. Each physician's telephone order form contained a place for the nurse to record the name of the family member who was notified of the new order; this area was blank on the above telephone order. -- b) An interview with the administrator, on 03/16/11 at 9:30 a.m., revealed the nurses were all educated to notify families of residents when a change was made in medications. . | 2014-07-01 |
| 2435 | 2435 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2017-06-30 | 155 | D | 1 | 1 | 45HC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure Resident #133 was afforded the right to request, refuse, and/or discontinue treatment, and to formulate an advance directive. Resident #133 was determined to have capacity to make medical decisions, however; his caregiver had signed all his admission paperwork for admission and treatment at the facility. This was true for one (1) of one (4) residents reviewed for the care area of Choices during Stage 2 of the Quality Indicator Survey. Resident identifier: #133. Facility census: 76. Findings include: a) Resident #133 A review of Resident #133's medical record, at 1:12 p.m. on 06/28/17, found the resident was [AGE] year old resident with an admission date of [DATE]. Consent for treatment and release of information found in medical records was signed by Resident #133's Medical Power of Attorney (MPOA) on 04/07/17. Review of the record found a Physician's Determination of Capacity dated 04/08/17 which indicated Resident #133 was capacitated to make medical decisions. Contained in Resident #133's medical record was a form titled, Resident Representative Designation which allows the representative on behalf of patient to sign the for purposes of nursing facility admission. This form was signed by Resident #133's MPOA on 04/11/17. Resident #133 did not sign this form. Review of Resident #133's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/12/17, found Resident #133's Brief Interview of Mental Status (BIMS) score was 14. This score indicates Resident #133 was cognitively intact. Further review of the record found no evidence to suggest the decisions made by Resident #133's MPOA were ever discussed with Resident #133. An interview with the Admission Director, at 10:26 a.m. on 06/29/17, confirmed she completed the admission form with Resident #133's MPOA on 04/07/17 and 04/08/17. She stated, what typically happens we have an admission meeting an… | 2020-09-01 |
| 2795 | 2795 | WAYNE NURSING AND REHABILITATION CENTER | 515168 | 6999 ROUTE 152 | WAYNE | WV | 25570 | 2017-05-05 | 155 | D | 1 | 1 | 43JR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, resident interview and staff interview, the facility failed to ensure Resident #9 was afforded the right to execute an advanced directive. Resident #9 was determined to have capacity to make medical decisions, however; her son had signed her Physician order [REDACTED]. Resident identifier: #9. Facility census: 55. Findings include: a) Resident #9 A review of Resident #9's medical record, at 1:12 p.m. on [DATE], found this [AGE] year old resident was admitted to the facility on [DATE]. Contained in Resident #9's medical record was a form titled, Authority to act on behalf of patient for purposes of nursing facility admission. This form was signed by Resident #9 on [DATE] and gave her son permission to act as her representative for the purpose of executing the admission agreement. Further review of the record found a POST form signed by Resident #9's son which was also dated [DATE]. This form indicated Resident #9 was designated as Do Not Resuscitate (DNR) with limited additional interventions with Intravenous Fluids for a trial period and no feeding tube. This form was not signed by Resident #9. Further review of the record found a Physician's Determination of Capacity dated [DATE] which indicated Resident #9 was capacitated to make her own medical decisions. Review of Resident #9's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], found Resident #9's Brief Interview of Mental Status (BIMS) score was 15. This score indicates Resident #9 was cognitively intact. Further review of the record found no evidence to suggest the decisions made by Resident #9's son on her POST form were ever discussed with Resident #9. During an interview with Resident #9 at 10:21 a.m. on [DATE], when asked, Has any one here ever talked to you about your wishes for CPR (Cardiopulmonary Resuscitation) and the use of other life sustaining measures? Resident #9 stated, No they have never talked to me about any of… | 2020-09-01 |
| 3468 | 3468 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2017-09-21 | 155 | D | 0 | 1 | ITHZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of four (4) resident's reviewed for the care area of choices was afforded the right to refuse a shower without receiving a [MEDICAL CONDITION] medication. Resident identifier: #25. Facility census: 83. Findings include: a) Resident #25 Review of the resident's Medication Administration Record, [REDACTED] [MEDICATION NAME] 0.5 milligrams (mgs) by mouth, as needed (PRN), every 24 hours for aggressive behavior, anxious mood/behavior related to unspecified dementia with behavioral disturbances, give before shower due to frequent refusal of care. Further review of the MAR found the resident had received the PRN [MEDICATION NAME] on 07/25/17, 08/23/17 and 09/03/17. An interview with the director of nursing (DON) at 2:10 p.m. on 9/20/17, found the resident had received the medication on 07/25/17, 08/23/17, and 09/03/17 for aggressive behaviors with non-pharmacological interventions prior to administration. Although the medication had not been administered for refusal of a shower, the DON confirmed the potential still existed for the resident to receive the medication if she refused a shower. The DON said the resident had the right to refuse her showers. She said she was going to call the doctor and get a new order as the current order, should have never been written this way. | 2020-09-01 |
| 3875 | 3875 | SUMMERSVILLE REGIONAL MEDICAL CENTER | 515029 | 400 FAIRVIEW HEIGHTS ROAD | SUMMERSVILLE | WV | 26651 | 2016-11-18 | 155 | D | 0 | 1 | TJMH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to ensure Resident #52 was afforded the right to have her advance directives incorporated into her treatment regimen, failed to communicate this choice to the Interdisciplinary Team (IDT), and failed to ensure that when the resident experienced a severe weight loss, her treatment reflected this choice. Resident identifier: #52. Facility Census: 52. Findings include: a) Resident #52 Review of Resident #52's medical records on 11/17/16 at 10:00 a.m. found the resident was admitted to the facility on [DATE]. A West Virginia Physician order [REDACTED]. A review of Resident #52's medical record at 9:11 a.m. on 11/17/16, found the following recorded weights (All weight loss/gain Percentages calculated using the following formula % of body weight loss = (usual weight - actual weight)/(usual weight) x 100.): -- Date of admission 01/20/16 - 172.4 pounds (lb) -- 01/31/16 - 169 lbs. -- 02/02/16 - 169 lbs. -- 02/09/16 - 167 lbs. -- 02/15/16 - 168 lbs. -- 02/23/16 - 174 lbs. -- 03/01/16 - 175 lbs. -- 04/01/16 - 176 lbs. -- 05/03/16 - 170 lbs. -- 06/06/16 - 168 lbs. -- 07/05/16 - 165 lbs. -- 07/07/16 - 165 lbs. -- 07/11/16 - 165 lbs. -- 08/02/16 - 161 lbs. -- 09/08/16 - 152 lbs. -- 10/03/16 - 149 lbs. -- 11/01/16 - 148 lbs. From 08/02/16 through 09/08/16, Resident #52 lost 9 lb or 5.6% (percent) in 30 days - a severe weight loss in 30 days. From 06/06/16 through 09/08/16, Resident #52 lost 16 lb or 9.5% in 90 days - a severe weight loss 90 days. From 03/01/16 through 09/08/16 Resident #52 experienced a 23 lb or 13.1% in 180 days - a severe weight loss in 180 days. Guidance to Surveyors related to suggested parameters for evaluating significance and unplanned and undesired weight loss, found in Appendix PP of the CMS (Centers for Medicare and Medicaid Services) State Operations Manual contained the following: Interval Significant Loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5… | 2020-04-01 |
| 3894 | 3894 | HARPER MILLS | 515086 | 100 HEARTLAND DRIVE | BECKLEY | WV | 25801 | 2016-09-23 | 155 | D | 0 | 1 | 0MB311 | Based on record review and staff interview, the facility failed to establish and maintain policies about a resident's right to refuse treatment. This had the potential to affect all residents currently residing at the facility. Facility Census: 178. Findings Include: a) Policy In the early afternoon of 09/23/16, the Assistant Nursing Home Administrator (ANHA) was asked to provide the facility's policy and/or procedures which were followed when a resident wished to exercise their right to refuse treatment. At 2:44 p.m. on 09/23/16, the ANHA and Nursing Home Administrator (NHA) both confirmed the facility did not have a policy in regards to the residents' right to refuse treatment. They provided the facility's advance directive policy. This policy did include the following statement, Prior to or upon admission of a resident to the facility, the Social Service Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate and advance directive. The remaining eight (8) statements contained in the policy were solely directed to written advanced directives such as medical power of attorney or a living will, and not the right to accept or refuse medical treatment. At approximately 3:00 p.m. on 09/23/16, the Admissions Coordinator #77 was asked to provide what written information was given to residents upon admission to the facility in regards to advance directives and their right to accept and/or refuse medical treatment other than an advance directive. She referred to the facility's Admission Information Packet pages 14 - 26. The information contained on these pages specifically related to the creation of and the authority of written advance directives such as a Medical Power of Attorney or Living Will. It did not include any information pertaining to the residents' right to accept or refuse medical treatment other than the creation of a written adv… | 2020-04-01 |
| 4697 | 4697 | BERKELEY SPRINGS CENTER | 515137 | 456 AUTUMN ACRES ROAD | BERKELEY SPRINGS | WV | 25411 | 2016-04-06 | 155 | D | 0 | 1 | TULX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to formulate a plan of care with written policies and procedures to provide cardiopulmonary resuscitation (CPR) to residents on the 500 hall/memory care unit; a separate unit isolated from other parts of the building. Staff were unaware of the location of emergency equipment and/or the planned procedure to call for additional staff in the event of a cardiac and/or respiratory emergency. This was found for two (2) of seven (7) residents with advanced directives for CPR residing on the memory care unit. Resident identifiers: #76 and #94. Facility census: 92. Findings include: a) Resident #76 Review of Resident #76's medical record on [DATE] at 11:00 a.m. revealed the West Virginia Physician order [REDACTED]. The resident's care plan with a revised date of [DATE], included, Resident has multiple cardiac issues; CAD ([MEDICAL CONDITION]),[MEDICAL CONDITION](hypertension), [MEDICAL CONDITIONS], stenosis of carotid artery. However, care plan did not reflect the resident's resuscitation status. b) Resident #94 Resident #94's medical record, reviewed on [DATE] at 11:30 a.m., found Resident #94's POST form, signed by her daughter/power of attorney (POA) on [DATE], identified the resident was to receive resuscitation with full interventions. c) Random observations of the unit on [DATE], and on [DATE] at 2:00 p.m., revealed no emergency equipment or written procedures for staff to follow in the event of a cardiopulmonary emergency. d) During an interview on [DATE] at 11:00 a.m. Registered Nurse (RN) #92 reported the 500 hall/memory care unit currently housed seven (7) residents and was staffed every shift by two (2) people - a nurse and a nurse aide (NA). She was unaware of any stairs connecting this unit to the remainder of the building and reported all staff must enter the unit from outside of the building. RN #92 reported Residents #76 and #94 had adv… | 2019-08-01 |
| 5101 | 5101 | RALEIGH CENTER | 515088 | 1631 RITTER DRIVE | DANIELS | WV | 25832 | 2015-04-10 | 155 | D | 0 | 1 | CRGX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review, and resident interview, the facility failed to ensure two (2) of two (2) sample residents, reviewed for the care area of choices during Stage 2 of the survey, were afforded the right to formulate an advanced directive. The facility determined each of the residents had capacity to make health care decisions; however, a family member for each resident signed their Physician order [REDACTED]. Resident Identifies: #32 and #83. Facility Census: 66. Findings Include: a) Resident #32 A review of Resident #32's medical record, at 9:04 a.m. on [DATE], found she was admitted to the facility on [DATE]. Review of the resident's admission information found Resident #32 signed all admission paperwork on [DATE]. Further review of the medical record found a Physician Determination of Capacity completed by Resident #32's attending physician on [DATE]. This form indicated Resident #32 was able to make her own informed medical decisions. The medical record contained a POST form which indicated Resident #32 was not to receive cardiopulmonary resuscitation (CPR). The form also noted she was to receive intravenous fluids and a feeding tube for a defined trail period only. The POST form was signed by Resident #32's daughter on [DATE]. Licensed Practical Nurse (LPN) #36 assisted Resident #32's daughter in completing this form on [DATE], as indicated by the LPN's signature on the back of the POST form. The form went into effect on [DATE], when Resident #32's attending physician signed the form making it a physician's orders [REDACTED].>The medical record contained no evidence indicating Resident #32's wishes for CPR, use of IV fluids, and use of a feeding tube were ever discussed with her. An interview with the Director of Admissions (DOA) #42, at 1:20 p.m. on [DATE], confirmed Resident #32 had capacity to make medical decisions. She stated the POST form should have been completed by Resident #32 and not her dau… | 2019-03-01 |
| 5185 | 5185 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2016-03-03 | 155 | D | 1 | 0 | MTOL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure the resident's right to refuse treatment. Resident #5 was given [MEDICATION NAME] ([MEDICATION NAME]) (an atypical antipsychotic medication) although the resident's son did not want the medication given until he read about the drug. This was true for one (1) of three (3) residents reviewed for unnecessary medications during a complaint survey. Resident identifier: #5. Facility census: 125. Findings include: a) Resident #5 Review of Resident's #5's medical records on 03/03/16 beginning at 9:00 a.m., revealed a physician's orders [REDACTED]. A nursing note, dated 07/19/15, revealed the facility called the resident's son, . to see if he wanted [MEDICATION NAME] (same as [MEDICATION NAME]) started. He stated that he would read up on it at home and sign it if he wanted to start the medications when he is in to visit again. I told him I would place the psychotic medication informed consent in her chart for him to sign if he decided to have his mother take it. The Medication Administration Record [REDACTED]. A physician's orders [REDACTED]. An additional physician order [REDACTED]. [MEDICATION NAME] was administered to Resident #5 on three (3) occasions after the resident's son verbally indicated he wanted the antipsychotic medication held until further notice. On 03/03/16 at 2:20 p.m., the director of nursing stated the mediation was given, held, and discontinued according to physician orders. | 2019-03-01 |
| 5242 | 5242 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2015-08-06 | 155 | D | 0 | 1 | SMTQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure the accuracy and clear intent of end of life decisions. The facility physician's orders did not reflect the resident's desire to be a do not resuscitate status in a timely manner. Two different sets of West Virginia Physician Orders for Scope and Treatment (POST) were in the medical record. This practice had the potential to affect one (1) of twenty five (25) stage 2 residents. Resident identifier: #174. Facility census 117. Findings include: a) Resident #174 Resident #174 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A closed record review performed [DATE] at 3:00 p.m. found she had a physician's order on the date of her admission declaring her a full code status. She filled out a Physician Orders for Scope and Treatment (POST) form twice since her admission requesting to be a do not attempt resuscitate (DNR) status, once on [DATE] and again on [DATE]. There was no physician's order in the medical record designating the resident as a DNR status until the following monthly orders for (MONTH) (YEAR). This matter discussed with the director of nursing (DON), on [DATE] at 9:30 a.m., revelaed the pharmacy received a facsimile of the change in code status, but no evidence of a physician's order in the medical record changing the code status of the resident from [DATE] until [DATE]. During an interview with Social Worker #105 on [DATE] at 9:00 a.m. she said after a POST form is completed, a physician's order is written for DNR if that is what is designated on the POST. She also said a red dot is put on the back (spine) of the hard chart and also a red page stating DNR is placed in the medical record when a resident is of DNR status. Review of HCR Healthcare, LLC procedure for EMERGENCY MANAGEMENT for code status identification, last revised ,[DATE] finds implementation of a color-coded cover sheet may be used to assist with easy access of infor… | 2019-02-01 |
| 5335 | 5335 | ROANE GENERAL HOSPITAL | 515099 | 200 HOSPITAL DRIVE | SPENCER | WV | 25276 | 2015-10-21 | 155 | E | 0 | 1 | 4PJF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to accurately and consistently incorporate the resident's choices regarding Advance Directives into the clinical record for seven (7) of fourteen (14) residents reviewed. Resident identifiers: #35, #9, #3, #26, #4, #21, and #29. Facility census: 29. Findings include: a) Resident #35 A review of Resident #35's clinical record, at 1:30 p.m. on 10/20/15, revealed the resident was [AGE] years old and was admitted to the facility on [DATE]. Resident #35 was determined by the physician to lack capacity to form her own health care decisions, and the record indicated Resident #35 had appointed a medical power of attorney (MPOA). The resident admission record front sheet indicated, under a section entitled Advanced Directives, that no advanced directives were selected for Resident #35. Further review of the record revealed a Physician Orders for Scope of Treatment (POST) form signed and completed on 03/06/14. In addition, the admission orders [REDACTED]. These findings were reviewed with Social Worker #37 at 2:20 p.m. on 10/20/15. Social Worker #37 acknowledged the statement on the admission record was an error and provided evidence of discussion of the DNR decision with the MPOA at the time of admission to the facility. She agreed the front sheet of the clinical record should reflect that choice and said she would have this corrected. A review of the facility policy entitled: Documentation of Advance Directives, provided by the Social Worker, indicated the existence of the advanced directive was to be entered into the record by the admissions department. If not present at admission, the policy stated, The unit clerk shall follow-up with the patient within 24 hours to secure a copy of the advance directive and will continue to do so during the admission until patient disposition, and This will be scanned to the record by the unit clerk. b) Resident #9, #3, #26, #4, and #21… | 2019-01-01 |
| 5456 | 5456 | LOGAN CENTER | 515175 | 55 LOGAN MINGO MENTAL HEALTH CENTER ROAD | LOGAN | WV | 25601 | 2015-06-22 | 155 | D | 0 | 1 | N2E611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of choices during the Quality Indicator Survey (QIS), was afforded the right to have her advance directive incorporated into her care and treatment. The resident indicated on her POST form, she did not want a feeding tube; however, a feeding tube was inserted. Resident Identifier: #67. Facility Census: 62. Findings include: a) Resident #67 Feeding Tube Resident #67's POST form, reviewed at 9:46 a.m. on 06/17/15, also revealed the resident indicated No feeding tube. Under section C titled: Medically administered fluids and nutrition: Oral fluid and nutrition must be offered as tolerated, an X was placed in the box beside, No feeding Tube, indicating the resident's wish to not have a feeding tube. According to information on the POST form, LPN #6 assisted the resident in completing the form on 12/20/14. The resident's medical record contained a Physician Determination of Capacity, completed on 12/30/14, by Licensed Psychologist #77. This form indicated Resident #67 lacked capacity to make healthcare decisions due to Multiple Infarct Dementia, cognitive loss, inappropriate answers to questions, and inability to understand or make medical decisions. Licensed Psychologist #77 indicated the incapacity would be short term in nature and would likely improve as the resident's medical condition improved. Also contained in Resident #67's medial record, was a medical power of attorney (MPOA) form, completed by Resident #67 on 08/26/13, appointing her niece as her MPOA. Additional review of the medical record found a physician's progress note dated 04/13/15, which contained the following text (typed as written): Spoke with MPOA and agreed for PEG (Percutaneous endoscopic gastrostomy) placement with (Name of local Physician) ASAP (as soon as possible). Resident #67's medical record contained information which indicated the reside… | 2019-01-01 |
| 5526 | 5526 | MCDOWELL NURSING AND REHABILITATION CENTER | 515162 | 150 VENUS ROAD | GARY | WV | 24836 | 2015-11-19 | 155 | D | 1 | 0 | TPT811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to afford Resident #99 the right to formulate an advanced directive. This was found for one (1) of five (5) sampled residents. Resident #99 was deemed to have capacity to make medical decisions; however, the facility allowed someone other than the resident to make decisions in regards to his advanced directives and/or refusals of treatment. Resident identifier: #99. Facility census: 98. Findings include: a) Resident #99 A review of Resident #99's medical record, at 1:10 p.m. on [DATE], found a Physician's Determination of Capacity completed by Resident #99's attending physician on [DATE]. This form indicated Resident #99 maintained capacity to make his own healthcare decisions. Further review of the record found a West Virginia Physician order [REDACTED].#99's attending physician on [DATE]. This form indicated Resident #99 was to receive cardiopulmonary resuscitation (CPR) in the event he would need it. This form was signed by another person, not the resident. There was no indication the resident was consulted about this decision or had asked for another person to sign on his behalf. The person who signed the POST form also signed a Psychoactive Medication Informed Consent form and an Informed Refusal of Treatment consent form on behalf of Resident #99. These forms were signed on [DATE], again with no evidence of input by the resident. An interview with Social Service Director (SSD) #21 and Social Worker (SW) #55, at 3:13 p.m. on [DATE], confirmed Resident #99 was deemed to have capacity to make healthcare decisions on [DATE] by his attending physician. SSD #21 and SW #55 indicated that until the attending physician saw the resident and made a determination of incapacity, the capacity of a resident who was alert and orientated should be assumed. They stated even though Resident #99 was somewhat confused on admission, his capacity should have been assumed. SSD #21 confirmed anot… | 2018-11-01 |
| 5645 | 5645 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2015-07-29 | 155 | D | 0 | 1 | DSPZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to ensure the responsible party of a resident with a severe decline in health status was given information about the resident's rights regarding cardiopulmonary resuscitation and the facility's policies regarding exercising these rights. Resident identifier: #98. Facility census: 99. Findings include: a) Resident #98 A review of the clinical record revealed that Resident #98 was a [AGE] year old male initially admitted to the facility on [DATE]. He had been determined by his physician to lack the capacity to make health care decisions and his brother was indicated as his MPOA (Medical Power of Attorney). He was designated to be a Full Code. His present [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED].#217 at 10:15 a.m. on 07/22/15. The resident had multiple hospitalization s in (YEAR). When discharged to the hospital on [DATE], his skin was clear with no pressure ulcers and on readmission on 04/02/15, his admission physical indicated [MEDICAL CONDITION] of his lower extremities, but no evidence of pressure ulcers. A Significant Change comprehensive assessment was completed on 04/09/15. An entry in the clinical record by NP #217 on 05/21/15, indicated the resident had multiple unstageable pressure wounds. His last readmission was 07/08/15 and although there was no terminal [DIAGNOSES REDACTED]. The record on readmission indicated Resident #98 was a Full Code. The record indicated Resident #98 now had 1 unstageable pressure ulcer and 11 DTI's (deep tissue injury) and the treatment goal stated by the NP/Physician stated, Expectation is for non-healing with goal to prevent worsening of wounds. The care plan meeting notes from 07/19/15, indicated he was a Full Code; had recent cognitive changes and scored 0/15 on his BIMS (brief interview for mental status); and was refusing oral intake. There was no evidence of any discussion of the resident's status with the MPOA.… | 2018-09-01 |
| 5712 | 5712 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2014-11-19 | 155 | D | 0 | 1 | H5V711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to involve the resident in formulating an advance directive. A medical power of attorney (MPOA) and physician filled out paperwork designating a resident as Do Not Resuscitate (DNR) without discussing the matter with the resident. This is true for one (1) randomly reviewed resident. Resident identifier: #211. Facility census: 110. Findings include: a) Resident #211 An interview conducted with the social worker occurred on [DATE] at 4:00 p.m. Two (2) surveyors witnessed this interview. The social worker stated Resident #211 was readmitted to the facility in (MONTH) 2014 and he no longer had capacity. The social worker said the medical power of attorney (MPOA) was who she contacted for issues such as care planning. A medical record review was performed, on [DATE] at 10:00 a.m., where a note was found written by the social worker. The note dated [DATE] stated Resident is a do not resucitate DNR and has a DNR order, MPOA, durable power of attorney (DPOA), and living will (LW) posted on his chart. Resident lacks capacity and is oriented to person, place and time. Resident's brief interview of mental status (BIMS) is 13 . According to the Minimum Data Set (MDS) completed with an assessment reference date (ARD) of [DATE], the resident had a BIMS of 13. This score means cognitively intact. The resident also had a capacity statement on the chart stating he had capacity, signed and dated by a physician on [DATE]. The medical record contained a physician prescription stating DNR signed and dated by a physician on [DATE]. There was also a Release of Liability for Withholding of Life Prolonging Interventions filled out by the resident's MPOA requesting to withhold CPR on [DATE]. This form was not signed and dated by the physician until [DATE], the same date the resident was determined to have capacity. On [DATE] at 10:30 a.m. an interview was held with the resident regard… | 2018-08-01 |
| 5827 | 5827 | ROSEWOOD CENTER | 515105 | 8 ROSE STREET | GRAFTON | WV | 26354 | 2015-01-29 | 155 | D | 0 | 1 | 3O8G11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure one (1) of twenty-three (23) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS) was afforded the right to refuse treatment. The resident desired a code status of Do Not Resuscitate (DNR); however, cardiopulmonary resuscitation (CPR) was performed on the resident. Resident identifier: #56. Facility Census: 67. Findings Include: a) Resident #56 Review of medical records, on [DATE] at 9:00 a.m., revealed Resident #56 was admitted on [DATE] and died on [DATE]. The medical record contained a Pre-admission Report Sheet which listed the resident as a DNR. Handwritten notes from the hospital discharge report also designated the resident as a DNR. A nursing progress note, dated [DATE] at 08:45 a.m., by Employee #100 included, Unable to get B/P, pulse or resp. at this time. Unable to verify post (POST - physician's orders [REDACTED]. Dr. (physician name) entered facility and called to res. room. Orders received to initiate CPR until post verified. CPR initiated by nursing staff. Review of the resident's interim care plan, dated [DATE], showed the advance directives section was blank and not filled out. The interim care plan is the method nursing staff use to be aware of each resident's immediate needs. On [DATE] at 4:35 p.m., the Social Worker (SW) said, The interim care plan should be completed by the admitting nurse. The SW reviewed the interim care plan for Resident #56 and confirmed the advanced directive section was not completed, but should have been completed by the admitting nurse. On [DATE] at 5:05 p.m., interview with Employee #53, a registered nurse (RN), revealed this was the nurse who admitted Resident #56 to the facility on [DATE] at 10:22 p.m. The nurse confirmed the advance directive section of the interim care plan should have been filled out upon the resident's admission. Employee #53 said he/she must have been missed filling out tha… | 2018-07-01 |
| 5860 | 5860 | HILLCREST HEALTH CARE CENTER | 515117 | 462 KENMORE DRIVE | DANVILLE | WV | 25053 | 2014-11-17 | 155 | D | 0 | 1 | LO0C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, and policy review, the facility failed to allow one (1) of four (4) Stage 2 residents reviewed for the care area of choices, the right to formulate an advanced directive related to cardiopulmonary resuscitation (CPR). After Resident #89 regained the capacity to make her own healthcare decisions, the facility failed to provide the resident the right to choose whether or not she wanted to receive CPR should it be necessary. Resident identifier: #89. Facility census: 87. Findings Include: a) Resident #89 Review of the resident's medical record at 10:08 a.m. on [DATE], revealed she was admitted to the facility on [DATE], at which time she lacked capacity to make healthcare decisions. Her son was appointed as her health care surrogate (HCS). The medical record contained a physician's orders [REDACTED]. The POST form indicated Resident #89 was to receive CPR in the event she would need it. Additional review of the medical record revealed a physician's determination of capacity completed by Resident #89's attending physician on [DATE]. This form indicated Resident #89 demonstrated capacity to make medical decisions. There was no evidence in the medical record to indicate the facility had ever discussed with Resident #89 her wishes in regards to CPR after she regained her capacity to make health care decisions on [DATE]. In an interview with Resident #89 at 11:27 a.m. on [DATE], she was asked if any one at the facility had ever discussed with her what her choices in regards to CPR would be. Resident #89 replied, No honey, they have never talked to me about that. I would want it because I want to live as long as possible, wouldn't you? An interview with the Social Service Supervisor (SSS), at 1:08 p.m. on [DATE], revealed if a resident was incapacitated upon admission to the facility, but then regained capacity at a later date, a new POST form should be completed with the resident to reflect… | 2018-07-01 |
| 6079 | 6079 | RIVER OAKS | 515120 | 100 PARKWAY DRIVE | CLARKSBURG | WV | 26301 | 2014-01-24 | 155 | E | 0 | 1 | ZW4411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure four (4) of thirty-four (34) sample residents were afforded the right to formulate an advance directive. The facility failed to clarify and periodically review existing advance directives. Advance directives were not accurately documented to effectively communicate the resident's choices to the direct care staff should the need to implement, or not implement, cardiopulmonary resuscitation (CPR) arise. Resident identifiers: #114, #130, #99, and #5. Facility census: 100. Findings include: a) Resident #114 A medical record review was conducted on [DATE]. Resident #114 had a FULL CODE sticker on his condition alert tab in the chart. A green page in the chart stated Full Code. The monthly physician's orders [REDACTED]. (A full code would mean the facility would attempt to resuscitate the resident.) The resident's West Virginia Physician order [REDACTED]. The POST form was signed by the medical power of attorney on [DATE], and was signed by the physician on [DATE]. The information on the POST form was not transferred to the remainder of the medical record. b) Resident #130 Resident #130 was admitted to Hospice services on [DATE]. A copy of a physician's prescription on the medical record stated Please make patient DNR (do not resuscitate) dated [DATE]. This information was not updated in the medical record. His condition alert tab stated FULL CODE. A green page in the medical record stated Full Code. A sticker was placed on this page stating, Do Not Thin From Chart. A physician's orders [REDACTED]. No POST form was in the medical record. c) Resident #99 The condition alert tab in the medically record of Resident #99 did not address the code status of Resident #99. A Medical Power of Attorney, notarized [DATE], stated Do Not Resuscitate. The physician's orders [REDACTED]. No POST form was present. This medical record provided conflicting information in regards … | 2018-05-01 |
| 6290 | 6290 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-04-15 | 155 | D | 0 | 1 | ZU6S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, interviews with the contracted facility staff, and interview with the resident's medical power of attorney, the facility failed to ensure a resident's rights were honored for one (1) of twenty-nine (29) residents reviewed in Stage 2 of the Quality Indicator Survey. The resident received anticoagulant therapy at the [MEDICAL TREATMENT] center. His medical record indicated he did not want anticoagulant therapy due to religious beliefs. Resident identifier: #169. Facility census: 105. Findings include: a) Resident #169 A medical record review, completed on 04/14/14 at 9:00 a.m., revealed Resident #169 received [MEDICAL TREATMENT] services. The current care plan indicated the facility would coordinate care with the [MEDICAL TREATMENT] center. A hospital discharge summary, dated 03/08/14, noted the resident did not receive anticoagulation therapy related to his religious beliefs. In addition, a physician's progress note included, (name of religion) . no anticoagulant therapy. During an interview with the medical power of attorney, on 04/14/14 at 4:30 p.m., she conveyed Resident #169's religious preferences were very important to him. She confirmed he did not want anticoagulant therapy. Upon inquiry, she related she was unaware of the [MEDICAL TREATMENT] process. She said the [MEDICAL TREATMENT] center had spoken with her, but she did not know how the process worked. An interview with [MEDICAL TREATMENT] staff, on 04/14/14 at 5:30 p.m., revealed they were not aware of the resident's refusal of anticoagulant therapy. Staff member #182, a registered nurse (RN) and Staff member #183 (RN) said information regarding the resident's preference for refusal of anticoagulant therapy was not conveyed to them. Employee #183 said communication with the facility was usually limited to communication forms. In addition, the [MEDICAL TREATMENT] center staff related they were not invited, and had never participated in… | 2018-04-01 |
| 6331 | 6331 | DAWN VIEW CENTER | 515163 | PO BOX 686 | FORT ASHBY | WV | 26719 | 2014-07-09 | 155 | D | 0 | 1 | 2M0C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident who had been determined by her attending physician to have the capacity to make her own healthcare decisions was provided with appropriate information and/or involved in the formulation of her advance directive. She was one (1) of a total of thirty-one (31) residents (both with and without capacity) in the sample reviewed. Resident identifier: #29. Facility census: 66. Findings include: a) Resident #29 A review of Resident #29's medical record revealed she was admitted on [DATE]. At that time, her attending physician deemed she had the capacity to form her own healthcare decisions. There was no evidence in the record stating she wished another individual to make her decisions. She had a Full Code (wanted to be resuscitated and have all life saving measures implemented) decision documented on admission. The resident's Physician order [REDACTED]. The form indicated the decision was explained to only MPOA (medical power of attorney), and was signed by the daughter (MPOA). There was no indication in the record the resident was involved in the decision or that it had been explained to her. During an interview with the director of nurses (DON) and the Social Worker (SW), at 2:00 p.m. on 06/30/14, the DON verified the resident was alert and oriented, and was able to make her needs known. The Social Worker said he remembered the daughter attending a care plan meeting and requesting a change to the DNR status, but he did not remember the resident being present. The SW returned at 2:20 p.m. on 06/30/14, after reviewing the entire record and acknowledged there was no documentation of a request by the resident instructing anyone to sign for her or that she was aware of the change in her code status. The care plan was revised to DNR status on 04/29/14, and included a nursing intervention stating, Inform (Resident #29) and/or healthcare decision maker of any change in stat… | 2018-04-01 |
| 6889 | 6889 | CABELL HEALTH CARE CENTER | 515192 | 30 HIDDEN BROOK WAY | CULLODEN | WV | 25510 | 2014-01-23 | 155 | D | 0 | 1 | ONTQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview and policy review, the facility failed to allow two (2) of three (3) Stage 2 residents reviewed for choices, the right to formulate an advanced directive related to Cardiopulmonary Resuscitation (CPR). Both residents were determined to have capacity to make medical decisions upon their admission to the facility. The facility allowed each resident's appointed Medical Power of Attorney to sign their Physician order [REDACTED]. Resident identifiers: #53 and #32. Facility Census: 85. Findings Include: a) Resident #53 Resident #53's medical record was reviewed at 10:24 a.m. on [DATE]. This review revealed the resident was admitted to the facility on [DATE]. The review also revealed a determination of capacity, completed on [DATE], which indicated the resident had capacity to make medical decisions. The resident's medical record contained a POST form dated [DATE]. This form indicated the resident was to receive CPR should she need it. The form was signed by Resident #53's appointed Medical Power of Attorney. The date this form was signed by the MPOA was left blank. The physician signed the POST form, making it an order, on [DATE]. Resident #53 was interviewed at 11:30 a.m. on [DATE]. When asked if she would want CPR should she need it, she replied, I would not want to have CPR. No one here has ever asked me about CPR, but I know I would not want to have it. She further stated, I would want to tell my son before I made any final decisions just to let him know what my plan was. The facility's Notification of Advance Directives policy was reviewed on [DATE] at 11:00 a.m This review revealed the following: The health care center informs and presents written materials to the residents who are admitted pertaining to their legal rights and decisions about medical care. These rights include the right to accept or refuse medical or surgical treatment, the right to choose to receive cardiopulmonary … | 2017-11-01 |
| 6989 | 6989 | EAGLE POINTE | 515159 | 1600 27TH STREET | PARKERSBURG | WV | 26101 | 2013-12-18 | 155 | D | 0 | 1 | EUXT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to ensure a resident was afforded the right to formulate an advanced directive. This was found for one (1) of four (4) sample residents reviewed for the care area of choices during Stage 2 of the survey. The resident's code status was determined by a medical decision maker during a time the resident did not have capacity to make medical decisions. The code status was not reevaluated with the resident when she regained capacity to make health care decisions. Resident Identifier: #91. Facility Census: 130. Findings Include: a) Resident #91 Resident #91's medical record was reviewed at 1:00 p.m. on 12/17/13. This review revealed two (2) Physician's Determination of Capacity forms. The first form was dated 12/04/13 and determined the resident had capacity to make medical decisions. The second form was dated 12/07/13, and also determined the resident had capacity to make medical decisions. The record also contained a social service progress note, dated 12/11/13, written by Employee #62, Social Worker. This note revealed Resident #91 was reevaluated for capacity because she had scored a 15 on her latest Brief Interview for Mental Status (BIMS). She indicated Resident #91 was reevaluated by two (2) physicians and had regained her ability to make medical decisions. Further review of Resident #91's medical record revealed a Do Not Resuscitate form. This form contained the following paragraph, I, the undersigned resident or duly authorized legal representative, have made a decision regarding resuscitation in the event that I (the above named resident) am discovered without respiration or pulse. The affected resident or legal representative wishes that medical personnel in attendance would NOT initiate cardiopulmonary resuscitation. I understand I may revoke these directions at any time. This form contained Resident #91's name. It was signed by her Legal Representative … | 2017-09-01 |
| 7172 | 7172 | PINEY VALLEY | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2014-07-16 | 155 | D | 1 | 0 | 1X1U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to determine on admission whether a resident, who had been determined by her attending physician to lack the capacity to form her own health care decisions, had an advance directive formulated by the appropriate legal representative and in compliance with State requirements regarding advance directives. This decision applied to one (1) of nine (9) residents reviewed during the investigation of a complaint. Resident identifier: #61. Facility census: 104. Findings include: a) Resident #61 A review of the medical record revealed Resident #61 was a [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital. Her [DIAGNOSES REDACTED]. She also had deep tissue injury to both feet, right hip, coccyx, both ears, and left hip. The 5 foot, 4 inch tall resident weighed 90.2 pounds on admission. Both the physician who discharged the resident from acute care and the attending physician at the nursing home, who was the resident's prior family physician, determined the resident lacked the capacity to process the information needed to form her healthcare decisions. A review of the hospital records forwarded to the facility revealed the resident had been referred to Adult Protective Services (APS) on admission to the hospital ([DATE]) because of suspected elder abuse neglect. A Forensic Nurse Examiner Consult completed on [DATE], revealed, . patient is confused, does know her name and that she lives in (name of town/city). The Nurse affirmed an APS referral had been made. She also indicated the hospital Social Worker had informed them the resident's Son #1, who was indicated to be the responsible party, had agreed to nursing home placement. The Discharge Instructions from the hospital included, Resuscitation Status: No CPR (cardiopulmonary resuscitation), . A form entitled (Name of other state) Medical Orders for Life - Sustaining Treatment (_OLST) accompanied the residen… | 2017-07-01 |
| 9033 | 9033 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2013-03-14 | 155 | D | 0 | 1 | RKHC12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, and policy review, the facility failed to assist two (2) of three (3) residents, reviewed for decision making, to formulate an advance directive, stating their desire to receive or not to receive cardiopulmonary resuscitation (CPR). Resident #193's wishes were to receive CPR if she was found to have no pulse, respirations and/or blood pressure. This was not assessed by the facility. She had a physician's orders [REDACTED]. Resident #217 had a Physician order [REDACTED].#217. The form was signed by her medical power of attorney (MPOA); however the resident still maintained capacity to make medical decisions. Resident identifiers: #193 and #217. Facility Census: 113 Findings Include: a) Resident #193 A medical record review was completed at 9:20 a.m. on [DATE]. This review revealed the resident had an order for [REDACTED]. The resident was readmitted to the facility from an acute care hospital on [DATE]. A care plan conference summary sheet was reviewed. It noted the resident wanted to be a Full Code. This indicated the resident wanted to have CPR initiated should it be needed. This summary was signed by Employee #36, a Registered Nurse (RN), minimum data set (MDS) Coordinator, Employee #51, Social Worker, a Licensed Physical Therapy Assistant, a Certified Occupational Therapy Assistant, and Resident #193. The resident's care plan was also reviewed. The care plan contained the following problem, The resident desires to be a DNR. The goal contained on the care plan was, DNR will be honored upon absence of pulse, respirations, and/or blood pressure. The care plan contained the following interventions. 1. Verify the absence of apical pulse, respirations, and/or blood pressure. 2. Notify Physician. 3. Notify Family. Additional review of the medical record revealed a hospital discharge summary, dated [DATE], which contained the following statements: It was questioned whether or not… | 2016-02-01 |
| 9141 | 9141 | CAREHAVEN OF PLEASANTS | 515191 | PO BOX 625 | BELMONT | WV | 26134 | 2012-04-26 | 155 | D | 0 | 1 | JRXZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, and record review, the facility failed to ensure one (1) of thirty-three (33) residents was provided the opportunity to exercise his right to refuse treatment. The resident was given a thirty (30) day notice for refusing care and treatment without evidence the facility assessed the reason's for the refusals and without evidence alternative treatments and/or times for treatments were offered. Resident identifier: #78. Facility census: 61. Findings include: a) Resident #78. Review of the medical record found several occasions when Resident #78 refused care and treatment. No evidence could be found the facility investigated why the resident refused care and treatment. Resident #78 was admitted to the facility on [DATE]. The admission [DIAGNOSES REDACTED]. During an interview with the resident, on 04/23/12 at 3:00 p.m., it was learned the resident did not like the type of solution used to treat his wounds. The resident stated, It's a bleach solution and [MEDICAL CONDITION] nose. The treatment was ordered twice a day. The resident stated he was not going to let the facility use Dakins solution twice a day. According to Employee #97 (treatment nurse), during an interview on 04/25/12 at 9:14 a.m., Resident #78 had voiced his opinion of the Dakins solution to her. She stated, He is non-compliant with a twice a day treatment. She further added she contacted the wound care center, but they would not change the treatment. Employee #97 was asked whether she had contacted the attending physician to get the treatment changed. She stated, He will not go against the wound care center. She stated at one time they had used a patch which only had to be changed every three (3) days, and the resident was more compliant with this treatment. No evidence could be found the physician was aware of Resident #78 having difficulty with the current treatment. Additionally, no evidence could be found the facility alerted the ph… | 2016-02-01 |
| 9636 | 9636 | BRIGHTWOOD CENTER | 515128 | 840 LEE ROAD | FOLLANSBEE | WV | 26037 | 2009-12-17 | 155 | D | 0 | 1 | 6HX711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, Hospice staff interview, and observation, the facility failed, for one (1) of eighteen (18) residents sampled, to allow refusal of treatment. The resident, who was also under the care of Hospice services, had requested through her medical power of attorney representative (MPOA) via the Physician order [REDACTED]. IV fluids had continued for a period of at least twenty-nine (29) days following the resident's hospitalization and return to the facility, with no evidence the facility recognized the right to refuse them and/or worked in conjunction with her physician and the Hospice agency to discontinue the IV fluids. Resident identifier: #13. Facility census: 105. Findings include: a) Resident #13 The medical record of Resident #13, when reviewed on 12/15/09, disclosed this [AGE] year old female had resided at the facility since 12/22/04. Her medical [DIAGNOSES REDACTED]. She had returned to the facility from her most recent hospitalization on [DATE], having been admitted to the hospital with [REDACTED]. On 12/08/09, the resident's attending physician wrote an order for [REDACTED]. The resident's medical record, when further reviewed, revealed she did not have the capacity to make her own medical decisions, as determined by her attending physician on 09/02/08. The most recent minimum data set (MDS), with an assessment reference date of 11/26/09, in the area of Cognitive / Decisionmaking described this resident as 3, severely impaired, rarely / never made decisions. The record disclosed a POST form which stated, This is a physician's orders [REDACTED]. Any section not completed indicates full treatment for [REDACTED]. All areas of the POST form were completed on 12/10/08, with the resident's MPOA signature noted in Section F. The document was reviewed on 11/30/09 with no changes noted. The form requested under Section A - Do Not Attempt Resuscitation; under Section B - Comfort Measures; under Secti… | 2015-10-01 |
| 9878 | 9878 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2013-05-17 | 155 | D | 0 | 1 | RKHC12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, resident interview, and policy review, the facility failed to assist two (2) of three (3) residents, reviewed for decision making, to formulate an advance directive, stating their desire to receive or not to receive cardiopulmonary resuscitation (CPR). Resident #193's wishes were to receive CPR if she was found to have no pulse, respirations and/or blood pressure. This was not assessed by the facility. She had a physician's orders [REDACTED]. Resident #217 had a Physician order [REDACTED].#217. The form was signed by her medical power of attorney (MPOA); however the resident still maintained capacity to make medical decisions. Resident identifiers: #193 and #217. Facility Census: 113 Findings Include: a) Resident #193 A medical record review was completed at 9:20 a.m. on [DATE]. This review revealed the resident had an order for [REDACTED]. The resident was readmitted to the facility from an acute care hospital on [DATE]. A care plan conference summary sheet was reviewed. It noted the resident wanted to be a "Full Code." This indicated the resident wanted to have CPR initiated should it be needed. This summary was signed by Employee #36, a Registered Nurse (RN), minimum data set (MDS) Coordinator, Employee #51, Social Worker, a Licensed Physical Therapy Assistant, a Certified Occupational Therapy Assistant, and Resident #193. The resident's care plan was also reviewed. The care plan contained the following problem, "The resident desires to be a DNR." The goal contained on the care plan was, "DNR will be honored upon absence of pulse, respirations, and/or blood pressure." The care plan contained the following interventions. "1. Verify the absence of apical pulse, respirations, and/or blood pressure. 2. Notify Physician. 3. Notify Family." Additional review of the medical record revealed a hospital discharge summary, dated [DATE], which contained the following statements: "It was questioned whe… | 2015-08-01 |
| 10745 | 10745 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2011-08-31 | 155 | D | 1 | 0 | H3XI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure the advance directives of one (1) of six (6) sampled residents were honored by the facility. Resident #94's expressed her wishes with respect to advance directives in writing prior to losing the capacity to make her own informed medical decisions. The facility permitted the resident's medical power of attorney representative (MPOA) to change these written instructions for end-of-life care after the resident was no longer able to express her wishes. Facility census: 93. Findings include: a) Resident #94 A review of Resident #94's closed medical record revealed she was admitted to the facility on [DATE]. On 05/08/11, the physician determined she possessed the capacity to make her own informed health care decisions. Further record review disclosed a combined WV Advance Directive / Living Will / Medical Power of Attorney document, which had been completed and signed by Resident #94 on 03/13/07. This form contained the following: "If I should reach a point when I lack capacity to make medical decisions, am in a terminal state, or become permanently unconscious or remain in a permanent vegetative state I have indicated my wishes by my initials on the lines below." In the section of the document labeled Living Will, the resident indicated she did not want life prolonging treatment and wished to be permitted to die naturally with only the administration of any medication or the performance of any medical treatment deemed necessary to alleviate pain. Regarding the administration of artificial nourishment, the resident stated, "I do not want artificially provided water or other artificially provided nourishment or fluids (tube feedings intravenous fluids etc)." The form had an area labeled "Special Directions or Limitations", in which the resident indicated she wanted to be kept comfortable and was to be a DNR (do not resuscitate). In the section designating a medical power of … | 2014-12-01 |
| 11022 | 11022 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2009-02-05 | 155 | D | 0 | 1 | 53ZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure that residents with capacity were involved in making decisions with respect to the advance directives documented on the Physician order [REDACTED]. Resident identifiers: #92 and #104. Facility census: 121. Findings include: a) Resident #92 A review of the medical record revealed a POST form indicating Resident #92 was to receive cardiopulmonary resuscitation (CPR) and "Limited additional interventions". This form was signed by the resident's medical power of attorney representative (MPOA) on [DATE]. The resident's attending physician determined Resident #92 lacked the capacity to understand and make healthcare decisions on [DATE]. This determination was validated by a second determination made by a psychologist on [DATE]. On [DATE], the resident's attending physician reversed this and determined the resident now had the capacity to formulate healthcare own decisions. However, there was no evidence in the record to indicate the advance directives recorded on the [DATE] POST form had been reviewed with the resident. During an interview at 11:45 a.m. on [DATE], the social worker (Employee #119) was asked if the advance directives noted on the POST form had been reviewed with the resident. The social worker could not remember and, at the time of exit, she had not produced any evidence to indicate the resident had been informed of the decisions made by the MPOA. b) Resident #104 A review of Resident #104's medical record revealed the resident was admitted on [DATE]. On [DATE], the social worker recorded in social services notes that the resident had the capacity to make his own healthcare decisions and he had "Full Code" status. His attending physician also determined, on [DATE], that Resident #104 had the capacity to make healthcare decisions. However, an attached form stated: "It is my desire that (Name) , my (wife) , sign all forms on my behalf to admit me to Heartland of… | 2014-09-01 |
| 11105 | 11105 | GRAFTON CITY HOSPITAL | 515057 | 1 HOSPITAL PLAZA | GRAFTON | WV | 26354 | 2011-04-27 | 155 | D | 1 | 0 | MWLC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, record review, and policy review, the facility failed to ensure that a resident's right to refuse treatment. This was evident for one (1) of six (6) sampled residents, who possessed the capacity to understand and make informed health care decisions. The resident refused an injection when he was attempting to leave the facility, and the nurse gave the injection contrary to his wishes. The syringe contained a psychoactive medication ([MEDICATION NAME]). Resident identifier: #23. Facility census: 61. Findings include: a) Resident #23 1. Interview with a social worker (Employee #312), on 04/26/11 at 3:30 p.m., revealed that, on 03/03/11, she observed staff physically trying to pull Resident #23, who was attempting to leave the facility. Employee #312 said she went outside and informed staff they could not do that, as the resident has capacity. She stated that, at one point during this incident, a licensed practical nurse (Employee #35) allegedly told the resident, "I have the insulin the doctor wants you to take," but it was [MEDICATION NAME], instead. At that point, the nurse left him alone and did not administer the injection. Employee #312 said, at another point, she looked out her window and saw two (2) maintenance men and the administrator talking to the resident, and the workers had their hands on the resident. She said those staff members somehow got him back inside the fence, and Employee #35 allegedly gave the injection of [MEDICATION NAME] through his clothing. - 2. Interview with another social worker (Employee #119), on 04/27/11 at 8:30 a.m., revealed Resident #23 was determined by his attending physician on 12/10/10 to have health care decision-making capacity, but at the time of the incident on 03/03/11, Resident #23 was extremely out of control. She said this resident walks with a crutch or a cane, and that was his weapon that day, although he did not hit anyone. Both she and the director of nursing (DON… | 2014-08-01 |
| 11342 | 11342 | DUNBAR CENTER | 515066 | 501 CALDWELL LANE | DUNBAR | WV | 25064 | 2010-12-09 | 155 | D | OEY611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review and staff interview, the facility failed to ensure one (1) of seven (7) sampled residents (who had the capacity to understand and make a health care decision) was fully informed in advance of the nature of a surgical procedure (incision and drainage of a large hematoma); understood the possible consequences of the procedure; and was asked for a written consent prior to the undertaking of the procedure. This invasive procedure resulted in harm to the resident, who experienced increased pain, anxiety, and bleeding, which necessitated a transfer to the hospital emergency room for additional procedures. Resident identifier: #118. Facility census: 117. Findings include: a) Resident #118 1. A review of Resident #118's closed medical record revealed this [AGE] year old female was originally admitted to the facility on [DATE], and her [DIAGNOSES REDACTED].#), history of venous [MEDICAL CONDITION] (blood clots) and embolism (a mass, such as a detached blood clot, that travels through the bloodstream and becomes lodged in a vessel, obstructing blood flow), [MEDICAL CONDITION], embolism and [MEDICAL CONDITION] of unspecified artery, [MEDICAL CONDITION], and coronary [MEDICAL CONDITION] unspecified type vessel native graft. This resident had been determined by her attending physician to have the capacity to understand and make informed healthcare decisions, and she was described in her nursing notes daily as being alert / oriented and able to make her needs known. In an interview with the social worker (Employee #3) at 3:15 p.m. on 12/08/10, she verified Resident #118 had capacity, although she stated Resident #118's son / MPOA was involved in the resident's care, usually assisted her in decision making, received notices of the care plan conferences, and was notified of changes in her care and health status. This was reflected in her medical record by his signature on various consent forms (e.g., flu vaccine, etc.), her re… | 2014-04-01 | ||
| 11529 | 11529 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2010-09-03 | 155 | D | GVP311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of hospital records, family interview, and interview with a hospital social worker, the facility failed, for one (1) of ten (10) sampled residents, to honor the advance directives formulated by this incapacitated resident's medical power of attorney representative (MPOA). Record review revealed nursing staff and the attending physician believed Resident #115 was to receive only "comfort measures", which was contrary to the advance directives executed by the resident's MPOA. Facility census: 114. Findings include: a) Resident #115 1. Record review revealed this [AGE] year old female was admitted to the nursing facility on 07/14/10, following a hospital stay during which she was treated for [REDACTED]. - 2. Review of Resident #115's medical record found a physician orders [REDACTED]. In Section B, the MPOA indicated that, if the resident has a pulse and/or is breathing, staff was to provide limited addition interventions, to include the use of medical treatment, IV fluids and cardiac monitoring as indicated. The resident's MPOA did not select "comfort measures", which was an option available in this section. In Section D, the MPOA specifically indicated the resident was not to receive a feeding tube; while the MPOA did not indicate a preference with respect to the IV fluids, there was no specific prohibition against the administration of IV fluids. - 3. At the insistence of the resident's legal representative, the resident was transferred to the hospital on [DATE], where she was readmitted for urosepsis, an infected pressure sore, and severe dehydration. During her 24-day stay at the nursing facility, there was no evidence to reflect the nursing staff was routinely assessing / monitoring the resident for changes in hydration status / fluid balance, nor was there evidence to reflect the facility identified the need for administration of intravenous (IV) fluids to restore fluid balance. - 4. According to the hospi… | 2014-01-01 | ||
| 395 | 395 | CLARY GROVE | 515039 | 209 CLOVER STREET | MARTINSBURG | WV | 25404 | 2017-08-11 | 156 | D | 1 | 0 | C6IS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon family interview, staff interview, record review, and facility policy review, the facility failed to ensure that one (1) of eleven (11) (Resident #115) sampled residents family representative was informed of the resident's rights and Medicare charges, and failed to obtain a consent for treatment upon admission. Facility census: 114. Findings include: a) Resident #115 Review of the resident's clinical record revealed he was admitted to the facility on [DATE] and discharge to home on 07/03/17. The resident's admissions [DIAGNOSES REDACTED]. On 06/15/17, the physician determined the resident lacked the capacity to make health care decisions. The admission agreement was signed by the resident's representative and Social Worker (SW) #38 on 07/03/17, but there was no signed consent for treatment in the resident's clinical record. During an interview on 08/08/17 at 4:01 p.m., SW #38 stated one of her responsibilities included obtaining the resident's signature, or the signature of the resident's representative on admission paperwork, which included consent for treatment, resident rights, and Medicare charges. SW #38 stated this information was obtained on admission to the facility within one (1) to two (2) days. SW #38 confirmed she had obtained Resident #115's representative signature on 07/03/17, but was unable to provide why the consent for treatment, resident rights and Medicare charges were not obtained on admission to the facility. During an interview on 08/08/17 at 4:20 p.m., Business Office Manager (BOM) #121 stated the social worker did all the admission paperwork with residents and their families. The BOM #121 stated the corporate expectation was for all admission paperwork to be completed within 72 hours of admission. During a telephone interview on 8/9/17 at 1:21 p.m., Resident #115's representative stated she was in the facility daily from 06/27/17 until the resident's discharge to home on 07/03/17. The representative state… | 2020-09-01 |
| 620 | 620 | HERITAGE CENTER | 515060 | 101-13TH STREET | HUNTINGTON | WV | 25701 | 2017-03-17 | 156 | E | 0 | 1 | 4QX611 | Based on observation and staff interview the facility failed to ensure residents had access to information regarding Resident Rights and the Regional Ombudsman contact information. The facility had not displayed the written information regarding Resident Rights and Ombudsman information in an easily accessible manner, as required by this regulation. This had the potential to affect any resident wishing to review resident rights or contact the Ombudsman. Facility census: 158. Findings include: a) On 03/13/17 at 1:05 p.m., it was discovered the Resident Rights poster with the Ombudsman contact information was located on the wall between two (2) sets of sliding doors at the entrance to the facility. This posting is required to fulfill the facility's obligation to adequately display Resident Rights and Ombudsman's contact information. b) During an interview with the Nursing Home Administrator (NHA) on 03/17/17 at 8:32 a.m., it was verified the Resident Rights poster with the Ombudsman contact information was not easily accessible for residents viewing. No additional information was provided prior to exit. | 2020-09-01 |
| 789 | 789 | ELDERCARE HEALTH AND REHABILITATION | 515065 | 107 MILLER DRIVE | RIPLEY | WV | 25271 | 2017-07-19 | 156 | D | 0 | 1 | HITB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to notify the beneficiary/responsible party of the facility's decision to terminate Medicare services for two (2) of three (3) residents reviewed for the care area of liability notices and beneficiary appeal. This failed practice had the potential to affect an isolated number of residents. Resident identifiers: #8 and #13. Facility census: 100. Findings include: a) Staff Interview At 2:15 p.m. on 07/17/17, the facility social worker, (SW) #102, was asked to provide copies of the information given to the three (3) residents selected by the Quality Indicator Survey (QIS) for review of the care area: Liability Notices and Beneficiary Appeal. The QIS automatically selects three (3) residents discharged from Medicare services within the last six (6) months to determine if the appropriate denial notice was provided. The SW #102 said he was unable to find any information for two (2) Residents: #8 and #13. The facility's resident financial coordinator, (RFC) #30 said she did not have copies of any notices given to Residents #8 and #13 at 2:20 p.m. on 07/17/17. b) Resident #8 At 2:20 p.m. on 07/17/17, RFC #30 verified Resident #8 was re-admitted to the facility on [DATE] and was covered by Medicare, Part A services. The resident was discharged from Medicare services on 06/13/17 and remained at the facility. c) Resident #13 At 2:20 p.m. on 07/17/17, RFC #30 verified Resident #13 was re-admitted to the facility on [DATE]. The resident was covered by Medicare, Part A services. Resident #13 was discharged from Medicare services on 03/09/17. The resident left the faciity on [DATE]. At 2:31 p.m. on 07/17/17, the administrator said he checked with the therapy department and he was unable to find the notices given to Resident's #8 and #13 for denial of Medicare covered services. | 2020-09-01 |
| 946 | 946 | PUTNAM CENTER | 515070 | 300 SEVILLE ROAD | HURRICANE | WV | 25526 | 2017-03-22 | 156 | D | 0 | 1 | SWUR11 | Based on resident interview, staff interview and facility record review, the facility failed to ensure residents received and/or were knowledgeable of how to contact State agencies for two (2) of four (4) residents interviewed. Residents were unable to articulate the name of the ombudsman, did not know the purpose of an ombudsman, and did not know how to contact State agencies, or where to find the information in the facility. Resident identifiers: Resident #13 and #126. Facility census: 117 Findings include: a) Resident #13 and #126 During an interview with Resident #126, on 03/22/17 at 10:31 a.m., the resident voiced concerns were reported to the facility staff. Upon inquiry, she said she did not know how to report to State agencies, and did not know the name of the ombudsman or how to contact her. Resident #13, interviewed at 10:38 a.m. on 03/22/17 at 10:38 a.m., said she would refer concerns to the facility. Upon inquiry, the resident said she did not know how to report to State agencies, and did not know how to contact the ombudsman, or the purpose of an ombudsman. Both residents, during the interviews, denied knowledge of where to find contact information for State agencies in the facility. An interview with Social Service Coordinator (SSC) #60, on 03/22/17 at 12:28 p.m., the SSC said signs were posted and residents and/or families were notified of reporting requirements during the 72 hour meeting on admission. When asked how the information was disseminated to all residents and/or families the coordinator said a copy of resident rights was given to residents yearly. Upon inquiry, the coordinator looked at the form and said it did not contain State agency contact information. The SSC confirmed residents were only provided contact information during resident council meetings. | 2020-09-01 |
| 2536 | 2536 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-08-08 | 156 | E | 0 | 1 | 0QX311 | Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility census: 88 Findings include: a) On 07/31/17 at 10:45 a.m., during an observation of the facility, it was discovered there was no written information posted in the facility to inform a resident on how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. During an interview with the Nursing Home Administrator on 07/31/17 at 11:50 a.m., agreed the information was not posted prominently to inform residents on how to apply for and use Medicare and Medicaid benefits. | 2020-09-01 |
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CREATE TABLE [cms_WV] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );