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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3641 | 3641 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2017-11-01 | 164 | E | 0 | 1 | 0.0 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure the privacy of medical records was maintained during medication administration observation for five (5) of seven (7) opportunities observed. This failed practice had the potential to affect more than a limited number of residents who received medications administered by facility staff. Resident identifiers: #15, #7, #19, and #1. Facility census: 22. Findings include: a) Resident #15 At 8:59 a.m. on 10/31/17 licensed practical nurse (LPN) #2 was observed administering medication to Resident #15. After LPN #2 entered the room for Resident #15 with the cup of medications, it was noted that the Medication Administration Record [REDACTED]. At 2:13 p.m. on 10/31/17 LPN #2 was observed administering medication to Resident #15. After LPN #2 entered the room for Resident #15 with the cup of medications, it was noted that the Medication Administration Record [REDACTED]. b) Resident #7 At 2:05 p.m. on 10/31/17 LPN #2 was observed administering medication to Resident #7. After LPN #2 entered the room for Resident #7 with the cup of medications, it was noted that the Medication Administration Record [REDACTED]. c) Resident #19 At 2:09 p.m. on 10/31/17 LPN #2 was observed administering medication to Resident #19. After LPN #2 entered the room for Resident #19 with the cup of medications, it was noted that the Medication Administration Record [REDACTED]. d) Resident #1 At 2:19 p.m. on 10/31/17 LPN #9 was observed administering medication to Resident #1. Resident #1 was in the hallway, past the water fountain near the nursing station. LPN #2 left her medication cart outside of the room for Resident #15, she went to the end of the hall and entered the room of Resident #1. She then walked back up the hall, passing her medication cart, and walked towards the nursing station to give Resident #1 his medication. She left the MAR indicated [REDACTED]. A medical record review was … | 2020-09-01 |
| 3642 | 3642 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2017-11-01 | 246 | D | 0 | 1 | 0.0 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interviews and staff interviews, the facility failed to ensure reasonable accommodation of needs with call bell accessibility. Two (2) residents who were not independent were observed with call bells placed in a fashion making it difficult, unsafe, if not impossible for them to use. This failed practice affected two (2) of twenty (20) residents reviewed. Resident identifiers: #1 and #12. Facility census: 22. Findings include: a) Resident #1 A record review revealed Resident #1 was admitted [DATE]. His [DIAGNOSES REDACTED]. According to his most recent minimum data set (MDS) quarterly assessment with an assessment reference date (ARD) of 09/13/17, he was totally dependent on staff and required assistance of one (1) to two (2) staff with all of his activities of daily living (ADL's). His brief interview of mental status (BIMS) score on his 09/13/17 quarterly MDS was 10. This means he had moderate cognitive impairment. A resident observation and interview was conducted with Resident #1 on 10/30/17 at 1:50 p.m. He had a special call bell clipped to his pillow that he was meant to press with his head in order to call for staff. When asked if he was able to use his call bell, Resident #1 said I have a hard time getting to it. He then demonstrated that he could not reach the bell, as it was clipped too far for him to reach with his head. Licensed practical nurse (LPN) #1 was summoned to the room. She re-adjusted the call bell and Resident #1 demonstrated he could use it. She had no comment about the bell being out of reach. b) Resident #12 A record review for Resident #12 revealed she was admitted on [DATE]. She had a [DIAGNOSES REDACTED]. She was ninety-eight (98) years old. Her most recent quarterly MDS with an ARD of 09/06/17 identified her as having a BIMS score of fifteen (15), meaning she was cognitively intact. Her MDS also stated she required assistance of staff for dressing and personal hygiene … | 2020-09-01 |
| 3643 | 3643 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2017-11-01 | 253 | D | 0 | 1 | 0.0 | Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services for one (1) of eleven (11) rooms observed during Stage 1 of the Quality Indicator Survey (QIS). The issues identified included a resident's room with oxygen on the floor and stained ceiling tiles with multiple holes. Room identifier: #300-B. Facility census: 22. Findings include: a) Observations The following observations were made on 10/30/17: --[RM #]0-B-Multiple holes and stains on the ceiling tiles. Oxygen tubing on the floor. The following observation was made on 10/31/17: --[RM #]0-B-Oxygen tubing on the floor. b) Interviews An interview with Licensed Practical Nurse (LPN) #2 on 10/31/17 at 10:00 a.m. revealed the oxygen tubing should not be touching the floor. The LPN stated she would let maintenance know about the ceiling tiles. An interview with the Director of Nursing (DON) on 11/01/17 at 9:00 a.m. revealed the DON did not know that oxygen tubing could not be on the floor. She stated she thought just as long as the part that touched the face was off the floor then everything else was okay to touch the floor. The DON stated she would inform the maintenance department of the ceiling tiles. | 2020-09-01 |
| 3644 | 3644 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2017-11-01 | 279 | D | 0 | 1 | 0.0 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan based on a resident's assessed vision impairment. This practice was found for one (1) of ten (10) Stage 2 Sample Residents whose Care Plans were reviewed during the Quality Indicator Survey (QIS). Resident identifier: #20. Facility census: 22. Findings include: a) Resident #20 An observation of Resident #20 on 10/30/17 at 11:00 a.m. revealed the resident was not wearing glasses. A review of Resident #20's Quarterly Minimum Data Set (MDS), dated [DATE], was conducted on 10/31/17 at 10:45 a.m. Section B (B1000)-Vision-revealed the resident was assessed as having impaired vision with the ability to see large print, but not regular print in newspapers/books. A review of Resident #20's initial Nursing Admission Assessment, dated 08/25/15, was conducted on 10/31/17 at 11:00 a.m. The resident was assessed as being visually impaired. A review of Resident #20's annual Social Service Assessment, dated 07/11/17, was conducted on 10/31/17 at 11:15 a.m. The resident was assessed as being visually impaired. A review of Resident #20's annual Nursing Assessment, dated 07/11/17, was conducted on 10/31/17 at 11:25 a.m. The resident was assessed as being visually impaired. A review of Resident #20's Activity Progress Notes, dated 10/18/17, was conducted on 10/31/17 at 11:45 a.m. The progress note stated Participation is limited due to hearing and vision problems. A review of Resident #20's current Care Plan, dated 07/25/17, was conducted on 10/31/17 at 12:00 p.m. The care plan did not include any problem, goals, or interventions for the resident's assessed vision impairment. An interview with Licensed Practical Nurse (LPN) #2, on 10/31/17 at 12:30 p.m., revealed Resident #20 has never had glasses since he has been in the facility. The LPN stated she was not aware the resident had any vision impairment. An interview with the Director of Nursing (DON), on … | 2020-09-01 |
| 3645 | 3645 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2017-11-01 | 313 | D | 0 | 1 | 0.0 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assist in providing vision treatment and devices for a resident. A resident with vision impairment was not assisted in seeing a physician or obtaining any type of vision correcting devices. This practice was found for one (1) of three (3) residents reviewed for vision services in Stage II of the Quality Indicator Survey (QIS). Resident identifier: #20. Facility census: 22. Findings include: a) Resident #20 An observation of Resident #20 on 10/30/17 at 11:00 a.m. revealed the resident was not wearing glasses. A review of Resident #20's Quarterly Minimum Data Set (MDS), dated [DATE], was conducted on 10/31/17 at 10:45 a.m. Section B (B1000)-Vision-revealed the resident was assessed as having impaired vision with the ability to see large print, but not regular print in newspapers/books. A review of Resident #20's initial Nursing Admission Assessment, dated 08/25/15, was conducted on 10/31/17 at 11:00 a.m. The resident was assessed as being visually impaired. A review of Resident #20's annual Social Service Assessment, dated 07/11/17, was conducted on 10/31/17 at 11:15 a.m. The resident was assessed as being visually impaired. A review of Resident #20's annual Nursing Assessment, dated 07/11/17, was conducted on 10/31/17 at 11:25 a.m. The resident was assessed as being visually impaired. A review of Resident #20's Activity Progress Notes, dated 10/18/17, was conducted on 10/31/17 at 11:45 a.m. The progress note stated Participation is limited due to hearing and vision problems. A review of Resident #20's current Care Plan, dated 07/25/17, was conducted on 10/31/17 at 12:00 p.m. The care plan did not include any problem, goals, or interventions for the resident's assessed vision impairment. Further review of the medical record on 10/31/17 at 12:45 p.m. revealed no indication the resident had any type of vision corrective devices or had been assisted in seeing a physician fo… | 2020-09-01 |
| 3646 | 3646 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2017-11-01 | 323 | E | 0 | 1 | 0.0 | Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. Chemical substances were unsecured and accessible to residents in the dining and shower rooms. This practice had the potential to affect more than a limited number of residents. Facility census: 22. Findings include: a) Dining Room A tour of the unit, on 10/30/17 at 9:30 a.m., revealed the dining room door was not shut. The room contained the following items on a cart: --One (1) container of Avagard Instant Hand Antiseptic with Moisturizer with the warning Keep out of reach of children-If swallowed get medical help or contact a Poison Control Center. --One (1) container of Spartan Steriphone II Disinfectant Deodorant Spray with the warning Precautionary Statement-Hazard to humans and animals-Warning-Causes substantial but temporary eye injury-Harmful if absorbed through the skin. An interview with the Director of Nursing (DON) on 10/30/17 at 9:35 a.m. revealed the items should have never been left in the dining room and that they should be locked up in a secured cabinet or room. b) Shower Room A tour of the unit, on 10/31/17 at 10:25 a.m., revealed the shower room door was not shut. The room contained the following items in an unlocked cabinet: --Two (2) containers of Clorox Bleach Germicidal Cleaner with the warning Caution-Causes moderate eye irritation-Avoid contact with eyes or clothing. --Three (3) containers of Spartan Steriphone II Disinfectant Deodorant Spray with the warning Precautionary Statement-Hazard to humans and animals-Warning-Causes substantial but temporary eye injury-Harmful if absorbed through the skin. --One (1) container of Spartan-Non Acid Disinfectant Bathroom Cleaner with the warning Hazard to humans and animals-Caution-causes moderate eye irritation-Harmful if absorbed through the skin. --One (1) container of Stride Citrus Neutral Cleaner with the warning Warning-Causes serious eye irritation-Avoid contact with eyes skin and clothing. An… | 2020-09-01 |
| 3647 | 3647 | MINNIE HAMILTON HEALTH CARE | 51A013 | 186 HOSPITAL DRIVE | GRANTSVILLE | WV | 26147 | 2017-11-01 | 441 | D | 0 | 1 | 0.0 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to ensure staff practices were consistent with infection control principles. A nurse administered medication after potential contamination. Resident oxygen tubing was found on the floor. This failed practice affected an isolated number of residents observed during the survey. Resident identifiers: #15 and #19. Facility census: 22. Findings include: a) Resident #15 An observation of medication administration for Resident #15 was held on 10/31/17 at 8:59 a.m. Licensed practical nurse (LPN) #2 dropped a tablet on to the top of the medication cart when she popped it out of the package. She donned a glove, picked up the tablet with her gloved hand, and placed the tablet into the cup with the rest of the medications she had already poured. LPN #2 then removed the glove and took the cup of medications in to Resident #15. This concern was discussed with LPN and the DON together on 10/31/17 at 3:37 p.m. They both verbalized understanding. b) Oxygen tubing The following observation was made on 10/30/17: --room [ROOM NUMBER]-B-Resident #19-Oxygen tubing on the floor. The following observation was made on 10/31/17: --room [ROOM NUMBER]-B-Resident #19-Oxygen tubing on the floor. An interview with Licensed Practical Nurse (LPN) #2 on 10/31/17 at 10:00 a.m. revealed the oxygen tubing should not be touching the floor. An interview with the Director of Nursing (DON) on 11/01/17 at 9:00 a.m. revealed the DON did not know that oxygen tubing could not be on the floor. She stated she thought just as long as the part that touched the face was off the floor then everything else was okay to touch the floor. | 2020-09-01 |
| 5005 | 5005 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2016-04-20 | 165 | D | 1 | 0 | 06GH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, family interview, staff interview, medical record review, and facility record review, the facility failed to ensure the rights of one (1) of six (6) sample residents to voice grievances without reprisal. Resident #33 related a Licensed Practical Nurse (LPN) and a Nurse Aide (NA) retaliated against the resident after a complaint was initiated over the administration of a medication. The nurse confronted the resident and the nurse aide did not assist with a transfer from chair to bed, and required the resident remain in his chair for over two (2) hours after dinner. Resident identifier: #33. Facility census: 57. Findings include: a) Resident #33 During an interview with Resident #33 and his wife on 04/18/16 from 4:04 p.m. to 4:45 p.m., Resident #33's wife said a complaint had been initiated about the administration of [MEDICATION NAME], but it was a misunderstanding. According to the resident's wife, the resident thought he received Tylenol instead of [MEDICATION NAME]. Resident #33 agreed with his wife's statement. Resident #33's wife related Licensed Practical Nurse (LPN) #20 came to the resident's room, and said they needed to talk. The nurse told Resident #33 She did not appreciate him reporting her to the administrator. The resident's wife indicated the nurse had said they had gotten her in trouble. Resident #33 and his wife also related LPN #20 had said to him that she had her medication cart at his door every day at 4:00 p.m. They also stated she asked him, Do you know what this is? and he had answered, Tylenol?, and the nurse had responded, No, it's (it is) your [MEDICATION NAME]. Resident #33's wife related the Center Nurse Executive (CNE) had entered the room and spoken with LPN #20, and they exited the room. Resident #33 related she had apologized to the nurse for the misunderstanding, and had called the facility and offered her apologies. Resident #33 related the day after the incident, he was in his c… | 2019-04-01 |
| 5006 | 5006 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2016-04-20 | 225 | D | 1 | 0 | 06GH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, family interview, staff interview, facility record review, review of facility policies, and medical record review, the facility failed to ensure all alleged violations concerning mistreatment, abuse, and neglect were reported immediately to the administrator and/or to State agencies. Additionally, the facility failed to provide sufficient evidence that all alleged violations were thoroughly and/or investigated timely, and failed to prevent further potential abuse while the investigation was in progress. This practice affected two (2) of three (3) sample residents. Resident identifiers: #33 and #27. Facility census: 57. Findings include: a) Resident #33 During an interview with Resident #33 and his wife, on 04/18/16 from 4:04 p.m. to 4:45 p.m., an inquiry as to whether the resident had experienced abuse or neglect revealed an incident involving the administration of [MEDICATION NAME]. Resident #33's wife recounted an incident on 04/05/16 concerning the administration of [MEDICATION NAME], and how it was actually a misunderstanding. His wife said Resident #33 thought he was receiving Tylenol, but was actually receiving [MEDICATION NAME]. She related Licensed Practical Nurse (LPN) #60 came to the room and said, We need to talk. Resident #33 and his wife related the nurse told the resident that she did not appreciate him reporting her to the administrator. His wife indicated the nurse spoke in an angry and confrontational manner and that LPN #60 thought Resident #33 should have known what he was receiving. She said the nurse came in again the next evening and asked, Do you know what this is? The resident had replied, Tylenol? and the nurse responded, No it's (it is) your [MEDICATION NAME]. The resident related his wife had apologized to LPN #60 for the misunderstanding. During the interview on 04/18/16, Resident #33's wife said she called her husband on 04/06/16, the evening after the confrontation with LPN #60. She… | 2019-04-01 |
| 5007 | 5007 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2016-04-20 | 226 | D | 1 | 0 | 06GH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interview, facility record review, and policy review, the facility failed to implement its written policies prohibiting mistreatment, neglect, and abuse of residents. The facility failed to conduct a thorough investigation, failed to report occurrences, and failed to ensure residents were protected from harm during an investigation. This affected two (2) of three (3) residents reviewed for allegations of abuse. Resident identifiers: #33 and #27. Facility census: 57 Findings include: a) Resident #33 During an interview with Resident #33 and his wife, on 04/18/16 from 4:04 p.m. to 4:45 p.m., an inquiry as to whether the resident had experienced abuse or neglect, revealed an incident involving the administration of [MEDICATION NAME]. Resident #33's wife recounted an incident on 04/05/16, concerning the administration of [MEDICATION NAME], and how it was actually a misunderstanding. His wife said Resident #33 thought he was receiving Tylenol, but was actually receiving [MEDICATION NAME]. She related Licensed Practical Nurse (LPN) #60 came to the room and said, We need to talk. Resident #33 and his wife related the nurse told the resident that she did not appreciate him reporting her to the administrator. His wife indicated the nurse spoke in an angry and confrontational manner and that LPN #60 thought Resident #33 should have known what he was receiving. She said the nurse came in again the next evening and asked, Do you know what this is? The resident had replied, Tylenol? and the nurse responded, No it's (it is) your [MEDICATION NAME]. The resident related his wife had apologized to LPN #60 for the misunderstanding. During the interview, on 04/18/16, Resident #33's wife said she called her husband on 04/06/16, the evening after the confrontation with LPN #60. She related the resident informed her that he was up in his chair and they would not put him to bed. The resident had told her LPN #60's husband, Nurse… | 2019-04-01 |
| 5008 | 5008 | ANSTED CENTER | 515133 | PO BOX 400 | ANSTED | WV | 25812 | 2016-04-20 | 253 | E | 1 | 0 | 06GH11 | > Based on observation, resident interview, staff interview, family interview, facility record review, and policy review, the facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior. Curtain tracks were coated with dust/grime, garbage was overflowing on to the resident's floor, and floors were dirty. This practice affected eight (8) residents. Resident identifier: #33. Rooms: 200, 201, 204, and 208. Facility census: 57. Findings include: a) Resident #33 1. During an interview and observation on 04/18/16 at 4:04 p.m., Resident #33 related the curtain track over his bed was filthy. Observation revealed a layer of dust/grime along the track. The resident and his wife pointed to a dark pink mark on the wall/window border about midway down the window area. Resident #33 also related the floor on the right side of his bed, between the bed and the window was dirty, and pointed to dark brown/black areas. The resident said the areas had been there for at least three (3) days. Resident #33 and his wife stated staff only mopped every two (2) to three (3) days. She related staff buffed, but only from the entry across the room and bathroom. Another observation on 04/19/16 at 9:05 a.m., revealed the dark areas on the floor on the far side of the bed by the window remained. An interview with the housekeeping supervisor, on 04/19/16 at 10:50 a.m., revealed she only had two (2) housekeeping staff, one (1) from 8:00 a.m. to 4:00 p.m. and one (1) from 11:00 a.m. to 7:00 p.m. She said the housekeeper who came on duty at 11:00 a.m., was the one who completed the detailed cleaning of the rooms, and upon completion, she assisted with cleaning other rooms. During rounds with the supervisor she confirmed the floor area on the right side of Resident #33's bed was dirty, and the curtain guide over the bed was coated with grime and dust balls. 2. While reviewing information about the admission process and residents rights with Resident #33 and his wife on 04/20/16 at 1:30 p.m., his… | 2019-04-01 |
| 934 | 934 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2019-05-17 | 625 | D | 0 | 1 | 06KF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to provide the second notice for the Bed Hold Policy to the resident representative via in writing or verbally within 24 hours of discharge to an acute care hospital. This was true for one (1) of three (3) residents reviewed for hospitalization s during the survey process. The resident representatives did not receive the Bed Hold notices timely in writing or verbally when R48 was transferred to the hospital. Resident identifiers: R48. Facility censes: 75. Findings included: a) R48 A medical record review for R48 on 05/13/19 revealed the second Bed Hold Notice had not been provided to the resident representative in writing or verbally within 24 hours when R48 was transferred to the hospital on [DATE]. In an interview with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) on 05/13/19 at 10:30 AM verified R48's resident representative did not receive the second Bed Hold notice in writing or verbally when he was transferred to the hospital. | 2020-09-01 |
| 935 | 935 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2019-05-17 | 656 | D | 0 | 1 | 06KF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to develop a care plan for a [MEDICAL TREATMENT] resident with interventions addressing complications related to [MEDICAL TREATMENT], pre and/or post [MEDICAL TREATMENT] assessments, blood pressure parameters, and post [MEDICAL TREATMENT] treatment care upon return to the facility from the [MEDICAL TREATMENT] center. This was true for one of one resident reviewed for [MEDICAL TREATMENT] services. This practice has the potential to affect a limited number of residents. Resident identifiers: R32 . Facility census: 75. Findings included: Review of records, on 05/14/19 at 09:39 AM, revealed Resident (R#32) brief interview for mental status (BIMS) score is fourteen (14) indicating resident is cognitively intact. The resident needs extensive to total assistance for activities of daily living. Some pertinent [DIAGNOSES REDACTED]. Records revealed R#32 regained their capacity to make medical decisions on 05/09/19. R#32 receives [MEDICAL TREATMENT] at an outpatient [MEDICAL TREATMENT] center three days a week. The orders showed Resident has [MEDICAL TREATMENT] on Monday, Wednesday, Friday at (name of [MEDICAL TREATMENT] center) at 12:00pm. (Name of ambulance service) to pick up at 11:30 a.m. An interview with the resident, on 05/14/19 at 09:39 AM, revealed the staff rarely ever takes her blood pressure or ask her anything specific when she returns to the facility from the [MEDICAL TREATMENT] center. R#32 said, They take my blood pressure in the mornings, most of the time. The residents stated the ambulance people that take her helps her back into the bed, and sometimes the nurse comes in and talks to the ambulance people. The resident said she comes back from the [MEDICAL TREATMENT] center with a dressing over her AV access and it is left on till the next day, and sometimes a nurse will look at it when she gets back from [MEDICAL TREATMENT]. An interview with licensed… | 2020-09-01 |
| 936 | 936 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2019-05-17 | 657 | D | 0 | 1 | 06KF11 | Based on medical record review, care plan review and staff interview, the facility failed to revise Resident #60's care plan to reflect the date of a pacemaker check had been rescheduled. This was found during a random review of the medical record for one of one reviewed for pacemaker care. Resident identifier: 60. Facility census: 75. Findings included: a) A review of the care plan in the medical record for resident #60 revealed the resident did have a pacemaker. The care plan showed a pace maker check was to be completed in April. There was no evidence that a pacemaker check had been done at that time. Discussion with the director of nursing on 5/15/19 in the afternoon verified that she could not find any documentation showing a pacemaker check. She then had nursing staff search for any information regarding the check. Nursing staff did submit evidence later that a pacemaker check had been completed in (MONTH) and at that time was rescheduled for six months which would be July. A new appointment was set for (MONTH) 26, 2019. The change in the appointment date was not changed on the care plan. The current care plan still stated pacemaker check for April, 2019. | 2020-09-01 |
| 937 | 937 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2019-05-17 | 684 | D | 0 | 1 | 06KF11 | Based on observation, record review, resident interview, and staff interview the facility failed to ensure resident #74 received an accurate skin assessment reflecting the status of the resident's skin. This was true for one of one resident reviewed for skin conditions (non-pressure). This practice has the potential to affect a limited number of residents. Resident identifiers: R#74 . Facility census: 75. Findings included: a) Resident #74 Observations, on 05/13/19 at 3:35 PM, revealed R#74 had a noticeable asymmetric uneven black brownish area of discoloration, almost the size of a dime, with blurred irregular edges on his left cheek. The area on the resident's cheek had the appearance of a flat irregular mole. Also observed was a large area on the residence right lower forearm of faintly reddish pink discoloration. Review of records, on 05/16/19 at 09:58 AM, revealed neither areas were documented on any skin assessments. On 05/16/19 10:08 AM interview and review of records with Assistant Director of Nurses (ADON #50) revealed both skin areas were not documented on the nursing assessments, neither on the admission assessment or any following assessments as they should have been. The ADON acknowledged the areas were present on the resident and should be evaluated. ADON#50 requested the physician to evaluate the skin areas, as the physician was making rounds that day and resident is on list to be seen. An interview with the resident, on 05/16/19 at 10:55 AM, revealed he has always had the moles they had not newly developed but the one on his cheek had changed a little. | 2020-09-01 |
| 938 | 938 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2019-05-17 | 698 | D | 0 | 1 | 06KF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview the facility failed to consistently perform pre and post [MEDICAL TREATMENT] resident assessments, before going and/or returning from the [MEDICAL TREATMENT] center. This was true for one of one resident reviewed for [MEDICAL TREATMENT] services. This practice has the potential to affect a limited number of residents. Resident identifiers: R32 . Facility census: 75. Findings included: a) Resident #32 Review of records, on 05/14/19 at 09:39 AM, revealed Resident (R#32) brief interview for mental status (BIMS) score is fourteen (14) indicating resident is cognitively intact. The resident needs extensive to total assistance for activities of daily living. Some pertinent [DIAGNOSES REDACTED]. Records revealed R#32 regained their capacity to make medical decisions on 05/09/19. R#32 receives [MEDICAL TREATMENT] at an outpatient [MEDICAL TREATMENT] center three days a week. The orders showed Resident has [MEDICAL TREATMENT] on Monday, Wednesday, Friday at (name of [MEDICAL TREATMENT] center) at 12:00pm. (Name of ambulance service) to pick up at 11:30 a.m. Review of the [MEDICAL TREATMENT] communication form, on 05/14/19 at 10:45 AM, show the following information was to be provided on the form by the facility before resident went for [MEDICAL TREATMENT] treatment: Resident's name; date; transported by; condition before leaving facility (Lines to write a narrative about the resident's condition); vital signs before [MEDICAL TREATMENT] (blood pressure, pulse, respirations, and temperature); received meal; and sent snack with resident. Information the [MEDICAL TREATMENT] center was to provide on the communication form was as follows: weight before; weight after; date of physicians visits at [MEDICAL TREATMENT]; labs drawn at [MEDICAL TREATMENT]; problems at [MEDICAL TREATMENT]; medications given; new orders; and vital signs before leaving [MEDICAL TREATMENT]. Review of the past month's [ME… | 2020-09-01 |
| 939 | 939 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2019-05-17 | 812 | E | 0 | 1 | 06KF11 | Based on observation and staff interviews, the facility failed to ensure foods were handled in a manner that promoted safe sanitation techniques. Foods were found stored incorrectly, and staff used the same gloves to handle food and non-food items This practice has the potential to affect more than a limited number of residents who are served from this central location. Facility census: 75. Findings included:a) During the initial tour of the dietary department at 11:00 a.m on 5/13/19 at lunch revealed the following issues. The dietary manager was present at the time of the observations. 1. Sugar was stored with the scoop being in direct contact with the product. Scoops are to be stored in a manner that the serving portion is not in contact with the product. 2. A styrofoam cup was stored directly in a plastic container in the product. The dietary manager identified it as thickened. This also should have the device used to scoop the item from the container not be in direct contact with the product itself. 3 A dietary staff member was noted to be handling fried green tomatoes with her gloved hand. The staff was also seen touching non-food items with those same gloves. This practice could lead to possible cross contamination of the foods. | 2020-09-01 |
| 940 | 940 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2019-05-17 | 923 | E | 0 | 1 | 06KF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, resident family interview, and staff interview the facility failed to ensure adequate ventilation in a communal resident television lounge room, adjoining hallways, and in nearby resident's room as evidenced by the strong cigarette smoke odor lingering in the facility during and after the resident's smoke breaks. This practice has the potential to affect more than a limited number of residents and more than a limited area is affected. Resident identifiers: R#14 and R#28. Facility census: 75. Findings included: a) Resident #14 and #28 On 05/13/19 at 11:22 AM, this surveyor was walking in the hallway between the two nurses' stations, when encountering an overwhelming strong smell of cigarette smoke. The Assistant Director of Nurses (ADON #50) appeared in the hallway coming from the communal television, the surveyor asked ADON #50 if they allowed the residents to smoke inside the building. ADON #50 replied, No they have to go outside to smoke. Looking through the television lounge doorway, observations revealed three (3) residents in wheelchairs right outside the door smoking in the courtyard and two (2) more residents in wheelchairs in the television lounge opening the door trying to go through the doorway to the outside. Interview with Resident (R#28)'s daughter, on 05/13/19 at 11:26 AM, revealed during the interview the daughter requested to stop the interview long enough for her to get up and close the resident's door to the room. The daughter stated, It must be time for the smokers to start smoking, the only way we can deal with it is if I close the door and turn on the exhaust fan in the bathroom. It helps some. The daughter said the facility took good care of her mother the only issue she has is the smoke smell that comes into the room. When asked if she ever told anyone about the smoke smell, the daughter stated it's been a while ago when a maintenance man came in the room change a filter in the … | 2020-09-01 |
| 1254 | 1254 | WILLOWS CENTER | 515085 | 723 SUMMERS STREET | PARKERSBURG | WV | 26101 | 2019-07-02 | 689 | E | 1 | 0 | 06LV11 | > Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which it had control. The facility did not secure a hot steam table, chemicals, a box cutter, an oxygen tank, and shaving razors, from residents. Room identifiers: West Hall Respiratory Room, West Hall Shower Room, East Hall Shower Room, and the Transitional Care Dining Room. Facility census: 96. Findings included: a) Transitional Care Dining Room An observation of the Transitional Care Dining Room, on 7/01/19 at 9:20 AM, revealed the room had an unsecured steam table with multiple bins. No staff or residents were present at the time of the observation. The room and the area where the steam table was located is on a resident hallway and is accessible to anyone at any time. One of the steam bins was hot to touch and was observed to be filled with approximately two inches of water. The water was also hot. The water was tested to be 125 degrees Fahrenheit with both the facility's and surveyor's thermometers. The controls for the steam table were underneath the table in an unsecured cabinet. One of the steam table's controls was set on level 4 heat. The dial has an off setting along with 1 through 7, with 7 being the hottest setting. The steam table could be reached from a sitting or standing position. An immediate interview with the Administrator, on 07/01/19 at 9:30 AM, revealed that he could not explain why the steam table was heated. The Administrator immediately turned the steam table control to off. The Administrator stated I am not sure why there is water in the steam table bin. The Administrator verified the Transitional Care Dining Room is open to anyone at any time. The Administrator stated the heating controls for the steam table have never been locked. The Administrator verified anyone can turn the heat on and off for the steam table. An interview with the Dietary Aide (DA) #1, on 07/01/19 at 10:20 AM, revealed she had turned the steam table on at 9:00 AM in the Transitional Care Dinin… | 2020-09-01 |
| 1255 | 1255 | WILLOWS CENTER | 515085 | 723 SUMMERS STREET | PARKERSBURG | WV | 26101 | 2019-07-02 | 842 | D | 1 | 0 | 06LV11 | > Based on medical record review and staff interview, the facility failed to maintain complete and accurate medical records. A resident's Medication Administration Record [REDACTED]. This practice affected one (1) of six (6) residents reviewed. Resident identifier: #6. Facility census: 96. Findings included: a) Resident #6 A review of the Resident's medical record, on 07/01/19 at 1:15 PM, revealed Medication Administration Records (MARs) with no dates as to which month the record was for. An interview with the Director of Nursing (DON), on 07/02/19 at 8:00 AM, revealed the MARS were for (MONTH) of 2019. The DON stated I have no idea why these are not dated. The DON stated she would ensure the records were dated accurately. | 2020-09-01 |
| 1256 | 1256 | WILLOWS CENTER | 515085 | 723 SUMMERS STREET | PARKERSBURG | WV | 26101 | 2019-07-02 | 880 | E | 1 | 0 | 06LV11 | > Based on observation, medical record review, staff interview, and policy review, the facility failed to provide a safe and sanitary environment that prevented the development and transmission of communicable diseases and infections. A resident on contact precautions did not have a sign on the door advising anyone entering the room to stop and to see the nurse before doing so. This was a random observation. Resident identifier: #7. Facility census: 96. Findings included: a) Observation A random observation of the East Hallway, on 07/01/19 at 8:55 AM, revealed an isolation cart outside the door of Resident #7. There was no sign on the door advising anyone what to do before entering the room. b) Interview An interview with Licensed Practical Nurse (LPN) #2, on 07/01/19 at 8:58 AM, revealed Resident # 7 is on contact precautions. The LPN stated there should be a stop sign on the door advising anyone entering the room to see the nurse. The LPN obtained a sign from the isolation cart by the room and posted it on the door. c) Record Review A medical record review for Resident #7, on 07/01/19 at 11:00 AM, revealed the Resident had the physician order Contact Precautions dated 06/29/19. d) Policy Review A review of the facility policy IC301 Contact Precautions with a revision date 06/15/19, was conducted on 07/01/19. The policy stated Place a STOP-Please see nurse before entering the room sign on the door for residents on contact precautions. | 2020-09-01 |
| 7767 | 7767 | DAWN VIEW CENTER | 515163 | 11 DIANE DRIVE | FORT ASHBY | WV | 26719 | 2013-01-25 | 157 | D | 0 | 1 | 06UD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility did not notify the physician when the medication [MEDICATION NAME] was held for a resident for nineteen (19) consecutive days. The medication was ordered for weight loss and depression. One (1) of thirty-four (34) sample residents was affected. Resident identifier: #88. Facility census: 59. Findings include: a) Resident #88 Review of the resident's medical record, on 01/23/13 at 1:00 p.m., revealed a physician's orders [REDACTED]. The medication was also given for the resident's weigh loss. On 01/23/13, review of the Medication Administration Record [REDACTED]. Further review revealed documentation on the last page of the MAR indicated [REDACTED]. Review of nurses' notes found no evidence the physician was notified the medication ([MEDICATION NAME]) had been held since 01/05/13. An interview held with Employee #41, director of nurses (DON), on 01/23/12 at 3:00 p.m., confirmed there was no evidence the physician was notified. The DON, after checking with the nurses, reported the daughter wanted the medication held because she thought the medication was making the resident drowsy through the day time. | 2017-02-01 |
| 7768 | 7768 | DAWN VIEW CENTER | 515163 | 11 DIANE DRIVE | FORT ASHBY | WV | 26719 | 2013-01-25 | 241 | D | 0 | 1 | 06UD11 | Based on observation and staff interview, the facility failed to provide a dining atmosphere and an environment that maintained or enhanced each resident's dignity and respect. Residents seated together in dining room, as well as in their rooms, were not served meals together, leaving individuals to watch others eat and finish their meals prior to being served themselves. This affected one (1) of thirty-four (34) residents in dining room and one (1) randomly observed resident who was eating in his room during the lunch meal. Resident identifiers: #84 and #66. Facility census: 59. Findings include: a) Resident #84 Random observations of the lunch meal service, on 01/21/13 at 11:45 a.m., noted two (2) residents seated in their room together. A staff member served the roommate of Resident #84 his lunch tray at 11:45 a.m. while Residents #84 watched. Resident #84 did not receive his meal and assistance to eat until 12:00 p.m., after the roommate had finished eating. The director of nursing, Employee #41, agreed the residents observed in their room were not served together. b) Resident #66 Observation of the noon meal, on 01/21/13 at 11:45 a.m., revealed three (3) residents, Residents #5, #66, and #97, were sitting at a table in the dining room. Residents #5 and #97 received their lunch meals at 11:45 a.m. Resident #5 finished her meal at 12:05 p.m. and Resident #97 finished her meal at 12:08 p.m. Resident #66 did not receive his lunch tray until 12:08 p.m., after the other two (2) residents had finished eating. | 2017-02-01 |
| 7769 | 7769 | DAWN VIEW CENTER | 515163 | 11 DIANE DRIVE | FORT ASHBY | WV | 26719 | 2013-01-25 | 279 | D | 0 | 1 | 06UD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to develop a comprehensive care plan for the problems of urinary tract infection and decline in bladder function. This was true for two (2) of thirty-four (34) Stage II sampled residents. Resident identifiers #54 and #36. Facility census: 59. Findings Include: a) Resident #54 Review of the hospital discharge summary revealed the resident was admitted to the hospital on [DATE] and was discharged on [DATE]. While hospitalized , the resident was treated for [REDACTED]. Further review found another hospital discharge summary indicating the resident was admitted to the hospital on [DATE] and was discharged on [DATE]. Again, the resident was started on treatment for [REDACTED]. Resident #54 returned to the facility to complete the treatment for [REDACTED]. Review of Resident #54's current care plan found it did not include a problem of urinary tract infections. On 01/24/13 at 10:10 a.m., the director of nursing agreed that urinary tract infections should have been included in the care plan. b) Resident #36 This resident's significant change minimum data set (MDS), with an assessment reference date (ARD) of 11/28/12, identified the resident was frequently incontinent of urine. Her comprehensive care plan, dated 11/29/12, did not include any plans for assisting the resident to improve her urinary continence status. An interview, conducted on 01/23/13 at 2:15 p.m., with Employee #54, the MDS coordinator, confirmed there was no care plan to address urinary incontinence. | 2017-02-01 |
| 7770 | 7770 | DAWN VIEW CENTER | 515163 | 11 DIANE DRIVE | FORT ASHBY | WV | 26719 | 2013-01-25 | 280 | D | 0 | 1 | 06UD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to revise the comprehensive care plan for two (2) of the thirty-four (34) sampled residents, to include interventions following accidents/falls. Resident identifiers: #36 and #88. Facility census: 59. Findings include: a) Resident #36 Review of the resident's medical record, on 01/22/13 at 11:00, revealed a current care plan with a problem of At risk for falls: recent illness, shortness of breath (SOB) and weakness. The goal was, Resident will have no falls with injury for 90 days. Interventions were, Assist resident getting in and out of bed with limited assist of one. Provide verbal cues for safety and sequencing when needed. Provide verbal cues for proper pacing and energy conservation. Place call light within reach at all times. Remind resident to use call light when attempting to ambulate or transfer. Maintain a clutter-free environment in the resident's room and consistent furniture arrangement. Monitor and assist toileting needs. Therapy/Rehab- PT (physical therapy) evaluation. As of 01/22/13, there was no revision of the care plan since 11/29/12. Review of nurses' notes revealed Resident #36 had experienced two (2) accident/falls. One was documented on 12/10/12, and another on 01/05/13. An interview conducted with Employee #41, the director of nursing (DON), on 01/23/13 at 2:30 p.m., confirmed the care plan had not been revised following the resident's accident/falls. b) Resident #88 Review of the resident's medical record, on 01/22/13 at 1:00 p.m., revealed a current care plan with a problem of At risk for falls: orthostatic [MEDICAL CONDITION]. The goal was, Resident will have no falls with injury for 90 days. The interventions were Assist resident with getting in and out of bed with 1-2 assistance. Medicate with alendronate related to [MEDICAL CONDITION]. Provide verbal cues for safety and sequencing when needed. Provide verbal cues for proper pac… | 2017-02-01 |
| 7771 | 7771 | DAWN VIEW CENTER | 515163 | 11 DIANE DRIVE | FORT ASHBY | WV | 26719 | 2013-01-25 | 371 | E | 0 | 1 | 06UD11 | Based on observation and staff interview, the facility failed to maintain proper sanitary storage of food. Chili was stored in a plastic container in the freezer with a lid that did not close tightly. This practice had the potential to affect all residents who consumed this food served from this central location. Facility census: 59. Findings include: a) Observation of the freezer, on 01/21/13 at 11:25 a.m., with the Employee #31 dietary manager (DM), revealed a large plastic container of chili with frost on top of the chili. The lid was not secured tightly. Interview on 01/21/13 at 11:25 a.m., with the dietary manager, confirmed the chili had not been properly stored and would have to be discarded. | 2017-02-01 |
| 7772 | 7772 | DAWN VIEW CENTER | 515163 | 11 DIANE DRIVE | FORT ASHBY | WV | 26719 | 2013-01-25 | 431 | E | 0 | 1 | 06UD11 | Based on observation, policy review, and staff interview, the facility failed to destroy expired medications to prevent the use of expired medication and failed to provide a separately locked, permanently affixed compartment for storage of a controlled drug (Ativan). This practice had the potential to affect more than an isolated number of residents. Facility census: 59. Findings include: a) Observation of the medication storage room, on 01/23/12 at 1:30 p.m., found thirteen (13) bags of Cefazolin (intravenous antibiotic) in the medication refrigerator with expiration dates of 12/31/12 on four (4) of them,01/03/13 on five (5) of them and 01/10/13 on four (4) of them. Also noted four (4) vials of controlled medication (Ativan) was found in a plastic removable box in the door of the refrigerator. Review of facility's policy for Storage and Expiration Dating of Drugs, Biologicals, Syringes and Needles revealed, Drugs and biologicals that have an expired date on the label or are after the manufacturer/supplier guidelines/recommendations, or if contaminated or deteriorated, are stored separately, away from use, until destroyed or returned to provider. Review of the last Consultant Pharmacist Summary, dated 01/14/13, revealed out of date (expired) medication had not been removed and/or re-ordered as necessary. b) According to the regulation found in Appendix PP, The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. Employee # 41, the director of nursing (DON) was present during the medication room inspection and confirmed the bags of intravenous antibiotic fluids were outdated and the vials of Ativan were located in a removable plastic box located in the door of the refrigerator. She al… | 2017-02-01 |
| 7773 | 7773 | DAWN VIEW CENTER | 515163 | 11 DIANE DRIVE | FORT ASHBY | WV | 26719 | 2013-01-25 | 441 | E | 0 | 1 | 06UD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, the facility failed to ensure transmission-based precautions were in place to prevent the spread of infection from a known positive source. The facility did not post signage indicating precautions were necessary and/or the type of precautions needed. This had the high potential to affect all residents on the 200 hall, as they were cared for by the same staff members. Resident identifier: #27. Facility census 59. Findings include: a) Resident #27 Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A urine culture collected on 12/21/12, was reported positive on 12/23/12 for multi-resistant [DIAGNOSES REDACTED] pneumonia. She was discharged to an acute care facility on 12/28/12 to the care of an epidemiologist. The resident was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her admission orders [REDACTED]. The resident was in a private room. A container for gloves, gowns, and disinfectant hand cleanser was just inside her room. The door was observed open at 11:10 a.m. on 01/21/13, during a general tour of the facility. No signage was observed to inform staff and/or visitors, prior to entry, of the need for preventive precautions. The room still did not have information, related to infection control requirements, posted at 4:00 p.m. the same day. The director of nurses (DON) was interviewed at 4:00 p.m. on 01/21/13. She was asked why there were no precaution/isolation signs. The DON stated they (nursing staff) were following precautions with the resident's many dressing changes and with her care, but did not think signage was needed. A review of the facility's isolation policies for residents with MDRO's (multi-drug resistant organisms) revealed signage was required. During an interview with the administrator, at 9:00 a.m. on 01/22/13, she acknowledged signage regarding infection control prec… | 2017-02-01 |
| 7774 | 7774 | DAWN VIEW CENTER | 515163 | 11 DIANE DRIVE | FORT ASHBY | WV | 26719 | 2013-01-25 | 514 | D | 0 | 1 | 06UD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and staff interview, the facility did not ensure medical records were complete and accurate. Orders for pressure ulcer treatments were written for the treatments to be provided for fourteen (14) days. The orders were not rewritten after the need for continued treatment beyond the fourteen (14) day period was identified. Resident identifier: #49. Facility census: 59. Findings include: a) Resident #49 Review of the physician orders, on 01/23/13 at 1:30 p.m., revealed a physician's orders [REDACTED]. The order was for the dressing to be changed daily, and whenever needed, for fourteen (14) days, and then to re-evaluate the wound. An order was also written, for a wound on the sacrum, to change the dressing daily, and whenever needed, for fourteen (14) days and re-evaluate. The orders were written on 12/12/12 and ended on 12/26/12. No new physician orders [REDACTED]. Review of the wound treatment sheet, on 01/23/13 at 1:30 p.m., revealed the same physician's orders [REDACTED]. According to the wound treatment sheet, staff continued to perform the same wound treatment to the right hip, which should have ended on 12/26/12, through 01/22/13. At that time, the treatment was discontinued because the wound had healed. Similarly, the wound treatment to the sacrum continued through 01/23/13. Employee #81, a registered nurse (RN), with the assistance of Employee #38 (RN), were observed performing wound care to the area on the resident's sacrum on 01/23/13 at 1:50 p.m. The treatment was performed using the same treatment order that ended on 12/26/12. In an interview with medical records personnel, Employee #75, on 01/23/13 at 2:00 p.m., she said she had put in the dates for the order to be checked by the nursing department, so either a new order could be written or the treatment discontinued. She confirmed no order was written for the continuation of the wound treatments to the right hip and the sacrum after 12/… | 2017-02-01 |
| 1491 | 1491 | EASTBROOK CENTER | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2019-06-27 | 580 | D | 1 | 0 | 07RN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interviews, the facility failed to notify the physician of a consultation recommendation from a surgeon. The facility nursing staff did not notify the physician for three (3) days of the surgeon's recommendation to hold all blood thinners for a resident. This had the potential to affect one (1) of six (6) residents reviewed for notifying the physician. Resident identifer: #1. Facility census: 121. Findings included: a) Resident #1 A review of Resident # 1's medical record on 06/24/19 at 4:00 PM, found the resident had a left total knee surgery on 03/11/19. The surgeon wrote a prescription for Resident #1 to take Xarelto 10 milligram (MG) one (1) time a day for [MEDICAL CONDITIONS]. The prescription revealed the Surgeon had dispensed 20 tablets. On 03/22/19, Resident #1 had a follow-up appointment to see the Surgeon. The Surgeon made the recommendation to to hold all blood thinners, and to follow up in one (1) week. A review of Resident #1's medical record finds the staff did not notify the physician of the Surgeon's recommendation to hold all blood thinners on 03/22/19. The physician wrote a progress note on 03/25/19 for Resident #1 to continue Xarelto. The physician progress notes [REDACTED]. In an interview on 06/27/19 at 9:20 AM, with Clinical Quality Consultant (CQC) #16, she was asked how do you obtain consultation report when a resident goes out to see a physician. The CQC stated that, the procedure is for the staff to send a consultation report with the resident on their appointment and the physician is to write their recommendation and sent this form back to the facility with the resident. The CQC revealed the staff should have contacted the Surgical Center once the the resident had returned back to the facility with no consultation report. The CQC verified the staff did not do this. On 06/27/19 at 10:45 AM, Registered Nurse Treatment Nurse (RNTN) #5 revealed how the facility had had obtained… | 2020-09-01 |
| 1492 | 1492 | EASTBROOK CENTER | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2019-06-27 | 607 | D | 1 | 0 | 07RN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a review of reportable abuse/neglect allegations, grievance and complaint files, family interview, staff interview, and policy review, the facility failed to ensure they implemented their policy regarding allegations of abuse/neglect. An allegation of neglect was not identified, reported or thoroughly investigated. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: Resident #2. Facility census: 121. Findings included: a) Resident #2 (R#2) Review of records, on 06/24/19 at 2:15 PM, revealed Resident (R#2) is totally dependent with all activities of daily living (ADL). R#2 is always incontinent of bowel and bladder. Some pertinent [DIAGNOSES REDACTED]. The resident has severe cognitive impairment. R#2 is deemed by a physician, on 02/25/19, to have mental capacity to make medical decisions on her own, and also has a medical power of attorney (MPOA). R#2 has a stage 4 pressure ulcer of the sacral region, that was present upon admission, and is being treated with a wound vac. R#2 has a PEG (Percutaneous Endoscopic Gastrostomy), where a feeding tube is surgically inserted into the stomach to feed patients that cannot swallow food. The resident is also on a mechanically altered diet (pureed food) requiring assistance to be fed due to her paralysis and muscle weakness. R#2 requires tube feedings to meet the resident's estimated nutrient needs due to dysphagia and poor intake of food by mouth. An interview with Resident (R#2) family member, on 06/26/19 at 6:25 PM, revealed the family member stated they reported a nurse aide that was not feeding R#2's her food from the meal tray. The family member said they told the Patient/Clinical Liaison (Staff#15), and as far as they knew there had not been anything done about it. Review of reportable abuse/neglect allegations, grievance, and complaint records, on 06/27/19 at 8:47AM, reveal no reports concerning a Nurse aide neglecting to feed a res… | 2020-09-01 |
| 1493 | 1493 | EASTBROOK CENTER | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2019-06-27 | 610 | D | 1 | 0 | 07RN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a review of reportable abuse/neglect allegations, grievance and complaint files, family interview, staff interview, and policy review, the facility failed to or report an allegation of neglect. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: Resident #2. Facility census: 121. Findings included: a) Resident #2 (R#2) Review of records, on 06/24/19 at 2:15 PM, revealed Resident (R#2) is totally dependent with all activities of daily living (ADL). R#2 is always incontinent of bowel and bladder. Some pertinent [DIAGNOSES REDACTED]. The resident has severe cognitive impairment. R#2 is deemed by a physician, on 02/25/19, to have mental capacity to make medical decisions on her own, and also has a medical power of attorney (MPOA). R#2 has a stage 4 pressure ulcer of the sacral region, that was present upon admission, and is being treated with a wound vac. R#2 has a PEG (Percutaneous Endoscopic Gastrostomy), where a feeding tube is surgically inserted into the stomach to feed patients that cannot swallow food. The resident is also on a mechanically altered diet (pureed food) requiring assistance to be fed due to her paralysis and muscle weakness. R#2 requires tube feedings to meet the resident's estimated nutrient needs due to dysphagia and poor intake of food by mouth. An interview with Resident (R#2) family member, on 06/26/19 at 6:25 PM, revealed the family member stated they reported a nurse aide that was not feeding R#2's her food from the meal tray. The family member said they told the Patient/Clinical Liaison (Staff#15), and as far as they knew there had not been anything done about it. Review of reportable abuse/neglect allegations, grievance, and complaint records, on 06/27/19 at 8:47AM, reveal no reports concerning a Nurse aide neglecting to feed a resident. On 06/27/19 at 11:32AM an interview with the Patient/Clinical Liaison (Staff#15) revealed when asked if anyone had e… | 2020-09-01 |
| 1494 | 1494 | EASTBROOK CENTER | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2019-06-27 | 689 | D | 1 | 0 | 07RN11 | > Based on observation, record review, staff interviews, policy and material safety data sheets (MSDS) review, the facility failed to provide an environment free from accident hazards over which the facility had control concerning a supply room with hazardous materials accessible to residents and leaving an air mattress motor lying on the floor. These were a random opportunity for discovery. This had the potential to affect a limited number of resident. Facility census 121. Findings include: a) Supply room on the 2nd floor Observation on 06/25/19 at 8:15 AM, found the facility's supply room on the second floor did not have a lock on the outside of the door. Inside the unlocked door on a shelf there were: 10 mouthwashes, eight (8) skin repair creams (Remedy, Nutrashield cream) 10 bottles of shampoo and body wash, two (2) shaving creams, 12 lotions. This room was accessible to the residents. The MSDS revealed the the hazard identified for each of the item found in the supply room are: -- Mouthwash: hazard to eyes, and if you ingestion. If swallowed, drink lots of water and induce vomiting. Flush eyes in clear running water. If irritation results and persists, get medical attention. -- Skin repair cream (Redmedy, Nutrashield Cream) hazard to eyes, and if you ingestion. The MSDS says to flush with water. Get medial attention if irritancy persists. If a person ingests large quantities of the skin repair cream seek medical attention. -- Shampoo/body wash hazard to eyes and if you ingest. Eye contact may cause temporary moderate irritation. Ingestion may result in gastric disturbances. --Lotion hazard if ingested. If swallowed induce vomiting. --Shaving Cream is hazard to eyes and inhalation. Cause Irritation to the eyes. Flush eyes with water for a least 15 minutes. For inhalation remove patient to fresh air lay down, keep patient warm and at rest. Registered Nurse Unit Manager (RNUM)of the second floor was informed on 06/25/19 at 8:20 AM, and the RNUM confirmed the door did not have a lock on the outside of the door. … | 2020-09-01 |
| 1495 | 1495 | EASTBROOK CENTER | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2019-06-27 | 693 | D | 1 | 0 | 07RN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, staff interview, and policy review the facility failed to ensure the administration of a resident's enteral nutrition is consistent with the physician's orders [REDACTED]. This is true for one (1) of one (1) resident reviewed for the care area of tube feeding status. This practice had the potential to affect more than a limited number of residents. Resident identifiers: Resident #2. Facility census: 121. Findings included: a) Resident #2 (R#2) Review of records, on 06/24/19 at 2:15 PM, revealed Resident (R#2) is totally dependent with all activities of daily living (ADL). R#2 is always incontinent of bowel and bladder. Some pertinent [DIAGNOSES REDACTED]. The resident has severe cognitive impairment. R#2 is deemed by a physician, on 02/25/19, to have mental capacity to make medical decisions on her own, and also has a medical power of attorney (MPOA). R#2 has a stage 4 pressure ulcer of the sacral region, that was present upon admission, and is being treated with a wound vac. R#2 has a PEG (Percutaneous Endoscopic Gastrostomy), where a feeding tube is surgically inserted into the stomach to feed patients that cannot swallow food. The resident is also on a mechanically altered diet (pureed food) requiring assistance to be fed due to her paralysis and muscle weakness. R#2 requires tube feedings to meet the resident's estimated nutrient needs due to dysphagia and poor intake of food by mouth. Physicians orders reviewed, on 06/25/19 at 3:01 PM, revealed Every night shift Tube feeding Glucerna 1.5 via GT. Administer via pump at 95ml/hour 1 times/day for total daily volume of 760ml/24 hours. Provides 1140 kcals, 62g protein, 1336ml free water every night shift. Review of the Medication Administration Record [REDACTED]. Administer via pump at 95ml/hour 1 times/day for total daily volume of 760ml/24 hours. Provides 1140 kcals, 62g protein, 1336ml free water with the time frame to administer feeding designated b… | 2020-09-01 |
| 1496 | 1496 | EASTBROOK CENTER | 515089 | 3819 CHESTERFIELD AVENUE | CHARLESTON | WV | 25304 | 2019-06-27 | 880 | D | 1 | 0 | 07RN11 | > Based on observations and staff interview, the facility failed to implement infection control practices and processes designed to prevent the transmission of disease, infection, and/or cross contamination concerning disposable wipes. This was true for one of one resident reviewed for peri-care (washing the genitals and anal area). This practice had the potential to affect more than a limited number of residents. Resident identifier: Resident #2. Facility census: 121. Findings included: a) Resident #2 (R#2) On 06/26/19 at 3:05 PM, observations of registered nurse RN#5 providing peri-care to Resident#2 after the resident had a bowel movement, revealed a breech in infection control principles. RN#5 used disposable wipes from a bedside package to clean the bowel movement off the resident. When the nurse finished cleaning the resident, RN#5 took her soiled contaminated gloved hand and pushed an unused clean disposable wipe back into the package and sealed it, thus contaminating the remaining disposable wipes in the package. The nurse acknowledged the remaining disposable wipes were now contaminated and would need to be discarded. RN#5 said she would get a new package and confirmed it was a breach in infection control principles. | 2020-09-01 |
| 10717 | 10717 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2011-08-22 | 278 | D | 1 | 0 | 08RC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure the accuracy of a weight recorded in the minimum data set assessment for one (1) of six (6) sampled residents. Resident identifier: #184. Facility census: 180. Findings include: a) Resident #184 Record review revealed this [AGE] year old female, who was originally admitted to the facility on [DATE] and was readmitted to the facility following a hospital stay on 05/23/11, weighed 87 pounds (#) on 05/25/11; this was recorded on sheet containing nothing but weights found in the medical record. Review of this resident's initial minimum data set assessment (MDS), with an assessment reference date of 05/29/11, found the assessor recorded the resident's weight as being 132# during this assessment reference period. During an interview on 08/17/11 at 3:30 p.m., the dietary manager (Employee #63) verified that she completed this section on this MDS. She stated she knew this weight of 185# was not accurate, because this resident never weighed 132#. She stated this must have been a data entry error, because she kept a close eye on this resident's weight and the resident never weighed that much. . | 2014-12-01 |
| 10718 | 10718 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2011-08-22 | 279 | D | 1 | 0 | 08RC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to develop a comprehensive care plan based on the results of a comprehensive assessment for one (1) of six (6) sampled residents. Resident #185's assessment identified his weight as 129 pounds (#). His care plan contained a goal for him to maintain his weight between 175# and 195#. This care plan was not based his assessment information. Resident identifier: #185. Facility census: 180. Findings include: a) Resident #185 Medical record review revealed this [AGE] year old male was admitted to the facility on [DATE]. According to his nursing admission assessment dated [DATE], he weighed 130 pounds (#) on admission. According to his weight record, subsequent weights were as follows: 129.2# on 05/31/11; 128# on 06/03/11; and 126.2# on 07/03/11. Further review of the medical record found a Medicare 14-Day minimum data set assessment (MDS) with an assessment reference date of 06/01/11, which stated, in Section K0200, that this resident's weight was 129#. The assessor indicated the resident had not experienced a significant weight loss of five percent (5%) in the last month or ten percent (10%) in the last six (6) months. The assessor further indicated that the received received fifty-one percent (51%) or greater of his total daily calories through his feeding tube. Review of a hospital record titled "Outside Facility Transfer Form" dated 05/19/11, the resident's weight was 185#. In another hospital record (a progress note by the hospital's dietician dated 05/19/11 at 9:11 a.m.), the resident's weight was 139.7#. The nursing home's consultant dietician completed a medical nutritional therapy review on the resident on 05/25/11. This assessment stated the resident's weight was 185# at that time. Subsequently, his initial comprehensive care plan, which was based on a weight of 185#, contained a goal for him to maintain his weight between 175# and 195#. The director of nursing (DON), when … | 2014-12-01 |
| 10719 | 10719 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2011-08-22 | 514 | D | 1 | 0 | 08RC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure the clinical record contained complete and accurate information about a resident's skin condition for one (1) of six (6) sampled residents (#184). On admission, Resident #184 had a Stage 3 pressure ulcer, which later declined to a Stage 4, and for which she received daily treatments. "Nursing Daily Skilled Summary" forms, used by the facility to record assessment information about various body systems, contained check boxes to prompt nurses to record specific information - such as the presence of pressure ulcers. Ten (10) such summary forms, entered in the resident's record between 06/07/11 and 06/24/11, were either left blank or were specifically - and incorrectly - marked "No problems". Additionally, although assessments of her wound were being recorded on a pressure ulcer log used to track the wounds of multiple residents simultaneously, Resident #184's own medical record did not contain a weekly description of the characteristics of her wound as it was being assessed between the dates of 07/05/11 and her date of discharge on 07/13/11. Resident identifier: #184. Facility census: #180. Findings include: a) Resident #184 1. Record review revealed this [AGE] year old female, who was originally admitted to the facility on [DATE], was readmitted to the facility following a hospital stay on 05/23/11. Assessment information revealed the presence of a Stage 3 pressure ulcer on the resident's coccyx upon her return from the hospital. Review of her physician's telephone orders found an order, dated 05/25/11 at 12:30 p.m., stating (quoted as written): "(1) Cleanse wound to Coccyx /c (with) [MEDICATION NAME], pat dry, apply Santyl. Cover /c 4x4 [MEDICATION NAME]. (Symbols for "change every day') and PRN (as needed) until resolved. @ (At) drsg (dressing) (symbol for 'change') complete daily pressure ulcer monitoring record. (2) Ensure drsg is C/D/I (clean / dry / intact) Q (eve… | 2014-12-01 |
| 10720 | 10720 | HUNTINGTON HEALTH AND REHABILITATION CENTER | 515007 | 1720 17TH STREET | HUNTINGTON | WV | 25701 | 2011-08-22 | 280 | D | 1 | 0 | 08RC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to review and revise the care plan a resident was no longer receiving a gastrostomy tube ([DEVICE]) feeding. The care plan did not reflect the resident's current health status and care needs for one (1) of six (6) sampled residents. Resident identifier: #184. Facility census: 180. Findings include: a) Resident #184 Record review revealed this [AGE] year old female, who was originally admitted to the facility on [DATE], was readmitted to the facility following a hospital stay on 05/23/11. Her care plan, dated 05/30/2011, stated she "receives enteral nutrition related to impaired swallowing, failure to eat, anorexia, burning mouth syndrome and nausea and vomiting." Her goal stated she would have nutrition and hydration needs met and maintained with enteral feedings as ordered and stable weights between 87 pounds (#) and 110#. The approaches were focused on the [DEVICE] feeding and monitoring her tolerance of the feeding. Resident #184 was transferred to the hospital on [DATE]; she was having some complications with her [DEVICE], and this was the second time she had been transferred to the hospital since her admission due to her [DEVICE] coming out. She was receiving speech therapy at that time and had been receiving some foods by mouth. When she returned from the hospital on [DATE], she was no longer receiving feedings by [DEVICE] but had an order for [REDACTED]. The care plan, upon her return from the hospital on [DATE], continued to identify this resident as receiving enteral nutrition. It was not updated to reflect that she was receiving food by mouth as her primary source of nutrition. The dietary manager (Employee #63), when interviewed at 3:30 p.m. on 08/17/11, verified that the care plan should have been updated when the resident returned from the hospital to reflect her current status, because she was receiving a regular diet at that time. Employee #63 verified that she w… | 2014-12-01 |
| 10276 | 10276 | ST. JOSEPH'S HOSPITAL, D/P | 515051 | AMALIA DRIVE #1 | BUCKHANNON | WV | 26201 | 2011-05-11 | 329 | D | 0 | 1 | 09KX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure each resident's medication was free of unnecessary drugs. One (1) of fourteen (14) Stage II sample residents received medications for an excessive duration with no gradual dose reduction (GDR) attempts for [MEDICATION NAME] and/or [MEDICATION NAME] or documentation stating such GDR attempts were clinically contraindicated. Resident identifier: #16. Facility census: 16. Findings include: a) Resident #16 Review of Resident #16's medical record disclosed this [AGE] year old female was admitted on [DATE] with [DIAGNOSES REDACTED]. Her admission physician's orders [REDACTED]." On 05/20/10, the physician ordered: "[MEDICATION NAME] 30 mg po HS (at bedtime) for depression." There was no evidence in the record of an attempted GDR of these medications, although the behavior monitoring records for this resident revealed there had been NO behaviors associated with depression and/or anxiety in the preceding four (4) months. A review of the physician's progress notes found only brief comments about the medications as follows: - 04/11/10 - "[MEDICATION NAME] controls [DIAGNOSES REDACTED]." - 08/31/10 - "...staff report she does get anxious...Continue [MEDICATION NAME] as ordered,..." - 10/08/10 - "Cont Rx (prescription), [MEDICATION NAME] & [MEDICATION NAME] effective & necessary." - 10/16/10 - "[MEDICATION NAME] 1 mg TID." (This was in response to a flagged alert from nursing for the physician to address the use of psychoactive medications.) During an interview with the director of nurses at 8:30 a.m. on 05/11/11, she stated she had flagged the progress notes when she realized no GDR had been done. She acknowledged that the entry above was the only response to her alert. In an interview with the consultant pharmacist at 8:45 a.m. on 05/11/11, she acknowledged, after reviewing the resident's record, that she had only questioned the use of [MEDICATION NAME] one (1) time, shortly aft… | 2015-05-01 |
| 10277 | 10277 | ST. JOSEPH'S HOSPITAL, D/P | 515051 | AMALIA DRIVE #1 | BUCKHANNON | WV | 26201 | 2011-05-11 | 371 | F | 0 | 1 | 09KX11 | . Based on observation, staff interview, and facility policy review, the facility failed to maintain recommended minimum safe holding temperatures for hot foods prior to service. Facility census: 16. Findings include: a) On 05/09/11 at 11:48 a.m., steam table temperatures were taken near the end of the luncheon meal tray line. They were taken by the facility's dietary manager (Employee #15) at the surveyor's request, and she confirmed the temperatures as follows: - Grilled Cheese Sandwich - 130 degrees Fahrenheit (F)- Home Fries - 132 degrees F b) On 05/10/11 at 11:50 a.m., steam table temperatures were again taken near the end of the luncheon meal tray line. They were taken by a dietary staff member (Employee #14) at the surveyor's request, and she confirmed the temperatures as follows: - Hot Dog - 115 degrees F - Chili Sauce - 130 degrees F - Baked Beans - 120 degrees F c) The facility's policy / procedure was obtained from the dietary manager at 12:08 p.m. on 05/10/11. Review of the Nutrition Services Policy Manual, Chapter Seven (VII), Section G, Food Quality Standards, found under the heading "Policy": "To provide a procedure for checking all food items for quality and safety prior to service to all patients and visitors." Item "d" under the heading "Procedure" stated: "Hot food will be held at 140 degrees F during service." The 2005 Food Service Code states hot food holding temperature should be at least 135 degrees. The code states danger zone holding temperatures are between 41 degrees F and 135 degrees F. . | 2015-05-01 |
| 10278 | 10278 | ST. JOSEPH'S HOSPITAL, D/P | 515051 | AMALIA DRIVE #1 | BUCKHANNON | WV | 26201 | 2011-05-11 | 428 | D | 0 | 1 | 09KX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the pharmacist failed to identify and report irregularities in the medication regimen of one (1) of fourteen (14) Stage II sample residents, who continued to receive psychoactive medications without gradual dose reduction (GDR) attempts when indicated. Resident identifier: #16. Facility census: 16. Findings include: a) Resident #16 Review of Resident #16's medical record disclosed this [AGE] year old female was admitted on [DATE] with [DIAGNOSES REDACTED]. Her admission physician's orders [REDACTED]." On 05/20/10, the physician ordered: "Remeron 30 mg po HS (at bedtime) for depression." There was no evidence in the record of an attempted GDR of these medications, although the behavior monitoring records for this resident revealed there had been NO behaviors associated with depression and/or anxiety in the preceding four (4) months. A review of the physician's progress notes found only brief comments about the medications as follows: - 04/11/10 - "Ativan controls [DIAGNOSES REDACTED]." - 08/31/10 - "...staff report she does get anxious...Continue Ativan as ordered,..." - 10/08/10 - "Cont Rx (prescription), Ativan & Remeron effective & necessary." - 10/16/10 - "Ativan 1 mg TID." (This was in response to a flagged alert from nursing for the physician to address the use of psychoactive medications.) During an interview with the director of nurses at 8:30 a.m. on 05/11/11, she stated she had flagged the progress notes when she realized no GDR had been done. She acknowledged that the entry above was the only response to her alert. A drug regimen review, completed by the pharmacist on 05/04/11, resulted in the physician being asked the following: "Is Ativan for tremors, anxiety, or both?" This query was never answered, but the monthly pharmacy reviews from 06/08/10 through 05/11/11 all indicated there were NO recommendations. In an interview with the consultant pharmacist at 8:45 a.m. on 05/11/11, she ac… | 2015-05-01 |
| 3807 | 3807 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-04-21 | 157 | D | 1 | 0 | 0AC711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and clinical record review, the facility failed to notify the physician when Resident #98 refused oral medications for eleven (11) days. This was found for one (1) of six (6) sampled residents reviewed. Resident Identifier: #98. Facility census: 97. The findings include: a) Resident #98 Clinical record review revealed Resident #98 resided in the facility from [DATE] until her death on [DATE]. Her [DIAGNOSES REDACTED]. Her oral medications at the time of her [DATE] admission included: - [MEDICATION NAME] 8 milligrams (mg) daily (a steroid), - [MEDICATION NAME] 100 mg twice daily (a stool softener), - [MEDICATION NAME] 4 mg every 8 hours (to prevent nausea and vomiting), - senna 176 mg/5 milliliters (ml) 15 ml twice daily (a laxative), - [MEDICATION NAME] 40 mg daily (a diuretic), - [MEDICATION NAME] 10 mg daily (for allergies [REDACTED].>- [MEDICATION NAME] 10 mg daily (allergies [REDACTED].>- Movantik 12.5 mg daily (for opiod induced constipation), - [MEDICATION NAME] 17 grams (g) daily (a laxative), - K-Dur 20 milliquivalents (meq) twice daily (a potassium supplement), and - [MEDICATION NAME] 100 mg/ 5 ml 20 mg every hour as needed (a highly concentrated [MEDICATION NAME]). Review of the (MONTH) (YEAR) Medication Administration Record (MAR) revealed all oral medications except the [MEDICATION NAME] were circled as not given from [DATE] until her death on [DATE]. The reasons stated on the MAR for refusing her medications were she was, too sick or complaint nausea/vomiting. The clinical record contained no evidence of notification of the physician until [DATE], at which time the physician discontinued the [MEDICATION NAME], [MEDICATION NAME], and K-Dur. During an interview on [DATE] at 11:58 a.m., Licensed Practical Nurse (LPN) #69 stated Resident #98 was always nauseated, and would not take her oral medications except for her [MEDICATION NAME] for pain. LPN #69 stated the medications made her feel more nauseated. LP… | 2020-08-01 |
| 3808 | 3808 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-04-21 | 166 | F | 1 | 0 | 0AC711 | > Based on a review of the Resident Council minutes, confidential resident interviews, confidential staff interviews, and grievance policy review, the facility failed to act promptly to resolved resident grievances. Confidential resident interviews revealed issues voiced in Resident Council from (MONTH) (YEAR) to the meeting (MONTH) (YEAR) included issues such as insufficient supplies of washcloths and towels to meet resident needs, over-bed tables that would not move or moved with difficulty, and staff not answering call lights timely. These findings had the potential to affect all residents residing in the facility. Facility census: 97. Findings include: a) Resident Council Minutes Review of the Resident Council minutes on 04/18/17 at 1:04 p.m., revealed the following information: - 12/22/16 - The minutes stated staff not answering call lights timely continued to be an issue. Resident Council President #51 stated she observed staff sitting at the Nurses' Station while three (3) call lights were active and staff did not respond to the call lights. The Department Response (Nursing) was to remind the residents to notify the nurse and staff were in-serviced regarding answering lights timely. - 01/18/17 - The minutes included, All resident's in attendance stated that call lights are still a problem. Takes a long time for them to be answered and some staff just walk by the call light and don't respond. The Department Response by the Director of Nursing (DON) stated a continuation to re-educate and monitor staff on a daily basis and reminding staff that everyone was responsible for answering call lights. - 02/15/17 - The minutes stated staff answering call lights was still a problem. The residents stated it took a long time for lights to be answered when assigned nurse aides (NA) were on lunch break. In addition, the residents stated NAs assigned to cover for NAs on lunch break did not answer call lights. The minutes included, That staff give them attitude all the time when they ask for something to be done. The minut… | 2020-08-01 |
| 3809 | 3809 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-04-21 | 278 | D | 1 | 0 | 0AC711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and clinical record review, the facility failed to ensure the accuracy of a significant change Minimum Data Set (MDS) assessment for one (1) of six (6) sampled residents. The facility failed to ensure Resident #21's pain assessment was accurate. Facility census: 97. The findings include: a) Resident #21 Clinical record review revealed Resident #21 had [DIAGNOSES REDACTED]. A 04/07/17 significant change Minimum Data Set (MDS) assessment indicated Resident #21 had short-term and long-term memory problems and was severely impaired in decision-making. Item J0200 of the assessment, which asked should pain assessment interview be conducted was answered Yes. For the question, Have you had pain or hurting at any time in the last 5 day? the assessor marked No. No staff assessment of the resident's pain was completed. During an interview on 04/19/17 at 5:39 p.m., Clinical Reimbursement Coordinator (CRC) #10 stated, Unless a resident is comatose, we always conduct a resident interview for a pain assessment. CRC #10 stated, We did not conduct a staff assessment of the resident's pain because she received no as needed pain medication in the previous 5 days. CRC #10 agreed that Resident #21 could only answer if she had pain at a particular moment in time but did not have the memory to recall pain over a 5 day period. | 2020-08-01 |
| 3810 | 3810 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-04-21 | 279 | D | 1 | 0 | 0AC711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews and clinical record review, the facility failed to develop care plan interventions for one (1) of five (5) sampled residents with pressure sores. Resident #98 had incontinence associated [MEDICAL CONDITION] (IAD), but the resident's care plan did not identify treatment modalities. Resident identifier: #98. Facility census: 97. The findings include: a) Resident #98 Clinical record review revealed Resident #98 resided in the facility from [DATE] until her death on [DATE]. Her [DIAGNOSES REDACTED]. Her admission orders [REDACTED]. The [DATE] care plan included, Resident has actual skin breakdown related to incontinence: IAD to buttocks care plan interventions were, Monitor skin for signs/symptoms of skin breakdown, provide pericare/incontinence care, skin check per policy. During an interview on [DATE] at 5:25 pm, Director of Nursing (DON) #18 stated the care plan should have at least included an intervention to provide treatment as ordered by the physician. | 2020-08-01 |
| 3811 | 3811 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-04-21 | 280 | D | 1 | 0 | 0AC711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, observation, and clinical record review, the facility failed to revise a resident's care plan to address assessing pain due to her pressure sores. This was found for one (1) of five (5) sampled residents with pressure sores. Resident Identifier: #21. Facility census: 97. The findings include: a) Resident #21 Clinical record review revealed Resident #21 had [DIAGNOSES REDACTED]. She was incontinent of bowel and bladder and had an unstageable pressure ulcer on her coccyx measuring 7 by 5 centimeters and a suspected deep tissue injury to right heel. On 04/19/17 at 10:10 a.m., nurse aide (NA) #39 came to the nurses' station and reported to Licensed Practical Nurse (LPN) #69 and Unit Manager (UM) #60 that Resident #21 was crying in pain whenever I touched her right foot. I think she needs something for pain. LPN #69 stated, while standing by the medication cart, I need to see if she needs Tylenol before you do the dressing change. UM #60 stated, I will check before I start, if she complains of pain, I will stop and do it later. On 04/19/17 at 10:12 a.m., UM #60 entered Resident #21's room to perform the resident's wound treatment. UM #60 touched Resident #21's right heel to apply Sureprep to the SDTI. Resident #21 closed her eyes, made a facial grimace as though in pain, open her mouth, cried out, pulled her arms to her chest, and clenched her fists. She shook her arms. UM #60 continued the treatment stating to resident, It is alright. UM #60 kept talking to resident about her family members, but continued with the treatment. UM #60 then performed the wound treatment to the unstageable coccyx wound. Resident #21 continued with facial grimacing and moaning. UM #60 then turned Resident #21 from side to side to change incontinence pad. Resident #21 cried out, grabbed at UM #60's ID badge, and pulled the badge with her closed fists. UM #60 completed the procedure at 10:30 a.m. and said to the resident, We will bring you som… | 2020-08-01 |
| 3812 | 3812 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-04-21 | 309 | G | 1 | 0 | 0AC711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon observation, staff interview, and clinical record review, the facility failed to manage pain for one (1) of three (3) residents observed for pressure ulcer dressing changes. A staff member reported the resident cried out when her right foot was touched. Without assessing the resident for pain or premedicating her for pain, a nurse proceeded to provide wound care. During the nineteen (19) minutes the nurse provided care to the wounds, the resident cried out, pulled away, clutched her fists, and grimaced. Although the nurse providing the treatment had told the nurse administering medications she would stop the treatments and let her know if the resident needed something for pain, she did not stop until the care was completed. This resulted in a determination of physical harm and mental anguish for Resident #21. Facility census: 97. Findings include: a) Resident #21 Clinical record review revealed Resident #21 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment with an assessment reference date of 04/06/17 indicated Resident #21 had short-term and long-term memory problems and was severely impaired in decision-making. The resident required extensive one-person assistance with toileting, personal hygiene, dressing, and bathing and the extensive assistance of 2 persons for bed mobility. This incontinent resident had an unstageable pressure ulcer on her coccyx measuring 7 by 5 centimeters (cm) and a suspected deep tissue injury (SDTI) to right heel. On 04/19/17 at 10:10 a.m., Nurse Aide (NA) #39 came to nurses' station and reported to Licensed Practical Nurse (LPN) #69 and Unit Manager (UM) LPN #60 that Resident #21 was crying in pain, .whenever I touched her right foot. I think she needs something for pain. LPN #69 stated, while standing by the medication cart, I need to see if she needs Tylenol before you do the dressing change. UM #60 stated, I will check before I start, if she complains of pain, I wil… | 2020-08-01 |
| 3813 | 3813 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-04-21 | 314 | D | 1 | 0 | 0AC711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interview, clinical record review, the facility failed to perform pressure ulcer dressing changes as ordered by the physician for one (1) of five (5) sampled residents with pressure sores. Resident identifier: #27. Facility census: 97. The findings include: a) Resident #27 Clinical record review revealed Resident #27 had a physician's orders [REDACTED]. Cover with optilock and medifix tape, change every 3 days and as needed. A nurse's note dated 04/18/17 at 2:35 p.m. stated, Resident refused dressing changes times two today, wanted to wait until after lunch then wanted to wait until he got a shower. Passed on in report that treatments still needed to be done. The (MONTH) (YEAR) Treatment Administration Record (TAR) revealed the right ischium dressing change had been refused on 04/18/17. During an interview on 04/19/17 at 11:08 a.m., the resident stated his right ischium dressing had not been done after his shower yesterday. The resident stated he had not refused any of his wound treatments. During an interview on 04/19/17 at 5:30 p.m., Director of Nursing (DON) #18 stated an every 3 day dressing change did not have to be done on a specific shift. Resident #27's dressing change should have been provided on the evening shift on 04/18/17, but was not performed as ordered by the physician. | 2020-08-01 |
| 3814 | 3814 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-04-21 | 514 | D | 1 | 0 | 0AC711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, observations, staff interviews, review of facility staff assignment sheets, and clinical record interview, the facility failed to ensure the accuracy and completeness of the clinical records for two (2) of six (6) sampled residents. Resident #27's treatment documentation was incomplete and a nurse documented the wrong type of intravenous access the resident had. For Resident #98, documentation regarding treatments were incomplete. Resident #27 and #98. Facility census: 97. The findings include: a) Resident #27 1. Clinical record review revealed Resident #27 had a physician's orders [REDACTED]. Cover with optilock and medifix tape, change every 3 days and as needed. On [DATE] 2:35 p.m., a nurse's note stated, Resident refused dressing changes times two today, wanted to wait until after lunch then wanted to wait until he got a shower. Passed on in report that treatments still needed to be done. The (MONTH) (YEAR) Treatment Administration Record (TAR) revealed the right ischium dressing change had not been refused on [DATE]. The (MONTH) TAR for right ischial dressing change was blank on [DATE], [DATE], and refused on [DATE]. During an interview on [DATE] at 11:08 a.m., the resident stated his right ischium dressing had not been done after his shower yesterday. The resident stated he had never refused any of his wound treatments. The resident stated he had gotten his wound treatment on all other days in (MONTH) as ordered by the physician. 2. The resident stated he had a midline placed 4 days ago for intravenous antibiotics for a urinary tract infection. The resident showed his access site in right upper arm. On [DATE], the physician ordered, (MONTH) place midline for Intravenous (IV) antibiotics. An infusion note indicated a 20 centimeter right basilic vein midline was placed on [DATE]. On [DATE] at 8:00 p.m. and 11:52 p.m., a nurse noted the Peripherally Inserted Central Catheter (PICC) line is patent. (Note: Midl… | 2020-08-01 |
| 3815 | 3815 | PIERPONT CENTER AT FAIRMONT CAMPUS | 515155 | 1543 COUNTRY CLUB ROAD | FAIRMONT | WV | 26554 | 2017-04-21 | 520 | F | 1 | 0 | 0AC711 | > Based on observation, staff interviews, resident interviews, confidential staff interviews, and confidential resident interviews, and review of Quality Assurance and Assessment (QA&A) Committee sign-in sheets, the facility failed to correct quality deficiencies of which they were aware, or should have been aware. These deficient practices included failure to answer call lights, insufficient supplies of washcloths and towels to meet residents' needs, and over-bed tables that did not function properly. These practices had the potential to affect all residents residing in the facility. Facility census: 97. Findings include: a) Call lights Review of the Resident Council minutes on 04/18/17 at 1:04 p.m., revealed the following information: - 12/22/16 - The minutes stated staff not answering call lights timely continued to be an issue. Resident Council President #51 stated she observed staff sitting at the Nurses' Station while three (3) call lights were active and staff did not respond to the call lights. The Department Response (Nursing) was to remind the residents to notify the nurse and staff were in-serviced regarding answering lights timely. - 01/18/17 - The minutes included, All resident's in attendance stated that call lights are still a problem. Takes a long time for them to be answered and some staff just walk by the call light and don't respond. The Department Response by the Director of Nursing (DON) stated a continuation to re-educate and monitor staff on a daily basis and reminding staff that everyone was responsible for answering call lights. - 02/15/17 - The minutes stated staff answering call lights was still a problem. The residents stated it took a long time for lights to be answered when assigned nurse aides (NA) were on lunch break. In addition, the residents stated NAs assigned to cover for NAs on lunch break did not answer call lights. The minutes included, That staff give them attitude all the time when they ask for something to be done. The minutes reflected that the DON would be informed of … | 2020-08-01 |
| 7613 | 7613 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2013-03-13 | 241 | E | 0 | 1 | 0BYS11 | Based on observation and staff interview, the facility failed to provide an environment to maintain the residents' dignity for four (4) of sixty-five (65) residents residing in the facility. Staff failed to close the door on the shower room leaving a resident completely exposed to anyone passing by the open door. The facility also failed to maintain the resident's dignity while assisting with meals. The nurse stood up to feed three (3) residents in the dining area. This had the potential to affect more than a limited number of residents. Facility census: #65. Resident identifiers: #71, #65, #2, and #10. Findings include: a) Resident #10 During a random observation, on 03/11/13 at 11:23 a.m., the shower room was found to be open. Resident #10 was sitting in a shower chair totally nude. The shower curtain was not pulled and the resident was exposed to anyone walking by the shower room. The observation was confirmed with Employee #62 (assistant director of nursing) on 03/11/13 at 11:23 a.m. b) Residents #71, #2, and #65 1) On 03/04/13 at 12:05 p.m., during dining room observations, Employee #52 was observed standing and assisting Resident #71 and Resident #2 to eat lunch. During this same dining room observation Employees #41 and #11 were observed standing and assisting residents to eat lunch. 2) On 03/07/13 at 8:20 a.m., Employee #63, was observed standing and assisting Resident #65 to eat breakfast. c) During an interview with the director of nursing (DON), on 03/07/13 at 10:50 a.m., she stated the staff should be sitting while assisting resident's to eat their meals. | 2017-03-01 |
| 7614 | 7614 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2013-03-13 | 272 | D | 0 | 1 | 0BYS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately complete an assessment for one (1) of twenty-nine (29) residents reviewed in Stage II of the survey. The resident was admitted to the facility on [DATE]. The nurse completing the admission assessment found no pressure ulcers present upon admission. The admission minimum data set (MDS) assessment was coded to indicate the resident had entered the facility with a pressure ulcer. Facility census: 65. Resident identifier: #67. Findings include: a) Resident #67 Review of the medical record, on 03/06/13 at 10:00 a.m., identified physician orders [REDACTED]. Further review of the medical record found Resident #67 was admitted to the facility on [DATE] at 1:10 a.m. The nurse completing the initial admission assessment listed an amputation of the right toes as the only skin condition this resident had. On 12/08/13, the wound care nurse identified Resident #67 had a deep tissue injury to her right buttocks. During an interview with Employee #65 (director of nursing), on 03/06/13 at 10:14 a.m., it was confirmed the deep tissue injury was not identified upon the initial admission nursing assessment. Employee #65 further confirmed the deep tissue injury was not identified until 24 hours after the resident was admitted to the facility. Employee #65 also verified a head to toe assessment was to be completed on every resident upon admission to the facility. Review of the MDS, on 03/06/13 at 10:00 a.m., further identified the facility coded the MDS incorrectly by coding the pressure ulcer as being present upon admission to the facility. Employee #65, on 03/06/13 at 10:14 a.m., stated the deep tissue injury was not identified until 24 hours after admission, when the wound care nurse identified the wound. On 03/06/13 at 10:30 a.m., Employee #58 (Coordinator of Clinical records) confirmed the MDS was coded incorrectly for Resident #67. She further stated she would correct the MDS. | 2017-03-01 |
| 7615 | 7615 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2013-03-13 | 278 | D | 0 | 1 | 0BYS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately complete an assessment for one (1) of twenty-nine (29) residents reviewed in Stage II. No pressure ulcers were identified on the nursing admission assessment for a resident. However, the admission minimum date set (MDS) assessment was coded to indicate the pressure ulcer was present on admission. Facility census: 65. Resident identifier: #67. Findings include: a) Resident #67 Review of the medical record, on 03/06/13 at 10:00 a.m., found Resident #67 was admitted to the facility on [DATE] at 1:10 a.m. The nurse completing the initial admission assessment listed an amputation of the right toes as the only skin condition this resident had. On 12/08/12, the wound care nurse identified Resident #67 had a deep tissue injury to her right buttocks. During an interview with Employee #65 (director of nursing-DON), on 03/06/13 at 10:14 a.m., it was confirmed the deep tissue injury was not identified upon the initial admission nursing assessment. Employee #65 (DON) further confirmed the deep tissue injury was not identified until 24 hours after the resident was admitted to the facility. Employee #65 also confirmed a head to toe assessment was to be completed on every resident upon admission to the facility. Review of the MDS on 03/06/13 at 10:00 a.m., further identified the MDS was coded incorrectly as the pressure ulcer as coded as being present upon admission to the facility. Employee #65 (DON), on 03/06/13 at 10:14 a.m., stated the deep tissue injury was not identified until 24 hours after admission, when the wound care nurse identified the wound. On 03/06/13 at 10:30 a.m., Employee #58 (Coordinator of Clinical records) confirmed the MDS was coded incorrectly for Resident #67. She further stated she would correct the MDS. | 2017-03-01 |
| 7616 | 7616 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2013-03-13 | 279 | D | 0 | 1 | 0BYS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility's interdisciplinary team failed to develop comprehensive care plans to address the care needs and to describe the services needed for residents to maintain a safe environment, prevent further condition decline, and prevent complications in their condition. The care plans were not complete and/or did not provide instructions to provide care in the areas of [MEDICAL TREATMENT], the use of [MEDICATION NAME] for the prevention of [MEDICAL CONDITION] due to a [MEDICAL CONDITION], contractures, and urinary continence The care plans did not address specific care needs for four (4) of twenty-nine (29) stage II sampled residents. Resident identifiers: #38, #55, and #40. Facility census: 65. Findings include: a) Resident #38 Medical record review, on 03/11/13 at 10:00 a.m., found a Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 01/21/13, that indicated the resident had a [DIAGNOSES REDACTED]. Review of the interdisciplinary care plan, initiated on 01/31/13, found no care plan related to [MEDICAL TREATMENT] treatments. An interview with Employee #65, the director of nursing (DON), on 03/11/13 at 11:30 a.m., confirmed the resident received [MEDICAL TREATMENT] treatment three (3) times a week. No care plan could be found. b) Resident #55 During review of the medical record, on 03/11/13, at 12:30 p.m., it was discovered Resident #55 was occasionally incontinent. Further review of the medical record identified the resident was care planned for being totally incontinent. An interview was conducted with Employee #58 (CRC), on 03/11/13 at 12:45 p.m. It was found if a resident had less than 7 (seven) episodes of incontinence, the MDS should be coded as occasional incontinence. The coding of the MDS was verified to be correct by Employee #58 (CRC). On 03/11/13 at 12:45 p.m., Employee #58 (CRC) confirmed the care plan was incorrect. Employee #58 confirmed the resident had only… | 2017-03-01 |
| 7617 | 7617 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2013-03-13 | 280 | E | 0 | 1 | 0BYS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of medical records, the facility's interdisciplinary team failed to periodically review and revise residents' care plans to address changes in their conditions and needs. Two (2) residents care plans were not updated to reflect their discharge plans, one (1) was not updated after an infection ([MEDICAL CONDITION]) had resolved, one (1) was not revised after the resident no longer needed a divided plate and special utensils, one (1) was not revised after a deep tissue injury had resolved, one (1) was not updated after the resident no longer used hyperglycemic and [MEDICAL CONDITION] medications, and one (1) was not revised after a deep tissue injury had resolved and therapy had recommended devices to prevent further skin issues. Six (6) of twenty-nine (29) residents on the Stage II sample were affected. Resident identifiers: #21, #67, #65, #104, #40, and #39. Facility census: 65. Findings include: a) Resident #21 Review of medical records, on 03/07/13 at 9:30 a.m., revealed this resident was admitted on [DATE]. The discharge plan on admission was for the resident to return to an assisted living facility in which the resident had resided prior to hospitalization . The plan was for this to occur within ninety (90) days. The quarterly care plan, dated 02/28/13, found a goal and interventions in which resident would be discharged within ninety (90) days after admission to the facility to an assisted living facility. An interview, on 03/07/13 at 10:00 a.m., with Employee #86, the social worker, confirmed the discharge plan had not been revised to indicate the resident's current discharge plan. She further stated, The resident had not progressed as expected in therapy and the resident's family had decided her stay at the center would be long term. b) Resident #67 1) Review of the care plan, on 03/07/13 at 2:05 p.m., revealed a care plan had been created on 12/27/12 related to a [DIAGNOSES REDACTED]… | 2017-03-01 |
| 7618 | 7618 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2013-03-13 | 282 | E | 0 | 1 | 0BYS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of facility policy and procedures, and staff interview, the facility failed to ensure implementation of established care plans for four (4) of twenty-nine (29) sampled residents in Stage II of the Quality Indicator Survey. The facility failed to provide care in accordance with the written care plan in the following areas: a resident's restraint was not released during a meal, a resident's hand splint was not applied, nutritional feedings provided by a feeding tube were not correctly administered, a resident was not properly positioned, a non-pressure wound was not assessed and treated, behavior monitoring sheets for a resident receiving an antipsychotic medication were not completed, and the care plan was not followed for a resident with nutritional problems and weight loss. This was true for four (4) of twenty-nine (29) residents reviewed in stage II of the Quality Indicator Survey. Resident identifiers: #58, #1, #31, and #65. Facility census: 65. Findings include: a) Resident #58 Review of the resident's Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 01/23/13, found Section P (entitled Restraints, P0100-e) indicated the resident had a daily trunk restraint. Further review of the medical record found a physician's orders [REDACTED]. A review of the care plan, at 12:30 p.m. on 03/11/13, found a problem, Resident is at risk for complications of restraint use lap buddy. Interventions associated with this care plan problem included: Reposition resident every one hour, release every two hours and during meals. Observation of the resident, at 12:00 noon on 03/06/13, found the resident was being fed by a family member in the dining room. The resident did not have the restraint released. This observation was confirmed with Employee #62, the registered nurse unit manager, who agreed the lap buddy should have been removed while the resident was eating. b) Resident #31 R… | 2017-03-01 |
| 7619 | 7619 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2013-03-13 | 309 | D | 0 | 1 | 0BYS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure three (3) of twenty-nine (29) Stage II sampled residents received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. One (1) resident was not assessed and / or monitored for an elevated [MEDICAL CONDITION] level (TSH); a resident was not provided ordered medications for a skin condition ([MEDICATION NAME]); and a resident's admission nursing assessment was not completed for a deep tissue injury. Resident identifiers: #88 and #1. Facility census: 65. Findings include: a) Resident #88 Review of the medical record found a laboratory test obtained on 02/05/13 for a [MEDICAL CONDITION] level (TSH). The physician signed and documented on the form on 02/07/13, . (an arrow pointing downward - which indicated reduce) [MEDICATION NAME]. Review of the documentation related to the [MEDICAL CONDITION] level found no evidence of the resident's medication ([MEDICATION NAME]) being reduced. An interview with Employee #65, the director of nursing (DON), on 03/12/13 at 11:15 a.m., confirmed the resident continued on the same dose of [MEDICATION NAME] and the physician had in fact written on the laboratory form to decrease the [MEDICATION NAME]. b) Resident #1 Medical records, reviewed on 03/07/13 at 10:00, found a physician order [REDACTED]. Review of the Activities of Daily Living (ADL) flow sheet and shower schedule found the resident received showers on Wednesdays and Saturdays. Review of Treatment Administration Records (TAR) found licensed nurses had signed and documented the [MEDICATION NAME] treatments on Mondays and Tuesday. An interview, on 03/07/13 with Employee #65 (DON), confirmed Resident #1's shower days were Wednesdays and Saturdays and the [MEDICATION NAME] treatments had not been received. The physician orders [REDACTED]. | 2017-03-01 |
| 7620 | 7620 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2013-03-13 | 314 | D | 0 | 1 | 0BYS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and observation, the facility failed to ensure pressure relieving interventions were applied as direct by physician's orders [REDACTED]. On 01/01/13, a deep tissue injury to the resident's right heel had healed and interventions were added to promote the prevention of pressure ulcer development. Bilateral boots were to be applied daily to the resident's feet. Observation on two (2) separate occasions found the boots were not applied as ordered. This was true for one (1) of two (2) residents reviewed in Stage II of the quality indicator survey for pressure ulcers. Resident identifier: #40. Facility census: 65. Findings include: a) Resident #40 Medical record review, on 03/12/13, found the resident was currently receiving treatment to a Stage IV pressure area to the coccyx. A physician's orders [REDACTED]. On 01/01/13 a physician's orders [REDACTED]. Further review of the medical record found a Braden scale for predicting pressure ulcer risk had been completed on 09/09/12. The information contained in the Braden scale found the resident was at severe risk for developing pressure ulcers related to the following conditions: very limited sensory perception, constant moisture to the skin, confinement to bed, and completely immobile. A notation was made on the form, Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. [DIAGNOSES REDACTED], contractures, or agitation leads to almost constant friction. Observation of the resident in her room, at 3:40 p.m. on 03/06/13, with Employee #71, a licensed practical nurse, found the resident was not wearing the pressure relieving boots. Review of the Medication Administration Record [REDACTED]. Employee #80, the treatment nurse, was interviewed on 03/06/13 at 3:40 p.m. She stated she had sent the boots to laundry. Observation of the resident at 1:10 p.m. o… | 2017-03-01 |
| 7621 | 7621 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2013-03-13 | 318 | D | 0 | 1 | 0BYS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure a resident received treatment and services, when identified as having contractures. The facility failed to assess and implement an individualized plan to prevent decline. This was true for one (1) of four (4) residents reviewed who triggered range of motion during Stage II of the Quality Indicator Survey (QIS). Resident identifier: #40. Facility census: 65. Findings include: a) Resident #40 During Stage I of this survey, this resident was identified as having contractures. Review of the resident's medical record found a current [DIAGNOSES REDACTED]. Further review of the last annual Minimum Data Set (MDS), with an assessment reference date of 03/02/12, revealed Section (S) coded the resident as having contractures of the hands, hips and ankles. A physician's orders [REDACTED].to prevent contractures per request of POA (power of attorney). The current care plan was reviewed with the director of nursing (DON), Employee #65, and the minimum data set (MDS) coordinator, Employee #58, at 12:30 p.m. on 03/13/13. Both employees acknowledged the care plan failed to address the contractures. and failed to address the physician's orders [REDACTED]. Observation of the resident, at 4:00 p.m. on 03/12/13, found she was in her room, in bed, with no interventions in place to address the contractures to her hips and ankles. In an interview on 03/13/13 at 12:30 p.m., the DON acknowledged the resident was not receiving therapy services and there were no current orders for restorative therapy. The DON was unable to provide documentation the resident would not be able to benefit from a restorative program or services by a licensed therapist. She was unable to provide verification of any evaluations by the therapy department for services within the past year. The DON stated range of motion would be provided while staff were providing the daily care, but there was no ord… | 2017-03-01 |
| 7622 | 7622 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2013-03-13 | 325 | D | 0 | 1 | 0BYS11 | Based on medical record review and staff interview, the facility failed to intervene when a resident had a weight loss. One (1) of six (6) Stage II residents reviewed for nutrition was affected. Facility census: 65. Resident identifier: #65. Findings include: a) Resident #65 During review of the facility's weights and vitals summary, it was discovered Resident #65 had weighed 116.9 pounds on 12/06/12. Further review of the medical record identified Employee #97 (registered dietitian) reviewed the resident's weights on 12/04/12. At that time Employee #97 decreased the resident's supplements to twice a day rather than the previous order of three (3) times a day. Further review of the weights and vitals summary identified on 01/07/13, the resident's weight decreased to 110.3 pounds, identifying a 5.0% weight loss in 30 days. The medical record revealed, on 01/15/13, Employee #97 again reviewed the weights for Resident #65. No evidence could be found Employee #97 addressed the weight loss or made any recommendations. On 02/14/13, the weights and vitals summary identified the resident weighed 107.9 showing a -7.5% weight loss over 90 (ninety days). During an interview with Employee #65 (director of nursing) on 03/12/13 at 10:13 a.m., it was confirmed Employee #97 reviewed resident's weights once a week and made needed recommendations. On 03/12/13, at 10:13 a.m., Employee #97 was interviewed related to Resident #65's weight loss. Employee #97 had her own copy of the weights and vitals sign summary. The weights and vitals summary contained the same information given to the surveyor. Employee #97 was asked if she had made any recommendations when the resident continued to show a weight loss. She confirmed she had not, at 10:13 a.m. on 03/12/13. | 2017-03-01 |
| 7623 | 7623 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2013-03-13 | 329 | D | 0 | 1 | 0BYS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, and staff interview, the facility failed to: (1) monitor the targeted behaviors identified for the use of an antipsychotic medication, (2) monitor for potential side effects of a antipsychotic medication and, (3) implement non-pharmacological interventions before administering the medication. This was true for two (2) of ten (10) residents reviewed in Stage II of the Quality Indicator Survey (QIS) who triggered unnecessary medications. Resident identifiers: #31 and #62. Facility census:65. Findings include: a) Resident #31 Medical record review found this resident began receiving [MEDICATION NAME] 0.5 mg. by mouth two times a day for aggressive behaviors on 07/19/11. The resident is currently receiving [MEDICATION NAME] 0.25 mg. by mouth two times a day. Review of the current care plan, on 03/11/13, revealed the problem, Resident is at risk for complications related to the use of [MEDICAL CONDITION] medications. The last revision of the care plan was 02/01/12. Interventions for this problem included, Complete behavior monitoring flow sheet. Monitor for behaviors: handwringing, cranky behaviors, cursing, threatening staff, and other residents, hitting paranoia and report to physician as indicated. Review of the facility policy entitled, Behavior Monitoring, revised on 12/15/08 found, .Initiate the use of a behavior monitoring form (refer to Pharmacy Services Policies and Procedures Pharmacy Standard Forms policy). During an interview with the director of nursing (DON), at 12:48 p.m. on 03/11/13, she verified she would have expected the facility to complete a behavior monitoring sheet for the antipsychotic medication, [MEDICATION NAME]. She reviewed the medical record and stated a behavior monitoring sheet had not been completed since August 2012. The DON further verified the behavior monitoring sheet instructions direct the nursing staff to document the targeted behaviors for the use o… | 2017-03-01 |
| 7624 | 7624 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2013-03-13 | 428 | D | 0 | 1 | 0BYS11 | Based on medical record review, review of facility policy, and staff interview, the pharmacist failed to identify the lack of monitoring of a Lanoxin (digoxin) level, and failed to identify the use of an antipsychotic without monitoring. Two (2) of ten (10) Stage II sample residents were affected. Resident identifiers: #98 and #31. Facility census: 65. Findings include: a) Resident #98 Review of the order summary report, on 03/11/13 at 12:29 p.m., revealed Resident #98 was receiving Lanoxin (Digoxin) 0.125 mg by mouth one time a day for atrial fibrillation. The medication was ordered 12/24/12 and started on 12/25/12. Review of the pharmacist's medication regimen review, on 03/11/13 at 1:04 p.m., revealed no irregularities for 12/7/12, 1/30/13, or 2/21/13. On 03/11/13 at 2:15 p.m., record review found no lab order from the physician for a Lanoxin (digoxin) level to be collected to ensure the correct dosage of Lanoxin was being administered to Resident #98. During an interview, on 03/11/13 at 2:40 p.m., with Employee# 65, the director of nursing (DON), was asked whether the pharmacist's report included any irregularities regarding a Lanoxin (digoxin) level needing to be done for Resident #98. She confirmed no irregularities were reported and that no digoxin level was ever collected. Employee #65 stated she would notify the physician and obtain an order that day to collect a digoxin level. b) Resident #31 Medical record review found this resident began receiving Risperdal 0.5 mg. by mouth two (2) times a day for aggressive behaviors on 07/19/11. The resident was currently receiving Risperdal 0.25 mg. by mouth two (2) times a day. Review of the facility policy entitled, Behavior Monitoring, revised on 12/15/08 found, .Initiate the use of a behavior monitoring form (refer to Pharmacy Services Policies and Procedures Pharmacy Standard Forms policy). During an interview with the director of nursing (DON), Employee #65, at 12:48 p.m. on 03/11/13, she verified she would have expected the staff to complete a behavior monit… | 2017-03-01 |
| 7625 | 7625 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2013-03-13 | 441 | D | 0 | 1 | 0BYS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to identify a resident with a [DIAGNOSES REDACTED]. One (1) of twenty-nine (29) residents reviewed in Stage II of the survey was affected. Resident identifier: #67. Facility census: 65. Findings include: a) Resident #67 Review of the acute care hospital discharge summary, on 03/06/13 at 09:41 a.m., revealed Resident #67 had returned from the acute care hospital on [DATE] with a [DIAGNOSES REDACTED]. Review of the infection control monitoring list, on 03/06/13 at 11:43 a.m., revealed Resident #67, was not placed on the infection control monitoring list for 12/27/12 related to the Clostridium difficile. During an interview with Employee #61, the assistant director of nursing (ADON), on 03/06/13 at 11:50 a.m., she was asked why Resident #67 had not been placed on the 12/27/12 infection control monitoring list, when she was identified as having Clostridium difficile. The ADON confirmed she had forgot to place this resident on the infection control list on 12/27/12. | 2017-03-01 |
| 7626 | 7626 | WHITE SULPHUR SPRINGS CENTER | 515100 | 345 POCAHONTAS TRAIL | WHITE SULPHUR SPRING | WV | 24986 | 2013-03-13 | 514 | D | 0 | 1 | 0BYS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interview, the facility failed to maintain an accurate medical record for two (2) of twenty-nine (29) residents reviewed in Stage II of the Quality Indicator Survey (QIS). The nursing assessment completed in conjunction with the Minimum Data Set had conflicting information for a resident with identified dental issues. physician's orders [REDACTED]. Resident identifiers: #42 and #1. Facility census: 65. Findings include: a) Resident #42 Review of the medical record, on 03/06/13 found a, nursing assessment, expanded MDS adm (admission)/qtrly (quarterly) /Annual/Sig (significant) change) completed on 12/10/12. According to the documentation on the assessment the resident had no dental issues. Further review of the Minimum Data Set ( MDS), with an assessment reference date (ARD) of 12/17/12, found section (L) oral/dental status, revealed the resident had obvious or likely cavities or broken natural teeth. On 03/06/13 at 3:47 p.m., an interview was conducted with the MDS coordinator, Employee #58. She stated she completed the MDS and coded the resident based on her findings. On 03/06/13 at 3:30 p.m. the resident's oral cavity was examined with the director of nursing. She validated the resident's MDS was correct and the nursing assessment was incorrect. b) Resident #1 Review of medical records, on 03/07/13 at 9:45 a.m., found a physician's orders [REDACTED]. Reviewed the restorative program found and exercise program for the upper extremities. An interview with Employee #65, the director of nursing (DON), on 03/07/13 at 10 a.m., confirmed the actual restorative exercise program was for the upper extremities not the lower extremities. | 2017-03-01 |
| 8709 | 8709 | HIDDEN VALLEY CENTER | 515147 | 422 23RD STREET | OAK HILL | WV | 25901 | 2013-04-25 | 157 | D | 1 | 0 | 0C5011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the responsible party of a resident's change in condition. The resident was ordered antibiotics for a [DIAGNOSES REDACTED]. The facility failed to notify the responsible party related to the refusals of taking the antibiotics, and the refusals of therapy services. One (1) of three (3) residents reviewed was affected. Resident identifier: #71. Facility census: 70. Findings include: a) Resident #71 Resident #71 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On 04/03/13, she was ordered antibiotics to treat a left lung infiltrate. The physician ordered [MEDICATION NAME] 500 mg twice a day for ten (10) days, [MEDICATION NAME] 500 mg three (3) times a day for ten (10) days, and [MEDICATION NAME] 600 mg twice a day for ten (10) days. The Medication Administration Record [REDACTED]. Further review of the medical record identified the facility had failed to notify the responsible party of the resident's refusal to take the medications as ordered, and of her refusal to participate in therapy services. Review of the therapy notes for 04/05/13 found the resident had been refusing to participate. The notes included She spends most of her time in the bed. She is being transferred to a personal care home on 04/07/13. Resident was educated on the need to get out of bed more. Discussed discharge plan to personal care home and resident became mildly agitated. The resident was seen four (4) days from 03/30/13 to 04/05/13. Therapy progress note for 03/13/13 through 03/29/13 included Resident was seen ten (10) days during therapy progress period. Patient has been educated on need to participate with rehabilitation services and the effects of bed rest. Potential for achieving goals: Resident has poor potential to achieve goals due to refusals. Resident would benefit from continued physical therapy services, but refuses to participate. On 03/22/13, resident refused… | 2016-04-01 |
| 11112 | 11112 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2011-04-01 | 157 | D | 1 | 0 | 0DKH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, medical record review, and staff interview, the facility failed to notify the legal representative of one (1) of three (3) sampled residents when she had been restrained to her bed without a physician's order. Resident identifier: #65. Facility census: 84. Findings include: a) Resident #65 Review of facility documents found that, on 03/10/11 at approximately 9:00 p.m., a quality assistant (QA - Employee #0) reported Resident #65's was restrained in her bed by a tightly tucked blanket / sheet. Review of Resident #65's medical record found no physician's order or care plan for the resident to be restrained in her bed by the use of tightly tucked sheets or blankets. Review of the facility's interview investigation, and interviews with facility staff and former staff conducted on 03/30/11, 03/31/11, and 04/01/11, confirmed the blanket / sheet on Resident #65's bed had been tightly tucked beneath her bed to the point that staff had to tear the blanket / sheet in order to free the resident. An interview with the director of nursing (DON), on the afternoon of 03/31/11, elicited that Resident #65's legal representative was not contacted about the incident nor informed that the resident had been restrained without a physician's order, until he came into the facility on [DATE]. The DON stated the legal representative relayed that a woman had called him and told him Resident #65 had been found tied to her bed. . | 2014-08-01 |
| 11113 | 11113 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2011-04-01 | 221 | D | 1 | 0 | 0DKH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, medical record review, staff interviews, and review of the State Operations Manual (Appendix PP - Guidance to Surveyors), the facility failed to assure one (1) of three (3) sampled residents was free from physical restraints imposed for the purpose of convenience and not required to treat the resident's medical symptoms. Resident identifier: #65. Facility census: 84. Findings include: a) Resident #65 Review of facility documents found a former quality aide (QA - Employee #0) reported Resident #65 had been restrained in her bed by the use a of tightly tucked blanket / sheet at approximately 9:00 p.m. on 03/10/11. Review of Resident #65's medical record found no evidence the treating physician ordered the resident to be restrained while in the bed. Further review of the medical record found a minimum data set (MDS) with an assessment reference date (ARD) of 01/17/11. Review of this MDS revealed this [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was assessed as having long and short term memory problems and difficulty focusing attention with disorganized thinking, and she displayed moderately impaired cognitive skills for daily decision making with noted delusions. She is always incontinent of bowel and bladder. She required one person physical assistance with bed mobility, transfers, dressing, eating, personal hygiene and total assistance with bathing. -- The following interviews were conducted with former and current staff: 1. Employee #0 (a QA) Employee #0 was interviewed at 9:59 a.m. on 04/01/11. She stated she was working the evening shift on 03/10/11 at approximately 9:00 p.m., when she walked past Resident #65's room and heard her call out "Baby Doll". Employee #0 stated she entered the resident's room to determine if the resident was trying to get up or had fallen. She noticed Resident #65 was lying on her back and was trying to raise her upper body … | 2014-08-01 |
| 11114 | 11114 | TRINITY HEALTH CARE OF MINGO | 515069 | 100 HILLCREST DRIVE | WILLIAMSON | WV | 25661 | 2011-04-01 | 225 | D | 1 | 0 | 0DKH11 | . Based on staff interview, review of the facility's abuse / neglect policies, and review of facility documents, the facility failed to ensure all allegations of abuse / neglect were immediately reported in accordance with State law for one (1) of two (2) allegations. Additionally, the facility failed to conduct a thorough investigation into this allegation, which was that a certified nursing assistant (CNA) was giving residents oral medications and an insulin injection. Facility census: 84. Findings include: a) During an interview conducted with a quality aide (QA - Employee #0) on the morning of 03/30/11, she stated she had reported to a licensed practical nurse (LPN - Employee #83) that a CNA (Employee #64) was witnessed giving oral medications and an insulin shot around the first part of February 2011. Review of the facility's reportable files for the previous three (3) months found no evidence the LPN reported this allegation as required. Review of the facility's abuse and neglect policies found the following: "THE INDIVIDUAL WHO OBSERVES AN INCIDENT OF ABUSE OR NEGLECT MUST BE THE ONE WHO REPORTS IT. THIS MUST BE REPORTED IMMEDIATELY TO THE LOCAL DEPARTMENT OF HUMAN SERVICES, ADULT PROTECTIVE SERVICE DIVISION...". When interviewed on the afternoon of 03/31/11, Employee #83 confirmed Employee #0 had reported this alleged abuse / neglect to her. She stated she did not report the allegation, and she could provide no evidence that a thorough investigation had been conducted. | 2014-08-01 |
| 5536 | 5536 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2014-09-16 | 279 | D | 0 | 1 | 0EZS11 | Based on record review and staff interview, the facility failed to develop a comprehensive care plan that included measurable goals and described the services to be provided for one (1) of three (3) residents reviewed for the care area of urinary incontinence during Stage 2 of the Quality Indicator Survey (QIS) process. The care plan reviewed for Resident #26 did not address the resident's incontinence needs and/or incontinence care. Resident Identifier: #26. Facility Census: 97. Findings include: a) Resident #26 On 09/15/14 at 11:30 a.m., a review of Section H (the bladder and bowel section) of the Minimum Data Set (MDS) assessments with assessment reference dates (ARD) of 06/24/14 and 08/22/14, revealed the resident was occasionally incontinent of urine. At 2:00 p.m. on 09/15/14, a review of the care plan for Resident #26 was completed. The care plan did not identify or address incontinence, with measurable goals or interventions. On 09/15/14 at 5:40 p.m., an interview was conducted with Employee #55, the MDS coordinator, a registered nurse (RN). The MDS nurse provided the Resident Continence Day reports she reviewed during the seven (7) day look back periods for the assessments. The reports were used to complete the bladder and bowel section of the MDS assessments. The look back period dated 06/20/14 through 06/26/14 revealed Resident #26 experienced two (2) episodes of urinary incontinence. The look back period dated 08/16/14 through 08/22/14 revealed the resident experienced three (3) episodes of urinary incontinence. Upon inquiry as to how incontinence was addressed, she said, it was addressed in the resident's care plan. A review of the care plan for Resident #26 was conducted with Employee #55, with the purpose of locating the resident's incontinence needs. After looking over the resident's care plan, she said, It is not there, but it will be soon. | 2018-10-01 |
| 5537 | 5537 | RIVERSIDE HEALTH AND REHABILITATION CENTER | 515035 | 6500 MACCORKLE AVENUE SW | SAINT ALBANS | WV | 25177 | 2014-09-16 | 371 | F | 0 | 1 | 0EZS11 | The facility failed to ensure foods were prepared and distributed under sanitary conditions. Fans with lint and debris were in use in the kitchen and a metal paper towel holder was rusted, preventing proper sanitation of the holder. The use of unclean and/or defective equipment in the kitchen area had the potential to result in contamination of the food being prepared and served to residents. This had the potential to affect all residents receiving foods from the kitchen. Facility census: 97. Findings include: a) During the observation of food preparation and service in the kitchen at 4:45 p.m. on 09/15/14, there were two (2) auxiliary floor fans in use. One was near the door to the dietary office and one was across the room from the steam table where the food was located. The fan was directed towards the steam table. Both of the fans were dirty with debris and lint visible on the wire-like blade covers. There was also a metal paper-towel holder mounted adjacent to the handwashing sink in the kitchen. The holder opening for the towels to emerge through was rusted, which would not allow for thorough cleaning of the equipment. These observations were pointed out to the dietary manager who was present in the kitchen at that time. | 2018-10-01 |
| 10045 | 10045 | CLAY HEALTH CARE CENTER | 515142 | HC 75, BOX 153 | IVYDALE | WV | 25113 | 2012-03-13 | 225 | E | 1 | 0 | 0FUR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, review of facility policy, and staff interview, the facility failed to ensure all allegations of abuse and neglect were immediately reported and thoroughly investigated in accordance with State law and facility policy. The facility failed to immediately report, thoroughly investigate, and provide protection to facility residents related to allegations of abuse/neglect involving three (3) of seven (7) sampled residents. Resident identifiers: #56, #31 and #21. Facility census: 55. Findings include: a) Resident #56 Review of facility documents found this former resident complained to the social worker, on 01/30/12, of staff members being too rough when removing her clothing. The documents indicated the resident had a history of [REDACTED]. Further review of documents found no evidence this allegation had been immediately reported to the state survey and certification agency and other officials in accordance with state law. Additionally, the documents contained no evidence the facility had conducted any investigation or obtained statements from staff members or the resident involved. Review of the facility's policy prohibiting abuse and neglect, amended 09/23/92, section entitled "Reporting," found the following language, "...7. The facility will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law." Further review of policy, section entitled "Investigations," found the following language, "1. The facility will thoroughly investigate all allegations and take appropriate actions. 2. Investigations will be prompt, comprehensive and responsive to the situation ... g. Interviews and written statements from individuals, whether residents, visitors, or staff, who may have first hand knowledge of the incident. (Written statements should include name, title, date and time statement is being w… | 2015-07-01 |
| 10046 | 10046 | CLAY HEALTH CARE CENTER | 515142 | HC 75, BOX 153 | IVYDALE | WV | 25113 | 2012-03-13 | 226 | E | 1 | 0 | 0FUR11 | . Based on facility policy review, review of personnel training records, and staff interview, the facility failed to ensure two (2) of five (5) newly hired employees received training related to the facility's policy on abuse, neglect, and misappropriation of resident property. This deficient practice had the potential to affect more than an isolated number of residents currently residing in the facility. Employee identifiers: #35 and #3. Facility census: 55. Findings include: a) Employees #35 and #3 Review of the facility's policy prohibiting abuse, neglect, and misappropriation of resident property found a section entitled "Training". Review of this section found newly hired employees were to receive training in "Patient Advocacy Protocols" as part of their orientation. Review of the training agenda found it included: -- definitions of abuse, neglect and misappropriation of property -- Identification of potential victims of abuse or neglect and those at high risk for abuse -- Appropriate interventions for resident behavior such as aggression or resistance -- Staff responsibility to immediately report any violation or alleged violations -- Measures to be taken to protect the residents --The consequences for failure to report any and all allegations. Review of five (5) randomly chosen training records for newly hired employees found the facility had not ensured Employee #35 (a nursing assistant) and Employee #3 (a licensed practical nurse) received training in these areas prior to providing care to residents. An interview with Corporate Employee #66 confirmed the employees had not received the training required by facility policy. . | 2015-07-01 |
| 10047 | 10047 | CLAY HEALTH CARE CENTER | 515142 | HC 75, BOX 153 | IVYDALE | WV | 25113 | 2012-03-13 | 241 | E | 1 | 0 | 0FUR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and review of the facility's dress code policy, the facility failed to ensure five (5) direct care staff members displayed a name tag which would enable residents and visitors to identify those providing care. The failure to wear this identification failed to promote an environment of respect and dignity for residents in that they were not afforded the right to identify those providing the most intimate of care. This deficient practice had the potential to affect more than an isolated number of residents currently residing in the facility. Facility census: 55. Findings include: a) During random observations of the resident environment, conducted upon entrance to the facility on [DATE] at 12:45 p.m., it was noted that five (5) direct care staff members did not wear name badges to inform residents and visitors of their identity. Nursing assistants (NA) #1, #55, #61, #6, and licensed practical nurse (LPN) #17 identified themselves verbally when asked. An interview with NA #6 revealed this staff member was aware of the requirement to wear a name tag. Review of the personal appearance and dress requirements for the facility (2009) found the following language, "Name tag is to be worn and clearly visible at all times, if required for your position". . | 2015-07-01 |
| 10048 | 10048 | CLAY HEALTH CARE CENTER | 515142 | HC 75, BOX 153 | IVYDALE | WV | 25113 | 2012-03-13 | 246 | D | 1 | 0 | 0FUR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, resident interview, and review of facility documents, the facility failed to ensure call bells remained within the reach of dependent residents. The failure to provide this reasonable accommodation affected three (3) of seven (7) sampled residents. Resident identifiers: #36, #33, and #31. Facility census: 55. Findings include: a) Resident #36 Random observations of the resident environment, conducted upon entrance to the facility on [DATE] at 12:45 p.m., noted Resident #33's call bell was not within his reach. The call bell was located on the floor approximately two (2) feet from his bed. b) Resident #33 A random observation conducted in Resident #33's room found her call bell on the floor behind an oxygen concentrator. The resident was alert and oriented and stated she utilized the call bell if she needed assistance. When asked what she would do if her call bell was in the floor, she stated she would have to yell until someone came to help her. c) Resident #31 Review of facility documents found an allegation had been made by Resident #31 on 02/17/12. The resident alleged her call bell was not within reach and she was left with unmet incontinence care needs for an extended period of time. Further review found a typed narrative, signed by the administrator, Employee #63, on 02/22/12 related to the resident's allegation. The typed narrative contained the following language, "I also informed the charge nurse to have the entire staff watch and make sure that all residents have their call lights within reach at all times." . | 2015-07-01 |
| 10049 | 10049 | CLAY HEALTH CARE CENTER | 515142 | HC 75, BOX 153 | IVYDALE | WV | 25113 | 2012-03-13 | 278 | F | 1 | 0 | 0FUR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview and position description review, the facility failed to ensure a registered nurse conducted or coordinated each assessment with the appropriate participation of health professionals. The facility employed and utilized the services of a licensed practical nurse (LPN) to act as the minimum data set (MDS) coordinator. This practice had the potential to affect all residents currently residing in the facility. Employee identifier: #13. Facility census: 55. Findings include: a) During random observations of the facility, on 03/13/12 at 11:15 a.m., a staff member approached and introduced herself as the minimum data set (MDS) coordinator. The employee wore a name badge identifying her as an LPN. A comprehensive interview with this LPN (Employee #13) concerning her role as MDS coordinator was conducted following the introduction. Employee #13 stated she coordinated the schedule for quarterly, annual, and significant change assessments. She stated she completed the MDS, conducted the Care Area Assessment (CAA) and, along with the interdisciplinary team (IDT), made the decision to care plan the Care Area Triggers (CAT). When asked what other members made up the IDT, she identified the social worker, the dietary manager, activities, therapy, etc. When asked if a registered nurse (RN) attended the IDT meetings, LPN #13 stated that no RN attended the IDT meetings. When asked what role an RN plays in the assessment process, LPN #13 stated she had to have an RN sign the MDS was complete. LPN #13 stated she had done this job for [AGE] years and had been the full time MDS coordinator for this facility as of October 2010. She denied RN participation in completing the CAA, making care plan decisions, or development of the care plans for residents. A copy of LPN #13's position description was obtained from the facility following the interview. -- Review of the POS [REDACTED]. --The Accountability Objective included, "Supervise and coor… | 2015-07-01 |
| 10050 | 10050 | CLAY HEALTH CARE CENTER | 515142 | HC 75, BOX 153 | IVYDALE | WV | 25113 | 2012-03-13 | 323 | D | 1 | 0 | 0FUR11 | . Based on observation, staff interview, and review of manufacturer's information, the facility failed to ensure a restraint-free alarm was properly applied to alert staff should Resident #18 try to exit the bed without assistance. Additionally, staff applied a padded lap tray restraint to Resident #3's wheelchair in an unsafe manner and not in accordance with manufacturer's instructions. Staff utilized a tightly knotted gait belt to secure the padded lap tray to the resident's wheelchair. This placed Resident #3 at risk should a medical or environmental emergency exist which required the restraint to be quickly released. Two (2) of seven (7) sampled residents were affected. Resident identifiers: #3 and #18. Facility census: 55. Findings include: a) Resident #3 During random observations of the resident environment, on 03/12/12 at 1:30 p.m., Resident #3 was noted to be seated in the lounge area adjacent to the nursing station. Observation revealed a padded lap tray was affixed to her wheelchair by use of a tightly knotted gait belt. The gait belt had been placed through the openings on the back of the lap tray, wrapped around the back of the resident's wheelchair, and securely tied with a knot. It was noted the lap tray did not remain securely in line with the arms of the resident's wheelchair, allowing a large gap between the edge of the lap tray and the arms of the wheelchair. The gap was of sufficient width to have enabled the resident to insert an arm or leg in the opening. Physical therapy assistant (PTA) Employee #65 was present in the lounge. At 1:30 p.m. on 03/12/12, he was asked to provide information concerning the use of a knotted gait belt to secure the resident's lap tray to her wheelchair. Employee #65 stated staff had come to the therapy department to inform them the straps utilized to secure the lap tray to Resident #3's wheelchair were missing. Employee #65 stated the staff members were instructed to order new ones. He agreed the lap tray was not secured in a safe manner, as the tray moved latera… | 2015-07-01 |
| 6109 | 6109 | MEADOW GARDEN | 515121 | 606 PENNSYLVANIA AVENUE | RAINELLE | WV | 25962 | 2015-05-01 | 354 | F | 1 | 0 | 0GM611 | Based on record review and staff interview the facility failed to use the services of a registered nurse (RN) for at least eight (8) consecutive hours a day, seven (7) days a week. This practice has the potential to harm every resident currently residing in the facility. Facility Census: 54. a) A review of the nurse staff postings on 04/29/15 at 12:30 p.m. revealed for the time period of 04/01/15 through 04/28/15 found no RN hours recorded for 04/11/15, 04/12/15, 04/18/15, 04/25/15, and 04/26/15. An interview with the Director of Nursing at 1:52 p.m. on 04/29/15, revealed the facility does not have an RN in the building for eight (8) consecutive hours, seven (7) days a week. The director of nursing stated, We do not have an RN here every other weekend. The director of nursing indicated that she or the Director of Care Delivery RN #27 were on call but were not in the building for eight (8) consecutive hours. She stated they were on the phone with the facility quite a bit when they were on call but they were not physically in the facility. | 2018-05-01 |
| 9266 | 9266 | CABELL HUNTINGTON HOSPITAL TCU | 515126 | 1340 HAL GREER BOULEVARD | HUNTINGTON | WV | 25701 | 2011-07-07 | 278 | D | 0 | 1 | 0IGF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete an accurate an assessment for one (1) of fourteen (14) sampled residents, by failing to identify the use of a psychoactive medication ([MEDICATION NAME]) during the assessment reference period for a minimum data set (MDS) assessment. Because the MDS was not accurate, the care area for [MEDICAL CONDITION] drug use was not triggered for further assessment, and no care plan was developed to address the drug's use. Resident identifier: #131. Facility census: 14. Findings include: a) Resident #131 Medical record revealed a physician's orders [REDACTED]. This medication is classified as an antianxiety medication. Review of the Medication Administration Record [REDACTED]. This resident's MDS assessment, with an assessment reference date of 06/21/11, indicated in Section N that she had not received any antianxiety medications during the seven (7) day look-back period from 06/15/11 - 06/21/11. During an interview on 07/07/11 at 1:00 p.m., the MDS nurse (Employee #5) confirmed that Resident #131 did receive this antianxiety medication during the look-back period of this assessment on two (2) occasions and that this MDS was coded incorrectly. She also confirmed that, had this been coded correctly, the care area for [MEDICAL CONDITION] drug use would have triggered for additional assessment and a care plan would have been developed for its use. | 2016-01-01 |
| 9267 | 9267 | CABELL HUNTINGTON HOSPITAL TCU | 515126 | 1340 HAL GREER BOULEVARD | HUNTINGTON | WV | 25701 | 2011-07-07 | 279 | E | 0 | 1 | 0IGF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to develop a comprehensive care plan to address resident-specific needs for four (4) of fourteen (14) sampled residents, to address falls, psychoactive drug use, and urinary catheter use. Resident identifiers: #133, #125, #134, and #131. Facility census: 14. Findings include: a) Resident #133 Record review revealed Resident #133 experienced a fall in the community and, subsequently, a [MEDICAL CONDITION] which required surgical repair. During that hospitalization , she fell again and fractured the other hip, which also required surgical repair. During an interview with Resident #133 in the early afternoon on 07/06/11, she stated her second fall occurred while she was a patient in the hospital and it was caused, in part, by a reaction to a medication; she is now recuperating with two (2) [MEDICAL CONDITION] repairs. Record review revealed a fall risk assessment was completed at the facility upon admission. Her fall risk score was 10, indicating she was at risk for falls. Record review revealed her admission care area assessment summary (CAAS) triggered for falls, and the person completing this section indicated that decision was made to develop a care plan for falls. During an interview with the minimum data set (MDS) nurse (Employee #5) on 07/07/11 at 3:45 p.m., she stated this resident did trigger on the CAAS for fall risk, and she should have been care planned for falls, but was not. -- b) Resident #125 Record review found that, upon admission, Resident #125 was prescribed an antidepressant and an antianxiety medication for daily use. Record review revealed the MDS triggered for [MEDICAL CONDITION] medication use, and a decision was made to develop a care plan for [MEDICAL CONDITION] medications. During interview with Employee #5 on 07/07/11 at 11:00 a.m., she stated Resident #125 should have been care planned for [MEDICAL CONDITION] medications and was not… | 2016-01-01 |
| 9268 | 9268 | CABELL HUNTINGTON HOSPITAL TCU | 515126 | 1340 HAL GREER BOULEVARD | HUNTINGTON | WV | 25701 | 2011-07-07 | 315 | D | 0 | 1 | 0IGF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure two (2) of fourteen (14) sampled residents with indwelling urinary catheters present were not catheterized unless each resident's clinical condition demonstrated that catheterization was necessary. Resident identifiers: #134 and #135. Facility census: 14. Findings include: a) Resident #134 Observation of Resident #134 revealed the presence of an indwelling urinary catheter connected to bedside drainage. Review of Resident #134's medical record found no physician's order for the use of [REDACTED]. Review of the care plan (interim care plan on the computer) revealed no mention of the urinary catheter. During an interview on 07/07/11 at 2:00 p.m., the nurse manager (Employee #1) and the minimum data set assessment (MDS) nurse (Employee #5) agreed Resident #134's Foley catheter was inserted while in the hospital's acute care unit prior to being transferred to the facility, and they confirmed there were no physician orders for the catheter or documented rationale for its use. -- b) Resident #135 Medical record review, on 07/06/11, disclosed this resident was admitted to the facility on [DATE], from the acute care hospital with medical [DIAGNOSES REDACTED]. Observations of the resident, on 07/06/11, found the resident continued to have an indwelling urinary catheter. Review of the current physician's orders for July 2011 found the reason for the indwelling catheter was [MEDICAL CONDITION]. Further review of the medical record found no evidence to reflect the resident's urinary status had been assessed to determine whether an ongoing need for the indwelling urinary catheter existed. During an interview on 07/07/11, at 3:30 p.m., Employee #1 confirmed there had been no assessment to determine whether the need of the indwelling urinary catheter existed, and there was no valid medical [DIAGNOSES REDACTED]. | 2016-01-01 |
| 9269 | 9269 | CABELL HUNTINGTON HOSPITAL TCU | 515126 | 1340 HAL GREER BOULEVARD | HUNTINGTON | WV | 25701 | 2011-07-07 | 329 | D | 0 | 1 | 0IGF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the medication regimen, for one (1) of fourteen (14) sampled residents, was free of drugs without adequate indications for use. Resident #131 received an antianxiety drug ([MEDICATION NAME]) to promote sleep in the absence of any documented evidence of [MEDICAL CONDITION] and in the absence of any evidence to reflect that non-pharmacologic interventions had been attempted without success prior to medicating the resident. Resident identifier: #131. Facility census: 14. Findings include: a) Resident #131 Medical record revealed a physician's orders [REDACTED]. This resident's admitted was 06/16/11, and record review verified she was not receiving this medication at that time. There was no documentation describing any problems sleeping prior to this medication being started. The care plan dated 06/16/11 was reviewed. It was copied by Employee #5, who verified this was the resident's complete and most current care plan. This care plan did not address that this resident was receiving a medication to promote sleep, and there were no evidence of any non-pharmacologic interventions that had been attempted to resolve the issue of sleeplessness (if it existed). There was no evidence in the medical record that this alert and oriented resident was complaining of sleeplessness prior to this medication being started. During an interview on 07/07/11 at 1:00 p.m., Employee #5 confirmed that Resident #131 did not have a care plan for the use of this antianxiety medication to treat [MEDICAL CONDITION]. Employee #5 confirmed there was no record of any non-pharmacologic interventions that had been provided prior to using medication to promote sleep and no attempts to identify the issues surrounding the residents sleeplessness. Employee #5 also confirmed that, according to the documentation, the resident was not having problems sleeping. | 2016-01-01 |
| 9270 | 9270 | CABELL HUNTINGTON HOSPITAL TCU | 515126 | 1340 HAL GREER BOULEVARD | HUNTINGTON | WV | 25701 | 2011-07-07 | 371 | F | 0 | 1 | 0IGF11 | Based on observation and staff interview, the facility failed to prepare and serve food under sanitary conditions. Observations of the food service in the kitchen area, on 07/05/11 at 5:30 p.m., found two (2) kitchen personnel involved in preparing and serving food who were wearing hair restraints that did not adequately cover their hair to prevent contamination of resident foods. The cook serving the food was wearing a net that covered a bun on the back of the head but did not cover the top and front of the hair. A second food service employee was wearing a hair net that did not cover bangs. This practice allows for the physical contamination of food from hair and had the potential to affect all fourteen (14) residents who consume oral diets. Facility census: 14. Findings include: a) During observations of the food service in the kitchen area on 07/05/11 at 5:30 p.m., two (2) kitchen personnel involved in preparing and serving food were wearing hair restraints that failed to adequately cover their hair. The cook, who was serving the food, was wearing a net that covered a bun on the back of the head, but it did not cover the top and front of the hair. Another food service employee was observed wearing a hair net that did not cover the bangs. This practice of failing to cover the hair entirely allows for physical contamination of foods by hair. During an interview on 07/07/11 at 3:00 p.m., the food service director (Employee #29) confirmed and agreed that these two (2) employees were not wearing hair covering as specified in the facility policy and as required by the USDA Food Code. | 2016-01-01 |
| 9271 | 9271 | CABELL HUNTINGTON HOSPITAL TCU | 515126 | 1340 HAL GREER BOULEVARD | HUNTINGTON | WV | 25701 | 2011-07-07 | 428 | D | 0 | 1 | 0IGF11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, OBRA's (Omnibus Budget Reconciliation Act) Unnecessary Drugs in the Elderly, the facility's policy on the drug regimen review, and staff interview, the pharmacist failed to recognize and report a drug irregularity to the physician and director of nursing for one (1) of fourteen (14) sampled residents. A [AGE] year old resident (Resident #135) had a physician's orders [REDACTED]. This order, which written on admission to the facility on [DATE], allowed staff to administer Ativan in a daily dose in excess of what was recommended for the elderly. Review of the resident's care plan, which was reviewed by all disciplines on 07/05/11, found the pharmacist had documented there were no issues found with the drug regimen review. Resident identifier: #135. Facility census: 14. Findings include: a) Resident #135 Medical record review, on 07/06/11, disclosed this [AGE] year old resident had been admitted to the facility on [DATE] with an order for [REDACTED]. Review of OBRA's Unnecessary Drugs in the Elderly found the maximum dose of Ativan recommended for use in the elderly was 2 mg per day. Review of the facility's drug regimen review policy / procedure (Policy 6, Section XIII) found on Page 1, the pharmacotherapy of each resident is to be reviewed initially within three (3) days of admission and then at least once monthly thereafter by a licensed pharmacist. Review of the resident's care plan, which was reviewed by all disciplines on 07/05/11, found the pharmacist had indicated there were no issues found in the drug regimen review. During an interview on 07/07/11 at 10:35 a.m., the minimum data set assessment (MDS) nurse (Employee #5) confirmed the pharmacist had not identified the excessive daily dose as an irregularity in the resident's medication regimen and the resident had the potential to receive Ativan in an amount not recommended for the elderly. | 2016-01-01 |
| 9272 | 9272 | CABELL HUNTINGTON HOSPITAL TCU | 515126 | 1340 HAL GREER BOULEVARD | HUNTINGTON | WV | 25701 | 2011-07-07 | 431 | D | 0 | 1 | 0IGF11 | Based on observation and staff interview, the facility failed to ensure all opened vials of insulin were labeled with the date opened and disposed of within the specified time period allotted for opened vials of insulin, which was within forty-two (42) days from opening Lantus insulin, according to manufacturer's specifications. This was evident for one (1) opened vial of Lantus insulin found in the medication refrigerator. Facility census: 14. Findings include: a) Lantus insulin Observation of the facility's medication refrigerator, on 07/06/11, found one (1) opened vial of Lantus insulin which was more than half empty. Inspection of the vial revealed there was no date to indicate when it was first opened / accessed and no date to indicate when this vial was to be discarded. During an interview on 07/06/11 at 10:30 a.m., the float nurse (Employee #30) stated this vial of insulin should have been discarded, since it is not labeled when it was opened, and she would dispose of it. When asked, she stated there were no patients in the facility who currently used Lantus insulin. | 2016-01-01 |
| 3385 | 3385 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 550 | E | 0 | 1 | 0LCE11 | Based on observation, resident interview and staff interview the facility failed to ensure a dignified experience during dining and receiving care. These were random opportunityies for discovery. Resident identifiers: #404, #101, #83 and 205. Facility census: 108. Findings included: a) Resident # 404 During an observation on 01/28/19 at 1:13 PM, Resident #404 said that, she always gets her tray 30 minutes to an hour after her roommate does. Her roommate had already finished her meal. During an interview on 01/28/19 at 1:20 PM, Nurse Aide (NA) #112 stated he does not know why the lunch trays were not delivered together. He also said it is anywhere from 30 minutes to an hour between tray deliveries. During an interview on 01/29/19 at 11:30 AM, DoN was asked about residents not being served lunch at the same time. She said the residents that are diabetic get their tray first, so their blood sugars do not drop. b) Resident #101 During an interview on 01/28/19 at 12:57 PM, NA #112 confirmed Resident #101 did not get her tray when roommate did, and it was an hour apart from when her roommate got hers. During an interview on 01/29/19 at 11:30 AM, DoN was asked about residents not being served lunch at the same time. She said the residents that are diabetic get their tray first, so their blood sugars do not drop. c) Resident #83 During an observation on 01/29/19 at 7:40 AM, Resident # 13 served on the first round of trays that were passed out, Resident #83 received her tray at 08:07 AM, both residents reside in the same room. NA #103 was asked why they were not severed at the same time, she said their trays were not on the same tray cart. She was informed that her roommate was served 27 minutes after her roommate. She turned her back and just walked away. During an interview on 01/29/19 at 10:59 AM, Consultant Dietitian said that, they are looking into changing the way trays are sent out. She provided the times the food carts are sent out. Breakfast Times --1st 100-200 halls 7:05 --1st 300-400 halls 7:10 --2nd 100-200 ha… | 2020-09-01 |
| 3386 | 3386 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 558 | D | 0 | 1 | 0LCE11 | Based on observation, staff interview, family interview, and resident interview, the facility failed to ensure reasonable accommodations of the resident's needs. Resident #153, who was able to use the call light system, did not have his call light within reach. This was a random opportunity for discovery. Resident identifier: #153. Facility census: 108. Findings included: a) Resident #153 On 01/28/19, at 1:12 PM, the resident's responsible party and the resident said the call light was not always within reach. The resident said he frequently uses the light to call for assistance when needed. Today the call light was within reach. The responsible party said she had placed the call light where the resident could reach it when she came to visit. Observation of the resident with Registered Nurse (RN) #69 at 8:00 AM on 01/29/19, found the resident was in bed. The resident's call light was wrapped around the bed frame, dangling downward towards the floor, at the top of the bed. The resident demonstrated he could not reach or find the call light. RN #69 placed the call light beside his left arm and clipped it to the bed for easy access. | 2020-09-01 |
| 3387 | 3387 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 561 | D | 0 | 1 | 0LCE11 | Based on observation, resident interview and staff interview, the facility failed to ensure resident choice was honored for breakfast to be served earlier instead of being the last person to be served. This was true for two (2) of three (3) residents reviewed for choices. Resident identifier: #55 and #43. Facility census 108. Findings included: a) Resident #55 During an interview on 01/28/19 at 11:30 AM, Resident #55 stated they bring her breakfast to her before she was even awake. During an interview on 01/30/19 at 11:00 AM, Resident # 55 stated if she does not get up and eat her breakfast when they bring it, they take it away uneaten. During an interview on 01/29/19 at 9:03 AM, DoN was asked why Resident #55 gets her breakfast so early when she would prefer to get hers later, because she does not like to wake up that early. DoN said this occurs because diabetics Residents are served first. Resident # 55 is not a diabetic. b) Resident #43 During an interview on 01/28/19 at 1:41 PM, Resident # 43 stated his breakfast does not come until 8:30 AM, and the people across the hall gets their trays before 8:00 AM. He stated he does not understand why he must wait 30 - 40 mins longer. He also stated the potion sizes is too small, and he only gets a half of a slice of bacon. During an interview and observation, on 01/29/19 at 8:22 AM, Resident # 43 states that he asked for fresh water at 7 AM, and still does not have any and is still waiting for his breakfast tray. All of 400 hall has trays except him and his roommate. An observation on 01/29/19 at 8:33 AM, Resident #43 was served his trays no bacon or any other type of meat was on his tray. Fresh water was given at 8:45 AM. During an interview on 01/30/19 at 10:12 AM, Kitchen Manager #28 said that if there is a resident who wants to eat later he can move their delivery time back to came out on a later food cart and if someone wants to eat sooner her can move them to get an earlier delivery, but it will take him awhile to figure it out how to do so. | 2020-09-01 |
| 3388 | 3388 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 584 | D | 0 | 1 | 0LCE11 | Based on observation, resident interview, and staff interview, the facility failed to ensure resident equipment was in good repair. Resident #47's wheelchair arm rests were torn with rough edges. This was a random opportunity for discovery. Resident identifier: #47. Facility census: 108. Findings include: a) Resident #47 On 01/28/19 at 1:34 PM, the resident said, The arms of my wheelchair are rough, I may have gotten a place on my arm from hitting it. The resident pointed to a small scab on the inner, lower, right arm. Observation found both arm rests on the wheelchair were cracked and torn. At 2:20 PM on 01/31/19, the resident's nurse, Registered Nurse (RN) #76 observed the wheelchair and said, I will get maintenance to change the arm rests. The resident again stated the arm rests were rough and sometimes scratched her skin. | 2020-09-01 |
| 3389 | 3389 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 622 | D | 0 | 1 | 0LCE11 | Based on medical record review and staff interview, the facility failed to ensure a discharge summary was completed for Resident #103 following his hospitalization . This was true for one (1) of three (3) closed records reviewed for discharge. Resident identifier: #103. Facility census: 108. Findings included: a) Resident #103 During a review of Resident #103's electronic medical record on 01/30/19 at 7:13 AM, it was noted that Resident #103 was discharged from the facility on 11/03/18 and had not returned to the facility prior to the survey. On 01/30/19 at 10:40 AM, the facility's Director of Nursing (DoN) was asked for the Physician's documentation regarding Resident #103's discharge from the facility. At 11:10 AM, the DoN provided a copy of Resident #103's Physician's progress notes. The progress notes contained two entries signed by the Physician. Only one entry was from 11/03/18. The entry said, Transfer to hospital. When asked if there was any more information from the physician regarding the transfer, the DoN stated that the information on this sheet was all that the Physician had documented regarding Resident #103's discharge to the hospital. On 01/30/19 at 11:16 AM, the DoN was asked for a copy of Resident #103's discharge summary. At 11:27 AM, the DoN provided a copy of a document titled, Resident/Patient Discharge Summary, which was completed by the interdisciplinary team and contained no documentation by the Physician. Under a section of the document titled, Recapitulation of Stay, the reason for discharge was listed as, discharged to hospital. The DoN stated that this was all the discharge documentation she was able to provide. On 01/30/19 at 12:08 PM, the facility's Administrator was informed of the above findings. She stated that the Physician usually only writes a short note regarding a resident's discharge. | 2020-09-01 |
| 3390 | 3390 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 641 | D | 0 | 1 | 0LCE11 | Based on record review and staff interview, the facility failed to ensure a correct and accurate Minimum Data Set (MDS) for one (1) of 31 residents reviewed during the long-term care survey process. Resident #36's MDS was inaccurate in the area of falls and medications. Resident identifier: 36. Facility census: 108. Findings included: a1) Resident #36 Review of Resident #36's medical records revealed she had experienced a fall on 09/14/18. Review of Resident #36's MDS with Assessment Reference Date (ARD) 11/24/18, Section J, Health Conditions, documented resident had not experienced a fall since the prior assessment. During an interview on 01/31/19 at 11:43 AM, MDS Registered Nurse (RN) #11 stated Resident #36's MDS with ARD 11/24/18 was incorrect in the area of falls. MDS RN #11 stated the assessment should have indicated Resident #36 had experienced one (1) fall since the prior assessment. a2) Resident #36 Review of Resident #36's medical records revealed she took the diuretic medication acetazolamid (Diuretic) since 07/05/18. Review of Resident #36's MDS with ARD 08/24/18, Section N, Medications, documented resident had taken diuretic medication zero (0) days during the seven (7) day look back period. During an interview on 01/31/19 at 11:50 AM, MDS Registered Nurse (RN) #11 stated Resident #36's MDS with ARD 11/24/18 was incorrect in the area of diuretic. MDS RN #11 stated the assessment should have indicated Resident #36 had taken a diuretic seven (7) days during the look back period. | 2020-09-01 |
| 3391 | 3391 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 656 | D | 0 | 1 | 0LCE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to develope and or implement care plans for three (3) of thirty-one (31) residents reviewed. For Resident #47 a care plan was not developed to include the Residents removal of her dressing after dailysis and her ablility to assess the [MEDICAL TREATMENT] after removal of the dressing. Resident #34's care plan did not include current information about advance directive. Resident #3's care plan was not implemented for dental care. Resident identifiers: #47, #34, and #3. Facility census: 108. Findings included: a) Resident #47 During an interview with the resident on 01/28/19 at 1:31 PM, regarding her [MEDICAL TREATMENT] treatment, the resident said she removes her own bandages to the fistula in the upper right arm. I don't want them (meaning the facility) to do it. I remove it after [MEDICAL TREATMENT] between 3:00 PM and 4:00 PM. The resident said sometimes she has some bleeding to the area. Observation of the residents' upper right arm found the dressing, placed by the [MEDICAL TREATMENT] center was still in place. The resident had received her [MEDICAL TREATMENT] treatment today. She said she has a 6:00 AM appointment every Monday, Wednesday and Friday. Medical record review found the resident receives [MEDICAL TREATMENT] at the [MEDICAL TREATMENT] center, three (3) times a week on Monday, Wednesday, and Friday at 6:00 AM. Resident #47 was admitted to the facility on [DATE]. She has capacity to make her own medical decisions. The treatment administration record (TAR) found a current order for, (MONTH) remove dressing to right upper extremity at bedtime after [MEDICAL TREATMENT]. The order did not dictate who would remove the dressing. The (MONTH) 2019, TAR was never initialed on any days by any of the nursing staff. The resident is receiving [MEDICATION NAME] ([MEDICATION NAME]) 9 milligrams daily. [MEDICATION NAME] is a blood thinner that treats and prevent… | 2020-09-01 |
| 3392 | 3392 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 657 | D | 0 | 1 | 0LCE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, the facility failed to implement individualized interventions, as well as revise the care plan accordingly, to address a resident's new behaviors. Person-centered interventions with measurable goals were not developed in response to Resident #94's wandering into other residents' rooms and rummaging through others belongings. This was found for 1 of 31 care plans reviewed. Resident identifier: #94. Facility census: 108. Findings include: a) Random observations on 01/28/19 and 01/29/19, found Resident (R) #94 wandering through the facility and into other residents' rooms. Review of the medical record on 01/29/19, revealed R#94 was admitted to the facility in 2012 with a [DIAGNOSES REDACTED]. The annual minimum data set (MDS) assessment with an assessment reference date (ARD) of 10/06/18, notes R#94 had a Brief Interview for Mental Status (BIMS) score of 9 (indicating moderate cognitive impairment) and no behaviors. The quarterly MDS with an ARD of 01/04/19, notes R#94's BIMS score has decreased to 6 (indicating severe cognitive impairment). In addition, she has verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others) 1-3 days of the 7 day look back period. The computerized records note the following documentations: 01/25/19 - Nursing wrote: Resident went into room (number) and took bed ones breakfast tray and over bed table into her room and ate 50% of it . 01/05/19 - Nursing wrote: Resident was at med cart attempting to take items off of med cart. Resident was threatening to strike out. Resident was redirected 2x (twice) before returning to room. The care plan, last revised 10/18/18, lists the following focus, goals and interventions for R#94's behaviors: - Focus: Rummaging (other resident rooms) related to cognitive impairment - Goal: Will return items belonging to others - Interventions: Distract and redirect as needed. Monitor ro… | 2020-09-01 |
| 3393 | 3393 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 677 | E | 0 | 1 | 0LCE11 | Based on observation, resident interview, staff interview and record review, the facility failed to ensure activities of daily living to maintain grooming, and personal and oral hygiene needs were met. This is true for two (2) of two (2) reviewed in the care area of Activities of Daily Living. Resident identifiers: #55 and #73. Facility census 108. Findings included: a) Resident #55 During an interview on 01/28/19 at 11:40 AM, Resident # 55 said they do not help with washing her face and brushing her teeth, they tell her to go to the her bathroom and do it herself, but she cannot get her wheelchair (W/C) in and out of the bathroom. She states she cannot open the bathroom door, turn on the lights or get her wheelchair even close to the sink. During an interview on 01/29/19 at 12:00 PM, Resident #55 said that, she did not receive help this morning. During an interview on 01/30/19 at 11:03 AM, Resident #55 said a Nurse Aide helped her today. She gave her a warm wash cloth to wash her face and a basin to use to brush her teeth. During an interview on 01/30/19 at 11:07 AM, Nurse Aide (NA) #112 was asked who provided care for Resident #55. He looked on a wall computer and said it was NA #105. He was not sure why she documented total dependent full staff, because he said she only needs to be set-up. NA#105 documented this on Monday and Tuesday. Record review revealed Bath/Shower for the month of (MONTH) Resident # 55 did not have a bath/shower from 1/1/19 to 1/16/19. There was inconsistent documentation on providing am care. In (MONTH) there was a period on nine (9) days she did not receive a bath/shower. During an interview on 01/30/19 at 12:10 PM, DON was informed of findings. She stated she already knew. Review of medical records revealed the following assistance needed on the Care Plan for Resident #55: --ADL Self-care deficit related to disease process deconditioning, Parkinson and physical limitations --Will receive assistance necessary to meet ADL needs --Will be clean, dressed and well-groomed daily to promote d… | 2020-09-01 |
| 3394 | 3394 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 684 | E | 0 | 1 | 0LCE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility failed to ensure [MEDICATION NAME] (PT) and International Normalized Ratio (INR) testing was obtained according to the physician orders [REDACTED].#101, #47, and #37. These residents were receiving the anticoagulation medication [MEDICATION NAME]. Four (4) out of four (4) residents in the facility receiving [MEDICATION NAME] were affected. Facility identifiers: #72, #101, #47, #37. Facility census: 108. Findings included: a) Resident #72 On 11/30/18, Resident #72's physician wrote an order for [REDACTED].#72's medical records demonstrated that INR testing was not performed on the following dates: 12/21/18, 12/25/18, 12/26/18, and 12/30/18. On 01/17/19, Resident #72's physician changed the order from daily INR testing to weekly PT/INR testing. Review of Resident #72's medical records demonstrated that PT/INR testing was last performed on 01/16/18. On 01/30/19 at 1:33 PM, Registered Nurse (RN) #13 confirmed INR testing had not been performed for Resident #72 on 12/21/18, 12/25/18, 12/26/18, and 12/30/18. RN #13 also confirmed Resident #72 had not had PT/INR testing since 01/16/19. He stated stat PT/INR testing would be performed. On 01/29/19, this surveyor requested the facility's Director of Nursing (DoN) to provide a copy of Resident #72's Medication Administration Record [REDACTED]. Resident #72's central line was a peripherally inserted central catheter (PICC) line inserted in his arm for intravenous antibiotics and fluid. The MAR indicated [REDACTED]. The dates 01/11/19 through 01/21/19 had either nurse initials or check marks for this order. The dates 01/21/19 through 01/24/19 and 01/26/19 through 01/28/19 contained no nurse initials or check marks. On 01/31/19 at 8:48 AM, Licen… | 2020-09-01 |
| 3395 | 3395 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 690 | D | 0 | 1 | 0LCE11 | Based on observation, staff interview and policy review, the facility failed to ensure the catheter is securely anchored to prevent excessive tension on the catheter. The anchoring of the Foley catheter tubing are used for interventions (such as avoiding tugging on the catheter during transfer and positioning) used to prevent inadvertent catheter removal or tissue injury from dislodging the catheter. This was true for one (1) of Three (3) reviewed urinary catheter or Urinary tract Infection. Resident Identifiers: #66 . Facility census: 108. Findings included: During an interview on 01/28/19 at 12:07 PM, with Resident # 66 it was noted that there was no anchor in place the stabilize the Foley catheter. Licensed Practical Nurse (LPN)#12 witnessed and verified the missing anchor and placed a belt on her leg to stabilize the Indwelling Foley catheter tubing. During an interview on 01/29/19 at 10:20 AM, DON was made aware of findings and provided no further information. | 2020-09-01 |
| 3396 | 3396 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 695 | D | 0 | 1 | 0LCE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure the necessary respiratory care and services that is in accordance with professional standards of practice, the resident's care plan, and physician's orders [REDACTED]. Resident identifier: #67. Facility census: 108. Findings include: a) Resident #67 Review of the resident's current physician's orders [REDACTED]. Start O2 at 5 liters with mask continuously. Review of the nursing notes found a change of condition note completed on 01/26/19 at 11:03 AM. The residents oxygen saturation level was recorded as 87.0%. The nurse recorded, Nursing observations, evaluation, and recommendations are decreased O2 saturation on 5 liters of oxygen via nasal cannula. On 01/28/19 at 2:50 PM, observation of the residents oxygen concentrator with Registered Nurse, #76 found the resident's oxygen concentrator was set at 10 liters instead of 5 liters, the current physician's orders [REDACTED].#76 said we need a clarification order from the physician. RN #76 said the resident has a non-rebreather mask and, You can't run it with anything less than 10 liters of oxygen. RN #76 said she would have to ask the unit manager, Registered Nurse (RN) #75 about getting an order. At 3:21 PM on 01/28/19, RN #75 said, I am writing a clarification order right now. I had the order this morning but I just hadn't transcribed it yet RN #75 said the oxygen had been running at 5 liters until this morning. According to the American Red Cross a non-rebreather mask is a face mask with an attached oxygen reservoir bag and one-way valve between the mask and bag; victim inhales oxygen from the bag and exhaled air escapes through flutter valves on the side of the mask. The common air flow rate for a non-rebreather mask is 10 to 15 liters. On 01/30/19 at 10:04 AM, the Director of Nursing (DON) said the nurse had until the end of her shift to document new orders. The DON could not say when the resident began receiving 10 lit… | 2020-09-01 |
| 3397 | 3397 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 697 | E | 0 | 1 | 0LCE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, family interview, record review, and staff interview, the facility failed to consistently assess the effectiveness of as needed (PRN) pain medication for two (2) of four (4) residents reviewed for the care area of pain management. Resident identifiers: #53 and #153. Facility census: 108. Findings included: a) Resident #53 On 01/28/19 at 1:02 PM, observation found the resident was complaining of pain to his foot. He said he thought it felt like he was wearing a steel toed shoe and someone needs to get it off. Record review found the resident was receiving Hospice services due to a [DIAGNOSES REDACTED].) The resident was currently receiving [MEDICATION NAME] 5-325 milligrams every eight hours as needed for pain. Review of the (MONTH) 2019, Medication Administration Record [REDACTED] 01/03/18 at 8:00 AM, 01/08/19 at 2:00 PM, 01/09/19 at 8:00 AM, 01/13/19 at 8:00 AM, 01/15/19 at 9:00 PM. On 01/30/19 at 10:00 AM, the resident's Licensed Practical Nurse (LPN) #65 said the effectiveness of the residents PRN medication is documented on a pain monitoring sheet. The monitoring sheet is suppose to be with the MAR. LPN #65 said someone must have forgotten to make a pain monitoring sheet for Resident #53 for the month of (MONTH) 2019, so no one documented the effectiveness of the resident's pain medication on the monitoring sheet. At 11:30 AM on 01/30/19, the Director of Nursing (DON) confirmed nursing staff should document the effectiveness of an as needed (PRN) pain medication about 1 hour after the medication is given. The DON was unable to find evidence of this practice. b) Resident #153 On 01/28/19 at 02:30 PM, the resident and the resident's responsible party said the resident is having some pain in his left foot. The resident was admitted to the facility, from the hospital, on 01/17/19, with a [DIAGNOSES REDACTED]. The resident has a wound vac on his left foot. A wound vac is negative-pressure wound therapy (NPWT) which… | 2020-09-01 |
| 3398 | 3398 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 698 | D | 0 | 1 | 0LCE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, staff interview, and record review the facility failed to ensure one (1) of one (10 resident reviewed for the care area of [MEDICAL TREATMENT] received care and services consistent with professional standards of practice. Resident #47 was not assessed for her ability to remove her own dressings and provide monitoring and assessment for any complications after [MEDICAL TREATMENT] treatment. Resident identifier: #47. Facility census 108. Findings include: a) Resident #47 During an interview with the resident on 01/28/19 at 1:31 PM, regarding her [MEDICAL TREATMENT] treatment, the resident said she removes her own bandages to the fistula in the upper right arm. I don't want them (meaning the facility) to do it. I remove it after [MEDICAL TREATMENT] between 3:00 PM and 4:00 PM. The resident said sometimes she has some bleeding to the area. Observation of the residents' upper right arm found the dressing, placed by the [MEDICAL TREATMENT] center was still in place. The resident had received her [MEDICAL TREATMENT] treatment today. She said she has a 6:00 AM appointment every Monday, Wednesday and Friday. Medical record review found the resident receives [MEDICAL TREATMENT] at the [MEDICAL TREATMENT] center, three (3) times a week on Monday, Wednesday, and Friday at 6:00 AM. Resident #47 was admitted to the facility on [DATE]. She has capacity to make her own medical decisions. The treatment administration record (TAR) found a current order for, (MONTH) remove dressing to right upper extremity at bedtime after [MEDICAL TREATMENT]. The order did not dictate who would remove the dressing. The (MONTH) 2019, TAR was never initialed on any days by any of the nursing staff. The resident is receiving [MEDICATION NAME] ([MEDICATION NAME]) 9 milligrams daily. [MEDICATION NAME] is a blood thinner that treats and prevents blood clots. On 01/29/19 at 4:09 PM, a second interview and observation of the resident found the… | 2020-09-01 |
| 3399 | 3399 | FAIRMONT HEALTHCARE AND REHABILITATION CENTER | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2019-01-31 | 726 | E | 0 | 1 | 0LCE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure staff was competent to provide treatment and care for residents receiving anticoagulant medication. The facility failed to ensure [MEDICATION NAME] (PT) and International Normalized Ratio (INR) testing was obtained according to the physician orders [REDACTED].#101, #47, and #37. These residents were receiving the anticoagulation medication [MEDICATION NAME]. Four (4) out of four (4) residents in the facility receiving [MEDICATION NAME] were affected. Facility census: 108. Findings include: a) Resident #72 On 11/30/18, Resident #72's physician wrote an order for [REDACTED].#72's medical records demonstrated that INR testing was not performed on the following dates: 12/21/18, 12/25/18, 12/26/18, and 12/30/18. On 01/17/19, Resident #72's physician changed the order from daily INR testing to weekly PT/INR testing. Review of Resident #72's medical records demonstrated that PT/INR testing was last performed on 01/16/18. Resident #72 was prescribed the medication [MEDICATION NAME], which is also known by the brand name [MEDICATION NAME] and is a medication used to prevent harmful blood clots from forming or growing larger. Because [MEDICATION NAME] interferes with the formation of blood clots, it is called an anticoagulant. Many people refer to anticoagulants as blood thinners ; however, [MEDICATION NAME] does not thin the blood but instead causes the blood to take longer to form a clot. The goal of [MEDICATION NAME] therapy is to decrease the clotting tendency of blood, not to prevent clotting completely. Therefore, the effect of [MEDICATION NAME] must be monitored carefully with blood testing. On the basis of the results of the blood test, the daily dose of [MEDICATION NAME] will be adjusted to keep the clotting time within a target range. The blood test used to measure the time it takes for blood to clot is referred to as a [MEDICATION NAME] time test, or [MEDICATIO… | 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 );