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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 11479 | 11479 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 278 | B | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of minimum data set (MDS) assessments, and staff interview, the facility failed to accurately document assessment data on the MDS relative to pressure ulcers, infections, and toileting plans for four (4) of twenty (20) sampled residents. Resident identifiers: #65, #3, #4, and #81. Facility census: 113. Findings include: a) Resident #65 Record review (on 01/06/09) revealed the resident had a Stage II pressure ulcer to the coccyx which was recorded as being healed on 12/02/08. This information was noted on the December 2008 treatment administration record and a nurse's note dated 12/02/08. A skin assessment, dated 12/20/08, recorded no pressure ulcer(s) present at that time. Review of the resident's MDS, with an assessment reference date (ARD) of 12/24/08, found the assessor recorded in Section M1 the resident had one (1) Stage II ulcer. The MDS nurse (Employee #23) was interviewed on 01/07/09 about the information coded in Section M1 of the MDS. After reviewing the issue, she verified the MDS was coded incorrectly. On 01/08/09 at 11:05 a.m., the MDS nurse provided a copy of a corrected MDS, with an ARD of 12/24/08. In Section M1, the assessor documented no pressure ulcer(s). b) Resident #31 Review (on 01/07/09) of the admission MDS, completed on 12/24/08, revealed the assessor indicated, in Section I2, the resident had an antibiotic-resistant infection. Interview with the director of nursing (DON - Employee #2), at about 6:00 p.m. on 01/07/09, and review of the laboratory reports confirmed that, when the resident was admitted on [DATE], the resident had a [DIAGNOSES REDACTED]. c) Resident #40 Review (on 01/06/09) of the quarterly MDS, completed on 11/12/08, revealed the assessor indicated the resident was non-ambulatory and incontinent of bladder. In addition, the assessor marked Item H3a to indicate the resident was on a scheduled toileting plan. Interview with a nursing assistant (Employee #63), on 01/0… | 2014-02-01 | ||
| 11480 | 11480 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 279 | E | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to develop individualized comprehensive care plans for each resident to include services / treatments to be provided and appropriate interventions to assist with achievement of established goals. Care plans were not developed and individualized to reflect the actual care and services to be provided for six (6) of twenty (20) sampled residents. Resident identifiers: #36, #10, #97, #28, #62, and #81. Facility census: 113. Findings include: a) Resident #36 Review of the interdisciplinary care plan for Resident #36, found a sixty-four (64) paged document consisting of pre-printed problems, goals, and interventions with blanks to be filled in to make the care plan individualized. The care plan was hard to follow, and it did not always accurately reflect what problems the resident was experiencing for which specific interventions were being applied. 1. This resident had a history of [REDACTED]. devices. There was a different care plan for each device. The problem statements and goals were the same for each device, and each began with the statement: "Refer to the physical restraint / enabler assessment." 2. The physical restraint / enabler care plan was reviewed. This care plan was dated 12/05/08. The plan did not have a problem statement, goal, or interventions to achieve the goal. The care plan simply said, "Refer to the physical restraint / enabler assessment." The goal associated with this problem was "(Resident) will be free of negative effects with the use of an enabler." This goal did not address what the resident would achieve through the use of the device, i.e., improve functioning, increased independence, etc.) Review of the interventions associated with this goal found no measures to assist the resident in achieving the stated goal. The interventions simply said to apply the enabler (a lap buddy) when in the wheelchair for poor safety awareness with freq… | 2014-02-01 | ||
| 11481 | 11481 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 309 | D | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to provide care in accordance with each resident's plan of care for three (3) of twenty (20) sampled residents. Resident #97 indicated she was in pain, and this expressed pain was not further assessed or treated. Resident #10 was receiving intravenous (IV) fluids on an "as needed" (PRN) basis for her poor fluid intake, and her fluid intake and output were not being accurately monitored; this same resident was observed to have severely contracted hands, and she did not have rolled wash cloths or any type of devices in her hands for positioning to prevent further contractures. The facility also failed to staff applied double geri-gloves and elevated the heels of Resident #40 as ordered by the physician. Resident identifiers: #97, #10, and #40. Facility census: 113. Findings include: a) Resident #97 Record review found a nursing note recording the resident requested pain medication at 10:50 a.m. on 12/18/08. The nurse noted having instructed the resident that her "pain medications are scheduled". There was no evidence that the nurse assessed the pain or offered her one (1) of her prescribed PRN medications for breakthrough pain. Another nursing note, dated 12/30/08 at 1:30 p.m., stated, "Resident belligerent with staff today about her pain medicine ([MEDICATION NAME]). Resident is on pain medication around the clock, offered Tylenol in between doses, resident refused meds (Tylenol). " Another note, dated 01/01/09 at 4:35 a.m., stated, "Resident requested this nurse to give pain pill early, when this nurse refused resident became upset mumbled statements under her breath, and accepted her set schedule resting at this time." A nursing note, dated 01/01/09 at 1:35 p.m., stated, "Resident upset pain meds are on a scheduled basis instead of PRN. Attempted redirection but resident became more agitated. Continue to monitor." There was no evidence of furthe… | 2014-02-01 | ||
| 11482 | 11482 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 371 | F | UFEY11 | Based on observations and staff interview, the facility failed to assure foods were served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. This practice has the potential to affect all residents who receive nourishment from the dietary department. Facility census: 113. Findings include: a) At 2:30 p.m. on 01/05/09, observations, during the initial tour of the dietary department, revealed two (2) trays of cups and five (5) trays of cereal bowls; the cups and bowls were inverted on a synthetic shelving mat on flat trays prior to air drying. The cups and bowls were observed with trapped moisture, creating a medium for bacterial growth. The assistant dietary manager (Employee #45) was present and confirmed the identified problem. b) Observation with the dietary manager (Employee #42), on the afternoon on 01/07/09, again revealed inverted cups on a flat tray with a shelving mat which prevented the cups from proper air drying. The tray was observed under the area where the residents' food trays were served in the dining room. . | 2014-02-01 | ||
| 11483 | 11483 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 441 | E | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on record review, staff interview, resident interview, and review of the infection incidence rate reports, the facility did not maintain an effective infection control program whereby infectious organisms leading to urinary tract infections (UTIs) were identified. Subsequently, the facility had no data by which analyze infection control data for trends and clusters. Organisms were not identified on the infection incidence log, nor were they tracked for infection control purposes. There was no evidence that clusters were identified. This was evident for four (4) of twenty (20) sampled residents. Resident identifiers: #11, #65, #75, and #35. Also, Resident #97 reported improper perineal care that could potentially cause a UTI from fecal contamination. Facility census: 113. Findings include: a) Residents #11 and #85 Resident #11 experienced repeated UTIs colonized with Escherichia coli (E. coli), bacteria found in feces. Record review revealed positive urine cultures for E. coli on the following dates: 05/18/08, 06/21/08, 08/28/08, 10/20/08, 12/07/08. Other organisms cultured included Alpha Streptococcus and [MEDICATION NAME] species on 07/25/08. Resident #11's roommate, Resident #85, also experienced UTIs as evidenced by positive urine cultures of E. coli with colony counts greater than 100,000 for the following dates: 09/23/08 and 11/03/08. Resident #85 also had a UTI identified in the emergency roiagnom on [DATE] (which was treated with Cipro), but the facility was unable to produce that culture report. Review of the facility's most recent quarter's infection incidence rate report (October, November, and December 2008) found Resident #11's E. Coli infections were not recorded for either October or December. With permission, perineal care was observed for Resident #85 on 01/07/09 at 1:45 p.m., after an episode of urinary incontinence. The nursing assistant used a [MEDICATION NAME] Care body wash / shampoo product for cleansing.… | 2014-02-01 | ||
| 11484 | 11484 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 328 | E | UFEY11 | Based on random observation, staff interview, and policy review, the facility failed to ensure that residents received proper care for the special service of respiratory care as per facility policy. This was evident for four (4) of six (6) residents on the 300 Hall (Residents #2, #21, #26, and #108) and three (3) residents on the 400 Hall (Residents #48, #62, and #105), whose oxygen delivery supplies were not being changed weekly in accordance with facility policy. Facility census: 113. Findings include: a) Residents #2, #21, #26, and #108 During initial tour of the 300 Hall on 01/05/09 at approximately 2:30 p.m., observation found four (4) of the six (6) residents on that hall had oxygen (02) concentrators with oxygen delivery tubing dated 12/20/08. This was true for Residents #2, #21, #26, and #108. Resident #108 also had a nebulizer tubing and mask dated 12/20/08. (A fifth resident was receiving oxygen but refused the surveyor admittance into her room.) These findings were reported to the nurse (Employee #27) at approximately 2:55 p.m. 01/05/09, who reported that oxygen tubing was to be changed weekly. After checking the above referenced residents, she said she would see they were taken care of and would notify the nurse covering the 300 Hall. b) Residents #48, #62, and #105 On the morning of 01/07/09, observation found two (2) residents on the 400 Hall (Residents #48 and #62) with had no dates on their oxygen tubings. Also on 400 Hall, Resident #105 had a nebulizer tubing dated 12/02/08. These findings were reported, and the tubings were shown to the nurse (Employee #35). When asked who typically changed the oxygen tubing, she replied they were changed weekly, and that Employee #16 usually changed them. c) On 01/06/09 at approximately 2:00 p.m., the facility's Oxygen Administration policy was reviewed. In the revised January 2006 Respiratory Practice Manual, under Section 6.2.1. Oxygen Administration, the policy stated: "Label nasal cannula (also humidifier) with resident name, date, and liter flow." Review o… | 2014-02-01 | ||
| 11485 | 11485 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 164 | E | UFEY11 | Based on observation, resident interview, confidential resident group interview, and staff interview, the facility failed to maintain resident privacy during showers. This was evident for three (3) of twenty (20) sampled residents and one (1) anonymous resident at the confidential resident group meeting. Resident identifiers: #51, #11, and #85. Facility census: 113. Findings include: a) Resident #51 During an interview on 01/06/09 at approximately 3:00 p.m., Resident #51 reported a lack of privacy in the shower room. She stated she was able to see the buttocks and breasts of other female residents, and that she, too, was exposed to another person in the adjoining shower. There was a big curtain separating the doorway from the shower stalls, but she stated you could see around the curtain where it was not fully block the view. b) Resident #11 On 01/07/09 at 9:25 a.m., Resident #11 was observed during a shower with her permission. She was in the left shower stall being bathed by a nursing assistant, while another resident was in the right shower stall being bathed by a different nursing assistant. A divider shower curtain between the two (2) stalls was present but not being used. Rather, the shower curtain was against the wall behind a Hoyer lift. c) Resident #85 On 01/07/09 at 9:25 a.m., Resident #85 was observed during a shower with permission. She was in the right shower stall being bathed by a nursing assistant, while another resident was in the left shower stall being bathed by a different nursing assistant. A divider shower curtain between the two (2) stalls was present but not being used. Rather, the shower curtain was against the wall behind a Hoyer lift. d) Confidential resident group meeting interview On 01/06/09 at 10:30 a.m., a resident who attended the confidential group meeting reported the shower was not private. She also reported she was not always fully dressed properly when brought out of the shower. When asked for clarification in a separate interview on 01/07/09 at 2:00 p.m. regarding how the sh… | 2014-02-01 | ||
| 11486 | 11486 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 221 | E | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, a review of the incident / accident reports, and staff interview, the facility failed to assure that devices, applied and/or attached to a resident to restrict voluntary movement and/or normal access to one's body, were ordered by a physician to treat a medical symptom after the completion of a comprehensive assessment, to include the development and implementation of plans to systematically and gradually reduce the use of these physical restraints. Staff applied socks to Resident #10's hands, which restricted movement, without a physicians' order. Documentation in the medical records of Residents #36, #5, #28, and #85 inconsistently addressed the purpose of lap buddies applied to prevent rising and subsequent falls; throughout their charts, staff referred to these devices as "enablers" instead of physical restraints. Resident #36 consistently resisted the use of her lap buddy, injuring herself when her device was being applied; a plan to address this, as well as a plan for the systematic / gradual reduction of the use of this device, was not initiated. Devices were not adequately addressed for five (5) of twenty (20) sampled residents. Resident identifiers: #10, #36, #35, #28, and #85. Facility census: 113. Findings include: a) Resident #10 During an observation on 01/05/09 at 2:30 p.m., Resident #10 was laying in the bed with a sock applied to her right hand. This sock covered the resident's entire hand and was pulled up to the resident's elbow. Another observation, on 01/06/09 at 10:00 a.m., found socks present on both of the resident's hands, pulled up to her elbows. Review of the resident's medical record, including the monthly recapitulation of physician's orders (dated 01/01/09 through 01/31/09) revealed no active physician's order for any type of physical restraint, including the application of socks on this resident's hands. Review of Resident #10's current care plan, dated 11/25/08, found a plan … | 2014-02-01 | ||
| 11487 | 11487 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 285 | D | UFEY11 | Based on record review and staff interview, the facility failed to assure that a Level II evaluation was completed, when indicated, prior to the admission of one (1) of twenty (20) sampled residents. Resident identifier: #108. Facility census: 113. Findings include: a) Resident #108 Record review, on 01/07/09, revealed Resident #108 was admitted to the facility in 2008. The Pre-Admission Screening and Resident Review (PASRR) Determination, dated eleven (11) days prior to the current admission, stated that a Level II evaluation was required for this individual. However, the Level II evaluation itself was not completed prior to this admission to this facility. These findings were reported to Employee #8 on the morning of 01/08/09. She, in turn, referred the matter to the admissions / social worker to see if more information was on record in the social worker's office. On 01/08/09 at approximately 11:55 a.m., Employee #8 produced a Level II assessment signed by a supervised psychologist that was dated six (6) days after Resident #108's current admission. Employee #8 stated they thought the PASRR had been completed by the transferring facility. The finding of the delinquent pre-admission Level II evaluation was reported to the director of nursing at approximately 6:30 p.m. on 01/07/09. . | 2014-02-01 | ||
| 11488 | 11488 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 329 | D | UFEY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility did not ensure the medication regimen of one (1) of twenty (20) sampled residents was free from unnecessary drugs without adequate indications for use. Resident #62 was under the care of a psychiatrist for her mood / behavior, having been evaluated on 05/09/08; in addition to medication changes, the psychiatrist recommended a follow-up appointment within nine (9) weeks or as necessary. Additional psychoactive medications ([MEDICATION NAME] and [MEDICATION NAME] ER) were added to the resident's medication regimen without first assessing for [MEDICATION NAME] / extrinsic factors that may have caused or contributed to changes in the resident's behavior and/or without contacting the psychiatrist. Resident identifiers: #62. Facility census: 113. Findings include: a) Resident #62 1. Medical record review, on 01/06/09 at 4:15 p.m., revealed Resident #62 received several psychoactive medications for mood / behavior, including [MEDICATION NAME], and [MEDICATION NAME]. Further review revealed a psychiatric evaluation was completed on 05/09/08, after which the psychiatrist recommended increasing her [MEDICATION NAME] and instructed the facility to watch her for serotoni[DIAGNOSES REDACTED], since she was already receiving [MEDICATION NAME] and [MEDICATION NAME]. The psychiatrist also recommended a follow-up appointment in nine (9) weeks, or sooner if needed. Subsequent to the psychiatric consult, the resident's attending physician increased the [MEDICATION NAME] to 0.5 BID on 05/10/08 and decreased her [MEDICATION NAME] to 5 mg BID on 05/15/08. 2. At the beginning of June, Resident #62 began to exhibit increased anxiety, and in July, she had a panic attack. The facility did not contact the psychiatrist regarding these events. 3. On 09/30/08, she exhibited increased behaviors and was given [MEDICATION NAME] 1 mg intramuscularly (IM). Nursing progress notes did not contain any documentation … | 2014-02-01 | ||
| 11489 | 11489 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 520 | E | UFEY11 | Based on medical record review, review of the facility's infection control tracking log, and staff interview, the facility failed to maintain a quality assessment and assurance (QAA) committee that identifies quality deficiencies (of which it should have been aware) and develops / implements plans of action to correct these deficiencies. The facility had a high number of residents with urinary tract infections (UTIs). The QAA committee failed to identify deficits in the infection control program (with respect to tracking infectious organisms, identifying trends through analysis of the facility's infection control data, and investigating the UTIs to identify any underlying causal or contributing factors) and failed develop / implement measures to address these deficits. Facility census: 113. Findings include: a) Record review, during the facility's annual certification resurvey conducted from 01/05/09 through 01/08/09, revealed multiple residents with UTIs, several of whom had the same infectious organism and resided in the same location (same room and/or hall within the facility). On the afternoon of 01/06/09, the director of nursing (DON - Employee #2) was identified as the individual designated as responsible for infection control tracking. At this time, a copy of the November and December 2008 infection control tracking logs was requested and received. A review of the infection control tracking logs revealed the DON / infection control nurse failed to log the organisms identified through cultures as being responsible for each infection. In an interview with the DON and administrator (Employee #1) on 01/07/09 at 4:30 p.m., the DON acknowledged that she did not record infectious organisms on the tracking logs. During interview with the director of nursing (DON) on 01/07/09 at approximately 6:30 p.m., she produced the facility's most recent quarter (October through December 2008) of monthly incidence rates of infections. This form was to contain the names and room numbers of each resident with infection as well a… | 2014-02-01 | ||
| 11490 | 11490 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 225 | D | UFEY11 | Based on a review of the facility's complaint files, observation, and staff interview, the facility failed to immediately report and/or thoroughly investigate injuries of unknown origin and allegations of abuse to the appropriate State agencies. For Resident #96, an allegation of abuse was reported to the facility and investigated, but the facility did not report the allegation to State agencies. Resident #75 had bruising of unknown origin to her leg and lower back area, and this was not reported or investigated. This was true for one (1) of six (6) randomly reviewed complaints (#96), and one (1) of twenty (20) sampled residents (#75). Facility census: 113. Findings include: a) Resident #96 Review of the facility's complaint files found a concern report, dated 12/02/08, documenting that this resident's daughter called and said her mother said her legs were hurting and, when the resident was given a shower, "the aids (sic) hurt her legs and were rough with her". The facility conducted an internal investigation and took statements from the aides, but the allegation of abuse / mistreatment was not immediately reported to State agencies as required, nor were the results of the facility's investigation forwarded to the State within five (5) working days of the incident. During an interview with the director of nursing (DON - Employee #2) on 01/07/09 at 6:30 p.m., she verified this incident was investigated but was not reported as abuse, stating it was already resolved by the time the concern was filed by the family. b) Resident #75 A record entry on a Physician Notification form, dated 01/07/09, noted bruises of unknown origin to the right inner thigh (measuring 18 cm x 0.25 cm) and the left inner thigh (measuring 1 cm x 8 cm) and a buttock abrasion (measuring 2.3 cm x 2 cm). The entry noted the physician was notified of these injuries at 8:40 a.m. on 01/07/09. During a review of the facility's incident / accident reports for that day, there was no evidence that an accident / incident report had been completed. There … | 2014-02-01 | ||
| 11491 | 11491 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-01-08 | 313 | D | UFEY11 | Based on observation, record review, and resident interview, the facility failed to assist residents with the use of assistive devices needed to maintain hearing or vision. Residents were observed without their assistive devices in place, which could affect their abilities to interact with their environment. This occurred for two (2) of twenty (20) sampled residents. Resident identifiers: #65 and #36. Facility census: 113. Findings include: a) Resident #65 On 01/07/09 at 10:00 a.m., Resident #65, when observed in physical therapy (PT), was not wearing eyeglasses. During resident interview, Resident #65 stated she needed her glasses both to read and to "see all the time". Staff members were present at the time this surveyor was questioning the resident, and one (1) staff member went to get the resident's glasses and returned to PT. She then placed the eyeglasses on the resident's face. b) Resident #36 During initial tour of the facility on 01/05/09 at 2:30 p.m., this surveyor spoke to Resident #36. The resident did not answer questions and looked at the surveyor with a puzzled look. The surveyor introduced herself and asked what her name was. She did not answer or give any sign that she understood what was being asked of her. During another visit on the morning of 01/06/09, Resident #36 was observed sitting up in her wheelchair; she had just finished eating her breakfast. This surveyor spoke to the resident, and again she looked puzzled as if she did not understand what was being said. The surveyor the leaned down and spoke louder and directly into the resident's left ear, asking how her breakfast was. The resident immediately started discussing her breakfast and responded appropriately to each question subsequently asked of her when it was spoken directly into her ear. The resident stated, "I don't hear well." After this, all communication was understood by this resident. In a nursing note entry, dated 01/07/09 at 10:00 p.m., the nurse recorded, "Resident noted to refuse to interact with staff members for brief p… | 2014-02-01 | ||
| 11399 | 11399 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 278 | D | FRRZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident observation, and staff interview, the facility failed to ensure resident assessment information was accurate for one (1) of fifteen (15) sampled residents. Resident #61's medical record indicated a history of [MEDICAL CONDITIONS] with right-sided [MEDICAL CONDITION]. An abbreviated quarterly minimum data set assessment (MDS), with an assessment reference date of 09/10/08, indicated the resident did not have any limitations in range of motion or voluntary movement to his right arm and hand. Resident identifier: #61. Facility census: 89. Findings include : a) Resident #61 Resident #61 was observed and interviewed at 2:45 p.m. on 01/21/09, at which time he was noted to have a contracture and paralysis of the right hand. Resident #61 reported he had a stroke several years ago and did not have function of his right arm and hand. Medical record review, on 01/22/09 at 10:45 a.m., revealed the resident had a history of [REDACTED]. On 01/21/09 at 10:45 a.m., the MDS coordinator (Employee #98) was interviewed. The MDS coordinator provided the resident's most recent quarterly MDS, a significant change in status MDS, and the current care plan. Review of Section G4 of the MDS dated [DATE], revealed the information contained in this section was incorrect; the assessment indicated the resident had no limitation in function and voluntary movement to his arm or hand. The resident did have functional limitations of his right arm and hand due to post-[MEDICAL CONDITION] paralysis. . | 2014-03-01 | ||
| 11400 | 11400 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 241 | D | FRRZ11 | Based on observation and staff interview, the facility failed to ensure care was promoted in a manner and in an environment that maintained the dignity of two (2) of fifteen (15) sampled residents. Resident #78 was observed in bed prior to having received morning care, while the maintenance man was painting the wall in the resident's room and was not interacting with the resident. Resident #86 was observed in a public area of the facility, crying and begging for help, and the resident's dentures were laying on her chest. Resident identifiers: #78 and #86. Facility census: 89. Findings include: a) Resident #78 On 01/20/09 at 8:15 a.m., observation found maintenance staff was painting the wall in this resident's room; the maintenance man was not engaging the resident in any conversation. The resident was still in bed, no morning care had been provided, and breakfast had not been served at this time. This resident should have been moved to another area of the facility after providing morning care and breakfast, and prior to the room being painted. During an interview on 01/21/09 at 3:30 p.m., the director of nursing (DON - Employee #62) agreed maintenance should not have painted in the resident's room at that time. b) Resident #86 On 01/20/09 at 2:10 p.m., observation found this resident was sitting in a wheelchair in the front lobby at the nurse's station. The resident was crying and begging this surveyor to help her, and her dentures were laying on her chest. Further observation found staff at the nurse's station and walking past the resident, paying no attention to the condition the resident was in. During an interview on 01/21/09 at 3:30 p.m., the DON agreed the resident should have been removed from the public area and the resident's discomfort assessed. . | 2014-03-01 | ||
| 11401 | 11401 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 279 | D | FRRZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop comprehensive care plans to include hospice services and review and revise a care plan for three (3) of fifteen (15) sampled residents. Residents #78 and #28 were receiving hospice services and the comprehensive care plan failed to include the services to be provided by hospice. A care plan had been developed for Resident #42 which did not accurately describe the resident's pain and had not been revised when reviewed. Resident identifiers: #78, #28, and #42. Facility census: 89. Findings include: a) Resident #78 Medical record review, on 01/20/09, revealed this resident had a [DIAGNOSES REDACTED]. Review of the comprehensive care plan, revised in November 2008, revealed the care plan did not include the services to be provided by hospice. The resident's comprehensive care plan failed to have an integrated care plan with hospice which included the services provided by hospice with interventions describing who would do them and when they would be done. During an interview on 01/22/09 at 2:00 p.m., the minimum data set assessment (MDS) coordinator confirmed the comprehensive care plan and the hospice care plan was not integrated ensuring continuity of care by both facility and hospice staff. b) Resident #42 Medical record review, on 01/20/09, and a review of the comprehensive care plan it was revealed during the review of the activity care plan this resident indicated she could not leave her room due to pain. During further review of the activity care plan dated September, 2008, under the heading of Problems / Strengths was a quote "I want something to do, but I can't leave my room due to pain and need to be comfortable. I lie in bed most of the day." During a review of the estimated date of the goals it was discovered this activity plan had been reviewed on 01/19/09 with no changes made. During interviews on 01/21/09 at 4:00 p.m., the director of nursing (DON) an… | 2014-03-01 | ||
| 11402 | 11402 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 309 | D | FRRZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure care and services were provided in a manner to maintain the highest practicable physical well-being for one (1) of fifteen (15) sampled residents. Resident #78 had a medical history of [REDACTED]. Resident identifier: #78. Facility census: 89. Findings include: a) Resident #78 On 01/20/09 at 8:15 a.m., observation found maintenance staff was painting the wall in this resident's room. The resident was still in bed, no morning care had been provided, and breakfast had not been served at this time. The room smelled strongly of paint. Medical record review revealed Resident #78's [DIAGNOSES REDACTED]. This practice put the resident at risk for respiratory distress and can contribute to a poor appetite. This resident should have been moved to another area of the facility prior to the room being painted. During an interview on 01/21/09 at 3:30 p.m., the director of nursing (DON - Employee #62) agreed the room should not have been painted while the resident was in the room. . | 2014-03-01 | ||
| 11403 | 11403 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 441 | D | FRRZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure a sanitary environment to prevent the spread of infections in the facility during treatments provided to residents with known infections. Observation of the treatment nurse (Employee #2) during a treatment found her kneeling beside the resident's bed while applying a dressing to Resident #86's wound; she contaminated her uniform by kneeling on the floor, as she wore no protective clothing during this dressing change. This resident (#86) had a history of [REDACTED]. Resident identifier: #86. Facility census: 89. Findings include: a) Employee #2 During treatment administration on 01/21/09 at 1:10 p.m., observation found the treatment nurse changing a dressing to a pressure sore on Resident #86's coccyx. The treatment nurse knelt on the floor beside the resident's bed while applying the dressing. Although the nurse used universal precautions during the procedure, she did not don protective clothing. By kneeling on the floor, the contaminated her uniform. Medical record review revealed the resident had a history of [REDACTED]. Observation found, upon entering the resident's room, a sign advised visitors of the need for contact isolation and to see the nurse before entering the room. During an interview on 01/21/09 at 4:15 p.m., the director of nursing (DON) agreed the treatment nurse should not have been on the floor of this resident's room while changing the dressing. . | 2014-03-01 | ||
| 11404 | 11404 | GOLDEN LIVINGCENTER - MORGANTOWN | 515049 | 1379 VAN VOORHIS RD | MORGANTOWN | WV | 26505 | 2009-01-22 | 225 | D | FRRZ11 | Based on review of the facility's complaint / grievance log and staff interview, the facility did not ensure two (2) of twenty (20) sampled complaints / grievances containing allegations of neglect were immediately reported to the appropriate State agencies. Resident identifiers: #22 and #96. Facility census: 95. Findings include: a) Resident #22 On 01/01/09, Resident #22 alleged, "he did not have a pad for his bed. CNA (named by resident) was asked to get one for his bed. The CNA told him no, that they took them out of the building. He reported that he had to sleep on a bath blanket which wrinkled and caused a sore to his buttocks." The facility's investigation revealed cloth pads were to be available for this resident, and the nurse had assessed the resident after he was placed on the bath blanket and found the resident's buttocks were more red and irritated. An interview with the social worker, on 01/20/09 at 10:00 a.m., revealed the facility had not reported this allegation of neglect to the appropriate State agencies. b) Resident #96 On 11/19/08, Resident #96 alleged, "Resident had call light on for 50 minutes and roommate also call light on also and that fresh water on the 2:00 p.m. to 10:00 p.m. shift was not provided." The facility's investigation revealed the nursing assistant involved was identified and education would be provided for answering call lights and providing fresh water to residents. An interview with the social worker, on 01/20/09 at 10:00 a.m., revealed the facility had not reported this allegation of neglect to the appropriate State agencies. . | 2014-03-01 | ||
| 11015 | 11015 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2009-02-05 | 274 | D | 0 | 1 | 53ZE11 | Based on medical record review, review of minimum data set (MDS) assessments, and staff interview, the facility failed to recognize a significant change and complete a comprehensive resident assessment for two (2) of twenty one (21) sampled residents. Resident identifiers: #84 and #92. Facility census: 121. Findings include: a) Resident #84 On 02/03/09 and 02/04/09, review of the resident's comprehensive admission MDS, with an assessment reference date (ARD) of 07/25/08, found the assessor indicated (in Section G1, subsections b, c, d, and e) that resident was independent in the following activities of daily living (ADLs): transfer, walking, and locomotion. In addition, assessor indicated the resident needed supervision and set-up help only for dressing (section G1g) and set-up help only for eating (section G1h). The resident was independent in toilet use (section G1i) and continent of bowel and bladder (sections H1a and b). Review of the resident's abbreviated quarterly MDS assessment, with an ARD of 10/26/08, revealed the assessor indicated the resident was now totally dependent for transfer and required the physical assistance of one (1) person to walk in his room. In addition, the assessor indicated the resident was totally dependent for dressing and feeding, requiring one (1) person to physically assist, and the resident was incontinent of bowel and bladder and totally dependent for toilet use. A comprehensive assessment was not conducted to address the significant decline in multiple ADLs that occurred to this resident over the preceding three (3) months. On 02/05/09 at 9:25 a.m., the MDS nurse (Employee #148) provided a quarterly MDS assessment, with an ARD of 01/18/09, which showed the significant changes had not resolved. The MDS nurse was interviewed at that time about the significant change. After reviewing the issue, she verified she "could see where there could have been significant change (comprehensive) assessment." b) Resident #92 A review of the medical record revealed the facility had failed to … | 2014-09-01 |
| 11016 | 11016 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2009-02-05 | 514 | B | 0 | 1 | 53ZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain complete and accurate clinical records for two (2) of twenty one (21) sampled residents. Resident identifiers: #53 and #92. Facility census: 121. Findings include: a) Resident #53 Record review, on 02/04/09, revealed a doctor's progress note indicating the resident lacked the capacity to make healthcare decisions. This progress note contained no date and time. A social worker (Employee #79) provided a copy of the doctor's progress note at 2:50 p.m. on 02/04/09. The social worker was interviewed at this time, reviewed the record, and verified the note contained no date and time. b) Resident #92 A review of the medical record revealed a social services progress note, dated 10/22/08, which contained the following: "Resident is a full-code status per POST." Review of the Physician order [REDACTED]. These additional limitations would be contrary to a "Full Code". During an interview with the two (2) social workers (Employees #79 and #119) at 11:45 a.m. on 02/04/09, they reviewed the record and agreed that "Full Code" was an error in their notes. . | 2014-09-01 |
| 11017 | 11017 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2009-02-05 | 165 | D | 0 | 1 | 53ZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to address grievances in a timely manner. Resident #109 had resided in the facility for over seven (7) years, and the facility failed to adequately address his repeated requests to have a cool sleeping environment at night. This was evident for one (1) of twenty-one (21) sampled residents. Resident identifier: #109. Facility census: 121. Findings include: a) Resident #109 Record review revealed Resident #109 was an alert, oriented [AGE] year old male who resided in the facility for nearly eight (8) years. His physician had determined he had the capacity to understand and make his own informed healthcare decisions. Due to [DIAGNOSES REDACTED], he required total assistance from staff with the performance of activities of daily living. He was unable to leave his bed unless lifted out with a mechanical or other total lift, was unable to walk, and used a motorized wheelchair. During an interview on 02/04/09 at approximately 10:00 a.m., he stated his desire to keep his room warm by day and cool at night. Per the resident, he gets up in his scooter by day and feels cold. At night, he likes to cover up in bed with his warm blanket to keep his trunk and extremities warm, but he needs to have cooler air during sleep to facilitate breathing, feeling like he smothers if the air is too hot. He stated staff has known of these needs for years. He stated the heat last night was so unbearable he could not breathe, but staff refused to turn down the heat as he requested. He said he awoke drenched in sweat and had to get up at 2:30 a.m. to sit in his scooter for the remainder of the night, so he could breathe. He said he would like to have his room at 66 degrees Fahrenheit (F) while sleeping at night, although this was an estimated number as there was no thermometer in the room to measure the exact temperature. He was considering moving to another facility, but he stated his pr… | 2014-09-01 |
| 11018 | 11018 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2009-02-05 | 279 | D | 0 | 1 | 53ZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a plan of care to address a change in a resident's psychosocial well-being, and failed to plan non-pharmacologic interventions to address a resident's problem of anxiety with bathing prior to initiating psychoactive medications. Resident identifier: #94. Facility census: 121. Findings include: a) Resident #94 Record review revealed Resident #94 was an [AGE] year old female with [DIAGNOSES REDACTED]. Additionally, she suffered a fall in the facility October 2008 and sustained a fractured ankle requiring surgical repair. Further record review revealed a nursing note, dated 12/29/08 at noon, describing Resident #94's anxiety with bathing as evidenced by behaviors of "yelling / screaming combative c/ (with) CNA's (certified nursing assistants) splashing bath water all over floor as well as CNA . . . hitting / hurting CNA." These behaviors were significant enough at this time for the nurse to notify the physician for "possible Rx (prescription) d/t (due to) anxiety with bath". On 12/30/08, the physician ordered anti-anxiety medication [MEDICATION NAME] 0.25 mg orally in the mornings on bath days Mondays and Fridays for a [DIAGNOSES REDACTED]. The resident had been on skilled care due to the fractured ankle, but nursing notes dated 01/13/09 documented that, on 01/12/09, she was skilled for wound dressing changes and for "mood and behaviors". A nursing note dated 01/19/09 cited the resident was still combative during bath time and "difficult to give care to", again necessitating physician notification on this date. Subsequently, injectable [MEDICATION NAME] 5 mg was ordered by the physician on 01/20/09, to be given an hour before bath time on Mondays and Fridays, instead of the [MEDICATION NAME] for increased agitation and anxiety. A minimum data set (MDS) assessment, with an assessment reference date of 01/13/09, cited behaviors and moods present under the corresponding subs… | 2014-09-01 |
| 11019 | 11019 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2009-02-05 | 371 | F | 0 | 1 | 53ZE11 | Based on observation and staff interview, the facility failed to ensure foods were stored and served under sanitary conditions, as evidenced by the absence of a thermometer in the kitchen's reach-in refrigerator, to allow monitoring of temperatures stored in this refrigerator. This practice had the potential to affect all residents in the facility who received nourishment from the facility's kitchen. Facility census: 121. Findings include: a) During service of the evening meal on 02/02/09 at 5:00 p.m., observation found dietary staff obtaining 8 oz cartons of milk from the kitchen's reach-in refrigerator and placing the milk cartons onto the residents' dining trays for the evening meal. No thermometer was visible in this refrigerator located beside the serving line, in which were stored numerous plastic crates containing cartons of milk. With no thermometer to measure the internal temperature of this storage area, it could not be assured that all the milk products were stored under proper temperatures. The assistant food service director (Employee #132) removed all crates from inside this refrigerator but was unable to locate a thermometer inside at this time. He agreed that each refrigerator and freezer in the dietary department should have a thermometer, and he reported this reach-in refrigerator generally had one, too. Subsequently, he located a thermometer and placed it inside the kitchen refrigerator. . | 2014-09-01 |
| 11020 | 11020 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2009-02-05 | 164 | D | 0 | 1 | 53ZE11 | Based on an observation and staff interview, the facility did not ensure one (1) resident of random selection (#120) was afforded the right to confidentiality of clinical records. Facility census: 121. Findings include: a) Resident #120 An observation, on 02/03/09 at 9:25 a.m., revealed Resident #120's Medication Administration Record [REDACTED]. The medication cart was in the hallway and visible to anyone walking in the area. An interview with the nurse (Employee #139) revealed she forgot to close the medication binder after she dispensed the prescribed medications and walked into the room to administer the medications to the resident. . | 2014-09-01 |
| 11021 | 11021 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2009-02-05 | 152 | D | 0 | 1 | 53ZE11 | Based on record review and staff interview, the facility failed to assure a resident, who had been determined to lack the capacity to understand and make informed healthcare decisions, had his decisions made by a legal surrogate designated in accordance with State law. The facility had Resident #92 sign an informed consent form authorizing the administration of the influenza vaccine, even though he had been determined to lack the capacity to make such healthcare decisions. Resident identifier: #92. Facility census: 121. Findings include: a) Resident #92 Medical record review revealed the attending physician determined Resident #92 lacked the capacity to understand and make healthcare decisions on 07/28/08. This determination was validated by a second determination made by a psychologist on 08/01/08. Further record review revealed Resident #92 had signed an informed consent form authorizing the administration of the influenza vaccine on 10/22/08. No other signature was on the form. During an interview with the social worker at 11:45 a.m. on 02/04/09, she acknowledged, after reviewing the chart, that Resident #92 should not have been asked to sign this form, as the resident did not have the capacity to understand and make healthcare decisions at that time. (Note: After the fact, on 11/19/08, the resident's attending physician reversed this and determined the resident had the capacity to formulate healthcare decisions. However, at the time the resident signed the vaccination consent form, he did not.) . | 2014-09-01 |
| 11022 | 11022 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2009-02-05 | 155 | D | 0 | 1 | 53ZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure that residents with capacity were involved in making decisions with respect to the advance directives documented on the Physician order [REDACTED]. Resident identifiers: #92 and #104. Facility census: 121. Findings include: a) Resident #92 A review of the medical record revealed a POST form indicating Resident #92 was to receive cardiopulmonary resuscitation (CPR) and "Limited additional interventions". This form was signed by the resident's medical power of attorney representative (MPOA) on [DATE]. The resident's attending physician determined Resident #92 lacked the capacity to understand and make healthcare decisions on [DATE]. This determination was validated by a second determination made by a psychologist on [DATE]. On [DATE], the resident's attending physician reversed this and determined the resident now had the capacity to formulate healthcare own decisions. However, there was no evidence in the record to indicate the advance directives recorded on the [DATE] POST form had been reviewed with the resident. During an interview at 11:45 a.m. on [DATE], the social worker (Employee #119) was asked if the advance directives noted on the POST form had been reviewed with the resident. The social worker could not remember and, at the time of exit, she had not produced any evidence to indicate the resident had been informed of the decisions made by the MPOA. b) Resident #104 A review of Resident #104's medical record revealed the resident was admitted on [DATE]. On [DATE], the social worker recorded in social services notes that the resident had the capacity to make his own healthcare decisions and he had "Full Code" status. His attending physician also determined, on [DATE], that Resident #104 had the capacity to make healthcare decisions. However, an attached form stated: "It is my desire that (Name) , my (wife) , sign all forms on my behalf to admit me to Heartland of… | 2014-09-01 |
| 11023 | 11023 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2009-02-05 | 159 | D | 0 | 1 | 53ZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility records, and staff interview, the facility failed to notify the responsible party an incapacitated Medicaid recipient when the amount in the resident's account was within $200.00 of the SSI resource limit, for one (1) of eighty-nine (89) residents with personal trust fund accounts managed by the facility. Resident identifier: #28. Facility census: 121. Findings include: a) Resident #28 A review of the Resident #28's medical record revealed this [AGE] year old female who had been determined to lack capacity and who had previously designated her daughter to serve as both her medical and financial power of attorney. The primary payer for her nursing home stay was MCD - Medicaid (West Virginia). The resident's trust statement, dated 02/03/09, stated the balance of funds in her account was $2,590.40. The balance had reached the total of $1800.00 on 12/01/08, at which time the facility should have notified the responsible party that the resident's account was within $200.00 of the allowed SSI limit. There was no evidence in the file to indicate the resident's responsible party had been notified of the account balance and the possible repercussions of this total (loss of Medicaid eligibility), although quarterly statements had been posted in January 2009. During an interview with Employee #159, who was responsible for handling resident funds, at 2:00 p.m. on 02/04/09, she stated she was aware of the balance and explained that she supplied a list of resident balances to the business office manager (Employee #154) each month. The business office manager was to notify families of high balances. Employee #154, when interviewed at 2:15 p.m. on 02/04/09, stated he had tried to contact Resident #28's responsible party by phone but had gotten no answer. He explained the practice of the facility was to notify the family when the balance reached $1800.00, and when the total reached $2000.00, he was to notify DHHR; he… | 2014-09-01 |
| 11024 | 11024 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2009-02-05 | 280 | D | 0 | 1 | 53ZE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to evaluate and revise the care plan as the resident's status changed, for one (1) of twenty-four (24) sampled residents. Resident identifier: #92. Facility census: 121. Findings include: a) Resident #92 A review of Resident #92's medical record revealed he was admitted on [DATE] after a lengthy hospitalization . His admission minimum data set (MDS) assessment indicated he was totally dependent for bed mobility, transfer, locomotion, dressing, eating, and hygiene, and there was no ambulation in the previous seven (7) days. A care plan was developed addressing these needs with appropriate goals for a severely debilitated resident. An abbreviated quarterly MDS, dated [DATE], indicated the resident required extensive assistance with bed mobility and transfer, limited assistance with ambulation and locomotion; and is now independent except for set-up with eating. However, the resident's most current care plan addressing activities of daily living (ADLs), last reviewed on 11/12/08, contained no evidence of revisions to the care plan to reflect an improvement in the resident's self-performance of ADLs. In an interview with the MDS nurse (Employee #171) at 4:00 p.m. on 02/04/09, she acknowledged, after reviewing the care plan, that it should have been revised as the resident was no longer totally dependent on others for the self-performance of ADLs. . | 2014-09-01 |
| 11288 | 11288 | BRAXTON HEALTH CARE CENTER | 515180 | 859 DAYS DRIVE | SUTTON | WV | 26601 | 2009-02-10 | 225 | D | 1 | 0 | 33YV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility did not ensure an incident of possible neglect, whereby a resident sustained [REDACTED]. Resident identifier: #59. Facility census: 58. Findings include: a) Record review revealed a nursing note, dated 10/29/08, documenting Resident #59 was being transferred by two (2) NAs and a nurse utilizing a mechanical lift, when the resident sustained [REDACTED]. An interview with the director of nursing (DON), on 02/10/09 at 10:00 a.m., revealed the facility did not submit an immediate report and 5-day follow-up report to the State nurse aide registry for the nursing assistants involved. The DON had reported the incident to only the State survey and certification agency and Adult Protective Services. . | 2014-07-01 |
| 11289 | 11289 | BRAXTON HEALTH CARE CENTER | 515180 | 859 DAYS DRIVE | SUTTON | WV | 26601 | 2009-02-10 | 309 | D | 1 | 0 | 33YV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility did not ensure one (1) of three (3) sampled residents received timely care and services to maintain physical well-being. Resident #59 sustained a [MEDICAL CONDITION] humerus and was not seen by an orthopedic specialist until eight (8) days later. Additionally, Resident #59 did not receive a skin assessment or skin care under an Ace wrap that was ordered by the physician to immobilize the fractured humerus, resulting in the development of an open area. Facility census: 58. Findings include: a) Resident #59 1. An interview with the director of social services, on 02/10/09 at 12:20 p.m., revealed she did not make medical appointments for the residents. She stated the admission coordinator was responsible for making these appointments. An interview with the admission coordinator, on 02/10/09 at 12:45 p.m., revealed she received a physician's telephone order from the nursing department requesting an appointment for Resident #59 to see an orthopedic specialist. The physician's orders [REDACTED]. She stated she told the specialist's office staff the resident had a fracture to her right elbow and needed to be seen as soon as possible. A nursing note, dated 10/29/08 at 3:50 p.m., revealed, "Resident transferred from bed to wheelchair using total body lift with assist of 2 CNA's (certified nursing assistants) and this nurse. Resident transferred without difficulty. Some crying noted, but stopped crying when sitting in wheelchair. Bruise to right inner elbow with [MEDICAL CONDITION] noted. Sitting upright with good posture." Another nursing note at 4:00 p.m. revealed, "Spoke with daughter about the bruising and swelling of elbow. Explained we are going to obtain a x-ray and will let her know of the results." A nursing note at 5:15 p.m. indicated, "Imaging contacted this nurse by phone and reported right distal humerus non-displaced fracture to right elbow. MPOA stated I think it could of happened… | 2014-07-01 |
| 11179 | 11179 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2009-02-12 | 319 | G | 1 | 0 | IH3P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility did not obtain psychological / psychiatrics services for a [AGE] year old male resident (#107) who was exhibiting an escalation in behaviors towards other residents, visitors, and staff that were socially and sexually inappropriate, verbally abusive, and physically aggressive. Resident #107 frequently propelled his wheelchair backwards in the corridor, thereby creating a safety hazard for other residents. He also pushed an overbed table into the leg of his roommate, frequently engaged in unwanted physical contact of a sexual nature with female residents, staff, and visitors (when he would touch their buttocks, inner thighs, and/or breasts), verbally abused and physically struck female staff on the chest and buttocks, exposed his genitals to others, and repeatedly removed the incontinence brief and exposed the perineal area of a [AGE] year old cognitively impaired, totally dependent female resident. Medical record review found no evidence of current quantitative and/or qualitative tracking Resident #107's behaviors. However, review of nursing notes, from 10/28/08 to 02/04/09, revealed one hundred and eight (108) separate entries, occurring over a 100-day period, documenting socially and sexually inappropriate behaviors, verbally abusive and/or physically aggressive behaviors, and behaviors that presented safety hazards to others. These entries anecdotally recorded various behaviors occurring multiple times weekly, and sometimes multiple times daily. Record review found Resident #107 had been exhibiting sexually inappropriate behaviors for several years, for which he received evaluations on at least three (3) occasions since 2006. His last consult, with a neurologist on 07/14/08, identified concerns with tremors, urinary urgency, and sexually aggressive behaviors. The consulting physician recorded, "His behavior problem is not responding to SSRI's (selective serotonin reuptake inh… | 2014-07-01 |
| 11180 | 11180 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2009-02-12 | 329 | D | 1 | 0 | IH3P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility did not, for one (1) of twenty-two (22) sampled residents, ensure medications were not given for an excessive duration and that monitoring was completed to evaluate the effectiveness of the medication. [MEDICATION NAME] was given for greater than three (3) months, and [MEDICATION NAME] was given without laboratory monitoring to determine efficacy. Resident identifier: #107. Facility census: 106. Findings include: a) Resident #107 1. Medical record review, conducted on the morning of 02/05/09, revealed Resident #107 was receiving [MEDICATION NAME] since 05/17/08. Review of the original physician order [REDACTED]. According to http://www.mayoclinic.com/health/[MEDICATION NAME]/NS_patient-[MEDICATION NAME]: "[MEDICATION NAME] should be used for short term therapy three (3) months or less and possible side effects include fatigue, dizziness, headache, irritability and sleepiness." Review of the monthly drug regimen review found no evidence the consultant pharmacist had recognized as an irregularity that Resident #107 had been receiving this medication for an excessive duration. During an interview on the afternoon of 02/10/09, the director of nursing (DON - Employee #5) offered to review the medical record to determine whether the consultant pharmacist identified this irregularity. Shortly after this interview, the DON identified that the consultant pharmacist did not identify this irregularity until 02/02/09, and the consultant report was in a separate file for the physician to review; it was not in this resident's closed medical record. The facility failed to ensure that [MEDICATION NAME] was not given in an excessive duration. 2. Medical record review also revealed that, on 09/10/08, [MEDICATION NAME] 50 mg two (2) times a day for tremors was ordered. On 11/12/08, another order was written for [MEDICATION NAME] 25 mg every day at 1:00 p.m. On 12/17/08, laboratory testing revealed… | 2014-07-01 |
| 11181 | 11181 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2009-02-12 | 428 | E | 1 | 0 | IH3P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of manufacturer's dosing instructions, and staff interviews, it was determined the pharmacist had not identified drug irregularities for five (5) residents. The pharmacist had not identified the facility's current scheduling of antibiotics as an irregularity. The current schedules for antibiotics did not maintain blood levels of the medication for optimal effect. Two (2) of nineteen (19) residents on the sample were identified as being affected, and review of the February medication administration records (MAR) for the 100 hall identified an additional two (2) residents. Additionally, the pharmacist had not identified that Resident #107 was receiving Melatonin for an excessive duration. Resident identifiers: #52, #15, #95, and #51. Facility census: 106. Findings include: a) Residents #15, #51, #52, and #95 1. Resident #15 Review of the resident's medical record found that, on 01/19/09, Augmentin (an antibiotic) had been ordered given three (3) times a day pending the culture of the resident's tracheostomy site. Review of his MARs revealed the antibiotic had been scheduled for administration at 8:00 a.m., 12:00 p.m., and 5:00 p.m. That meant the three (3) antibiotic doses were given in an approximately nine (9) hour period, leaving fifteen (15) hours between the 5:00 p.m. dose and the 8:00 a.m. dose on the following day. 2. Resident #51 The resident's current orders included Bactrim DS to be given twice a day for five (5) days. The antibiotic was scheduled for administration at 9:00 a.m. and 5:00 p.m. on the MAR. This schedule provided for the doses for one (1) day to be given eight (8) hours apart, and the next dose would not be given for approximately sixteen (16) hours. Review of the pharmacist's drug regimen review for Resident #51, dated 02/02/09, found the schedule for the Augmentin the resident received in January 2009 had not been noted as an irregularity. 3. Resident #52 The resident's curre… | 2014-07-01 |
| 11182 | 11182 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2009-02-12 | 498 | D | 1 | 0 | IH3P11 | Based on observations, it was determined the facility had not ensured each nurse aide demonstrated competency in techniques necessary to care for residents' needs. A nursing assistant (NA) was observed assisting back to bed one (1) resident of random opportunity. The NA pulled a belt from under the resident after the resident was lying on her bed, creating a potential for shearing and/or friction injury to the resident. Resident identifier: #9. Facility census: 106. Findings include: a) Resident #9 On 02/10/09 at approximately 8:45 a.m., a NA (Employee #106) was observed assisting the resident from the bathroom to her bed. After the resident had lain down on the bed, she turned onto her left side. The NA released the fastening device and pulled the belt and the larger part of the fastening device under the resident's body, creating a potential for injury from shearing or friction, especially as the larger portion of the clasp was pulled beneath the resident. . | 2014-07-01 |
| 11183 | 11183 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2009-02-12 | 323 | G | 1 | 0 | IH3P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility did not provide adequate supervision to prevent a [AGE] year old male resident (#107) from being socially and sexually inappropriate, verbally abusive, and physically aggressive towards staff, other residents, and visitors. Resident #107 frequently propelled his wheelchair backwards in the corridor, thereby creating a safety hazard for other residents. He also pushed an overbed table into the leg of his roommate, frequently engaged in unwanted physical contact of a sexual nature with female residents, staff, and visitors (when he would touch their buttocks, inner thighs, and/or breasts), verbally abused and physically struck female staff on the chest and buttocks, exposed his genitals to others, and repeatedly removed the incontinence brief and exposed the perineal area of a [AGE] year old cognitively impaired, totally dependent female resident. Medical record review found no evidence of current quantitative and/or qualitative tracking Resident #107's behaviors. However, review of nursing notes, from 10/28/08 to 02/04/09, revealed one hundred and eight (108) separate entries, occurring over a 100-day period, documenting socially and sexually inappropriate behaviors, verbally abusive and/or physically aggressive behaviors, and behaviors that presented safety hazards to others. These entries anecdotally recorded various behaviors occurring multiple times weekly, and sometimes multiple times daily. Record review found Resident #107 had been exhibiting sexually inappropriate behaviors for several years, for which he received evaluations on at least three (3) occasions since 2006. His last consult, with a neurologist on 07/14/08, identified concerns with tremors, urinary urgency, and sexually aggressive behaviors. The consulting physician recorded, "His behavior problem is not responding to SSRI's (selective serotonin reuptake inhibitors). I wonder if a medication such as Proscar mig… | 2014-07-01 |
| 11323 | 11323 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2009-02-12 | 364 | B | 0 | 1 | IH3P11 | Based on observation and staff interview, the facility failed to provide food that was attractive in appearance for the evening meal on 02/09/09. The food items served during evening meal provided only white, brown, and yellow as colors on the resident trays. This had the potential to affect all residents who chose the main entree for dinner on 02/09/09. Facility census: 106. Findings include: a) Observation of the dinner meal, on 02/09/09 at 5:00 p.m., found the meal consisted of chicken nuggets, cauliflower, and hashbrown casserole, which were brown and white in color. Pineapple was the dessert and was yellow in color. The appearance of the items on the residents' plates offered no variety in color and texture. An interview with the dietary manager ,and a review of the menus on the late morning of 02/12/09, found that fruit ambrosia was supposed to have been on the menu for that day. . | 2014-06-01 |
| 11324 | 11324 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2009-02-12 | 371 | F | 0 | 1 | IH3P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure pre-poured containers of thickened milk and [MEDICATION NAME] milk were held at acceptable temperatures of 41 degrees Fahrenheit or less. This had the potential the affect all ten (10) residents who were to receive these beverages. The facility also did not keep records to make sure that cold foods were at appropriate temperatures when received from the food supplier. This had the potential to affect all residents. Facility census: 106. Findings include: a) Five (5) glasses of thickened milk and five (5) glasses of Lactacid milk were on a tray sitting on the counter during observation of the evening meal at 5:00 p.m. on 02/09/09. Temperatures taken of sampled glasses found the beverages were held at 42.9 and 43 degrees Fahrenheit. An interview with the dietary manager, after this observation, found the milks were on a tray with ice packs under it, but this method did not ensure the milk was being held at a cool enough temperature. b) During the dietary observation on 02/09/09 at 5:00 p.m., the dietary manager indicated that, when food was received from the food supplier, temperatures were taken but were not recorded in order to ensure that foods were kept at proper temperatures. . | 2014-06-01 |
| 11325 | 11325 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2009-02-12 | 441 | D | 0 | 1 | IH3P11 | Based on observation, it was determined the infection control program failed to ensure staff practices were consistent with appropriate infection control techniques. A nurse donned gloves, then contaminated the gloves prior to dressing the resident's wound. One (1) of nineteen (19) current residents on the sample was affected. Resident identifier: #45. Facility census: 106. Findings include: a) Resident #45 On the mid-morning of 02/11/09, a nurse (Employee #112) was observed providing treatment to an unstageable wound on the resident's left heel. The wound was covered with eschar that had loosened from the healthy skin surrounding the wound. After cleaning the wound, the nurse removed her gloves, washed her hands, and donned new gloves. After donning the clean gloves, she opened the packages containing the dressing supplies, then put her hand in her pocket to extract an ink pen. The pen was uncapped, and she used it to label the dressing. The dressing was then applied to the resident's heel wound. The nurse's pocket would be considered an unclean area, as would the pen. This created a potential to introduce nonresident organisms into the resident's wound. . | 2014-06-01 |
| 11326 | 11326 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2009-02-12 | 309 | E | 0 | 1 | IH3P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of manufacturer's dosing instructions, and staff interviews, the facility did not ensure antibiotics were administered at times that would maintain blood levels of the medication for optimal effect. Two (2) of nineteen (19) residents on the sample were identified as being affected, and review of the February medication administration records (MAR) for the 100 hall identified an additional two (2) residents. Resident identifiers: #52, #15, #95, and #51. Facility census: 106. Findings include: a) Resident #15 Review of the resident's medical record found that, on 01/19/09, [MEDICATION NAME] (an antibiotic) had been ordered given three (3) times a day pending the culture of the resident's [MEDICAL CONDITION] site. Review of his MARs revealed the antibiotic had been scheduled for administration at 8:00 a.m., 12:00 p.m., and 5:00 p.m. That meant the three (3) antibiotic doses were given in an approximately nine (9) hour period, leaving fifteen (15) hours between the 5:00 p.m. dose and the 8:00 a.m. dose on the following day. b) Resident #51 The resident's current orders included Bactrim DS to be given twice a day for five (5) days. The antibiotic was scheduled for administration at 9:00 a.m. and 5:00 p.m. on the MAR. This schedule provided for the doses for one (1) day to be given eight (8) hours apart, and the next dose would not be given for approximately sixteen (16) hours. c) Resident #52 The resident's current MAR indicated [REDACTED]. The antibiotic was scheduled for administration at 8:00 a.m., 12:00 p.m., and 5:00 p.m. d) Resident #95 A current order for Bactrim DS to be given twice a day for ten (10) days was noted on the resident's current MAR. The medication was scheduled to be given at 8:00 a.m. and 5:00 p.m. e) The director of nursing was interviewed on 02/11/09. When asked about the scheduling of antibiotics, she was unable to offer a reason for the current schedules. During a discussion re… | 2014-06-01 |
| 11327 | 11327 | HEARTLAND OF PRESTON COUNTY | 515072 | 300 MILLER ROAD | KINGWOOD | WV | 26537 | 2009-02-12 | 279 | E | 0 | 1 | IH3P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, observations, and staff interviews, the facility did not develop a care plan for each resident which was based on the comprehensive assessment and included measurable goals. For example, residents were assessed as being on scheduled toileting plans, yet their care plans did not include a plan for incontinence management. Goals were not stated in measurable terms, so that progress toward the goal or a need to alter the approaches to the problem could be determined. Additionally, in some instances, the interventions did not lend to achievement of the stated goal. Resident identifiers: #82, #30, #80, and #15. Facility census: 106. Findings include: a) Resident #82 1. Review of the resident's most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/01/08, revealed she had both short-term and long-term memory problems. She had been assessed as having severe impairment in the area of decision-making; as being understood sometimes; and as rarely being able to understand what was said to her. Her [DIAGNOSES REDACTED]. She was able to move about in her wheelchair independently. Observations of the resident, on 02/11/09, found she had wandered into a room near her own room at 3:30 p.m., and at 3:45 p.m., she had maneuvered her wheelchair into another room nearby. A nursing assistant (Employee #77) was asked whether the resident often wandered into other residents' rooms and replied that she did. Review of the resident's care plan found no care plan to address the issue of this resident wandering into other residents' rooms. 2. Review of the medical record found a nursing entry on 10/03/08 regarding the resident licking her bedside table. Subsequent nurses' notes also described the resident licking things such as the desk at the nurses' station. On 02/11/09, in mid morning, Employee #112 was asked whether the resident still licked things. She said the resident continued to lick thin… | 2014-06-01 |
| 11368 | 11368 | VALLEY HAVEN GERIATRIC CENTER | 515123 | RD 2, BOX 44 | WELLSBURG | WV | 26070 | 2009-03-18 | 431 | E | IFJQ11 | Based on an observation and staff interview, the facility did not ensure that two (2) of two (2) treatment carts were entered only by authorized personnel. A nursing assistant was permitted to have a key to open both treatment carts, which contained supplies and topical medications prescribed to residents by the physician. Facility census: 53. Findings include: a) An observation, on 03/18/09 at 10:00 a.m., revealed a nursing assistant (NA) was assisting the treatment nurse with resident treatments on 200 hall of the facility. The NA was observed using a key to enter the treatment cart and remove treatment supplies. An interview the NA, on 03/18/09 at 10:30 a.m., revealed she assisted the treatment nurse and was permitted to have a key to open both treatment carts. She also stated she would retrieve the necessary supplies and treatments (which would include physician-ordered topical medications) for the nurse. . | 2014-04-01 | ||
| 11369 | 11369 | VALLEY HAVEN GERIATRIC CENTER | 515123 | RD 2, BOX 44 | WELLSBURG | WV | 26070 | 2009-03-18 | 225 | D | IFJQ11 | Based on facility record review and staff interview, the facility failed to make reasonable efforts to uncover criminal histories of two (2) sampled employees, by failing to conduct criminal background checks in all States in which these employees had previously worked. Employee identifiers: #1 and #4. Facility census: 53. Findings include: a) Employee #1 A review of the personnel file of Employee #1, who was hired on 01/21/08, revealed she possessed a nursing license from the Commonwealth of Pennsylvania, and information on her her employment application indicated prior work history in that State. However, there was no evidence of efforts by the facility to inquire about possible criminal convictions in that State which would have made her unsuited to work in a nursing facility. This was verified by the administrator after he had reviewed the file himself. b) Employee #4 A review of the personnel file of Employee #4, who was hired on 12/23/08, revealed prior work history in the State of Ohio. However, there was no evidence of efforts by the facility to inquire about possible criminal convictions in that State which would have made her unsuited to work in a nursing facility. This was verified by the administrator after he had reviewed the file himself. . | 2014-04-01 | ||
| 11370 | 11370 | VALLEY HAVEN GERIATRIC CENTER | 515123 | RD 2, BOX 44 | WELLSBURG | WV | 26070 | 2009-03-18 | 314 | G | IFJQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation,and staff interview, the facility failed to provide the necessary care and services to prevent new pressure sores from developing for one (1) of three (3) residents whose medical records were reviewed for pressure ulcers. Resident #16 had been assessed as being at low risk for development of pressure ulcers. Medical record review revealed the resident developed a pressure ulcer, which was treated, healed, and then re-opened, because the facility failed to provide a pressure relieving device for chairs in which the resident spent most of the day sitting. Resident identifier: #16. Facility census: 53. Findings include: a) Resident #16 Medical record review revealed Resident #16 developed a pressure ulcer on 01/08/09. The resident was treated, and staff recorded the wound was healed on 02/16/09, after which preventive treatment was used. Review of the resident's Braden Scale, used to predicting pressure sore risk, revealed the resident was rated as being at mild risk for the development of pressure sores. During a treatment on 03/17/09 at 10:00 a.m., observation revealed the resident had a red area on the lower coccyx at the cleft of the buttocks. When the treatment nurse cleansed the red area, observation revealed two (2) small areas open areas which measured 0.2 x 0.2. Interview with the treatment nurse (Employee #80) during this observation revealed the area had been healed and these two (2) areas had just re-opened. When the treatment nurse was questioned as to why the resident had developed a pressure ulcer and why the area had re-opened, the nurse indicated the resident spent a large part of her day sitting in a chair at the nurse's station, and she stated the resident probably needed a pressure relieving cushion. On 03/17/09, observations found the resident moved independently in bed and was ambulatory with a walker and staff assistance. Observations beginning at 11:00 a.m. found the resident si… | 2014-04-01 | ||
| 11371 | 11371 | VALLEY HAVEN GERIATRIC CENTER | 515123 | RD 2, BOX 44 | WELLSBURG | WV | 26070 | 2009-03-18 | 329 | D | IFJQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interview, the facility failed to ensure the medication regimen of one (1) of ten (10) sampled residents was free of unnecessary drugs. Resident #21, who was receiving 2 mg a day of [MEDICATION NAME] (greater than the maximum daily dosage recommended for geriatric residents), was exhibiting no behaviors for which the medication was originally ordered, had the medication held on several occasions due to sleeping, and had no attempted gradual dose reduction for ten (10) months. Resident identifier: #21. Facility census: 53. Findings include: a) Resident #21 A review of the resident's medical record indicated this [AGE] year old female was admitted to the nursing facility on 05/07/08, with a physician's orders [REDACTED]." The resident continued to the present to receive the original dose [MEDICATION NAME] 0.5 mg four (4) times a day, for a total of 2 mg a day. A review of the facility's behavior record indicated that, for the months of February 2009, January 2009, December 2008 , November 2008, and October 2008, the resident did not exhibit any behaviors. The behaviors identified on this record for monitoring included agitation over need to leave and exit-seeking behavior. A review of the physician's progress notes revealed that only one (1) entry addressing the [MEDICATION NAME], dated 11/25/08, in which the physician indicated, "Continue [MEDICATION NAME] less overall anxiety and less of a fall risk at present." Observations of the resident, on 03/11/09 at 3:30 p.m. and 03/12/09 at 11:00 a.m., revealed the resident sitting in a wheelchair with the staff moving the resident to other locations in the facility. An observation of the resident, on 03/16/09 at 10:30 a.m.. revealed the resident lying in bed sleeping. Later at 2:30 p.m., the resident was again observed lying in bed sleeping. A nursing note, dated 02/26/09 (no time was documented), indicated the resident was lethargic related to not slee… | 2014-04-01 | ||
| 11216 | 11216 | REYNOLDS MEMORIAL HOSPITAL, D/P | 515112 | 800 WHEELING AVENUE | GLEN DALE | WV | 26038 | 2009-03-27 | 329 | G | 1 | 0 | 1UMJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed, for one (1) of eight (8) sampled residents, to ensure medications were not given without adequate indications of use and at an excessive dosage. The facility also failed to ensure that alternative causes for behaviors were ruled out and non-pharmacologic interventions were attempted without success prior to the use of psychoactive medications. Resident #19 experienced harm as evidenced by oversedation and decreased respirations after administration psychoactive medications. Resident identifier: #19. Facility census: 18. Findings include: a) Resident #19 Medical record review, on 03/25/09, revealed Resident #19 was admitted to the facility on [DATE]. On 09/15/08, a physician order [REDACTED]. Review of the nursing progress notes failed to record any behaviors to indicate the need for [MEDICATION NAME]. On 09/16/08 at 13:49 (2:49 p.m.), nursing progress note indicated, ". . . had been resting in chair very drowsy arouse when name called tho very weak, color dusky O2 sat on 3 liters 96 %, apical rate 92 and regular, faint bowel sounds, abdomen firm and distended had small loose stool this am (morning)." On 09/18/08, the physician ordered [MEDICATION NAME] 0.5 mg by mouth now for agitation and then [MEDICATION NAME] 0.5 mg every six (6) hours as needed for constant position changes, along with [MEDICATION NAME] 12.5 mg by mouth at night for the [DIAGNOSES REDACTED]. A nursing progress note, dated 09/18/08 at 18:23 (6:23 p.m.), revealed, "Pt becoming more restless and confused, attempts to get out of bed unassisted, family members cannot reason with him, medicated for pain." A subsequent nursing progress note, dated 09/19/08 at 00:19 (12:19 a.m.), stated, "1915 Pt voice was heard loudly from room out at nurses station, wife was holding pt's hands. Pt was agitated was to leave, she was trying to calm and reported by daughter bent her fingers back, he was out one side of the be… | 2014-07-01 |
| 11307 | 11307 | WELCH COMMUNITY HOSPITAL | 51A009 | 454 MCDOWELL STREET | WELCH | WV | 24801 | 2009-04-10 | 323 | D | 0 | 1 | 4JJY11 | Based on observations, medical record review, and staff interviews, the facility failed to ensure the residents' environment was as free of accident hazards as possible. One (1) of the three (3) styles of beds in use in the facility exhibited gaps between the side rail and the mattress sufficient to pose a risk of entrapment to a resident's arm or leg. Six (6) of nine (9) residents on the sample were affected. Additionally, a housekeeper was observed mopping the floor in the hall. She mopped across the entire hall and did not leave a dry lane for residents who were traveling through the hall. One (1) resident was observed removing the bar from a Merrywalker-type chair so she could sit on her bed. She had difficulty lifting her foot over the strap of the chair, which passed between her legs, in order to exit the chair. This created a falls hazard. Resident identifiers: #5, #9, #22, #34, #35, #47, and #12, and any residents ambulating through the hall. Facility census: 47. Findings include: a) Residents #5, #9, #22, #34, #35, and #47 These residents had been observed periodically throughout the survey to have their side rails elevated when they were in bed. On the morning of 04/10/09, nine (9) of the twelve (12) residents on the sample were still in bed. The space between the side rails and the mattresses were evaluated. It was found that one could easily pass one's arm (to a height above the elbow) through the space between the mattress and below the the end of the side rails on these residents' beds. The thin arms and legs of the residents could easily become entrapped between the rails and the mattress. Resident #47's bed rails were covered with fitted pads, but the pads did not prevent passage of one's arm between the rails and the mattress. Three (3) styles of beds and side rails were assessed. Two (2) styles did not pose a problem. However, the third type of bed had side rails that were offset from the frame, resulting in a gap between the side rail and mattress. b) Housekeeping On 04/09/09 at 10:40 a.m., a h… | 2014-07-01 |
| 11025 | 11025 | HEARTLAND OF KEYSER | 515122 | 135 SOUTHERN DRIVE | KEYSER | WV | 26726 | 2009-04-27 | 323 | E | 0 | 1 | 53ZE12 | Based on observation and staff interview, the facility failed to ensure medication carts were locked when left unattended by the nurse. This occurred for two (2) of four (4) medication carts observed during tour on 04/19/09. Facility census: 114. Findings include: a) Observations, on 04/19/09 at 9:15 p.m., found the medication cart was left unlocked by the nurse. The nurse (a registered nurse - Employee #24) was not within sight of the cart, and the corridor door to the room in which the nurse was passing medications. Upon coming out of the room, the nurse was notified the medication cart was not locked. b) Observations, on 04/19/09 at 9:30 p.m., found the medication cart was left unlocked by the nurse. The nurse (a licensed practical nurse - Employee #11) was not within sight of the cart, and the corridor door to the room in which the nurse was passing medications was closed. There were sixteen (16) vials of insulin located on the top of the medication cart in a box. . | 2014-09-01 |
| 11115 | 11115 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2009-04-30 | 279 | E | 0 | 1 | 6TSD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, observation, and staff interview, the facility failed to initiate a care plan and/or adequately address problems identified in the comprehensive resident assessment for five (5) of thirteen (13) sampled residents. Resident identifiers: #83, #78, #24, #43, and #158. Facility census: 101. Findings include: a) Resident #83 A review of Resident #83's medical revealed an [AGE] year old female with [DIAGNOSES REDACTED]. She was identified, on her quarterly minimum data set assessment (MDS) completed on 04/08/09, as exhibiting the behavior of wandering, and there were two (2) recorded incidents of resident-to-resident conflicts (08/01/08 and 03/06/09) involving her wandering behavior. A resident assessment protocol indicated this behavior would be care planned, but a review of the resident's entire current care plan failed to find wandering identified as a care plan problem with measurable goals and/or nursing interventions to be implemented. During an interview with the administrator and the director of nursing (DON) at 5:15 p.m. on 04/28/09, the DON acknowledged that, except for general interventions for cognitive deficiency, the resident's wandering behaviors were not addressed in her current care plan. On 04/30/09, the DON presented copies of an addendum to the resident's care plan addressing, "Resident @ risk for injury R/T (related to) wandering with-in facility." b) Resident #78 A review of Resident #78's medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. At the confidential resident group meeting held at 3:00 p.m. on 04/28/09, five (5) residents in attendance complained about Resident #78 wandering in and out of their rooms many times during the night. Resident #78 was also observed walking in a random manner several times throughout the survey. Review of her significant change in status MDS (02/07/08) and the most recent quarterly MDS (03/04/09) revealed the assessor indica… | 2014-08-01 |
| 11116 | 11116 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2009-04-30 | 152 | D | 0 | 1 | 6TSD11 | Based on record review and staff interview, the facility failed to ensure that the persons making healthcare decisions for two (2) of thirteen (13) sampled residents, who had been determined to lack the capacity to make such decisions for themselves, were appointed in accordance with State law. Resident identifiers: #45 and #60. Facility census: 101. Findings include: a) Resident #45 A review of Resident #45's medical record revealed a copy of a document appointing the resident's son as her medical power of attorney representative (MPOA). Review of the resident's advance directives, consents for vaccination, and other legal documents revealed these healthcare decisions had been made by the resident's daughter as evidenced by her signatures on these documents. During an interview with the director of nursing (DON) at 5:15 p.m. on 04/28/09, she stated the son was the MPOA of record, but the facility accepted the daughter's signature because she was the one who came in most often. b) Resident #60 A review of Resident #60's medical recordrevealed the individual who gave consent for a do not resuscitate order and for use of psychoactive medications, and who made other healthcare decisions for Resident #60 was not the person designated by the resident to serve as MPOA. During an interview with the DON at 5:15 p.m. on 04/28/09, she acknowledged that the person making the resident's healthcare decisions was not the resident's legally appointed MPOA. | 2014-08-01 |
| 11117 | 11117 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2009-04-30 | 150 | D | 0 | 1 | 6TSD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to act upon a resident's wish to change her advance directives. Resident #54, who was determined to possess the capacity to understand and make her own medical decisions, upon admission indicated she wished to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or [MEDICAL CONDITION] arrest. Shortly after admission, she decided she did not want to receive CPR, and the facility failed to act upon her request for do not resuscitate (DNR). Resident identifier: #54. Facility census: 101. Findings include: a) Resident #54 Record review, on [DATE], revealed Resident #54 was admitted to the facility on [DATE]. Review of her interdisciplinary progress notes (by nursing) revealed an entry, dated [DATE], stating the resident was a "full code at this time", meaning the resident was to receive CPR in the event of cardiac or [MEDICAL CONDITION] arrest. A physician's orders [REDACTED]. Review of a subsequent entry in the interdisciplinary progress notes (by social services), dated [DATE], revealed, "POST (physician's orders [REDACTED]. Code status DNR." This form was completed by the resident and Employee #133, but there was no physician's signature on it. Interview with Employee #80 on [DATE], and with other staff reviewing the resident's medical record on [DATE], confirmed the facility had not followed through to ensure the resident's request for DNR was confirmed by an order signed by the attending physician. . | 2014-08-01 |
| 11118 | 11118 | NEW MARTINSVILLE CENTER | 515074 | 225 RUSSELL AVENUE | NEW MARTINSVILLE | WV | 26155 | 2009-04-30 | 156 | E | 0 | 1 | 6TSD11 | Based on record review and staff interview, this Medicare-participating facility failed, for four (4) of four (4) residents reviewed, for whom a determination was made by the facility that Medicare will not pay for skilled nursing or specialized rehabilitative services and that an otherwise covered item or service may be denied as not reasonable and necessary, to notify the resident or his/her legal representative in writing why these specific services may not be covered; the beneficiary ' s potential liability for payment for the non-covered services; the beneficiary right to have a claim submitted to Medicare; and the beneficiary ' s standard claim appeal rights that apply if the claim is denied by Medicare. This practice had the potential to affect all residents for whom a determination of non-coverage by Medicare had been made by the facility. Resident identifiers: #52, #99, #66, and #4. Facility census: 101. Findings include: a) Residents #52, #99, and #66 A review of the forms entitled "SNF Determination on Continued Stay" for these residents revealed only the date that Medicare-covered services would be discontinued; there was no mention in writing of what specific service may no longer be covered or why. The only verbiage included in the form was "no longer requires skilled services" or "exhausted benefits". During an interview with the administrator and the office person responsible for providing this notification at 3:20 p.m. on 04/27/09, they acknowledged that this was form given to the resident and/or the responsible party as the notification of discontinuance of Medicare-covered skilled services and of their right to appeal this decision. They also agreed, after reviewing the forms, that the documentation did not on these residents' forms did not specify the service that was no longer being covered. When asked, neither person was able to state, during the interview, exactly what service had been discontinued for each of these three (3) residents. b) Resident #4 A review of the Notice of Medicare Prov… | 2014-08-01 |
| 11120 | 11120 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2009-05-08 | 323 | E | 0 | 1 | V73M11 | Based on observation and staff interview, the facility failed to ensure the environment was as free of accident hazards as possible. During the medication pass observation, one (1) of four (4) nurses observed failed to ensure filled syringes and medications were locked in the medication cart when the cart was left unattended and out of the nurse's line of sight. Facility census: 27. Findings include: a) During the medication pass on 05/06/09 at 9:05 a.m., when approaching the medication cart on the 260 hall, observation found the cart was unattended in the hall. Further observation found two (2) 10 cc syringes containing a clear liquid and two (2) 50 cc bags which contained IV (intravenous) medications on top of the cart. Observation of the 260 hall found the medication nurse (Employee #29) was in a resident's room and not within sight of the medication cart. During an interview on 05/06/09 at 10:30 a.m., the director of nursing confirmed that the practice of leaving filled syringes and medications unattended on top of a medication cart presented an accident hazard and the medications should have been locked in the cart. . | 2014-08-01 |
| 11121 | 11121 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2009-05-08 | 431 | E | 0 | 1 | V73M11 | Based on observation and staff interview, the facility failed to ensure drugs used in the facility were stored under proper temperature controls. Observation of one (1) of one (1) refrigerator in the facility, used to store drugs requiring refrigeration, found the internal temperature was 50 degrees Fahrenheit (F). The refrigerator contained three (3) vials of Novolin R insulin, two (2) boxes containing vials of influenza virus vaccine, and one (1) 50 cc bag of IV (intravenous) Vancomycin which required refrigeration. Both the insulin and the influenza vaccines are to be stored in a refrigerator with an internal temperature between 36 degrees F and 46 degrees F. This practice had the potential to alter the effectiveness of temperature-sensitive drugs. Facility census: 27. Findings include: a) Inspection of the refrigerator in the medication room, on 05/06/09 at 9:45 a.m., found the thermometer inside the refrigerator indicated an internal temperature reading of 50 degrees F. Review of May 2009 temperature log for this refrigerator revealed temperatures of 50 degrees F on the 05/01/09, 05/03/09, and 05/05/09. The temperature log for April 2009 recorded readings of 50 degrees F on 04/23/09 and 48 degrees F on 04/24/09 and 04/26/09. The temperature log for March 2009 recorded temperatures of 48 degrees F on 03/04/09 and 03/06/09, with a high reading of 60 degrees F on 03/08/09. Inspection of the contents of the refrigerator revealed three (3) vials of Novolin R insulin, two (2) boxes containing vials of influenza vaccine, and one (1) 50 cc bag of IV Vancomycin which had been mixed. According to Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th edition), unopened vials of Novolin R insulin are to be stored in a refrigerator with an internal temperature between 36 degrees F and 46 degrees F. Review of the instructions on one (1) of the boxes of influenza vaccine revealed this, too, was to be kept refrigerated between 36 degrees F and 46 degrees F. During an interview on the morning of 05/06/09, the facility'… | 2014-08-01 |
| 11122 | 11122 | UNITED TRANSITIONAL CARE CENTER | 515107 | 327 MEDICAL PARK DRIVE | BRIDGEPORT | WV | 26330 | 2009-05-08 | 225 | D | 0 | 1 | V73M11 | Based on a review of facility complaint records and staff interview, the facility failed to implement its policy regarding the reporting of neglect for one (1) of three complaints reviewed. Complaint #l included allegations of a nursing assistant refusing to assist a resident to find her shoes and refusing to bath the resident. There was no evidence to reflect this allegation of neglect had been reported to State agencies, including the Nurse Aide Abuse Registry, as required by State law. Facility census: 27. Findings include: a) Complaint #1 Review of the facility's complaint records revealed Complaint #1, dated 12/11/08, which documented a resident's report that a nursing assistant had refused to help find her shoes and refused to give her a bath because she was going home. Further review revealed no evidence the facility reported this allegation of neglect to State agencies, including the Nurse Aide Abuse Registry, as required by State law and in accordance with the facility's abuse policy (which was reviewed on 05/07/09). During an interview on 05/07/09 at 1:30 p.m., the director of nursing (Employee # 49) confirmed this allegation of neglect had not been reported to State agencies as required. . | 2014-08-01 |
| 11295 | 11295 | ARBORS AT FAIRMONT | 515189 | 130 KAUFMAN DRIVE | FAIRMONT | WV | 26554 | 2009-05-14 | 353 | E | 1 | 0 | 674B11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff, and resident interview, and a review of assignment sheets and schedules, the facility failed to deploy sufficient direct care staff across all shifts and units to meet the assessed care needs of dependent residents. This deficient practice affected more than an isolated number of residents. Facility census: 119. Findings include: a) On the evening of 05/10/09 (from 7:30 p.m. through 12:00 a.m.) continuing into the early morning of 05/11/09, observations revealed the following: - On the 3:00 p.m. to 11:00 p.m. (3-11) shift on 05/10/09, there were four (4) nurses and six (6) nursing assistants present for one hundred nineteen (119) residents. Per the planned nursing schedule, there should have been four (4) licensed nurses and eleven (11) nursing assistants in the facility. - On the 11:00 p.m. to 7:00 a.m. (11-7) shift beginning on 05/10/09 through 05/11/09, there were four (4) nurses and four (4) nursing assistants present in the facility. Per the planned nursing schedule, there should have been four (4) licensed nurses and four (4) nursing assistants in the facility. On 05/10/09, all nursing staff members who were present in the facility for the 3-11 and 11-7 shifts were confidentially interviewed. A review of the twenty-four (24) hour nursing reports for the 11-7 shift revealed: - On 05/13/09, there were only three (3) licensed nurses and four (4) nursing assistants for the entire shift. - On 05/08/09 from 11:00 p.m. through 3:00 a.m., there were only four (4) licensed nurses and three (3) nursing assistants. - On 05/07/09 from 11:00 p.m. through 3:00 a.m., there were only three (3) nurses and three (3) nursing assistants, with a fourth coming in from 3:00 a.m. to 7:00 a.m. - On 05/06/09 from 11:00 p.m. through 3:00 a.m., there were three (3) nurses and three (3) nursing assistants until 3:00 a.m., when a fourth (4) nursing assistant came in from 3:00 a.m. to 7:00 a.m. - On 05/05/09, there were four (4) nurses an… | 2014-07-01 |
| 11184 | 11184 | WEIRTON MEDICAL CENTER, D/P | 515077 | 601 COLLIERS WAY | WEIRTON | WV | 26062 | 2009-05-20 | 465 | D | 1 | 0 | V0TW11 | Guidelines for Design and Construction of Health Care Facilities 2 Building Systems 2.1 Plumbing 2.1.1 General. Unless otherwise specified herein, all plumbing systems shall be designed and installed in accordance with the International Plumbing Code. 2.1.2 Plumbing and Other Piping Systems 2.1.2.1 Hot water systems. The following standards shall apply to hot water systems: *(1) Capacity. The water-heating system shall have sufficient supply capacity at the temperatures and amounts indicated in the applicable table. Storage of water at higher temperatures shall be permitted. (2) Hot water distribution systems serving patient/resident care areas shall be under constant recirculation to provide continuous hot water. This Standard is Not Met as evidenced by: Based on measured water temperatures, the facility failed to provide continuous hot water at the required temperatures indicated in Table 4.1-3 (95 - 110 degrees Fahrenheit (F)). Facility census: 28. Findings include: a) At approximately 10:50 a.m. on 05/19/09, hot water temperature was measured in the sink serving resident room #630. The hot water temperature at this sink was measured to be 65.9 degrees F after heavily flowing water for four (4) minutes. The hot water temperature at a second sink serving the Ante-room portion of this resident room was measured at 66.0 degrees F initially and rose to 108.0 degrees F after three (3) minutes. The hot water temperature of the first sink was re-measured and found to be 108 degrees F. To conclude, a time frame of seven (7) minutes was required to obtain an acceptable hot water temperature and continuous hot water is not provided. As such, the comfort of the resident is compromised. . | 2014-07-01 |
| 11285 | 11285 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2009-05-21 | 279 | D | 1 | 0 | JD6Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and staff interview, the facility failed to develop a comprehensive care plan for one (1) of eight (8) sampled residents. A resident was admitted to the facility with an antibiotic-resistant respiratory infection and was ordered antibiotic therapy by the physician. The facility did not address the respiratory infection on the resident's care plan. Resident identifier: #59. Facility census: 56. Findings include: a) Resident #59 Resident #59's closed medical record, when reviewed on 05/20/09, revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 02/05/09, the physician ordered, "[MEDICATION NAME] 600 milligrams BID (twice daily) [MEDICAL CONDITIONS]-resistant Staphylococcus aureus)." The resident's admission minimum data set assessment (MDS), dated [DATE], in Section I, 2., indicated the resident had an antibiotic-resistant infection. Review of the resident's care plan, dated 02/05/09, found no mention of the resident's antibiotic-resistant respiratory infection. The assistant director of nursing (ADON - Employee #1), when interviewed on 05/21/09 at 10:20 a.m., stated she was the facility's infection control nurse and confirmed the resident's care plan did not address the respiratory infection. The ADON further stated it was the facility's policy to [MEDICAL CONDITION] infections on the care plan. . | 2014-07-01 |
| 11286 | 11286 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2009-05-21 | 323 | G | 1 | 0 | JD6Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to assure the safety of one (1) of eight (8) sampled residents, by not providing adequate supervision to prevent an accident with injury requiring emergency medical intervention. Resident identifier: #57. Facility census: 56. Findings include: a) Resident #57 Review of Resident #57's closed medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. The resident fell in her room on 06/04/08, striking her head and requiring an emergency transport to the hospital for closure of the laceration. The resident's daughter, when interviewed, reported the resident was standing at the sink while a nursing assistant was making her bed when she fell , although her mother was supposed to have the assistance of two (2) staff members when up. The resident's daughter stated she questioned the facility about the lack of assistance at the time of the fall. Documentation on the incident report of the fall stated, "Pt. (patient) was ambulating in walker and CNA (certified nursing assistant), lost balance and fell backwards." While the description of the circumstances surrounding the fall varied between these two (2) sources, both the incident report and the resident's daughter indicated only one (1) staff member was present at the time of Resident #57's fall. A review of Resident #57's care plan revealed a nursing intervention indicating the resident required the assistance of two (2) staff members when getting out of bed. An activities of daily living (ADL) assistance form communicated to the nursing assistants, on 09/26/07 and again on 04/24/08, that the number of staff Resident #57 required for bed mobility, transfers, and toileting as "2+" (two (2) or more). Documentation by the nursing assistants on the ADL flow sheet, for 06/04/08, recorded Resident #57 required maximum physical help or total dependence of staff for bed mobility, transfers, and toileting. The … | 2014-07-01 |
| 11287 | 11287 | CANTERBURY CENTER | 515179 | 80 MADDEX DRIVE | SHEPHERDSTOWN | WV | 25443 | 2009-05-21 | 225 | D | 1 | 0 | JD6Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, family interview, and staff interview, the facility failed to immediately report and/or thoroughly investigate an allegation of neglect, when one (1) of eight (8) sampled residents, who did not receive the assistance of two (2) staff members with transfer or ambulation, fell and sustained an injury. Resident identifier: #57. Facility census: 56. Findings include: a) Resident #57 Review of Resident #57's closed medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. The resident fell in her room on 06/04/08, striking her head and requiring an emergency transport to the hospital for closure of the laceration. The resident's daughter, when interviewed, reported the resident was standing at the sink while a nursing assistant was making her bed when she fell , although her mother was supposed to have the assistance of two (2) staff members when up. The resident's daughter stated she questioned the facility about the lack of assistance at the time of the fall. Documentation on the incident report of the fall stated, "Pt. (patient) was ambulating in walker and CNA (certified nursing assistant), lost balance and fell backwards." While the description of the circumstances surrounding the fall varied between these two (2) sources, both the incident report and the resident's daughter indicated only one (1) staff member was present at the time of Resident #57's fall. A review of Resident #57's care plan revealed a nursing intervention indicating the resident required the assistance of two (2) staff members when getting out of bed. An activities of daily living (ADL) assistance form communicated to the nursing assistants, on 09/26/07 and again on 04/24/08, that the number of staff Resident #57 required for bed mobility, transfers, and toileting as "2+" (two (2) or more). Documentation by the nursing assistants on the ADL flow sheet, for 06/04/08, recorded Resident #57 required maximum physical help or tota… | 2014-07-01 |
| 10593 | 10593 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 225 | E | 0 | 1 | 5BYT11 | Based on a review of personnel files and staff interview, the facility failed to adequately screen employees to ensure they were free from personal histories of criminal conviction which would indicate unfitness for service in a nursing facility. The facility did not complete statewide criminal background checks for four (4) of five (5) sampled employees who lived in Ohio. Employees: #1, #2, #3, and #4. Facility census: 95. Findings include: a) Employees #1, #2, #3, and #4 Review of sampled personnel files revealed four (4) of five (5) new employees lived in another State (Ohio). Further review failed to find evidence of statewide criminal background checks completed for this individuals in that State. Interview with human resources personnel, on the late morning of 05/22/09, verified the above findings. . | 2015-01-01 |
| 10594 | 10594 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 253 | E | 0 | 1 | 5BYT11 | Based on observation and staff interview, the facility failed to assure the doors to resident rooms, bathrooms, and closets were in good repair. Ten (10) doors observed on the 200 Hall were in need of repair, with deep scratches and holes in the doors making these surfaces difficult to clean thoroughly. This was true for one (1) of four (4) hallways observed. Facility census: 95. Findings include: a) 200 Hall During a tour of the facility on 05/19/09 at 9:30 a.m., observation found doors to resident rooms, bathrooms, and closets on the 200 Hall were in poor condition, with deep scratches and holes in need of repair. The doors were for the following rooms: 201, 202, 204,205, 206, 207, 209 210, 211, and 212. During a tour with the maintenance personnel, staff confirmed these doors were scratched and/or had holes in them. . | 2015-01-01 |
| 10595 | 10595 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 272 | D | 0 | 1 | 5BYT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure one (1) of thirty-two (32) residents reviewed during Stage II of the survey was assessed for fluid needs. Resident #106, admitted about one (1) week ago, was receiving [MEDICAL TREATMENT] three (3) times a week, and her record contained no evidence of any assessment with respect to daily fluid needs. After surveyor intervention, the [MEDICAL TREATMENT] center's physician ordered a fluid restriction of 1500 cc daily. Facility census: 95. Findings include: a) Resident #106 Resident #106 was a fairly new admission of one (1) week's duration whose interim care plan did not address her daily fluid needs. Interview with Resident #106, on 05/21/09 at 11:30 a.m., revealed she was unaware of any type of fluid restriction. She also seemed somewhat confused at this time. Medical record review, on 05/21/09 at 2:35 p.m., revealed no physician orders dictating the amount of daily fluids allowed for this resident who received [MEDICAL TREATMENT] treatments three (3) times weekly. On 05/21/09 at 2:35 p.m., a staff nurse (Employee #25), when interviewed regarding fluid needs for this resident, reviewed the medical record and plan of care and agreed there was no order regarding daily fluid intake. She stated she thought there was no fluid restriction for this resident or, perhaps, the order got lost between the physicians. She immediately called the [MEDICAL TREATMENT] center, received an order for [REDACTED]. . | 2015-01-01 |
| 10596 | 10596 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 279 | D | 0 | 1 | 5BYT11 | **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 for two (2) of thirty-two (32) residents in Stage II. The antipsychotic medication of Resident #53, with a history prior to admission of exhibiting violent behavior, was discontinued, and the care plan did not direct staff to monitor the resident for a resurgence of violent behavior following discontinuation of the drug, did not identify non-pharmacologic approaches to use when the behavior occurred, and did not specify the therapeutic goal(s) of the other psychoactive medications the resident was still receiving. Resident #219 was admitted for falls and decreased mobility, and care plans for not developed to address either of these concerns. Facility census: 95. Findings include: a) Resident #53 Resident #53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 04/02/09 hospital discharge summary revealed the resident had been admitted from another hospital on [DATE], due to violent behavior and increased confusion. "According to the facility administrator, the patient the day prior to admission (on 03/26/09) became very violent and punched 2 female staff members and attempting to twist the wrist of another one, and as a result, was sent to the Emergency Department at __________(on 03/27/09)." Record review resident's admission orders [REDACTED]"agitation", and [MEDICATION NAME] 0.5 mg every six (6) hours PRN for "anxiety." A hospital history and physical examination [REDACTED]." A review of the nursing notes found an entry, dated 04/04/09 at 2300, recording, "Wakeful - numerous attempts to get OOB (out of bed) unassisted. Alert - confused x 3." On 04/05/09 the 10:00 a.m., a nurse wrote, "In bed with legs hanging out over the edge - When this nurse attempted to put legs back in bed Resident attempted kick and then striked (sic) at this nurse." A 04/12/09 nursing note recorded the physician's discontinuation of [MEDICA… | 2015-01-01 |
| 10597 | 10597 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 280 | D | 0 | 1 | 5BYT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to review and revise a resident's care plan when the reason for use of an indwelling Foley urinary catheter changed. This was true for one (1) of thirty-two (32) residents in the Stage II sample. Resident identifier: #78. Facility census: 95. Findings include: a) Resident #78 Medical record review revealed a care plan, written on 02/05/09, addressing the presence of an indwelling Foley urinary catheter. According to this care plan, the problem stated: "Risk for infection indwelling catheter d/t (due to) pressure area (hx of UTI'S) (history of urinary tract infections). The three (3) goals associated with this problem were: 1) "Resident will be free of complications of indwelling catheter daily", 2) "Will remain free from s/s (signs and symptoms) of UTI by next review date, and 3) "Foley will be d/c (discontinued) as condition and mobility improve prior to d/c (discharge) home." There was no evidence found in the medical record to show that, on 02/05/09, Resident #78 had pressure ulcers necessitating the use of an indwelling urinary catheter as stated in the plan of care. A quarterly care conference was held on 04/29/09, but the use of this catheter was not reviewed. There was no evidence, as of 05/20/09, to reflect this care plan had been reviewed or revised. Further review of the medical record revealed this catheter had been discontinued and was subsequently reinserted due to the resident's [MEDICAL CONDITION]. During an interview on 05/22/09 at 10:30 a.m., the care plan nurse confirmed this care plan should have been reviewed and revised during the 04/29/09 care plan meeting. After surveyor intervention, a new physician's orders [REDACTED]. . | 2015-01-01 |
| 10598 | 10598 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 309 | D | 0 | 1 | 5BYT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, family interview, resident interview, and policy review, the facility failed to establish parameters for the administration of pain medication when multiple pains medications were ordered; failed to document the effectiveness of PRN pain medication after it was given; and failed to report to the physician when "as needed" (PRN) medications were used frequently, so the physician would order around-the-clock pain medication for increased pain management. This was evident for three (3) of thirty-two (32) Stage II residents reviewed for pain management. Resident identifiers: #135, #9, and #137. Facility census: 95. Findings include: a) Resident #135 During an interview on the afternoon of 05/19/09, Resident #135 expressed pain in his stomach. Interview with the resident's nursing assistant (Employee #83), at 9:10 a.m. on 05/21/09, revealed Resident #135 did reported stomach pain and received medication for this symptom. Interview with the licensed practical nurse (LPN - Employee #16), at 10:45 a.m. on 05/21/09, revealed the resident expressed stomach discomfort, and this had also been reported by the resident's wife. The wife confirmed this at lunch time when interviewed on 05/21/09. She reported he had an ongoing problem with stomach pain for which they had not been able to determine the cause. He received [MEDICATION NAME], and this brought relief. A review of his medical record revealed Resident #135 had orders for Tylenol 325 mg two (2) tablets by mouth every four (4) hours PRN for pain and [MEDICATION NAME] with [MEDICATION NAME] 10-500 mg tablet by mouth every six (6) hours PRN for pain with a pain assessment to be completed every morning. The pain assessment was to include asking the resident what level the pain he was experiencing prior to medication administration on a scale from "0" to "10", with "10" being the worst. Review of the May 2009 Medication Administration Record [REDACTED]. On the reve… | 2015-01-01 |
| 10599 | 10599 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 323 | D | 0 | 1 | 5BYT11 | Based on observation, review of manufacturer's instructions for the application of a wrist restraint, and staff interview, the facility failed to apply a physical restraint, to one (1) of thirty-two (32) residents in the Stage II sample, in accordance with the manufacturer's instructions. Resident #137 was observed with the wrist restraint secured to the side rail, rather than the bed frame per the manufacturer's instructions. This practice placed the resident at risk for an accident. Facility census: 95. Findings include: a) Resident #137 On 05/21/09 at 11:00 a.m., observation by two (2) surveyors found the resident with a wrist restraint tied to the side rail. The side rail was a one-quarter length rail raised to an approximate forty five degree position, and the wrist restraint was tied to the bottom part of the rail. The resident was then observed with the director of nursing (DON) immediately after the first observation. Per the DON, the wrist restraint was applied to prevent the resident from pulling out a tracheostomy and a feeding tube. The DON indicated, during the observation, that the wrist restraint should not have been tied to the side rail, but should have been tied to the bed frame. According to the product's instructions, the device should have been secured to the movable part of the bed frame. . | 2015-01-01 |
| 10600 | 10600 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 329 | D | 0 | 1 | 5BYT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one (1) of thirty-two (32) residents in the Stage II sample. Resident #53 was admitted to the facility on [DATE] with physician's orders [REDACTED].", and [MEDICATION NAME] 0.5 mg every six (6) hours PRN for "anxiety." These medications were used in an excessive dose (duplicate therapy), without adequate monitoring for the resurgence of behaviors after the Zyprex was discontinued, and without monitoring to evaluate the efficacy of the medications and for possible adverse side effects. Facility census: 95. Findings include: a) Resident #53 Resident #53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 04/02/09 hospital discharge summary revealed the resident had been admitted from another hospital on [DATE], due to violent behavior and increased confusion. "According to the facility administrator, the patient the day prior to admission (on 03/26/09) became very violent and punched 2 female staff members and attempting to twist the wrist of another one, and as a result, was sent to the Emergency Department at __________(on 03/27/09)." Record review resident's admission orders [REDACTED]"agitation", and [MEDICATION NAME] 0.5 mg every six (6) hours PRN for "anxiety." A hospital history and physical examination [REDACTED]." A review of the nursing notes found an entry, dated 04/04/09 at 2300, recording, "Wakeful - numerous attempts to get OOB (out of bed) unassisted. Alert - confused x 3." On 04/05/09 the 10:00 a.m., a nurse wrote, "In bed with legs hanging out over the edge - When this nurse attempted to put legs back in bed Resident attempted kick and then striked (sic) at this nurse." A 04/12/09 nursing note recorded the physician's discontinuation of [MEDICATION NAME]. On 05/14/09 the 9:00 a.m., a nurse wrote, "Rsdt (resident) down in bed Nursing Assistants at bedside providing … | 2015-01-01 |
| 10601 | 10601 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 463 | E | 0 | 1 | 5BYT11 | Based on observation and staff interview, the facility's call alarm system was altered and not functioning as intended for the 100 Hall. The ceiling-mounted speaker used for the nurse call system's auditory alarm was covered with tape to make the volume too low to be heard by staff on the unit; the auditory alarm could only be heard at the nurses' station. Additionally, the length of the pull cord for call light in the bathroom of Room #113 was too short to be reached from the toilet if the resident needed to summon staff assistance. This deficient practice had the potential to affect all twenty-five (25) residents residing on 100 Hall. Facility census: 95. Findings include: a) Nurse call system on 100 Hall When verifying the functionality of the nurse call system on the 100 Hall on 05/21/09 at 11:00 a.m., observation revealed the visual alarm activated in the corridors above each resident doorway, and an auditory alarm sounded at the nurses' station. However, an auditory alarm could not be heard sounding on the hall itself. The environmental supervisor (Employee #103) went to the speaker where the sound should have been coming out and found the speaker was covered with surgical tape, which muted the auditory alarm. When the tape was removed, the alarm was audible from the speaker. The environmental supervisor verified the tape should not have been on the speaker. b) Call light for Room 113's bathroom Observation of the nurse call system serving the bathroom in Room 113 revealed the pull was only approximately 2 inches in length. A resident using the toilet, or a resident having fallen to the floor, would not have been able to reach the pull cord to summon assistance. The environmental supervisor was made aware of light, and a new pull cord was installed. . Resident 1: call alarms were covered with tape and inaudible | 2015-01-01 |
| 10602 | 10602 | PLEASANT VALLEY NSG. & REHAB C | 515064 | 1200 SAND HILL ROAD | POINT PLEASANT | WV | 25550 | 2009-05-22 | 514 | B | 0 | 1 | 5BYT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 1: oxygen tubing treatment sheets not complete Based on observation, medical record review, and staff interview, the facility failed to each resident's clinical record was accurate and complete. Staff failed to document weekly oxygen tubing changes ordered by the physician. Resident identifiers: #2188 and #3439 on the 400 Hall, and Residents #3163 and #1889 on the 100 Hall. Facility census : 95. Findings include: a) Residents #2188, #3439, #3163, and #1889 During random observations during tour on 05/19/09 and during resident interviews on the day of entry, four (4) residents were observed to have no dates on their oxygen tubings to indicate when they had most recently been changed. Also, there was no documentation on the residents' treatment records to reflect the tubing had been changed weekly as the physician had ordered. 1. Residents #2188 and #3439 On the 400 Hall on 05/19/09 at 9:30 a.m., Residents #2188 and #3439 were noted to have oxygen concentrators in use with no dates to show when the tubing had been changed. The filters on both concentrators were dirty. On 05/20/09 at 9:55 a.m., interview with the charge nurse (Employee #26) revealed the facility did not have a separate respiratory therapy department. Rather, a nurse came to the facility twice weekly, and she changed all the oxygen tubing in the facility on Fridays. Employee #26 also reported they had aides change the tubing if the nurse is not there. The charge nurse and surveyor checked the residents' treatment records and found Resident #2188's tubing change was not recorded for 05/08/09, and Resident #3439's tubing change was not recorded for 05/08/09 or 05/15/09. Both residents had orders for oxygen tubing to be changed weekly. The director of nursing (DON), who was present at this time, stated oxygen tubing was changed weekly in the facility and, when told of the above findings, said they would take care of it right away. 2. Residents #3163 and #1889 On the 100 Hal… | 2015-01-01 |
| 10944 | 10944 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2009-05-22 | 154 | D | 0 | 1 | T34S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, review of the facility's policy regarding cardiopulmonary resuscitation (CPR), and staff interview, the facility failed to ensure residents were fully informed in advance of care or treatment that might affect their well-being. Resident #94's medical record included a Physician order [REDACTED]. There was no evidence the resident / responsible party had been made aware of the facility's policy. One (1) of eight (8) residents whose closed record was reviewed was affected. Resident identifier: #94. Facility census: 86. Findings include: a) Resident #94 Review of the resident's medical record found a POST form had been completed by the resident's medical power of attorney representative (MPOA) on [DATE]. The MPOA had checked the POST form, indicating the resident was to be resuscitated. Further review of the medical record found an entry, dated [DATE] at 3:00 a.m., recording, "Called to residents (sic) room by staff at 12:30 AM (sic) No pulse - radial/carotid. No respirations. Skin cold to touch. Pupils fixed / dilated /c (with) pupil indented. Tem (temperature) 87.2 (degree mark) F...." The note continued, and the MPOA was quoted as saying, "I spent a long time with her a couple of days ago and I have been expecting this." No attempts were made to provide CPR. The director of nursing (DON), when interviewed regarding these findings at 7:45 a.m. on [DATE], stated they have night time briefs so staff do not have to disturb residents so often. She said staff does not go in and check to see whether residents are still breathing every two (2) hours, as this would disturb the sleeping residents. The DON said this resident had been stiff when she was found, and the resident's death was "very unexpected". The DON was asked whether there was a policy regarding when CPR would be provided. Shortly after, she provided a copy of the facility's policy entitled "Cardiopulmonary Resuscitation." The policy included, "Cardiopu… | 2014-11-01 |
| 10945 | 10945 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2009-05-22 | 156 | C | 0 | 1 | T34S11 | Based on observation and staff interview, the facility failed to post accurate information regarding the regional ombudsman. This practice had the potential to affect all residents. Facility census: 86. Findings include: a) During the initial tour of the facility on 05/18/09 at approximately 3:45 p.m., observation revealed the signs posted in the front lobby area of the building contained the incorrect telephone number and no name listed for the regional ombudsman. Other signs containing this same type of information were posted in various locations throughout the building and did have to correct information related to the regional ombudsman. At approximately 5:00 p.m. on 05/18/09, the administrator agreed the sign in the front area of the building needed to be corrected. . | 2014-11-01 |
| 10946 | 10946 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2009-05-22 | 157 | D | 0 | 1 | T34S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility failed to notify the physician when a resident repeatedly refused a medication in the evenings. The resident's medication administration records (MARs) indicated she had refused an evening dose of [MEDICATION NAME] for at least the last four (4) months. There was no evidence the physician had been notified of the resident's continued refusal to take the medication. Resident identifier: #51. Facility census: 86. Findings include: a) Resident #51 A nurse (Employee #7) was observed administering medications to this resident at approximately 7:10 p.m. on 05/20/09. She poured the resident's dose of [MEDICATION NAME], then initialed and circled the space for the resident's evening dose of [MEDICATION NAME] (ordered for constipation). As she did so, she explained the resident had been refusing to take the medication. On 05/22/09, the resident's MARs for February, March, April, and May 2009 were reviewed. The medication had consistently been circled, and an "R" had been written under the nurses' initials to indicate she had refused the medication. There was no evidence the physician had been notified so that he/she would be aware and might determine whether the resident's medication regimen needed to be changed. . | 2014-11-01 |
| 10947 | 10947 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2009-05-22 | 240 | D | 0 | 1 | T34S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and medical record review, the facility did not ensure staff provided residents with care and services in a manner and in an environment that promoted comfort and/or enhanced quality of life, affecting three (3) of fifteen (15) sampled residents. Resident #57 did not have access to her bedside table which contained a glass of water. Resident #74's call light was not placed within her reach to allow her to summon staff assistance when needed. Resident #44 complained of being cold. She told the nurse she had asked staff for a blanket three (3) times but had not yet received one. The nurse assured her one would be provided for her, but the nurse forgot to do so after she administered the resident's medications. Resident identifiers: #57, #74, and #44. Facility census: 86. Findings include: a) Resident #57 On 05/20/09 at approximately 8:20 a.m., Resident #57 asked for something to drink. Her bedside table was pushed up against the wall out of her reach. The resident had fall mats beside her bed, making it difficult to place the bedside table within her reach. Employee #17 (a licensed practical nurse) indicated the resident could not get her own water without pouring it out onto her clothing. On 05/20/09 at approximately 1:05 p.m., the director of nursing indicated the resident probably could drink from her glass but could not pour water out of her pitcher. The DON said the fall mats should not prevent the resident's table from being within her reach. She also felt it was important for the resident to have access to fluids, even though she does get fluids during the scheduled hydration pass. The minimum data set (MDS) quarterly review, with an assessment reference date (ARD) of 04/12/09, indicated the resident needed set up help only with eating. The resident also had a care plan in place for dehydration. b) Resident #74 On 05/19/09 at approximately 1:00 p.m., residents were eating lunch i… | 2014-11-01 |
| 10948 | 10948 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2009-05-22 | 279 | D | 0 | 1 | T34S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on care plan review and staff interview, the facility failed to ensure all interventions being used to prevent one (1) of fifteen (15) residents from having skin breakdown were included in the section of the care plan pertaining to this issue. Resident identifier: #53. Facility census: 86. Findings include: a) Resident #53 A review of Resident #53's care plan revealed the following problem statement: "Potential altered skin integrity R/T (related to): urinary / bowel incontinence." The resident had a physician's orders [REDACTED]. This intervention was not listed on the care plan. The director of nursing agreed this intervention needed included in the care plan. . | 2014-11-01 |
| 10949 | 10949 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2009-05-22 | 281 | D | 0 | 1 | T34S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, resident interview, staff interview, and review of the facility's policy regarding medications, the facility failed to ensure staff followed facility policy and generally accepted guidelines when a resident repeatedly refused a medication in the evenings. The resident's medication administration records (MARs) indicated she had refused an evening dose of [MEDICATION NAME] for at least the last four (4) months. There was no evidence the physician had been notified, nor was there documentation found to indicate nurses had explored why the resident did not take the medication. Resident identifier: #51. Facility census: 86. Findings include: a) Resident #51 The nurse (Employee #7), when administering medications to this resident at approximately 7:10 p.m. on 05/20/09, initialed and circled the space for the resident's evening dose of [MEDICATION NAME], saying the resident had been refusing to take the medication. She did not check with the resident first, nor did she make a notation regarding why the medication was not given other than to put an "R" to indicate it had been refused. On 05/22/09, the resident's MAR for February, March, April, and May 2009 were reviewed. The medication had consistently been circled, and an "R" had been written under the nurses' initials to indicate she had refused the medication. Review of the backs of the MARs and the nursing entries for these months found nothing to indicate why the resident had refused the medication. On 05/22/09 at 9:55 a.m., the resident was asked why she refused the medication in the evening. She replied she received the medication twice a day and did not feel she needed it twice a day every day. Review of the facility's policy entitled "Preparation and General Guidelines" found, "If a dose of regularly scheduled medication is withheld, refused, or given other than the scheduled time... the space of the front of the MAR for that dosage administration is (ini… | 2014-11-01 |
| 10950 | 10950 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2009-05-22 | 309 | E | 0 | 1 | T34S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of medical records, staff interviews, and resident interviews, the facility failed to ensure residents were assessed for efficacy of treatment changes; positioned to facilitate comfort and/or good body alignment; and received adaptive equipment as ordered by the physician. A resident had [MEDICAL CONDITION] for which the dosage of her diuretic was changed, but there was no evidence the effectiveness of this medication was monitored. Two (2) residents were observed while in bed without benefit of having been positioned for comfort, to enhance their physical abilities, and/or to maintain good body alignment. Two (2) residents had orders for specific devices for their wheelchairs which were no employed. Five (5) of fifteen (15) current residents on the sample were affected. Resident identifiers: #61, #44, #86, #47, and #53. Facility census: 86. Findings include: a) Resident #61 During the initial tour of the facility on 05/18/09 at approximately 4:15 p.m., observation found this resident sitting in her wheelchair in her room. Her feet were propped up on her bed, and her ankles and feet appeared [MEDICAL CONDITION]. After lunch on 05/20/09, the resident put her feet up on her bed while she was sitting in her wheelchair, She said, "They don't even go down at night anymore." She added that the [MEDICAL CONDITION] in her feet and legs used to go "down" at night while she was in bed. On 05/20/09 at 6:10 p.m., the resident was again observed. She again was sitting in her wheelchair with her feet propped up on her bed. Her feet, ankles, and lower legs were [MEDICAL CONDITION]. She said, "They haven't told me what's wrong, but it's getting so they don't go down at night." Review of the resident's medical record found the following: 1. She had been initially admitted to the facility on [DATE], with readmitted s of 02/12/09 and 03/19/09. 2. Her [DIAGNOSES REDACTED]. 3. A history and physical completed by the physician, dated … | 2014-11-01 |
| 10951 | 10951 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2009-05-22 | 310 | E | 0 | 1 | T34S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observations during meal times, the facility failed to ensure a resident's ability to eat did not diminish unless the individual's clinical condition made the diminution unavoidable. Residents were not seated and/or positioned to enable them to feed themselves with optimal comfort and ease. Eight (8) residents were observed to be in need of repositioning and/or changes in the height of the surface on which their meals were served relative to their bodies. Resident identifiers: #59, #64, #38, #1, #19, #54, #2, and #44. Facility census: 86. Findings include: a) Resident #59 At approximately 12:40 p.m. on 05/20/09, the resident was seated at a round table with three (3) other residents in the first floor dining room. The resident was seated in a reclining geri-chair. The top of the table was at the level of the resident's axilla. This resident was observed during the evening meal, at approximately 6:05 p.m., in the first floor dining room. She was seated in a geri-chair, and her meal tray had been placed on a table. The height of the table relative to her chair resulted in her plate being at the height of the base of her neck. b) Resident #64 On 05/20/09, this resident was observed at approximately 12:40 p.m. while eating in the first floor dining room. Her meal was at the height of the resident's axillary region. c) Resident #38 During lunch on 05/20/09, the resident was observed in her bed eating lunch. The head of her bed had been elevated to almost 90 degrees, and she had slid down in the bed until her subscapular region was resting near where her hips should have been in the angle of the bed. Her right shoulder was lower than the left. She was trying to eat with her left hand. It was noted she had not touched her Jello. When asked, she said she did not know it was there. At that time, Employee #97 entered the room, moved the bowl of Jello nearer to the resident, and told her it was Jello with bananas. The resident began to e… | 2014-11-01 |
| 10952 | 10952 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2009-05-22 | 371 | F | 0 | 1 | T34S11 | Based on observations made during the initial tour of the facility's kitchen and staff interview, the facility failed to store and prepare foods under sanitary conditions. A dented can was noted in the dry storage area, and equipment used to prepare food was noted to be in need of cleaning. This had the potential to affect any resident who received foods from the kitchen. Facility census: 86. Findings include: a) During the initial tour of the kitchen, a #10 can of peaches was noted on the shelf in the dry storage area. The can had a dented area involving the rim of the can and another dent greater than 45 degrees near the bottom of the can. Employee #64, when asked how dented cans were handled, said they were returned to the vendor. The can of peaches should not have been on the shelf. b) The Hobart floor stand mixer was noted to have bits of food hanging off of the head of the machine and food debris on the outside of the vessel. c) The Robot Coupe was noted to have the lid placed on the container in the closed position. There was moisture inside of the container, and a small bit of meat was adhering to the inside of the container. . | 2014-11-01 |
| 10953 | 10953 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2009-05-22 | 441 | E | 0 | 1 | T34S11 | Based on observations, the facility's infection control program was not effective in ensuring staff practiced aseptic techniques during dressing changes. The nurse removed a pen from her pocket after donning gloves, then had direct contact with the resident's wound; 4 x 4s came in direct contact with a can of saline spray used for multiple residents; a Sharpie was place on the clean field; and a measuring device was placed directly against a wound after having been placed on the resident's bed. Resident identifiers: #9, #47, #40, and #11. Facility census: 86. Findings include: a) Resident #9 On 05/20/09 at 7:50 a.m., a nurse (Employee #10) was observed providing care to a wound on the resident's right medial ankle. The nurse donned gloves then removed a pen from her uniform pocket. While wearing the same gloves, she had contact with the wound area. This created a potential to transfer organisms from her pocket and the pen to the resident's wound. When cleansing the wound, the nurse sprayed saline onto the sponges with her left hand. After moistening the sponges, she transferred them from her right hand to the left hand and cleansed the wound. The can of saline spray had been on the treatment cart and had been used for other residents. When the nurse transferred the sponges from her right hand to her left, a potential for transfer of organisms from the can to the resident's wound was created. b) Resident #47 Employee #10 was observed providing care to an open area on the resident's spine in the morning on 05/20/09. She sprayed Wound Wash Saline onto some gauze (4 x 4s), then allowed the 4 x 4s to come in contact with the can of spray. c) Resident #40 On the morning of 05/20/09, Employee #10 provided care to the resident's wound. Again the can of saline spray came in contact with the clean 4 x 4s. d) Resident #11 During the treatment procedure for this resident on the morning of 05/20/09, Employee #10 place a Sharpie she had removed from her pocket on her dressing field. The Sharpie would be considered a contaminat… | 2014-11-01 |
| 10954 | 10954 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2009-05-22 | 492 | D | 0 | 1 | T34S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to ensure determinations of incapacity were completed in accordance with the requirements of the West Virginia Code (Chapter 16 Article 30) and Physician order [REDACTED].?[DATE]. Three (3) of the fifteen (15) current residents on the sample were affected. Two (2) residents had been determined to lack the capacity to make medical decisions, but the determinations did not identify the nature of the incapacity and/or only included a [DIAGNOSES REDACTED]. One (1) resident's POST form had not been completed in accordance with the form's instructions. Resident identifiers: #20, #14, and #57. Facility census: 86. Findings include: a) Resident #20 The POST form, as specified in ?[DATE] of the West Virginia Code, includes the following instruction in Section F: "If I lose decision-making capacity, I authorize my medical power of attorney representative / health care surrogate to make all medical decisions for me, including those regarding CPR and other life-sustaining treatment and to complete a new form. (Initials in box indicate patient acceptance of this statement)." The form signed by the resident, on [DATE], had a check mark in the box instead of the resident's initials as specified on the form. The initials were intended to verify the resident had made the choice to allow another to change his or her wishes should he or she no longer be able to express his or her wishes regarding end of life care. b) Resident #14 Review of the resident's determination of incapacity dated [DATE] found the only cause listed was "Dementia". There was no additional informations provided to indicate how advanced the resident's dementia was to establish she was no longer capable of making decisions on her own behalf. Additionally, under the section "Nature" nothing had been checked. The West Virginia Code includes the following: "?[DATE]. Determination of incapacity. "(a) For the purposes of… | 2014-11-01 |
| 10955 | 10955 | GREENBRIER MANOR | 515185 | ROUTE 2, BOX 159A | LEWISBURG | WV | 24901 | 2009-05-22 | 514 | D | 0 | 1 | T34S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, the facility failed to ensure the clinical record of each resident was accurate and complete. One (1) resident was listed as living in another facility on the face sheet. Another resident had an order for [REDACTED]. Two (2) of fifteen (15) current residents on the sample were affected. Resident identifiers: #45 and #68. Facility census: 86. Findings include: a) Resident #68 According to nursing entries, contact isolation was ordered for this resident on 02/06/09, but the order was not written until sometime between 02/16/09 and 02/19/09. When the order was written, it was noted as being late, but no specific date was included in the order. Review of the nursing entries, between 02/06/09 and 02/19/09, did not find any evidence the resident had been placed on contact precautions other than the one (1) entry made by the nurse who later wrote the order. b) Resident #45 During the medical record review for Resident #45 on 05/19/09, the face sheet revealed the resident's address as being that of a neighboring facility. At approximately 4:30 p.m. on 05/19/09, the administrator agreed the face sheet needed changed to reflect the resident's current address. | 2014-11-01 |
| 11037 | 11037 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2009-05-22 | 323 | E | 0 | 1 | ETK911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on water temperature measurements, staff interview, and observation, the facility failed to assure the residents' environment was as free of accident hazards as possible. Water temperatures were too hot in residents' hand sinks, a resident was not ambulated as ordered to prevent falls, and a treatment cart was left unlocked and unattended in the hallway. These practices had the potential to affect one (1) sampled resident and all residents who could ambulate independently. Resident identifier: #51. Facility census: 55. Findings include: a) Water temperatures On 05/22/09, temperatures of hot water were taken with the facility's environment services supervisor (ESS). The water temperatures were taken of the hand sinks on "B," "C," and "D" Halls, with the following findings which exceeded the maximum safe temperature (110 degrees F): - B-2 was 118 degrees F at 10:08 a.m. - C-3 was 116 degrees F at 10:10 a.m. - D-1 was 116.8 degrees F at 10:10 a.m. Interview with the ESS, at 9:45 a.m. on 05/22/09, revealed he mistakenly believed 110 degrees F was the minimum allowable temperature in resident areas, instead of the maximum allowable temperature. Record review revealed water temperatures were being taken, but the exact temperatures were not being recorded. A check mark was being placed beside 110 degrees F. According to the ESS, this check meant the hot water was 110 degrees F or above. b) Resident #51 Medical record review revealed an order for [REDACTED]. This information was also found on the closet sheet. At noon on 05/22/09, this resident was observed being ambulated to and from the dining room without being followed with a wheelchair, creating an accident hazard for this resident. c) Treatment cart On 05/21/09 at 11:45 a.m., random observations of the resident environment found s treatment cart parked in the "C" hallway with no staff members present in the hallway. Inspection of the treatment cart found it had been left unlocked and stoc… | 2014-09-01 |
| 11038 | 11038 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2009-05-22 | 332 | D | 0 | 1 | ETK911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to assure medication were administered with an error rate below 5 percent (5%). Facility nursing staff members made three (3) medication errors with an opportunity for fifty-three (53) errors for an overall error rate of 5.6 %. This deficient practice affected three (3) of seven (7) residents receiving medications. Resident identifiers: #55, #37, and #35. Facility census: 55. Findings include: a) Resident #55 Observations of the medication administration pass, on 05/20/09 at 9:10 a.m., found the nurse pouring liquid Potassium into a plastic medication cup. Review of the medication administration record (MAR) noted the physician ordered Resident #55 to receive 7.5 cc of liquid Potassium. The nurse was asked to measure the amount of liquid Potassium present in the cup by using a syringe. The nurse determined the cup only contained 6.25 cc of liquid Potassium. b) Resident #37 Observation of the medication administration pass, on 05/21/09 at 9:15 a.m., found the nurse preparing medications for Resident #37. Review of the MAR noted the resident was to receive 150 mg of [MEDICATION NAME]. Inspection of the bottle of [MEDICATION NAME] utilized by the nurse revealed each tablet contained 75 mg. of [MEDICATION NAME]. The nurse placed one (1) tablet of [MEDICATION NAME] into the resident's medication cup and administered it to the resident along with her other medications. The nurse was asked to again review the MAR and bottle of medication following the administration. She agreed the she should have administered two (2) tablets of [MEDICATION NAME] to the resident. c) Resident #35 Review of the medical record found Resident #35 was prescribed [MEDICATION NAME] 120 mg three-times-a-day (TID) before each meal for treatment of [REDACTED]. Observations of the resident, on the morning of 05/21/09, found no nurse administered [MEDICATION NAME] prior to the noon meal. Revie… | 2014-09-01 |
| 11039 | 11039 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2009-05-22 | 428 | F | 0 | 1 | ETK911 | Based on medical record review and staff interview, the facility failed to assure a licensed pharmacist conducted a review of each resident's drug regimen at least once a month. This deficient practice affected all residents currently residing in the facility. Facility census: 55. Findings include: a) Review of thirteen (13) medical records found no evidence a licensed pharmacist conducted a drug regimen review for the month of April 2009. An interview with the director of nursing (DON), on the morning of 05/20/09, confirmed a drug regimen review was not conducted by a licensed pharmacist in April 2009. . | 2014-09-01 |
| 11040 | 11040 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2009-05-22 | 441 | D | 0 | 1 | ETK911 | Based on random observation and review of facility policy, the facility failed to assure nurses administered eye drops in a manner to prevent the potential spread of infection for two (2) of two (2) eye drop administrations observed. Resident identifiers: #55 and #50. Facility census: 55. Findings include: a) Resident #55 During observations of the medication administration pass on 05/21/09 at 9:10 a.m., the nurse (Employee #52) administered eye drops to Resident #55. The nurse did not wash or sanitize her hands. She removed gloves from a box in the room, wadded them up in her hands, carried the resident's oral medications and bottle of eye drops into the resident's room, then removed another pair of gloves from the box in the room and placed them into her uniform pocket. The nurse administered the resident's oral medications. She then removed a pair of gloves from her uniform pocket, donned the contaminated gloves, and administered one (1) drop of medication into each of the resident's eyes. The director of nursing (DON) provided the facility's policy on the instillation of eye drops at 10:30 a.m. on 05/20/09. Review of the policy section entitled "Infection Control Protocol and Safety" (revised August 2002) found the following instructions: "1. Wash your hands thoroughly with soap and water at the following intervals: a. before the procedure; ... ." b) Resident #50 On 05/21/09 at 9:15 a.m., the nurse (Employee #30) administered eye drops to each of Resident #50's eyes. During this administration, the nurse allowed the tip of the eye drop bottle to come into contact with the lashes of the resident's left eye. . | 2014-09-01 |
| 11041 | 11041 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2009-05-22 | 502 | D | 0 | 1 | ETK911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain laboratory services to meet the needs of one (1) of thirteen (13) sampled residents. Resident identifier: #1. Facility census: 55. Findings include: a) Resident #1 Review of the medical record found a physician's orders [REDACTED]. The medical record contained no evidence the facility had obtained the ordered laboratory test for this resident. An interview with the director of nursing (DON), on 05/21/09 at 12:00 p.m., confirmed the facility did not obtain the ordered laboratory test. . | 2014-09-01 |
| 11042 | 11042 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2009-05-22 | 225 | E | 0 | 1 | ETK911 | Based on review of the facility's complaint records and staff interview, the facility failed to thoroughly investigate allegations of neglect upon receipt, and failed to report licensed healthcare professionals involved in instances of neglect to the appropriate licensing boards, and failed to assure staff immediately reported all allegations of neglect to the facility's administrator. These practices were evident for six (6) of ten (10) allegations reviewed. Resident identifiers: #5, #6, #35, #57, and #58. Facility census: 55. Findings include: a) Resident #6 On 01/06/09, Resident #6 reported to the facility she sometimes turned on her bathroom light and was not assisted for several minutes. The facility interviewed assigned nursing assistants and took statements. In one (1) of these statements, a nursing assistant identified by name another nursing assistant who had also helped the resident on the 7-3 shift on 01/06/09. The facility did not interview this other nursing assistant and/or obtained a statement from him/her. b) Resident #35 On 01/30/09, Resident #35's family expressed concern that the resident might not be getting showers on her scheduled shower days. The facility's investigation indicated statements were collected from nursing staff; however, upon request, the facility could not produce these statements. On 03/10/09, this resident's family again expressed concern that the resident was not receiving her scheduled showers. There was no investigation of this allegation; the facility only obtained statements from staff regarding what was supposed to occur regarding residents and their shower days. In addition, the family also expressed concern that the resident's personal items were being used for other residents. This concern was not addressed at all. c) Resident #5 On 02/20/09, Resident #5 reported she had not been receiving her medications for her mouth since admission on 02/05/09. The facility investigated the situation and disciplined several nurses for failing to order the medication and/or faili… | 2014-09-01 |
| 11043 | 11043 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2009-05-22 | 364 | F | 0 | 1 | ETK911 | Based on observation and staff interview, the facility failed to assure potatoes were prepared by a method which conserved nutritional value. They were soaked in water, creating a loss of nutrients. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 55. Finding include: a) On 05/18/09 at 2:00 p.m., observation revealed a large pan of potatoes in a large amount of water in the cooler. Upon inquiry, at that time, the cook stated the potatoes were for the following day. Further inquiry revealed the water would be drained off and discarded. This practice creates a loss of potassium in the potatoes. This process is called "leaching" and is used when potassium needs to be removed from potatoes for potassium restricted diets. | 2014-09-01 |
| 11044 | 11044 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2009-05-22 | 315 | D | 0 | 1 | ETK911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and staff interview, the facility failed to provide services and treatment to restore as much normal bladder function as possible for one (1) of twelve (12) sampled residents. The facility did not assess one (1) of thirteen (13) sampled residents or put individualized measures in place to help restore continence when a resident had a decline in bladder continence. Resident identifier: #12. Facility census: 55. Findings include: a) Resident #12 Medical record review, on 05/20/09, revealed this resident had an indwelling Foley urinary catheter when she was admitted on [DATE]. The facility implemented a bladder training schedule for discontinuation of the catheter on 08/20/08, 08/21/08 and 08/23/08, and the catheter was discontinued at 12:00 a.m. on 08/23/08. A bladder assessment was completed on 10/13/08. This assessment indicated the resident was continent of bladder. Review of the resident's minimum data set assessment (MDS), with an assessment reference date (ARD) of 02/08/09, revealed the resident's bladder continence was coded "2", indicating occasional bladder incontinence. This coding represents incontinence two (2) or more times a week, but not daily. Review of the resident's MDS, with an ARD of 05/03/09, revealed the resident was coded "3", indicating frequent bladder incontinence. This coding represents incontinence daily. Review of the resident's care plan, dated 05/05/09, revealed the following problem: "Having incontinence of bowel and bladder which has worsened." The interventions for this problem did not include anything regarding assessment for causal factors. The interventions described the resident had declined a toileting schedule. There was no evidence of any other plans to assist the resident in becoming continent and/or less incontinent. The facility's urinary continence and incontinence assessment and management policy, provided by the director of nursing (DON), instructed fa… | 2014-09-01 |
| 11045 | 11045 | FAYETTE NURSING AND REHABILITATION CENTER, LLC | 515153 | 100 HRESAN BOULEVARD | FAYETTEVILLE | WV | 25840 | 2009-05-22 | 246 | D | 0 | 1 | ETK911 | Based on observation and staff interview, the facility failed to made reasonable accommodations with staff's routine and/or practices to ensure residents received timely assistance with toileting to maintain independent functioning and dignity. This affected two (2) residents of random observation. Resident identifiers: #39 and #51. Facility census: 55. Findings include: a) Residents #51 and #39 After the noon meal on 05/22/09 at 1:45 p.m., observation found Resident #51 waiting for a staff member to take her to the bathroom. Upon inquiry, the resident stated she had already asked staff to take her, but they have not "gotten to me yet". The resident then stated, "If I don't go to the bathroom soon, I'm gonna go. I know what everyone feels like now when they've gotta go and no one to take them." Further discussion revealed staff told the resident she would have to wait until the trays were picked up to be taken to the bathroom. A few minutes later, the resident was taken to her room and into the bathroom. While Resident #51 was in the bathroom, her roommate (Resident #39) was brought to the entrance of their room to be taken to the bathroom. When Resident #39 was informed Resident #51 was in the bathroom, Resident #39 stated she had to go "now" and "I am about to wet myself." A nursing assistant and a nurse were just outside the door when this occurred. When asked what should be done in this situation, the nurse stated, "That's a good question. This has not come up before." Neither nursing staff member considered, or took, Resident #39 to a different bathroom. . | 2014-09-01 |
| 11505 | 11505 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2009-05-29 | 152 | D | E5O711 | Based on medical record review, and staff interview, the facility failed to assure the right to make medical decisions for one (1) of ten (10) sampled residents was exercised in accordance with State law (the West Virginia Health Care Decisions Act). The facility allowed a health care surrogate (HCS) to transfer decision-making authority to a different family member when the HCS was unavailable. Resident identifier: #4. Facility census: 29. Findings include: a) Resident #4 Review of Resident #4's medical record found the treating physician determined the resident lacked capacity to understand and make informed medical decisions on 04/17/09. The physician appointed Family Member #1 to act as the resident's HCS. Further review found a handwritten, notarized document which appeared to be authored by Family Member #1, transferring the health care decision-making authority to Family Member #2 in the event Family Member #1 could not be reached. On 05/28/09 at 1:00 p.m., the document was shown to two (2) facility nurses (Employees #24 and #27). Each was asked what they would do if Family Member #1 could not be reached to make a health care decision. Both stated that, because the document was notarized, they would contact Family Member #2 to make health care decisions. Review of section 16-30-8 (a) of the West Virginia Health Care Decisions Act found the following language, "When a person is or becomes incapacitated, the attending physician or the advanced nurse practitioner with the assistance of other health care providers as necessary, shall select, in writing, a surrogate." The facility allowed a HCS to transfer medical decision-making authority to another individual in violation of the West Virginia Health Care Decisions Act. Only the attending physician or advanced nurse practitioner may select a surrogate decision-maker. . | 2014-01-01 | ||
| 11506 | 11506 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2009-05-29 | 225 | E | E5O711 | Based on review of personnel records and other facility documents and staff interview, the facility failed to assure comprehensive screening was completed for three (3) of five (5) newly hired employees. Additionally, the facility failed to report an allegation of abuse involving one (1) resident to the State survey and certification agency and other officials in accordance with State Law. These deficient practices had the potential of affecting more than an isolated number of residents currently residing in the facility. Employee identifiers: #7, #14, and #76. Resident identifier: #2. Facility census: 29. Findings include: a) Employees #7, #14, and #76 1. Review of personnel records, on the afternoon of 05/29/0,9 found the facility did not obtain references from two (2) known previous employers prior to hiring Employee #7. 2. Further review found the facility did not obtain a criminal background check for the state of Ohio, when this state was listed as a previous residence of Employee #14. 3. It was also found the facility failed to access the Nurse Aide Abuse Registry to assure Employee #76 did not have findings of abuse or neglect registered with this state agency. Employee #32, who was assisting with review of the personnel records, was unable to provide evidence to show the required pre-employment screening for Employees #7, #14, and #76 was obtained by the facility. b) Resident #2 Review of facility records found, on 05/04/09, the daughter of Resident #2 sent an e-mail to the social services director alleging Employee #3 was "... smacking Mom's behind for wanting up at night to use the potty chair ... The woman may be teasing with Mom, but Mom is taking it as a punishment. Mom should not have to receive this treatment." Further review could find no evidence this allegation of abuse was reported to the State survey and certification agency or adult protective services in accordance with State law. An interview with Employee #32, on the afternoon of 05/29/09, confirmed this allegation had not been reported a… | 2014-01-01 | ||
| 11507 | 11507 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2009-05-29 | 329 | E | E5O711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and pharmacist recommendation, the facility failed to assure the drug regimens of three (3) of ten (10) residents remained free from unnecessary drugs, used in excessive dose, for an excessive duration, and/or without indications for use. Resident identifiers: #1, #14, and #10. Facility census: 29. Findings include: a) Resident #1 1. Review of the medical record found Resident #1 was currently receiving [MEDICATION NAME] 50 mg twice-a-day (BID) and [MEDICATION NAME] 100 mg BID. Further review found a 03/17/09 recommendation from the consultant pharmacist informing the physician these two (2) drugs were considered duplication of therapy. The pharmacist asked the physician to consider stopping one (1) of the drugs. The physician did not acknowledge the pharmacist's recommendation. 2. Further review found the resident received [MEDICATION NAME] 1 mg at bedtime. A pharmacy recommendation, dated 01/20/08 (more than fifteen (15) months earlier) notified the physician that a gradual dose reduction needed to be attempted every six (6) months. The physician did not acknowledge the pharmacist's recommendation, and the resident remained on [MEDICATION NAME] 1 mg at bedtime. b) Resident #14 Review of the medical record found a physician's orders [REDACTED]. The resident was [MEDICATION NAME] mg BID for ten (10) days. On 04/13/09, an order for [REDACTED]. The medical record contained the urine culture report, marked as having been received at 5:01 p.m. on 04/13/09. The report documented no growth of bacteria after forty-eight (48) hours. There was no documentation to reflect the treating physician was notified of this laboratory report. The nurses administered [MEDICATION NAME] 500 mg for a total of eight (8) days beginning at 2:00 p.m. on 04/13/09, and continued [MEDICATION NAME] mg for seven (7) days after receiving the laboratory report. c) Resident #10 The physician [MEDICATION NAME] mg BID for ten (10) days for treatmen… | 2014-01-01 | ||
| 11508 | 11508 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2009-05-29 | 428 | D | E5O711 | Based on medical record review and review of a pharmacy report of irregularities for two (2) of ten (10) sampled residents, the facility failed to assure the pharmacist's recommendation for a gradual dose reduction of Ativan was acted upon by the physician. Resident identifiers: #1 and #14. Facility census: 29. Findings include: a) Resident #1 Review of the medical record found Resident #1 was currently receiving Lyrica 50 mg twice-a-day (BID) and Neurontin 100 mg BID. Further review found a 03/17/09 recommendation from the consultant pharmacist informing the physician these two (2) drugs were considered duplication of therapy. The pharmacist asked the physician to consider stopping one (1) of the drugs. The physician did not acknowledge or act upon the pharmacist's recommendation. b) Resident #14 Review of the medical record found a pharmacy's consult to the physician dated 04/22/09. The pharmacist notified the physician the resident was ordered MS (morphine sulfate) 30 mg BID on 04/06/09, in addition to a current order for Oxycodone 10/650 every six (6) hours as needed (PRN) for pain. The pharmacist noted the order for Oxycodone did not contain parameters for nursing as to when the PRN Oxycodone should be administered. The physician failed to acknowledge or act upon the pharmacy recommendation. . | 2014-01-01 | ||
| 11509 | 11509 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2009-05-29 | 502 | D | E5O711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure laboratory services were obtained for one (1) of ten (10) sampled residents. Resident identifier: #10. Facility census: 29. Findings include: a) Resident #10 Review of the medical record found the resident was administered antibiotics for treatment of [REDACTED]. The treating physician ordered a repeat urinalysis with urine culture on 04/12/09. Review of the medical record found no evidence the laboratory test was obtained. An interview with a member of the nursing staff (Employee #27), on 05/28/09 at 9:50 a.m., confirmed the facility had not obtained the ordered test. . | 2014-01-01 | ||
| 11510 | 11510 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2009-05-29 | 505 | D | E5O711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure the physician was promptly notified of laboratory findings for two (2) of ten (10) sampled residents. Resident identifiers: #14 and #10. Facility census: 29. Findings include: a) Resident #14 Review of the medical record found a physician's orders [REDACTED]. The resident was [MEDICATION NAME] mg BID for ten (10) days on 04/10/09. On 04/13/09, an order for [REDACTED]. The medical record contained the urine culture report, marked as having been received at 5:01 p.m. on 04/13/09. The report documented no growth of bacteria after forty-eight (48) hours. There was no documentation to reflect the treating physician was notified of this laboratory report. The nurses continued to administer both [MEDICATION NAME] 500 mg [MEDICATION NAME] mg after receiving the laboratory culture which indicated no bacteria growth after forty-eight (48) hours. The medical record contained no evidence the facility notified the physician of the laboratory results. An interview with a member of nursing staff (Employee #27), on the morning of 05/29/09, confirmed the facility could provide no evidence the physician was notified. c) Resident #10 The physician [MEDICATION NAME] mg BID for ten (10) days for treatment of [REDACTED]. On 03/24/09 at 9:31 a.m., the facility received a laboratory report which determined the bacteria present in the resident's urine (Escherichia Coli) were resistant to Cipro. A handwritten note indicated the report was faxed to the physician at 10:00 a.m. on 03/24/09. The resident continued to [MEDICATION NAME] the evening shift on 03/24/09 and the day and evening shifts on 03/25/09, after being notified by the laboratory the bacteria present in the resident's urine were resistant to Cipro. The facility did not receive orders for an appropriate antibiotic until 5:00 a.m. on 03/26/09. The facility could provide no evidence the physician was notified in a timely manner … | 2014-01-01 | ||
| 11511 | 11511 | MONTGOMERY GENERAL HOSP., D/P | 515081 | WASHINGTON STREET AND 6TH AVENUE | MONTGOMERY | WV | 25136 | 2009-05-29 | 309 | D | E5O711 | Based on medical record review and staff interview, the facility failed to assure appropriate follow-up nursing assessment was provided to one (1) of ten (10) sampled residents. Nursing staff documented Resident #10 experienced bright red bleeding from the perineal area with no evidence of continued monitoring or assessment. Resident identifier: #10. Facility census: 29. Findings include: a) Resident #10 Review of the medical record found a 04/20/09 nursing note which documented the resident was having a small amount of bright red bleeding from the perineal area during her bed bath at 10:30 a.m. The nursing note documented that, upon assessment, the bleeding appeared to be coming from the urinary meatus. The medical record contained no further information concerning the bleeding from the resident's perineal area. The next nursing note was not written until the weekly note on 04/24/09. An interview with a member of the nursing staff, on the morning of 05/29/09, could provide no evidence the resident received further assessment or monitoring of the area. . | 2014-01-01 | ||
| 11075 | 11075 | NICHOLAS COUNTY NURSING AND REHABILITATION CENTER | 515190 | 18 FOURTH STREET | RICHWOOD | WV | 26261 | 2009-06-04 | 241 | D | 0 | 1 | CKVD11 | Based on observation and staff interview, the facility did not assure residents with lap buddies were given the opportunity to dine in dignity in the community dining area free from restrictive devices while being directly supervised. This was evident for three (3) of fifteen (15) sampled residents. Resident identifiers: #13, #62, and #51. Facility census: 89. Findings include: a) Resident #13 On 06/02/09 at 8:55 a.m., observation found Resident #13 eating at the dining room table while sitting in her wheelchair with a lap buddy attached. Interview with Employee #17 revealed this resident always had on the lap buddy on while she ate. On 06/03/09 at 4:00 p.m., Employee #17 clarified, after checking with her supervisor, and reported Resident #13 was not supposed to use the lap buddy while dining. Employee #17 said this must have been an oversight. b) Resident #62 On 06/02/09 at 12:30 p.m., observation found Resident #62 sitting at the dining room table in her wheelchair with a lap buddy attached. Two (2) nursing assistants were setting up the lunch tray, which was on the dining room table in front of the resident. The lap buddy was not removed until surveyor intervention. c) Resident #51 On 06/02/09 at 12:30 p.m., observation found Resident #51 sitting at the dining room table in her wheelchair with a lap buddy attached. Two (2) nursing assistants were setting up the lunch tray, which was on the dining room table in front of the resident. The lap buddy was not removed until surveyor intervention. d) Review of the care plans for Residents #13, #62, and #51 found no documentation regarding removing the lap buddies while in the facility's dining room under supervision. These findings were reported to the director of nursing on 06/03/09 prior to leaving the facility at 5:00 p.m. . | 2014-09-01 |
| 11076 | 11076 | NICHOLAS COUNTY NURSING AND REHABILITATION CENTER | 515190 | 18 FOURTH STREET | RICHWOOD | WV | 26261 | 2009-06-04 | 279 | E | 0 | 1 | CKVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, resident interview, and staff interview, the facility failed to develop comprehensive care plans to address the individualized needs of four (4) of fifteen (15) sampled residents. Resident identifiers: #13, #51, #62, and #68. Facility census: 89. Findings include: a) Resident #68 Resident #68, when interviewed on 06/02/09 at 1:30 p.m. and on 06/03/09 at 3:00 p.m., reported he had a stroke approximately six (6) years ago resulting in [MEDICAL CONDITION]. The resident was divorced and rarely received any visitors. He had a fall resulting in a [MEDICAL CONDITION] in April 2009 and was admitted to the facility for rehabilitative therapy services. The resident reported his life work was sports, having been a sports writer for a newspaper and a golf coach, and his primary interest was in sports, but the facility did not provide any activities relating to his interest in sports. The resident's activity assessment, dated 05/12/09, identified the resident had been a golf coach and sports writer. Review of Resident #68's medical record, on 06/04/09 at 10:00 a.m., found the resident's current plan of care, dated 05/30/09, did not address specific activity / social needs, likes, and/or interest for this [AGE] year old blind resident. When interviewed on 06/04/09 at 11:00 a.m., the registered nurse care plan coordinator (Employee #107) was unable to produce any additional evidence that the care plan addressed this resident's social needs and sports interest. b) Resident #13 Review of Resident #13's care plan revealed a goal indicating she will participate in an activity of choice three (3) times weekly. Two (2) interventions were listed to meet this goal - to encourage the resident to make decisions such as which activity to attend daily and to invite and take the resident to activities she may enjoy daily. However, the care plan did not identify any specific activities Resident #13 enjoyed and could do. Review of her participatio… | 2014-09-01 |
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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 );